DIABETIC FOOT CARE IN BRAZIL: ACHIEVEMENTS

AND CHALLENGES

Dr Hermelinda Pedrosa

Director Department of the Diabetic Foot

Brazilian Diabetes Society

Diabetic Foot:

Where we were ?

Diabetes National ProgrammeImplementation - 1988

Targets:

• Set up basic diabetes teams:

primary /secondary care

• Establish multidisciplinary teams:

tertiary care - public hospitals

Manual de Diabetes. Ministério da Saúde, 1990. ISBN 85-334-0031-4

What about

diabetic foot care ?

1990’s: depressing situation in Brazil

• Low interest in foot problems• Diabetic foot care: restricted to surgical

interventions (vascular, orthopedist)• Lack of specialist foot clinics• Scarce orthotics and foot material • High major amputation rates• No podiatrists

Pedrosa HC et al. É possível salvar o pé diabético ? Arq Bras Endoc Metab, 1991.Spiechler E, Spiechler D, Forti AC, et al. OPAS Bulletin, 2001

Hospital stay

• UK and USA 25 - 21 days

• International Consensus

(average) 30 - 40 days

• CEPEDF 60 – 90 days

(Brasilia)

IWGDF, 1999; Miziara MDY, Dias MSO, Farias L, Pedrosa HC, 1991

Strategies:

Save the Diabetic Foot Project

implementation

• To set up a specialist foot clinic

• To train health professionals on foot exam and

care

• To get the policymakers and hospital endocrine

staff to understand the diabetic foot devastation

• 1990´s – diabetic foot approach started to

be linked to the hospital diabetes team

Implementation

Costs: the best approach to policy makers

Ulcer and amputations (US $):

• Ulcer + amputation 30,000-60,000

• Primary Ulcer 7,000-10,000• Brazil-RS 7,000

2005 : R$ 16.000,00

Setting up a foot team:

Without a podiatrist – a remarkable barrier ?

How to motivate professionals? foot workshops

1. Foot exam – screening techniques

2. Basic podiatry procedures

3. Ulcer management

4. Education – family, carers

5. Organization of care*

6. Prevention – Practical Guidelines*

* Practical Guidelines – International Consensus, 1999. IWGDF – International Working Group on the Diabetic Foot

Setting up a multidisciplinary team

• Basic podiatry care: nurses join the project

Berry BL, Black JA. What is chiropody / podiatry ? The Foot. 1992; 2: 59-60

Basic foot kit : simple and affordable

• Tuning fork, hammer, cotton wool, pin, monofilament, ecodoppler

• Goniometer (physiotherapy staff)

Foot exam:

mandatory

Neuroischaemic foot

Neuropathic foot

Ischaemic foot

Organization of care

Targets: • Primary care integration• Referral and contra referral system

HospitalSpecialist interdisciplinary

team

Health CentreFamily health programme

Achievements

Sala Professor Andrew Boulton

(new structure inauguration – 1999)

Hospital Foot Team 1992 • Diabetologist• Nurses and Nurse Aid (Helpers)

2005 • Diabetologists / Medical residents• Nurses and Nurse Aid (Helpers) • Social Worker• Dietitians• Physiotherapists• Vascular Surgeons • Orthopaedist • Physiatrist• Orthotists • Dermatologist• Infectious Disease Specialist • Plastic Surgeon • Psychiatrist

02

13

2

1

4

1

2

44

7

9

0

1

2

3

4

5

6

7

8

9

10

1990 1992 1994 1996 1998 2000

Major amputations (1992-2000)

Trends towards

reduction = 77%

Note: Data - LEAS protocol and guidelines - data collection restricted to the reference hospital (Pedrosa HC et al. Diabetes Monitor, 2004)

0

5

10

15

20

25

30

35

2000 2001 2002 2003 2004

major

minor

Amputation rate: according to level of procedure

Note: Data - LEAS protocol and guidelines on data collection restricted to the reference hospital (Pedrosa HC et al. Diabetes Monitor, 2004)

Insole provision: 1999-2004

1046

12491102946

600

198

0

200

400

600

800

1000

1200

1400

1600

1999 2000 2001 2002 2003 2004

Total = 5.141 Increase = 687.7%

Workshops and project demonstration: 1992/2005

Ministry of Health, Brazíl; Brazilian Diabetes Society,Foot Department, 2005

Workshops 37

Workshop attendees* 4.035

National Congress Regional Seminars

21

National Congress, Regional Seminars attendees**

4.950

mean attendance: workshop = 100; meetings = 200

total attendance estimated : 9.000

Brazilian version*

XIII Brazilian Congress of Diabetes

Rio de Janeiro,

October

10-14th, 2001

* 4.000 issues

Brazilian Diabetes Society Journal

Diabetic Foot Forum*

(*since 2001)

The good news, the bad news:

What are the challenges ?

2002 – 2005: main problems

• PAD: late diagnosis confirmation

• Revascularisation: scarce

• Long hospital stay

• Footwear: not available (yet)

• Prosthetic provision: too late

(6 months)

• High amputation rates

• No podiatrists yet

Official Plans for 2005 - 2006

Ministry of Health / SBD

• Formation: Diabetic Foot Task Force Group*

• Podiatry Course ? (US and UK support)*

• Practical Guidelines – Primary Care

• Basic care teams training: 4.000 (FHP**)

• Outpatients Foot Clinics: improve structure

* Support: Ministry of Health – SBD; * IDF / WDF

**Family Health Programme

National Campaign – Logo:a sensibization approach

Logo – Ministry of Health