DIABETIC FOOT CARE IN BRAZIL: ACHIEVEMENTS AND CHALLENGES Dr Hermelinda Pedrosa Director Department of the Diabetic Foot Brazilian Diabetes Society - PowerPoint PPT Presentation

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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 ?. Diabetes National Programme Implementation - 1988. Targets: Set up basic diabetes teams:

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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 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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1990’s: 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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Strategies:Save the Diabetic FootProjectimplementation


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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

  • 1990´s – 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 team:Without 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

37

Workshop attendees*

4.035

National Congress

Regional Seminars

21

National Congress, Regional Seminars attendees**

4.950

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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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 – Logo:a sensibization approach

Logo – Ministry of Health


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