DIABETIC FOOT CARE IN BRAZIL: ACHIEVEMENTS AND CHALLENGES Dr Hermelinda Pedrosa Director Department...
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Transcript of DIABETIC FOOT CARE IN BRAZIL: ACHIEVEMENTS AND CHALLENGES Dr Hermelinda Pedrosa Director Department...
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