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Poster session 14: Organization of footcare
P14.01
The economic burden of diabetic foot ulcers in Russia
Victoria Ignatyeva, The Russian Presidential Academy of National Economy and Public
Administration, Moscow, Russia
Gagik Galstyan, The Endocrinological Scientific Center of the Ministry of Health, of RF,
Moscow, Russia
Maria Avxentyeva, The Russian Presidential Academy of National Economy and Public
Administration, I.M. Sechenov First Moscow State Medical University, Moscow, Russia
Oleg Udovichenko, Moscow Municipal outpatient clinic #22, Endocrinological department,
Moscow, Russia
Vadim Bregovsky, Federal Almazov Medical Research Center, St.Petersburg, Russia
Aim: To evaluate current outcomes and costs of diabetic foot ulcer (DFU) treatment and
cost-effectiveness of interventions aimed at decreasing the number of amputations in
Russia.
Methods: We developed a decision tree model estimating annual number of major and
minor amputations and costs for the following simplified scenarios of medical care:
1)Outpatient diabetic foot clinic, 2)Non-specialized outpatient care, 3)Cessation of the
outpatient treatment by patient 4)Care provided only at hospital (no previous visits to
outpatient clinic).
The rates of treatment cessation, hospitalization, amputation and distribution of the patient
cohort (1000 patients) among the scenarios were based on published Russian studies and
experts’ survey. The costs were calculated from the overall governmental budget
perspective. Prices were taken from published Russian study and tariffs in public medical
insurance and social care. We also simulated 2 interventions: preventive services for
patients at a very high risk of DFU (6 additional outpatient visits and 2 pairs of orthopedic
shoes) and provision of care for DFU patients at hospital by multidisciplinary foot care team
(MDT). The effectiveness of interventions was derived from published research.
Results: The mean annual cost per patient with DFU in modeled cohort was €454. The
highest cost (€1 124) and amputation rates (0.27 for minor and 0.19 for major) per patient
were expected in the group treated at hospital only. The lowest cost (€332) and rate of
amputations (0.12 for minor and 0.02 for major) were in the group receiving treatment in the
outpatient diabetic foot clinic. The annual cost of prevention program for 1000 diabetes
patients would be €197 036. The expected number of major amputations would decrease by
16 with the additional costs per prevented amputation €5 561, assuming that all patients are
compliant to the given recommendations. The inpatient treatment by MDT would require
additional €406 228 per 1000 DFU patients, resulting in 41 prevented major amputations.
Conclusions: Our results support the idea that early and adequate treatment of foot ulcers
in diabetic patients is mandatory to prevent amputations and reduce the costs. Both
simulated interventions require considerable additional budget spending.
www.diabeticfoot.nl
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P14.02
A JOURNEY IN A WORST OUTCOME OF DIABETIC FOOT: EXAMPLE OF CLINICAL
INERTIA
Luiz Clemente Rolim, Diabetes Center of UNIFESP, São Paulo, Brazil
Maria Lucoveis, Diabetes Center of Federal University of São Paulo, São Paulo, Brazil
Mônica Antar Gamba, Federal University of São Paulo, São Paulo, Brazil
Sérgio Atala Dib, Diabetes Center - UNIFESP, São Paulo, Brazil
Aim: despite the screening and multidisciplinary approach to diabetic foot (DF) has led to
decrease in amputation rates in many countries, the global prevalence of amputation has
increased in the last decades and this fact could be due to clinical inertia (CI). Our aim was
to report a case of CI in DF and to carry out a critical review of literature on this topic.
Methods: firstly, we present the history of a patient user of the Unified Health System (SUS)
in Brazil. The patient appeared in our service in May 2014 and Consent Agreement was
done; secondly, we did a review of literature in PubMed with the terms "clinical inertia and
diabetes mellitus" (DM). We found 99 papers and of these, 28 were selected in order to
establish if the concept of CI in DM could be applied to DF care.
Results: case report: AGS, 41 years old, male, precocious type 2 DM (A1C=11%). First day:
on the day after he walked on the beach, he felt a strong pain in the right foot (RF). By the
time he looked for a basic unit health, the nurse said there was a black foreign body within
the lesion in the RF and guided him to look for a hospital service near his home. Doctors
prescribed him penicillin. Second day: clean wound with soap and water. Third day: the pain
got worse and he could not walk, he returned to a private hospital for evaluation. The doctor
inspected and examined the lesion hole, stated that there was no drainage of any exudate,
and ordered him to come home; after 3 days formed bubbles with hematic content from the
back foot to the ankle. He came back to the Public Hospital, where he was admitted for
drainage of bubbles and vascular evaluation. Because of the delay, more than 48 hours, his
brother transferred to another public hospital. Admitted to the 4th hospital, after evaluation
by the vascular surgery, major amputation was indicated.
Conclusions: The case presented is a typical example of clinical inertia. The literature
review showed numerous factors that could be translated as the cause of CI in DF and one
seems to be determinant: the negative physician and team behaviours in relation to patients
with DF. Therefore, if we had to recommend just one solution for the many causes of CI in
DF, we would propose this: better doctor-team-patient intercommunication.
www.diabeticfoot.nl
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P14.03
Delay: is it really so bad with the loss of time before patients with diabetic foot ulcers
visit a podiatrist?
Antal Sanders, Leiden University Medical Center, Leiden, Netherlands
Lian Stoeldraaijers, Podiatry Valkenswaard, Valkenswaard, Netherlands
Mieke Pero, Pero Podiatry, Geldrop, Netherlands
Patty Hermkes, Maatschap Podotherapie Venlo, Venlo, Netherlands
René Carolina, Podiatry Zaanstad, Zaandam, Netherlands
Petra Elders, VU Medical Center, Academic Network of General Practitioners, Amsterdam,
Netherlands
Aim: We often are confronted with statements in our clinical settings, professional network,
in medical publications and during conference presentations about long patient and
professional delays in patients with diabetic foot ulcers, especially those with loss of
protective sensation. Do you recognize this? Do you know how large the delay is of patients
with diabetic foot ulcers and of their health care professionals before these patients present
themselves in your clinic? We did not. In the literature, few studies pay attention to the time
interval between ulcer identification and the start of health care. The present cohort study
investigated referral and treatment trajectories of patients with diabetic foot ulceration
consulting podiatrists. The study aims were to quantify patient, professional and treatment
(=total) delay and to identify relationships between patient- or professional-related
characteristics, delays or ulcer healing time.
Methods: Ten podiatrists specializing in diabetes care included 54 consecutive adults with
diabetic foot ulceration. Assessments were performed retrospectively (e.g. delays) and
prospectively (12 weeks).
Results: Median (SD; range) patient delay was 3.0 days (50.6; 0-243), professional delay
7.0 days (63.4; 0-279) and treatment delay 20.5 days (97.3; 0-522)., Fifty-seven percent of
patients took more than 2 weeks before visiting a podiatrist. Ulcers healed in 67% of patients
in 49.0 days (90.2; 4-408). The number of health care professionals in the referral trajectory
was positively related to treatment delay (p <0.01) and to ulcer healing time (p <0.01).
Professional delay and treatment delay was positively correlated with the duration of the
podiatric treatment (p <0.05). Patient awareness of ulceration risk tended to decrease the
healing time.
Conclusions: Patients with diabetic foot ulcers presented small median delays in the
referral trajectory to podiatrists specializing in diabetes. The study results suggest that
reducing the number of health care professionals in the referral trajectory might decrease
treatment delay and ulcer healing time. Also improving patient awareness of ulceration risk
might be beneficial for the healing time.
www.diabeticfoot.nl
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P14.04
Establishment of the brunei diabetic foot registry
Norafizah Haji Zaine, University of Sydney, Sydney, New South Wales, Australia
Haslinda Hassan, Diabetes Centre, Raja Isteri Pengiran Anak Saleha Hospital, Brunei
Darussalam, Bandar Seri Begawan, Brunei
Mauro Vicaretti, Westmead Research Centre for the Evaluation of Surgical Outcomes,
Sydney, New South Wales, Australia
John Fletcher, Westmead Research Centre for the Evaluation of Surgical Outcomes,
Sydney, New South Wales, Australia
Kerry Hitos, Westmead Research Centre for the Evaluation of Surgical Outcomes, Sydney,
New South Wales, Australia
Joshua Burns, University of Sydney, Sydney, New South Wales, Australia
Background: The national diabetes prevalence estimates for Brunei Darussalam in 2010
was 10.7% and is expected to increase to 13.4% by 2030 [1]. There are no published reports
on the prevalence and characteristics of diabetic foot ulcers in Brunei. Therefore the primary
aims of the Brunei Diabetic Foot Registry are to determine longitudinally the incidence,
characteristics and treatment outcomes of diabetic foot ulcers in the population of Brunei and
to determine which factors are associated with the development and healing of diabetic foot
ulcers in a tertiary outpatient hospital setting.
Methods: The Registry includes dataforms capturing patient details (e.g. demographics,
medical history, history of ulcers and amputations), subjective and objective foot health
assessments (e.g. photoplethysmography) and wound diagnostics (e.g. grading of ulcers
and infection). Validation of the Registry includes a 6-month pilot study (January to June)
and a reliability study. These studies are conducted to check ascertainment, data entry
errors, fields, and training effectiveness. The inter-rater reliability study is tested on the
subjective components of the Brunei Diabetic Foot Registry. The Podiatrists at the main
referral hospital in Brunei participated in this study and are trained on all aspects of the
Registry via the standardised Training Manual.
Results: The subjective components of the Brunei Diabetic Foot Registry contained 133
items. The Kappa value ranged from 0.3 to 1.0 and the intra-class correlation (model 1 1)
ranged from 0.94 to 0.995.
Conclusions: The increasing incidence of patients with diabetes and associated
complications is a national health priority in Brunei Darussalam. There is a paucity of data on
the characteristics and treatment outcomes of diabetic foot ulcers. The Brunei Diabetic Foot
Registry will identify gaps in care for service improvements for management of the diabetic
foot and define research priorities as one of the strategic objectives of the Ministry of Health
in Brunei Darussalam.
References:
1. International Diabetes Federation: Diabetes Atlas Fourth Edition 2009.
Acknowledgement:
We would like to thank the Podiatry team, the Ministry of Health and the Brunei Government
for their support during the course of the study.
www.diabeticfoot.nl
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P14.05
The National Diabetes Footcare Audit of England and Wales
William Jeffcoate, Nottingham University Hospitals Trust, Nottingham, United Kingdom
Naomi Holman, Public Health England, York, United Kingdom
Louise Dunn, Health and Social Care Information Centre, Leeds, United Kingdom
Bob Young, Salford Royal Hospital NHS Foundation Trust, Salford, United Kingdom
Aim: In a drive to eliminate variation in foot care outcome an ongoing National Diabetes
Footcare Audit (NDFA) was established England and Wales in July 2014. The audit is a
subsection of the National Diabetes Audit which is a government-funded quality
measurement system for diabetes care in England and Wales, held on a secure central
database.,
Methods: The footcare module requires clinicians providing specialist care for diabetic foot
ulcers to register online (with consent) every new referral and to record just two items of
clinical detail: 1. the time elapsed between first assessment of the ulcer by any health care
professional and assessment in the specialist service and 2. the type and severity of the
ulcer using the SINBAD scale/score The NHS number identifier allows foot care details to be
linked to the core NDA (demographics, diabetes characteristics and cardiovascular risk
factors), as well as the national databases of hospital admissions (admission reason,
amputation, duration) and death registrations., Clinical carers are also asked to record at 12
weeks and at 24 weeks after presentation to their service a single detail of outcome: whether
the person is alive and free from any active foot ulcer., A parallel audit requires care
managers to answer each year three Yes/No questions relating the structure of services in
the locality – provision of routine screening, the management of people with increased foot
risk and the existence of care pathways for new ulcers.
Results: Over 60 centres have commenced participation in 2014. An earlier pilot study
demonstrated how the data included can generate a Standardised Healing Ratio permitting
valid comparisons of units and localities.
Conclusions: The case-mix adjusted measurements from this new audit will expose
variations in outcome for people with newly occurring ulcers and permit identification of the
most successful systems of care. This is being achieved while reducing to an absolute
minimum the additional recording burden on clinical staff.
www.diabeticfoot.nl
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P14.08
Can two years of dutiful registration of diabetic foot patients tell us something about
the quality of care?
Barbara den Boogert, Reinier de Graaf hospital, Rotterdam, Netherlands
In 3% of the patients with diabetes, a foot ulcer occurs. Sooner of later 15% of these patients
have an amputation of (a part of) the foot or lower leg. In, the occurrence of a diabetic foot
wound many factors play a role. Estimation of the degree of tissue perfusion is essential;
healing will not occur in severe ischemia, moderate ischemia is associated with delayed
wound healing and a poorer prognosis in infection. Therefore a systematic study is important
and will be the guideline for treatment.
A nation wide classification system on identical aspects is needed. Then hospitals in the
Netherlands compare patients with diabetic foot ulcer and improve the quality of care locally.
On, national level health care associations are enabled to identify early quality problems and
can act on improvement. Unambiguous classification is a presupposition, for a successful
national registration and for further use of indicators.
There are three systems of classification. The Wagner classification the PEDIS and the
Texas. In Dutch hospitals diabetic feet are registered according to the Texas classification
for two years already.
In the Reinier de Graaf Hospital we have a multi disciplinary outpatient foot clinic. In my
presentation, I will discuss why the inspection of health care has chosen the Texas quality
indicator. Then I will appoint the number of patients of the last two years accompanied by the
results and the healing tendency.
Therefore I will use the following, questions:
1. can we say anything about the outcome of these measurements?
2. has this classification system predictable value in our current practice?
3. can two years of dutiful registration of diabetic foot patients tell us something about the
quality of care?
www.diabeticfoot.nl
Page 6 of 8
P14.09
Utilizing a team approach for limb salvage by combining vascular intervention and
proper podiatric surgical planning: a case report
Cherreen Tawancy, MedStar Washington Hospital Center, Washington DC, United States
Tiffany Hoh, MedStar Washington Hospital Center, Washington DC, United States
Virit Butani, MedStar Washington Hospital Center, Washington DC, United States
Katherine Raspovic, MedStar Washington Hospital Center, Washington DC, United States
John Steinberg, MedStar Washington Hospital Center, Washington DC, United States
Aim: Dry gangrene of the lower extremity is commonly encountered in patients with diabetes
and peripheral vascular disease; this can lead to loss of limb or life if not properly managed.
We present a case of dry gangrene of the lower extremity that initially would have received a
below the knee amputation. However, a Chopart amputation was successfully performed
and healed after appropriate revascularization.,
Methods: An 86 year-old male with coronary artery disease, diabetes, hypertension,
peripheral vascular disease, and end stage renal disease was hospitalized for dyspnea and
incidentally found to have dry gangrene to the right second digit. He was afebrile but had a
leukocytosis of 19 300. Clinically the digit appeared necrotic with erythema and edema
extending over the second ray. The patient underwent revascularization with subsequent
surgical debridement and an ultimate transmetatarsal amputation. Less than a month after
discharge, the patient was readmitted for wound dehiscence of the amputation site with
extensive necrosis. He underwent additional surgical debridements with an ultimate Chopart
amputation, which, after undergoing additional vascular intervention, went on to heal.
Results: At two months post-op he had only a small, superficial wound to the lateral aspect
of the surgical site with no signs of necrosis that healed uneventfully with local wound care.
This case illustrates the effects that surgical debridement and vascular intervention can have
on healing a limb that may have otherwise been fated for a higher-level amputation.
Conclusion: When encountering a patient with dry gangrene it is important to take a team
approach. The vascular surgeon plays a critical role in examining arterial supply and
ensuring adequate blood flow to the extremity. The podiatric surgeon must provide
appropriate wound care with surgical debridement as necessary with the goal of limb
salvage. With the appropriate revascularization, surgical debridement, and wound care the
diabetic gangrenous limb can be salvaged.
www.diabeticfoot.nl
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P14.10
Multidisciplinary team approach ( plastic surgery & podiatry) in the treatment of a
diabetic neuropathic foot ulcer
Eduardo Simon Perez, Hospital Recoletas Campo Grande, Valladolid, Spain
Jose Ignacio Rodriguez Mateos, Hospital Universitario Rio Hortega, Valladolid, Spain
Luke Cicchinelli, East Valley Foot & Ankle Specialist, Phoenix, AZ, United States
Introduction: The diabetic foot is one of the chronic complications of diabetes that imposes
a large social and economic burden. Each year, worldwide, 4 million diabetics develop foot
ulcerations. Spain being the 2nd most prevelant country, in regards to lower extremity
amputations due to type 2 Diabetes.
Material and Methods: 67 year old type 2 diabetic, patient of 14 years evolution under
treatment with oral hypoglycemics. Diabetic polynueropathy, palpable dorsalis pedís and
posterior tibial pulse in both feet. ABI 0.8
Consult for 4 mtp joint ulcer of the right foot. Cellulitis extended to the dorsal foot from the
4th interspace with a deep necrotizing infection. Intravenous broad spectrum antibiotics were
administered and hospital admission. Patient underwent multiple debridements urgently until
the infection was controlled. The 4th toe was amputated and the dorsal wound was covered
with a skin graft and direct primary closure of the plantar wound.
10 months later the patient returned, with a transfer ulcer under the 3rd mtp joint. The probe
to bone test and xrays were consistent with osteomyelitis. Culture: multiresistant
Psuedemonas aerginosa. The patient was admitted to the hospital and administered
meropenem intravenously and underwent resection of the 3rd mtp joint. Offloading of the
ulcer with adhesive felt of 1.5 cm and the ulcer healed in 6 weeks. Custom made foot
orthoses and every 2 months followups in the podiatry clinic.
Conclusion: The improvement in quality of the treatment of diabetic patients is based on 3
pillars. Continuing education and interest by all health care professionals. Treatment within
inter and multidisciplinary settings. The formation and establishment of effective protocols for
Diabetic foot care.
www.diabeticfoot.nl
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