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
Feels like Dinosaurus
My own grandmother
v
v
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
30 years ago
Forgotten Complication
� Publication New England
Diabetes today on a global level
IDF atlas 2016
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,…)
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
Change in Medicine as such� From clinical exam >to high technical approach
Clinical exam in competition
Change of clinical presentation of Foot Syndrome
� From neuropathic to neuro-ischaemic ulcer
Co- morbidity…..
Change of “concepts”� From amputation to limb salvage DF care and
surgery
Limb salvage approach
wound assessment
TIVITA®
Innovative diagnostics in wound medicine
3rd Winner„Most Innovative Product“Innovation award
Winner 2017
© Diaspective Vision GmbH | www.diaspective-vision.com
Imaging TissueOximetry
Hyperspectral ImagingTIVITA®Spectroscopy
TIVITA® - Technology
© 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
Change of “concepts”� Multidisciplinary DF clinics
Change of “concepts”� Multidisciplinary DF clinics
� Accreditation & benchmarking
Karel Bakker, Chairman IWGDF
Karel Bakker, Chairman IWGDFDMRR journal in november 2015
Change of “concepts”� Integrated care
� Pre- ulcer phase > ulcer-phase > post-ulcer phase
Foot ProtectionTeam
GP practices
In-patient service
Community Nurses
Multidisciplinary foot care team
Integrated care
SkillsKnowledgeRespectCo-operationCommunicationAwareness Neil Baker slide
Change of “concepts”� Diabetes related foot disease & cancer model
� Remission instead of healing & survival
NEJM, 2018
Diabetic foot: cancer and cancer-model
Armstrong DG et al. International Wound Journal 2007; 4 (4): 286-7
NO reason to be CINDERELLA….
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
Chile 2014
Global change� From 1st meeting for DF disease in Malvern
Global change� From 1st meeting for DF disease in Malvern
� First Diabetic Foot Sudy Group: DFSG Barcelona 1998
Global change� From 1st meeting for DF disease in Malvern
� > to meetings all over the world
The picture can't be displayed.
Health economics & quality of life
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
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
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$1,481
http://siteresources.worldbank.org /
Think of this quantity as an index of the annual ability to pay for treatment
Case: Urban Treatment Costs in Int$
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
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)
* 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
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
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
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
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
EWMA
Basic publication: Supplement to DMMR
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
Why more guidance?-Rob Hinchcliff in Almelo
8 X variation incidence amputation DM
Organisation/ acces care
Variations in clinical practice
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
An initiative of the IWGDF/IDF CS and the WDFKickoff meeting Step by Step, 2003 with
Sharad Pendsey and Abbas
Dr. Z. G. Abbas
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
3135 healthcare professionals have been trained in 15Latin American countries2012-2015
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
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
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.
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,”
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.”