RS10 - Initial Success Collaborating with Chickasaw Nation’s Primary Care Clinics to Promote Limb Preservation

Objectives: A 12-year review of state hospital discharge data shows hospitalized First Americans in Oklahoma with diabetes and peripheral arterial disease (PAD) have one of the highest rates of lower limb amputation. To improve patient outcomes, our vascular surgery team collaborated with Chickasaw Nation primary care practices (PCPs) to initiate a pilot outreach program, “Caring for Our Feet.” This report describes the early effects of our study. The program's primary objectives were to (1) conduct a needs assessment of PCPs and (2) implement a systems-based strategy for lower limb disease detection and prevention. We hypothesized that a bundled intervention – including in-person education and support by vascular specialists – would improve amputation risk assessment and increase the provision of preventive care.

Methods: Using an effectiveness-implementation study design, our multidisciplinary limb salvage team – including vascular surgeons, podiatrists, internists, and ultrasonographers – visited all PCPs in Chickasaw Nation. A combination of surveys, semi-structured interviews, and clinic observations was used for the needs assessment. Our implementation bundle included didactic lectures and discussions, provider mentoring, and free PAD patient screening using lower extremity arterial duplex imaging and ankle-brachial index measurements. We calculated descriptive statistics for all quantitative pre- and post-survey responses and used the Wilcoxon Signed Rank Test to assess the changes in scores from baseline to the end of the study.

Results: All four Chickasaw Nation PCPs participated, with 34 practitioners initially consenting and 30 (88%) completing the study. Field notes showed high receptivity and inquiry among participants from the lectures and discussions. Pre- and post-survey results showed practitioners felt more comfortable diagnosing, treating, and educating patients with diabetic foot complications, peripheral arterial disease, and foot deformities after the intervention. Overall, 27/28 (96%) of survey measures showed improvement and 21/28 (75%) were statistically significant (p-value < 0.05). Twenty patients were successfully screened, and 8 (40%) were newly diagnosed with peripheral arterial disease.

Conclusions: Our needs assessment shows there are practice gaps in primary care that, if addressed, can improve the detection and early management of at-risk limbs. Importantly, survey data suggests our intervention bundle effectively develops amputation prevention competencies. Furthermore, this program is a viable and replicable strategy to foster a PCP-specialist-patient collaboration, for we successfully enrolled all four Chickasaw Nation practices, the practitioner program completion rates were high, and patients were successfully recruited. However, evaluating the use of our intervention bundle at additional sites will be crucial for a successful program expansion.