A Global Perspective of the Diabetic Foot andwhere we have come

from

Dr. Kristien Van AckerPresident D-Foot International

www.d.foot.org

Feels like Dinosaurus

My own grandmother

v

v

agenda� Forgotten Complication

� Diabetes Care over the years

� Change in Medicine as such

� Change of clinical presentation of Foot Syndrome

� Change of “concepts”

� Global change

� Health economics

� Guidance and Implementation

30 years ago

Forgotten Complication

� Publication New England

Diabetes today on a global level

IDF atlas 2016

Diabetes Care over the years� Injections: syringes were made in glass and had to

be boiled for re-use

� no HBA1c, no microalbumuria, …

� DCCT

� UKPDS

� Diabetes is a cardiovascular disease

� Pumps, CGM, modern inulines, more Oral Antiabetics ( flexibility, individualised treatment,…)

Diabetes Care over the years� Joslin:

� Once insuline treatment was available , it was clear that the ptoblem was not saved…

� We had to deal with complications� First DF Clinic ever:

� “wandering nurses,” the forerunners of today’sdiabetes nurse educators, visited patients throughoutNew England, sometimes living with a family forseveral weeks

Change in Medicine as such� From clinical exam >to high technical approach

Clinical exam in competition

Change of clinical presentation of Foot Syndrome

� From neuropathic to neuro-ischaemic ulcer

Co- morbidity…..

Change of “concepts”� From amputation to limb salvage DF care and

surgery

Limb salvage approach

wound assessment

TIVITA®

Innovative diagnostics in wound medicine

3rd Winner„Most Innovative Product“Innovation award

Winner 2017

© Diaspective Vision GmbH | www.diaspective-vision.com

Imaging TissueOximetry

Hyperspectral ImagingTIVITA®Spectroscopy

TIVITA® - Technology

© Diaspective Vision GmbH | www.diaspective-vision.com

„Establish Hyperspectral Imaging in medicine as standard diagnostics for physiological monitoring”

X-Ray Ultrasound MRI PET/CT HSI

Change of “concepts”� Multidisciplinary DF clinics

Change of “concepts”� Multidisciplinary DF clinics

� Accreditation & benchmarking

Karel Bakker, Chairman IWGDF

Karel Bakker, Chairman IWGDFDMRR journal in november 2015

Change of “concepts”� Integrated care

� Pre- ulcer phase > ulcer-phase > post-ulcer phase

Foot ProtectionTeam

GP practices

In-patient service

Community Nurses

Multidisciplinary foot care team

Integrated care

SkillsKnowledgeRespectCo-operationCommunicationAwareness Neil Baker slide

Change of “concepts”� Diabetes related foot disease & cancer model

� Remission instead of healing & survival

NEJM, 2018

Diabetic foot: cancer and cancer-model

Armstrong DG et al. International Wound Journal 2007; 4 (4): 286-7

NO reason to be CINDERELLA….

Diabetic foot: cancer and cancer-model

Even when an ulcer is successfully healed, risk for recurrence is high,

with reported rates between 30 and 40% within the first year

Chile 2014

Global change� From 1st meeting for DF disease in Malvern

Global change� From 1st meeting for DF disease in Malvern

� First Diabetic Foot Sudy Group: DFSG Barcelona 1998

Global change� From 1st meeting for DF disease in Malvern

� > to meetings all over the world

The picture can't be displayed.

Health economics & quality of life

The Cost of Treating Diabetic Foot Ulcers in 5 Different Countries

Cavanagh P, Attinger C, Abbas Z, Bal A, Rojas N, Xu ZR. Cost of treating diabetic foot ulcers in five different countries. Diabetes Metab Res Rev. 2012 Feb; 28 Suppl 1:107-11.

Peter Cavanagh, Christopher Attinger, Zulfiqarali Abbas,

Arun Bal, Nina Rojas, and Zhangrong Xu

The locations and the co-authors

Dr. Chris AttingerWashington DC, USA

Dr. Arun BalMumbai, India

Dr. Zulfiqarali AbbasDar es Salam, Tanzania

Dr Zhang-Rong XuBeijing, China

Dr. Nina RojasChile

GDP Per Capita in International $

World Rank Country GDP per capita

9 US Int$47,244

49 Chile Int$16,659

94 PRC Int$8,268

138 India Int$3,419

167 Tanzania Int$1,481

http://siteresources.worldbank.org /

Think of this quantity as an index of the annual ability to pay for treatment

Case: Urban Treatment Costs in Int$

0

40,000

80,000

120,000

160,000

200,000

Chile China India Tanzania USA

10,43421,372 19,599

3,060

188,645

CASE: Patient’s Financial Burden in Urban ClinicExpressed as Months of Income*

*Calculated as 12* (Patient co-pay in Int$/per capita PPP-adjusted GDP)

0

20

40

60

80

Chile China IndiaTanzania USA

3.0 3.1

68.8

24.8

9.6

Mon

ths

Calculated as 12* (Patient co-pay in Int$/per capita PPP-adjusted GDP)

* Based in a prevalence of 7.12 million with diabetes

Type 2 prevalence 7.12 million

Ulcers 6,8% - 484.569

Hospital admissions 35% - 169.569

Amputations - Maior- Menor

44,2% - 35.75155,8% - 45.133

Death 12,8% - 21.705

Diabetic foot in Brazil: hypotheticalscenario

Rezende KF, Ferraz MB, Malerbi DA, Melo NH, Nunes MP, Pedrosa HC, Chacra AR. Direct costs and outcomes for inpatients with diabetes mellitus and foot ulcers in a developing country:

The experience of the public health system of Brazil. Diabetes Metabol Syndrome: Clinical Res Rev 3 (2009); 228-232

DF - Estimated costs in Brazil(for a hypothetical cohort of 7.12

million of Type 2 DM)

Rezende KF, Ferraz MB, Malerbi DA, Melo NH, Nunes MP, Pedrosa HC, Chacra AR. Predicted Annual Costs for Inpatients with Diabetes and Foot Ulcers in a Developing Country – a

Simulation of the Current Situation in Brazil. Arq Bras Endocrinol Metab 2008; 52: 523-530.

•US$ = 1.64 real ( Aug 2008) •US$ = 2.00 real (Mar 2013)•US$ = 2.40 real (Oct 2014)

Annual cost (hospital admission)

US$ 461 million

Annual cost(amputation)

US$ 222.3 million

Pedrosa HC , Novaes C, Leme LAP, Boulton AJM. International Diabetes Monitor 16; 11-17, 2002

60 DF outpatients clinics

Brazilian Save theDiabetic Foot Project:Situation of DF outpatientsclinics

§Needs to be updated§ Lack of support: discontinuation

of many services

World Bank and WHO: Analysis for Cost-Effectiveness

Foot care:

§ Patient education

§ Provision of proper footwear

§ Multidisciplinary clinics

Venkat NKM, Zhang P, Kanaya AM et al. Diabetes: the pandemic and potential solutions.In: Disease Control Priorities in Developing Countries (2nd ed), Jaminson, Breman Measham (eds).

World Bank-Oxford University Press, NY, 2006;591-604

Cost saving in all developing countries

80% of Diab Patients in Low and Middle Incomeregions

Guidance and Implementation

� Forgotten Complication

� Diabetes Care over the years

� Change in Medicine as such

� Change of clinical presentation of Foot Syndrome

� Change of “ concepts”

� Global change

� Health economics

� Guidance and Implementation

EWMA

Basic publication: Supplement to DMMR

120.000 copies

1999 2015

26 translations

55

South Korea, Russia, Bosnia Herzegovina, Iran, Turkey. Republic of China, Japan?

Portugal, Kuwait and Germany, The Netherlands are busy working on the translation

? copies

Why more guidance?-Rob Hinchcliff in Almelo

8 X variation incidence amputation DM

Organisation/ acces care

Variations in clinical practice

Step-by-Step� Pilot programmes in India (2004) and Tanzania (2004);

� Goals: to improve educational skills and the management of diabetic foot problems ® cascade effect and sustainability in the region/country

� An experienced national and international faculty is responsible for teaching and for the practical sessions.

� Teams: a doctor and a nurse or paramedic

An initiative of the IWGDF/IDF CS and the WDFKickoff meeting Step by Step, 2003 with

Sharad Pendsey and Abbas

Dr. Z. G. Abbas

Train the Foot trainer course South- and Central America,Brasil, December 2012

13 countries: Argentina, Bolivia, Brazil, Chile, Colombia, Cuba, Dominicana, Ecuador, Mexico, Panama, Paraguay, Peru and

Uruguay

3135 healthcare professionals have been trained in 15Latin American countries2012-2015

3,135 TYPE OF MEDICAL SPECIALISTS AND NURSES TRAINED IN THE SACA

REGION 2012 - 2015

Diabeto's

Endo's

Internal Med

Gp's

Genral Surg

Vasc Surg

Orthop Surg

Nurses

248

532

205

913

96

44

35

973

Conclusion� No Forgotten Complication anymore

� More complex medical world and diabetes care

� Change of clinical presentation of Foot Syndrome

� Change of “concepts” and organisation of DF-care

� Many DFSG’s and DF meetings

� Health economics and Quality of life- still a lot to do

� Guidance but Implementation TODAY

Global Conclusions� “How can we reduce morbidity and mortality from

diabetic foot disease?”

� The answer to this key question might not be toodifficult, Dr. Boulton said.

Global Conclusions� “When Paul Brand was asked to make a

recommendation to a US Department of Health conference on reducing amputations in diabetes, most listeners were probably expecting an answerpromoting vascular surgery or modern medications,”

Global Conclusions� “They were surprised to hear that his key

recommendation was a national campaign toencourage health care professionals to removepatients shoes and socks and examine the feet.

� Unfortuntately this simple advice is ignored in manycountries.”