The Burden of Diabetes in Underserved Populations.

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"The Burden of Diabetes in Underserved
Populations."

• Ace Anglin, M.S., DPM
• Chief of Podiatric Medicine Surgery
• Health Services Incorporated

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OBJECTIVES

• Explain the Burden of Diabetes
• Discuss how patient and caregiver can teach Self
  Management of the Diabetic Foot.
• Explain the Podiatrist Role as a Diabetic
  Educator
• Remove the Barriers that prevent patients from
  being Compliant with Treatment.
• Identify Feet At-Risk for Amputation

The Burden of Diabetes
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My current practice with the underserved includes
educating elderly, diabetics with Medicare about
the Burden of Diabetes

• Burden of Diabetes

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Health Services Incorporated Montgomery,
ALBernell Mapp, CEO Julian McIntyre, MD
Medical DirectorNonprofit AL FQHC with 10 Health
Centers.Provides for over 30,000 residents
Montgomery County.

• 3,000 Diabetics (10 Diabetic)
• Annual Visit 90,000.
• African American (52.5)
• Caucasians (45)
• Latinos (1.4)
• Asians (1.2)
• Native Americans 0.9
• Sliding scale Patient fees discount for services.
  

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Burden of Diabetes, U.S.20.8 million has
Diabetes (ADA)

• 130,000 amputations a year (1/30 Sec) 67 due
  Diabetes
• 50 Amputation unnecessary (CDC)
• 50 Amputees undergo second amputation.
• 50 Amputees Die 2-5 years After Amputation.
• Diabetes costs this country 85 billion a year in
  total health care expenditures.

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The Burden of Diabetes in Alabama

• AL, had the highest rate
• Diabetes (JAMA, 03).
• 10.5 have Diabetes

Comparison AL to CA Population CA 36
Million Population AL 4.5 Million 2 Million
Diabetics CA 639,000 Diabetics AL
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Explain the Podiatrists role in diabetic
education? Teaching Performing Foot
Examinations!
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Podiatrist Main role in diabetic education must
center on amputation prevention just as the
Ophthalmologist role must be prevention of
blindness.
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Partnerships which are beneficial to the diabetic
underserved population? Lower Extremity
Amputation Prevention (LEAP)

• Patient Education Self-management skills is the
  second component of the LEAP Program.
• Once patients are taught simple self-management
  techniques, they assumes personal responsibility
  and becomes a full partner with the health care
  team in preventing foot problems.

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Describe self-management programs. Lower
Extremity Amputation Prevention (LEAP)

• Provider refer all diabetics for Comprehensive
  foot exam
• Comprehensive exam include Vascular,
  Dermatological, Biomechanical Neurological
  Testing all Diabetics
• Neurological testing all diabetics to determine
  risk level
• Foot exam every 2-3 months (High risk patients)
• Foot exam every 6-12 months (Low risk patients)
• Extra Depth Shoes all Low risk patients
• Custom Mold shoes or Extra depth Shoes High risk
  patient
• Patient education on amputation prevention all
  Diabetics
• Debridement of Fungal nails and/or Callous

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Effectiveness of LEAPLouisana State Univ.
Health Sciences Center 3/98

• Reduction in foot-related ulcer days 49
• Reduction in hospitalizations 89
• Reduction in emergency room visits 81
• Reduction in antibiotic prescriptions 57
• Reduction in foot operations 87
• Reduction lower-extremity amputations 79
• Reduction in Missed workdays 70
• CONCLUSIONS of LSU Cohort Study
• Large reduction in foot related Complications
  after first year of comprehensive preventive foot
  care.
• Diabetes Care 2313391342, 2000

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What Makes People really make a change in their
lifestyle to control their disease? Pain!!
What stops them from changing? Neuropathy!!

• Pain!!
• Painlessness Make Diabetes Destructive!
• Diabetics will walk 10 miles without changing
  Strides.
• Diabetics Do not Limp!
• Diabetics wear Shoes Too Tight!!

• Understanding the Gift of Pain

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• Amputation Risk
• Patients with Absent pedal pulses
• Patients with Foot deformity
• Patients with Prior amputation
• Patients with Loss of protective sensation (LOPS)
• Elderly Diabetics

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Sensory ExamSemmes-Weinstein monofilamentFree
monofilaments www.bphc.hrsa.dhhs.gov/leap/
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(No Transcript)
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How open are elderly diabetics to receiving
information about making life style changes? For
Example Diabetic Shoes. Whats the compliance
rate for patients wearing say Diabetic Shoes as
opposed to regular walking shoes?
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Compliance rate for patients wearing diabetic
shoes are low. Recurrence of diabetic foot
ulcers, even in specialty foot clinics, is often
very high, ranging from 25 to 80 per year.

• Specialty diabetic foot clinics have been shown
  to reduce the incidence of ulceration and
  amputation in high-risk patients.
• Often these foot clinics provide protective shoes
  and insoles, foot-specific education, and
  advanced clinical care. These clinics usually
  deliver services that are well above the local
  community standard

• The Burden of Diabetes

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Lower Extremity Amputations Among Persons With
Diabetes
Age-adjusted rate per 1,000
1997-99
2001-03
20
15
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2010 Target 2.9
5
0
Black
White
Female
Male
lt65
65-74
75
Total
Race
Age
Gender
I 95 confidence interval. Age adjusted to
the 2000 standard population. Age-specific
rates are not age-adjusted. NOTE Includes any
amputation of lower limb. For NHDS data prior to
2000, only one race category was recorded
reporting more than one race was not an option.
For NHIS data prior to 1999, respondents reported
one or more races and identified one race as best
representing their race. Respondents were asked
to select one or more races starting in 1999
(NHIS) or 2000 (NHDS), although more than one
race selection was not used for 1999 NHIS data in
order to be consistent with 1997-1998 data. Data
for the single race categories shown are for
persons who reported only one racial group.
SOURCE National Hospital Discharge Survey
(NHDS) and National Health Interview Survey
(NHIS), CDC, NCHS.
Obj. 5-10
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Barriers for Underserved Obtaining Diabetic
(Extra Depth Shoes)1.Treadsafe (Wal-Mart) 2.Tom
McCann (K-Mart)Medicare Therapeutic Shoe Bill,
May 1993
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Success stories on educating diabetics,
especially elderly diabetes from underserved
populations?

• EXTRA!! EXTRA!!
• November is National Diabetes Month
• Come Get Your Free Foot Exam!!

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Success stories on educating diabetics,
especially elderly diabetes from underserved
populations?

• FACT
• 55 of diabetic amputations occur in patients
  older than 65 years of age.

• EXTRA!! EXTRA!!
• August is National Foot Health Month
• Come Get Your Free Foot Exam!!

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Success stories on educating underserved elderly
diabetics populations? The publication of the
first self management book on diabetic foot care
and amputation prevention. www.savingthediabetic
foot.comwww.amazon.com
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Advice on Diabetic Self-Management 10 Steps to
Healthy Feet

• Step 1. Have your doctor check your feet
  regularly.
• Step 2. Wear the right shoes and socks. Never go
  barefoot.
• Step 3. Check your feet every day.
• Step 4. Treat cuts, scrapes and blisters. See
  your doctor if a wound does not heal.
• Step 6. Cut your toenails correctly. See a
  Podiatrist
  if your nails are too thick or ingrown.
• Step 7. Treat athlete's foot.
• Step 8. Get proper treatment for calluses and
  corns.
• Step 9. Avoid heating pads and hot water foot
  soaks.
• Step 10. Take action to improve your
  circulation.
• High blood pressure, high cholesterol levels and
  smoking can harm the circulation in your feet and
  keep sores from healing. Ask your doctor for help
  if you have any of these problems.

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Advice on Diabetic Self Management? The Burden
of Diabetes in Underserved Populations

• Self-management is the cornerstone of diabetes
  treatment. Unfortunately, persons with diabetes
  are not equipped to deal with the long term
  self-management requirements of diabetes.
  Alabama Behavioral Risk
  Factor Surveillance System Data

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Multidisciplinary Approach (Team
Approach)Paul Brand, MDA Mans Got to Know His
LimitationsClint Eastwood

• Patient
• Family
• Internal Medicine
• Nurse, Social Worker
• Cardiology/ Nephrology
• Endocrinologist
• Infectious Disease
• Orthopedic Surgeon
• Podiatric Surgeon

• Home Health Worker
• Community Organization
• Vascular Surgeon
• Wound Care Specialist
• Nutritionist
• Pedorthist
• PT/ OT
• Family Medicine

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Advice on Diabetic Self Management? The Burden
of Diabetes in Underserved Populations

• The challenge to any Disciplines
• caring for the Diabetic Foot is that there can
  be no turf wars, recognizing instead strengths to
  achieve success
• Gary Gibbons, MD
• Harvard Medical School

• Burden of Diabetes
• Let the Strong Bear the Infirmities of the Weak
  Romans 151