This study addressed whether peer chart audit performed by residents, without formal feedback, is associated with improved standards of care for the foot exam in patients with diabetes mellitus. Follow-up chart audit results were associated with a fourfold increase in the number of well-documented foot exams. Although the magnitude of improvement in documentation is statistically significant, the current study was not designed to address what care was actually delivered pre- and post-intervention.
The positive educational impact of the peer chart audits is highlighted by the absence of an extensive instructional component about diabetic foot care. We do not feel that a one-time, half-hour discussion regarding foot care would have had much impact, as past studies with even more extensive physician education have been mixed in terms of demonstrating improved outcomes [14
The impact of peer involvement may be an important factor contributing to our findings. Studies show that peer coaching, for example, contributes to physicians' professional development of both the learner and the mentor by encouraging reflection time and learning [15
]. We suspect that faculty and residents informally engaged in discussions during the process and learned that the foot exam is an important and reliable indicator of care.
We did not see any change in the history or review of systems; other studies have found these items inconsistently asked and documented [16
]. This finding may be further explained by the fact that the foot examination is often emphasized as the measure of quality.
Although it is well known that routine visits for patients with diabetes should include advice that they examine their feet daily and obtain an annual foot exam by their provider, studies found that the single most important item of the exam – the neurological exam- was performed in only one third of patients [17
]. Our findings are consistent with other studies demonstrating less than optimal foot exams and poor adherence to diabetes guidelines [19
]. For example, in a study by Greenfield et al., the prevalence of foot checks was 61.8% by general internists and 49.6% by endocrinologists [21
Overall, the data support chart audits as a useful tool for teaching Practice-Based Learning and Improvement. Another study showed that a quality improvement curriculum can produce creative projects that address the core competencies [22
]. We also incorporated additional ACGME core competencies including effective patient care, application of medical knowledge to patient care and systems-based practice. In our study we used an accepted standard of care to assess compliance and measure improvement of the foot exam. During the process we learned that implementation was feasible and did not require professional chart abstractors. However, it did require additional personnel, careful planning, and expertise in data management. These additional resources will have financial implications for residency program directors and department heads.
Our study has some limitations. Improvements in foot exam documentation might not reflect changes in practice; we were not able to directly measure practices. Observed improvements might be due to factors other than the peer chart audit activity. For example, the observed changes may have been due to the Hawthorne effect, in which subjects of a study modify their behavior because they are participating in a study [23
]. Also, because a variety of other conferences and teaching activities occur elsewhere in our curriculum, it is difficult to control for learning that may have taken place in other forums. However, to our knowledge, no other structured program was implemented at the same time as our chart review. Evidence to more definitively link the peer chart audit activity to observed changes in documentation (and clinical practice) will require a stronger evaluation design such as a randomized controlled trial. Follow-up studies might include a control group of residents, informed of the measurement process but not actually participating in the chart audit process, in order to link the audits to observed improvements.