title: Increasing podiatry referrals for patients with inflammatory arthritis at a tertiary hospital in Singapore: A quality improvement project.
abstract: BACKGROUND
  Foot disease is highly prevalent in people with inflammatory arthritis and is often under-recognized. Podiatry intervention can significantly reduce foot pain and disability, with timely access being the key factor. The aim of this study was to plan and implement a quality improvement project to identify the barriers to, and improve, uptake of podiatry services among patients with inflammatory arthritis-related foot problems seen at a tertiary hospital in Singapore.
  
  
  METHODS
  A 6-month quality improvement program was conducted by a team of key stakeholders using quality improvement tools to identify, implement and test several interventions designed to improve uptake of podiatry services. The number of patients referred for podiatry assessment was recorded on a weekly basis by an experienced podiatrist. The criterion for appropriate referral to podiatry was those patients with current or previous foot problems such as foot pain, swelling and deformity.
  
  
  RESULTS
  Interventions included education initiatives, revised workflow, development of national guidelines for inflammatory arthritis, local podiatry guidelines for the management of foot and ankle problems, routine use of outcome measures, and introduction of a fully integrated rheumatology-podiatry service with reduced cost package. Referral rates increased from 8% to 11%, and were sustained beyond the study period. Complete incorporation of podiatry into the rheumatology consultation as part of the multidisciplinary team package further increased referrals to achieve the target of full uptake of the podiatry service.
  
  
  CONCLUSIONS
  Through a structured quality improvement program, referrals to podiatry increased and improved the uptake and acceptance of rheumatology-podiatry services.
authors.affiliation: Podiatry Department, Rehabilitation Centre, National University Health System Singapore, Singapore. Electronic address: kate_frances_carter@nuhs.edu.sg.
authors.forename: K
authors.initials: K
authors.lastname: Carter
authors.affiliation: Yong Loo Lin School of Medicine, National University of Singapore, Singapore; Division of Rheumatology, Department of Medicine, National University Health System Singapore, Singapore.
authors.forename: P P
authors.initials: PP
authors.lastname: Cheung
authors.affiliation: Health and Rehabilitation Research Institute, Faculty of Health and Environmental Sciences, AUT University, Auckland, New Zealand.
authors.forename: K
authors.initials: K
authors.lastname: Rome
authors.affiliation: Yong Loo Lin School of Medicine, National University of Singapore, Singapore; Division of Rheumatology, Department of Medicine, National University Health System Singapore, Singapore.
authors.forename: A
authors.initials: A
authors.lastname: Santosa
authors.affiliation: Yong Loo Lin School of Medicine, National University of Singapore, Singapore; Division of Rheumatology, Department of Medicine, National University Health System Singapore, Singapore.
authors.forename: M
authors.initials: M
authors.lastname: Lahiri
mesh_terms: D001172:Arthritis, Rheumatoid / Q000175:diagnosis / Q000453:epidemiology / Q000628:therapy*; D003906:Developing Countries; D005260:Female; D006801:Humans; D015994:Incidence; D008297:Male; D011032:Podiatry / Q000706:statistics & numerical data*; D058996:Quality Improvement; D012017:Referral and Consultation / Q000706:statistics & numerical data*; D012846:Singapore; D062606:Tertiary Care Centers
keywords: Healthcare improvement; Inflammatory arthritis; Podiatry; Quality improvement