OGANIZING MEDICAL CARE

FOR DFS PATIENT

Michael Knizhnik, Rabin M.C., Israel

Almaty

4 July 2014

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The Diabetic Foot Ulcer

• Ulceration due to neuropathy and

repetitive trauma, often complicated by

infection and ischemia.

• Host resolution impaired by

immunopathy and peripheral arterial

disease.

Diabetic Foot Ulcers

• 85% of amputations preceded by DFU.

• 25% of diabetics will develop DFU.

• 2.0-6.8% a year.

• 9-17% experience 2nd amp same year.

• 25-68% within 5 years.

• 5 yr mortality after amputation is 46%

Diabetic Foot Ulcers

• Accounts for 20% of the $174 Billion yearly expenditure on diabetic healthcare $34.8B.

• # of diabetic amputees in US expected to double by 2050.

• Post amputation status carries financial burden of cost of prostheses, mobility devices, and disability.

• Amputation reduces life expectancy.

Causes of Delayed Treatment

of DFU

• Patient unawareness/denial/fear.

• Primary physician not removing socks and shoes during checkups.

• Offloading shoes not widely prescribed.

• Underestimation of severity of infection.

• Lack of recognition of repairable arterial blockages.

•Mills et al: The Diabetic foot:Consequences of Delayed treatment and referral, Southern Med J 1991, 84:970-974l

DFU in Israel

• Estimate at least 500,000 Diabetics

• Another 500,000 undiagnosed

• # increasing with aging population

• 20% of population (7.6 M) >65

• 10% of these are diabetic, 4% DFU/year

• Estimate 6,000 DFU/year,2,500 Gush Dan.

Roots of the Problem:

• Delay in identifying the problem (patient and

physician).

• Time lost during fragmented, inappropriate

care, resulting in avoidable amputation.

• Inability of public system to match demands

of increasing prevalence of DFU.

Healing of DFU is a steep,

slippery slope

• Fragmented care evokes tale of

Sisyphus pushing a rock up a hill

repeatedly.

• Integrated “toe and flow” approach

reduces incidence of amputations, and

rescues Sisyphus.

• This will be done by establishing the

foot center in Tel Aviv. •Mills JI, Armstoring DG, Andros G:Rescuing Sisyphus:The team approach to amputation prevention:J Vasc Surg 2010;52:1S-2S

TEAM WORK

interventional radiologist

vascular surgeon

orthopaedist

podiatr cardiologist

endocrinologist

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plastic surgeon

The “Toe and Flow” Concept

of the Diabetic Foot Team

Diabetic Foot Center of Tel

Aviv

• DCTA will be a comprehensive multispecialty center of

excellence providing prompt, protocol based preventive

care and treatment for the Diabetic Foot.

• Endocrinology, Infectious Disease, Podiatry, Orthopedics,

Endovascular and Vascular Surgery, Plastic Surgery,

Dietician, Exercise Physiologist, Diabetic nurse/educator,

psychologist.

• Cardiologist, Nephrologist and Opthamologist will be

available for consultation

The Stairway to Amputation

The S Curve for Likelihood of

Healing

Approach of DCTA-1

• Initial evaluation by diabetologist and

podiatrist to include staging/control of DM,

assessment of feet for evidence of

neuropathy, ischemia and infection.

• Referral to appropriate specialist who will

see patient within 24-48 hours.

• Strict flow sheet protocol to be followed.

Approach of DFCTA-2

• Primary physician will receive copies of

consultations, lab results and treatments.

• Regular meetings will be held to discuss

problematic patients, consider changes to

protocol, and discuss potential new

treatments.

• DCTA intends to actively publish.

Role of the Diabetologist

• Conductor of the orchestra.

• Initial evaluation of the patient.

• Responsible for subsequent triage to other

specialists.

• Optimize glucose control.

Role of Infectious Disease

Specialist

• Provide appropriate antimicrobial therapy.

• Confirm adequacy of resolution of infection.

• Assess need for PICC placement for IV antibiotics, which will be done within 24-48 hr notice.

• Assist in identifying borderline patients requiring immediate surgery.

Role of the Podiatrist

• Manage off loading in the center

• Primary provider for wound healing

treatments performed in center.

• Manager of preventive care.

• Off site surgery when indicated.

Off Loading

• Simple first step in healing/preventing

ulcer.

• Not widely used in Israel.

• Can be done in the center during initial

visit to podiatrist.

• Together with debridement, often all

that is needed.

Podiatric/Orthopedic Methods

for wound healing

• Debridement

• Non surgical interventions (ozone

therapy, soft laser, wound

vacuum,artificial skin,etc).

• Surgical off loading.

• Foot sparing amputation.

Diabetic “small vessel

disease” • Misconception of an angiopathy distal to the

palpable pedal pulse which is therefore not

amenable to revascularization.

• Based on single amputation study done in

1959 which has been refuted.

• In fact small vessels of the foot often spared in

diabetics, and the clinically relevent changes

occur at the macroarterial level.

Role of Endovascular Specialist

• Interpret non invasive studies performed in center.

• Interpret CTA, MRA performed elsewhere.

• Perform diagnostic angiography and endovascular repair.

• Liason with vascular surgeon when endovascular repair is not an option.

Advantages of Screening

• Occult PVD (ABI < 0.9) is an accepted

coronary disease equivalent marker.

• Elevated ABI in diabetics (>1.3) is also

associated with decreased long term survival.

• Early detection can increase survival by

signalling need for risk factor control and

coronary and cerebrovascular screening.

Endovascular Therapy

• Advanced techniques such as atherectomy

and drug eluting balloon angioplasty allow

for treatment of long calcified tibial lesions,

as well as popliteal disease at the knee joint,

which is a “no stent zone”.

Distal Bypass

• Although less durable and more time

consuming than aortofemoral and popliteal

bypass, the grafts usually remain open long

enough to heal the ulcer, after which graft

surveillance and secondary endovascular

interventions can be performed, along with

aggressive preventive care.

Role of Exercise Physiologist

• Work in concert with the endocrinologist, at the very first stage of referral.

• Prescribe and monitor individualized exercise protocol designed to improve exercise capacity, reduce cardiovascular risk profile, and improve quality of life.

• Explain to patient the importance of the above, in order to increase motivation and compliance.

Concept of Business Plan

• Concept is for global fee (monthly or per DFU).

• This will cover all services provided at the center.

• Procedures/surgeries performed outside will not be included.

• Viability of this concept will be assessed by business plan, once we have the data for a proforma.

Benefits to Patient

• Faster assessment of wound care

healing status

• Faster access to multispecialist care

under one roof.

• Foundation for lifetime surveillance.

Benefits for

Partnering/Contracting Insurers

• Link to team of specialists to effectively manage pts with complex comorbidities.

• Leadership role in information dissemination, enhance identity as a leader.

• Savings on hospitalization costs.

• Patient satisfaction. Attraction to join kupa.

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