a global perspectiveof the diabeticfoot and wherewe have ... · a global perspectiveof the...
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A Global Perspective of the Diabetic Foot andwhere we have come
from
Dr. Kristien Van AckerPresident D-Foot International
www.d.foot.org
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Feels like Dinosaurus
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My own grandmother
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agenda� Forgotten Complication
� Diabetes Care over the years
� Change in Medicine as such
� Change of clinical presentation of Foot Syndrome
� Change of “concepts”
� Global change
� Health economics
� Guidance and Implementation
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30 years ago
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Forgotten Complication
� Publication New England
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Diabetes today on a global level
IDF atlas 2016
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Diabetes Care over the years� Injections: syringes were made in glass and had to
be boiled for re-use
� no HBA1c, no microalbumuria, …
� DCCT
� UKPDS
� Diabetes is a cardiovascular disease
� Pumps, CGM, modern inulines, more Oral Antiabetics ( flexibility, individualised treatment,…)
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Diabetes Care over the years� Joslin:
� Once insuline treatment was available , it was clear that the ptoblem was not saved…
� We had to deal with complications� First DF Clinic ever:
� “wandering nurses,” the forerunners of today’sdiabetes nurse educators, visited patients throughoutNew England, sometimes living with a family forseveral weeks
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Change in Medicine as such� From clinical exam >to high technical approach
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Clinical exam in competition
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Change of clinical presentation of Foot Syndrome
� From neuropathic to neuro-ischaemic ulcer
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Co- morbidity…..
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Change of “concepts”� From amputation to limb salvage DF care and
surgery
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Limb salvage approach
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wound assessment
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TIVITA®
Innovative diagnostics in wound medicine
3rd Winner„Most Innovative Product“Innovation award
Winner 2017
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© Diaspective Vision GmbH | www.diaspective-vision.com
Imaging TissueOximetry
Hyperspectral ImagingTIVITA®Spectroscopy
TIVITA® - Technology
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© Diaspective Vision GmbH | www.diaspective-vision.com
„Establish Hyperspectral Imaging in medicine as standard diagnostics for physiological monitoring”
X-Ray Ultrasound MRI PET/CT HSI
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Change of “concepts”� Multidisciplinary DF clinics
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Change of “concepts”� Multidisciplinary DF clinics
� Accreditation & benchmarking
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Karel Bakker, Chairman IWGDF
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Karel Bakker, Chairman IWGDFDMRR journal in november 2015
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Change of “concepts”� Integrated care
� Pre- ulcer phase > ulcer-phase > post-ulcer phase
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Foot ProtectionTeam
GP practices
In-patient service
Community Nurses
Multidisciplinary foot care team
Integrated care
SkillsKnowledgeRespectCo-operationCommunicationAwareness Neil Baker slide
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Change of “concepts”� Diabetes related foot disease & cancer model
� Remission instead of healing & survival
NEJM, 2018
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Diabetic foot: cancer and cancer-model
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Armstrong DG et al. International Wound Journal 2007; 4 (4): 286-7
NO reason to be CINDERELLA….
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Diabetic foot: cancer and cancer-model
Even when an ulcer is successfully healed, risk for recurrence is high,
with reported rates between 30 and 40% within the first year
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Chile 2014
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Global change� From 1st meeting for DF disease in Malvern
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Global change� From 1st meeting for DF disease in Malvern
� First Diabetic Foot Sudy Group: DFSG Barcelona 1998
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Global change� From 1st meeting for DF disease in Malvern
� > to meetings all over the world
The picture can't be displayed.
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Health economics & quality of life
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The Cost of Treating Diabetic Foot Ulcers in 5 Different Countries
Cavanagh P, Attinger C, Abbas Z, Bal A, Rojas N, Xu ZR. Cost of treating diabetic foot ulcers in five different countries. Diabetes Metab Res Rev. 2012 Feb; 28 Suppl 1:107-11.
Peter Cavanagh, Christopher Attinger, Zulfiqarali Abbas,
Arun Bal, Nina Rojas, and Zhangrong Xu
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The locations and the co-authors
Dr. Chris AttingerWashington DC, USA
Dr. Arun BalMumbai, India
Dr. Zulfiqarali AbbasDar es Salam, Tanzania
Dr Zhang-Rong XuBeijing, China
Dr. Nina RojasChile
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GDP Per Capita in International $
World Rank Country GDP per capita
9 US Int$47,244
49 Chile Int$16,659
94 PRC Int$8,268
138 India Int$3,419
167 Tanzania Int$1,481
http://siteresources.worldbank.org /
Think of this quantity as an index of the annual ability to pay for treatment
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Case: Urban Treatment Costs in Int$
0
40,000
80,000
120,000
160,000
200,000
Chile China India Tanzania USA
10,43421,372 19,599
3,060
188,645
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CASE: Patient’s Financial Burden in Urban ClinicExpressed as Months of Income*
*Calculated as 12* (Patient co-pay in Int$/per capita PPP-adjusted GDP)
0
20
40
60
80
Chile China IndiaTanzania USA
3.0 3.1
68.8
24.8
9.6
Mon
ths
Calculated as 12* (Patient co-pay in Int$/per capita PPP-adjusted GDP)
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* Based in a prevalence of 7.12 million with diabetes
Type 2 prevalence 7.12 million
Ulcers 6,8% - 484.569
Hospital admissions 35% - 169.569
Amputations - Maior- Menor
44,2% - 35.75155,8% - 45.133
Death 12,8% - 21.705
Diabetic foot in Brazil: hypotheticalscenario
Rezende KF, Ferraz MB, Malerbi DA, Melo NH, Nunes MP, Pedrosa HC, Chacra AR. Direct costs and outcomes for inpatients with diabetes mellitus and foot ulcers in a developing country:
The experience of the public health system of Brazil. Diabetes Metabol Syndrome: Clinical Res Rev 3 (2009); 228-232
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DF - Estimated costs in Brazil(for a hypothetical cohort of 7.12
million of Type 2 DM)
Rezende KF, Ferraz MB, Malerbi DA, Melo NH, Nunes MP, Pedrosa HC, Chacra AR. Predicted Annual Costs for Inpatients with Diabetes and Foot Ulcers in a Developing Country – a
Simulation of the Current Situation in Brazil. Arq Bras Endocrinol Metab 2008; 52: 523-530.
•US$ = 1.64 real ( Aug 2008) •US$ = 2.00 real (Mar 2013)•US$ = 2.40 real (Oct 2014)
Annual cost (hospital admission)
US$ 461 million
Annual cost(amputation)
US$ 222.3 million
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Pedrosa HC , Novaes C, Leme LAP, Boulton AJM. International Diabetes Monitor 16; 11-17, 2002
60 DF outpatients clinics
Brazilian Save theDiabetic Foot Project:Situation of DF outpatientsclinics
§Needs to be updated§ Lack of support: discontinuation
of many services
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World Bank and WHO: Analysis for Cost-Effectiveness
Foot care:
§ Patient education
§ Provision of proper footwear
§ Multidisciplinary clinics
Venkat NKM, Zhang P, Kanaya AM et al. Diabetes: the pandemic and potential solutions.In: Disease Control Priorities in Developing Countries (2nd ed), Jaminson, Breman Measham (eds).
World Bank-Oxford University Press, NY, 2006;591-604
Cost saving in all developing countries
80% of Diab Patients in Low and Middle Incomeregions
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Guidance and Implementation
� Forgotten Complication
� Diabetes Care over the years
� Change in Medicine as such
� Change of clinical presentation of Foot Syndrome
� Change of “ concepts”
� Global change
� Health economics
� Guidance and Implementation
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EWMA
Basic publication: Supplement to DMMR
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120.000 copies
1999 2015
26 translations
55
South Korea, Russia, Bosnia Herzegovina, Iran, Turkey. Republic of China, Japan?
Portugal, Kuwait and Germany, The Netherlands are busy working on the translation
? copies
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Why more guidance?-Rob Hinchcliff in Almelo
8 X variation incidence amputation DM
Organisation/ acces care
Variations in clinical practice
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Step-by-Step� Pilot programmes in India (2004) and Tanzania (2004);
� Goals: to improve educational skills and the management of diabetic foot problems ® cascade effect and sustainability in the region/country
� An experienced national and international faculty is responsible for teaching and for the practical sessions.
� Teams: a doctor and a nurse or paramedic
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An initiative of the IWGDF/IDF CS and the WDFKickoff meeting Step by Step, 2003 with
Sharad Pendsey and Abbas
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Dr. Z. G. Abbas
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Train the Foot trainer course South- and Central America,Brasil, December 2012
13 countries: Argentina, Bolivia, Brazil, Chile, Colombia, Cuba, Dominicana, Ecuador, Mexico, Panama, Paraguay, Peru and
Uruguay
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3135 healthcare professionals have been trained in 15Latin American countries2012-2015
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3,135 TYPE OF MEDICAL SPECIALISTS AND NURSES TRAINED IN THE SACA
REGION 2012 - 2015
Diabeto's
Endo's
Internal Med
Gp's
Genral Surg
Vasc Surg
Orthop Surg
Nurses
248
532
205
913
96
44
35
973
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Conclusion� No Forgotten Complication anymore
� More complex medical world and diabetes care
� Change of clinical presentation of Foot Syndrome
� Change of “concepts” and organisation of DF-care
� Many DFSG’s and DF meetings
� Health economics and Quality of life- still a lot to do
� Guidance but Implementation TODAY
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Global Conclusions� “How can we reduce morbidity and mortality from
diabetic foot disease?”
� The answer to this key question might not be toodifficult, Dr. Boulton said.
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Global Conclusions� “When Paul Brand was asked to make a
recommendation to a US Department of Health conference on reducing amputations in diabetes, most listeners were probably expecting an answerpromoting vascular surgery or modern medications,”
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Global Conclusions� “They were surprised to hear that his key
recommendation was a national campaign toencourage health care professionals to removepatients shoes and socks and examine the feet.
� Unfortuntately this simple advice is ignored in manycountries.”
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