Set up basic diabetes teams: primary /secondary care

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DIABETIC FOOT CARE IN BRAZIL ACHIEVEMENTS AND
CHALLENGES Dr Hermelinda Pedrosa Director
Department of the Diabetic Foot Brazilian
Diabetes Society
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Diabetic Foot Where we were ?
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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
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What about diabetic foot care ?
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1990s 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
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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
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StrategiesSave the Diabetic Foot Project
implementation
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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
• 1990s diabetic foot approach started to be
  linked to the hospital diabetes team

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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
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Setting up a foot teamWithout a podiatrist
a remarkable barrier ?
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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
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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
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Basic foot kit simple and affordable

• Tuning fork, hammer, cotton wool, pin,
  monofilament, ecodoppler
• Goniometer (physiotherapy staff)

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Neuropathic foot
Foot exam mandatory
Ischaemic foot
Neuroischaemic foot
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Organization of care

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

Hospital Specialist interdisciplinary team
Health Centre Family health programme
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Achievements
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Sala Professor Andrew Boulton (new structure
inauguration 1999)
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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
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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)
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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)
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Insole provision 1999-2004

Total 5.141 Increase 687.7
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Workshops and project demonstration 1992/2005


mean attendance workshop 100 meetings 200
total attendance estimated 9.000
Ministry of Health, Brazíl Brazilian Diabetes
Society, Foot Department, 2005
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(No Transcript)
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(No Transcript)
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Brazilian version XIII Brazilian Congress of
Diabetes Rio de Janeiro, October 10-14th,
2001 4.000 issues
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Brazilian Diabetes Society Journal Diabetic
Foot Forum (since 2001)
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The good news, the bad news What are the
challenges ?
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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

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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

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National Campaign Logoa sensibization approach
Logo Ministry of Health