Article Text

Download PDFPDF

Increasing identification of foot at risk of complications in patients with diabetes: a quality improvement project in an urban primary health centre in India
  1. Abha Mehndiratta1,
  2. Satish Chandra Mishra2,
  3. Prashant Bhandarkar3,
  4. Kunal Chhatbar3,
  5. Francoise Cluzeau1,
  6. Team PrimaryCareDoctors4
  1. 1Global Health and Development Group, Imperial College London, London, UK
  2. 2Department of Surgery, WHO Collaboration Centre for Research in Surgical Care Delivery in LMIC, Bhabha Atomic Research Centre Hospital, Mumbai, India
  3. 3Department of Surgery, WHO Collaboration Centre for Research in Surgical Care Delivery in LMIC, BARC Hospital, Bhabha Atomic Research Centre Hospital, Mumbai, India
  4. 4East Deonar Dispensary, Bhabha Atomic Research Centre Hospital, Mumbai, India
  1. Correspondence to Dr Satish Chandra Mishra; mishrasatishdr{at}


The majority of foot amputations are preventable in people with diabetes. Guidelines recommend that people with diabetes should receive a foot examination for risk assessment, at least annually. In an audit at a primary health centre (PHC) in Mumbai, India, no patient with diabetes was offered preventive foot assessment in preceding 12 months. Problem analysis identified a lack of clinic policy, training and equipment for foot assessment. There was no standardised referral pathway for patients identified with foot at risk of diabetes complications. Furthermore, limited data review, high patient volumes and little time available with healthcare providers were important constraints. A quality improvement project was carried out at the PHC from January to September 2017. The project aimed at increasing compliance to standardised foot assessment in patients with diabetes presenting to the PHC from a baseline of 0% to 100% over 6 months. This would help identify patients having a foot at risk of complications due to diabetes. The Quality Standard on foot assessment was adopted from the Ministry of Health and Family Welfare Diabetic Foot Guideline. The electronic medical record (EMR) was standardised, health providers were trained, PHC processes and referral pathways were redesigned. Plan-Do-Study-Act was used to address barriers with weekly data review. 88.2% (848) of patients with diabetes visiting the PHC during the study period received a foot examination. Out of these, 11% (95) were identified to have a foot at risk and referred to a specialist foot centre. 57% of referred patients followed with specialised foot protection services. Training of healthcare providers, standardisation of processes and regular data feedback can improve diabetic foot care. Integrating quality indicators in the EMR helps monitor compliance. The inability to use doctor’s time efficiently was the biggest challenge and sustaining the change will require organisational changes with suitable task shifting.

  • diabetes mellitus
  • electronic health records
  • implementation science
  • primary care
  • healthcare quality improvement

This is an open access article distributed in accordance with the Creative Commons Attribution 4.0 Unported (CC BY 4.0) license, which permits others to copy, redistribute, remix, transform and build upon this work for any purpose, provided the original work is properly cited, a link to the licence is given, and indication of whether changes were made. See:

View Full Text

Statistics from


  • Contributors AM, SCM, KC, FC, TP and PB conceptualised and developed the project design. TP collected the data and TP along with AM, SCM, KC and FC participated in weekly audits, feedback and designing of solutions to address barriers. PB retrieved, analysed and interpreted the data along with AM, SCM, KC, FC and TP. The first draft was created by AM, SCM and PB. The content was further revised and the final version of the manuscript was approved by AM, FC, SCM, KC and TP. All authors act as guarantors.

  • Funding This work was supported by The Bill and Melinda Gates Foundation Global Health and Development Group (International Decision Support Initiative) with grant number OPP1134345.

  • Competing interests We have read and understood BMJ policy on declaration of interests and declare the following: AM, SCM and KC were members of the guideline development group for the standard treatment guideline on The Diabetic Foot: prevention and management in India, 2016 published by the Ministry of Health and Family Welfare, Government of India.

  • Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.

  • Patient consent for publication Not required.

  • Ethics approval The Ethics Committee from BARC Hospital approved the project and advised explicit consent to be obtained from patients with diabetes.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data availability statement Data are available upon request.

Request Permissions

If you wish to reuse any or all of this article please use the link below which will take you to the Copyright Clearance Center’s RightsLink service. You will be able to get a quick price and instant permission to reuse the content in many different ways.