DIABETIC FOOT CARE IN BRAZIL: ACHIEVEMENTS AND CHALLENGES 15/04/2017 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 ? 15/04/2017 Diabetic Foot: Where we were ?

Diabetes National Programme Implementation - 1988 15/04/2017 Diabetes National Programme Implementation - 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 ? 15/04/2017 What about diabetic foot care ?

1990’s: depressing situation in Brazil 15/04/2017 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 15/04/2017 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 15/04/2017 Strategies: Save the Diabetic Foot Project implementation

Implementation To set up a specialist foot clinic 15/04/2017 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

Costs: the best approach to policy makers 15/04/2017 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 ? 15/04/2017 Setting up a foot team: Without a podiatrist – a remarkable barrier ?

How to motivate professionals? foot workshops 15/04/2017 How to motivate professionals? foot workshops Foot exam – screening techniques Basic podiatry procedures Ulcer management Education – family, carers Organization of care* Prevention – Practical Guidelines* * Practical Guidelines – International Consensus, 1999. IWGDF – International Working Group on the Diabetic Foot

Setting up a multidisciplinary team 15/04/2017 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 15/04/2017 Tuning fork, hammer, cotton wool, pin, monofilament, ecodoppler Goniometer (physiotherapy staff)

Foot exam: mandatory Neuropathic foot Ischaemic foot 15/04/2017 Neuropathic foot Foot exam: mandatory Ischaemic foot Neuroischaemic foot

Specialist interdisciplinary team Family health programme 15/04/2017 Organization of care Targets: Primary care integration Referral and contra referral system Hospital Specialist interdisciplinary team Health Centre Family health programme

15/04/2017 Achievements

Sala Professor Andrew Boulton (new structure inauguration – 1999) 15/04/2017

Hospital Foot Team 02 13 1992 Diabetologist 15/04/2017 Hospital Foot Team 1992 Diabetologist Nurses and Nurse Aid (Helpers) 2005 Diabetologists / Medical residents Social Worker Dietitians Physiotherapists Vascular Surgeons Orthopaedist Physiatrist Orthotists Dermatologist Infectious Disease Specialist Plastic Surgeon Psychiatrist 02 13

Trends towards reduction = 77% Major amputations (1992-2000) 15/04/2017 Trends towards reduction = 77% Note: Data - LEAS protocol and guidelines - data collection restricted to the reference hospital (Pedrosa HC et al. Diabetes Monitor, 2004)

according to level of procedure 15/04/2017 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)

15/04/2017 Insole provision: 1999-2004 Total = 5.141 Increase = 687.7%

Workshops and project demonstration: 1992/2005 15/04/2017 Workshops and project demonstration: 1992/2005 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 Ministry of Health, Brazíl; Brazilian Diabetes Society, Foot Department, 2005

15/04/2017

15/04/2017

Brazilian version* XIII Brazilian Congress of Diabetes Rio de Janeiro, 15/04/2017 Brazilian version* XIII Brazilian Congress of Diabetes Rio de Janeiro, October 10-14th, 2001 * 4.000 issues

Brazilian Diabetes Society Journal 15/04/2017 Brazilian Diabetes Society Journal Diabetic Foot Forum* (*since 2001)

The good news, the bad news: What are the challenges ? 15/04/2017 The good news, the bad news: What are the challenges ?

2002 – 2005: main problems PAD: late diagnosis confirmation 15/04/2017 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 15/04/2017 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 15/04/2017 Logo – Ministry of Health