Economic Burden of Diabetic Foot

1. Economic Burden of Diabetic Foot Dr Sanjeev Kelkar Head, Project Management Group Secretary DFSI October 2007 MSD Training Program Information of this presentation courtesy Dr Anil Kapur of WDF Denmark

2. Economic Burden of Diabetic Foot Even those patients with diabetes having ready access to health care and are provided with education on foot care, 9% develop foot infections in a two year follow up, (Lavery LA, et al, Risk factors for foot infections in persons with diabetes mellitus, Diabetes Care, 2006,; 29:1288-93) This is an English study

3. Chennai Bangalore Hyderabad Chennai Chennai Kudremukh Ramachandran A et al

4. Family History Risk of Diabetes 20 % 40 % 70 % - F/H/O Diabetes - One parent diabetic - One parent diabetic and other from a diabetic family Diabetes Mellitus- Genetics • Family history significant predictor of Diabetes V Mohan & KGMM Alberti International Textbook of Diabetes Mellitus,1992,178.

5. Symptoms All Type 1 Type 2 Tiredness / Fatigue 50.7% 46.5% 51.0% Excess Urination 43.3% 59.2% 42.4% Excess Thirst/Hunger 38.2 % 52.1% 37.4% Weight Loss 19.7% 34.4% 18.9% Nausea/ Abdom. Pain 18.0% 17.8% 16.5% Non Healing Wound 7.4% 7.4% 7.4% Others 2.1% 2.1% 2.1% Skin Infection 1.9% 3.2% 1.8% Heart Problems 1.3% 0.7% 1.3% Loss of Sensation 0.4% 0.4% 0.4% CODI Study Presenting Symptoms

6. Test All Type 1 Type 2 Urine 93.8% 97.9% 93.6% FBS 91.8% 94.7% 91.6% PPBS 93.2% 96.1% 93.0% OGTT 17.9% 19.1% 17.8% GHb 7.6% 18.4% 7.0% Serum Lipids 7.4% 9.9% 7.3% Kidney Function 11.1% 17.4% 10.8% X-rays 16.8% 24.5% 16.4% ECG 25.5% 38.3% 24.8% Others 3.3% 4.3% 3.3% BP Measurement 54.3% 51.8% 54.4% Foot Examination 7.5% 11.7% 7.2% CODI Study Lab Tests / Clinical Examination Since Diagnosis Eye Examination 35.1% 37.6% 35.0%

7. Types of Complications Number of Complications 39% 31% 10% 14% 7% 46% 3% 1% 30% Foot Eye MI Stroke ESRD Nil One Two Three+ DiabCare Asia India Late Complications • Does Not Include • Hypertension (27%) • Proteinuria (8%) • Elevated Creatinine (4%) • Lipid Abnormalities (54%)

8. CODE 2: Effect of complications on per patient costs 3.5 X 2.0 X 1.7 X None Microvascular Macrovascular Both Lucioni C et al. PharmacoEconomics- Italian Research Articles, 2000 2(1):1-21

9. Knee & Above 60% 5% Below Knee No Education 35% Education 15% Toe & Metatarsal 46% 12% Effect Of Patient Education On Amputation Rates University Hospital of Geneva 1979-1989. All comparisons p<0.001. Assal JP et al. Diabete Metab 1993.

13. Classification of Diabetic foot Wounds • Several available – none universally acceptable • Wagner – Meggitt six grade classification by depth of the ulcer and extent of gangrene • The University of Texas Classification grades wounds by the ulcer depth and then stages by presence of infection and ischemia

14. Classification of Diabetic foot Wounds • S(AD) grades wound in five categories depending upon the size which includes area and depth, in addition to the presence of sepsis, arteriopathy, and denervation • PEDIS by the International working group on the Diabetic Foot – grading on Perfusion, Extent, Depth, Infection and Sensation

15. Classification of Diabetic foot Wounds • The Infectious Diseases Society of America • Subdivides infected diabetic foot wounds in mild ie restricted involvement of skin and subcutaneous tissue moderate ie, more extensive or affecting deeper tissues severe ie,accompanied by systemic signs of infection or metabolic instability

16. Classification of Diabetic foot Wounds • Mike Edmonds – Ali Foster • Normal Foot • High risk foot • Ulcerated foot • Infected foot • Ischemic foot • Gangrenous foot

17. Classification of Diabetic foot Wounds • The purpose is as for all classifications • To be able to describe as closely as possible, to analyse such hopefully accurate descriptions of wounds in comparing results • Overlaps notwithstanding comparisons across studies may be difficult