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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
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
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
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
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
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
Setting up a foot team:Without a podiatrist – a remarkable barrier ?
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
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
Basic foot kit:simple and affordable • Tuning fork, hammer, cotton wool, pin, monofilament, ecodoppler • Goniometer (physiotherapy staff)
Neuropathic foot Foot exam: mandatory Ischaemic foot Neuroischaemic foot
Organization of care Targets: • Primary care integration • Referral and contra referral system Hospital Specialist interdisciplinary team Health Centre Family health programme
Sala Professor Andrew Boulton (new structure inauguration – 1999)
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
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)
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)
Insole provision: 1999-2004 Total = 5.141 Increase = 687.7%
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
Brazilian version* XIII Brazilian Congress of Diabetes Rio de Janeiro, October 10-14th, 2001 * 4.000 issues
Brazilian Diabetes Society Journal Diabetic Foot Forum* (*since 2001)
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
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
National Campaign – Logo:a sensibization approach Logo – Ministry of Health