Preventive Foot Clinics

Sanjeev Kelkar

Why Preventive Foot Clinics?

• Need• Concept• Actualization• Experience• Learning

Preventive Foot Clinics

• Ulcer – gangrene – amputation – going on for long across the world and our country

• Energy and resources spent – huge• Treat as you can, send when it complicates• An Attitude for early detection when no co-

morbidities are present difficult to inculcate both among the HCPs and patients

• Treating an unborn future that does not get conceived

Diabetic Foot Statistics

• Estimated life time risk of diabetic foot - 15%• • 5-10% of all diabetic patients have or have had

foot ulceration of various degrees and about 1% have undergone amputation

• Diabetes accounts for up to 50% of non traumatic leg amputations*

• Of all the diabetic amputees about 50% will lose their life or their other leg by 3 years

Major Problem in India• Neuropathic ulcer ( 85--95 %), Eminently preventable• Patients are younger, • Mean age of amputation earlier, • Far too many amputations for neuropathic ulcer. • Neuropathy that is significant enough to cause foot

ulceration may affect 40% of diabetic population, especially elderly with type 2 diabetes.

• Upto 35% of all diabetic patients have asymptomatic neuropathy

• Diabetic Neuropathy affects 70% of the Diabetes patients –

The Compounded Problem

• Component causes leading to foot ulcers• Peripheral neuropathy : 78%• Minor trauma : 77%• Deformity : 63%• Edema : 37%• Peripheral ischemia : 35%• Callus : 30%• Infection : 01%

The Compounded Problem

• Contra-lateral amputation rate of 12 to 28% between 1 to 3 yrs

• Mortality - 16 to 38% :1 year• - 35 to 65% :3 year• - 75 to 80% : 5 year

Preventive Foot Clinics

Concept

Concept

• Assembly line operation• Multiport data entry• End to end solution• Skill transfers

CLINICAL EXAMINATION

1

2

3

1. Monofilament 2. Doppler

3. VPT

Overview

DIABETES EDUCATORS AT FOOT CLINIC

DIABETES EDUCATORS AT FOOT CLINIC

PREVENTIVE FOOT CARE, AID, KMCH, CHENNAI, INDIA

INDIVIDUAL COUNSELING

EDUCATOR’S COUNSELING THE PATIENTS

FOOT CARE - THE 10 COMMANDMENTS

THE 10 COMMANDMENTS OF FOOT CARE EXPLAINED BY NURSE EDUCATOR

Preventive Foot Clinics - Assets

• Enablers: Aware profession, available infrastructure within the country

• Need: People from the lower economic strata have much higher levels of complications across the board –

BUDS, CODI, NUDS,

Preventive Foot Clinics• Data entered online by three different

persons – baseline at the reception, clinical by the doctor, SW MF, VPT, HCP in VPT negative patients by trained techs,

• Doppler for PVD

Preventive Foot Clinics• Footwear inspection by a trained podiatrist,

advice given, • Second phase of preventive foot clinic – • Aims at establishing capacity to manufacture in

house foot wear, outsource it• The clinic charges for an extended period, not on

a visit to visit basis,• People pay –tariff low

Preventive Foot Clinics

These trained but non medical persons, they handle different jobs

eg baseline clinical data work at reception, help manage data entry etc.

• Understand the problems

Preventive Foot Clinics

• We can’t treat all, all along with the complications and all the works associated with it – let us face it

• But we can teach and prevent• The real solution is prevention prevention

and prevention

PREVENTIVE FOOT CARE CLINICDr. AMBEDKAR INSTITUTE OF DIABETESKILPAUK MEDICAL COLLEGE HOSPITAL

Summary Statistics

TOTAL NUMBER OF PATIENTS SCREENED : 6800 AS ON 14.7.2005

Number of patients examined : 6800

Number of patients with Foot problem : 5700

P. Neuropathy : 83.8%, PVD : 3.5 %,

Foot ulcers : 4.5% Preventive foot care education : All 6800Number of patients undergoing Minor / Major Amputations : 36

43

57

0

10

20

30

40

50

60

MALE FEMALE

MALE FEMALE

TOTAL SCREENED - n = 6800

%

FOOT EXAMINATION IN DIABETES

83.8

36.4

47.4

0102030405060708090

TOTAL MALE FEMALE

% OF MALES & FEMALES WITH FOOT PROBLEMSn = 6800

1) 16.2 % Did not have foot Problems2) Problems were more in Females

FOOT PROBLEMS AT SCREENING - AID KMCH - CHENNAI

0Ulcer

Amputation

GangreneCornClawtoesFissures

Calluses

Fung. Inf IngrownToe Nails

(n = 6800)%

of F

oot P

robl

ems

57.8

45.849.8

13.8

3.3 2.9 4.50.5 0.8

0

10

20

30

40

50

60

MONOFILAMENT EXAMINATION - n = 6800

60.5%

39.5%

0

10

20

30

40

50

60

70

P. Neuropathy in Diabetics - 1

NORMAL

ABNORMAL

% o

f pro

blem

s

Monafilament test is less reliable than VPT

16.2

83.8

24.531.8 27.5

0

20

40

60

80

100

Normal Total VPT+ve

Mild Moderate Severe

Normal Total VPT +ve Mild Moderate Severe(n = 6800)

P. Neuropathy in Diabetics - 2

Loss of VPT is more reliable test than MF

1.5

8.2

34.7

54.3

1.30

10

20

30

40

50

60

Non DM <5 6 to 15 16 to 25 >25

DURATION OF DM – WITH FOOT PROBLEMS(n = 6800)

Foot

pr o

blem

s %

Duration in Years

> 256 to 15< 5

More than 50% have foot problems at < 5 years

16-25

FOOT WEAR IN DIABETICS - n = 6800

41

20.816.7 15.9

3.81.8

05

1015202530354045

Hawai Plastic Others Bare FootedLeatherHawai MCR Plastic Others

Foot Problems are more with Hawai & Plastics even with MCR – Great Toes / Little Toes were outside the Foot Wear.

Foot

Wea

r %

34.7%

83.8%

3.5%

n = 6800

NEUROPATHY Vs VASCULAR PROBLEMS IN DIABETICS

NEUROPATHY

VPT MF DOPPLER AB INDEXVASCULAR

PVD is very minimal in this study

Action

• Evaluate the findings

• Pass the patient through an education session, put relevant educational material in vernacular in the hand

• Monitoring advised, • Revisit fixed, drugs prescribed

What Paul Brand Said - We did

• The single most important intervention to reduce amputation is to remove the footwear and see the feet of a diabetic

• Paul Brand as told to the Americans

Educate, educate and educate

Effect Of Patient Education On Amputation Rates

Knee & Above

12%

15%

5%

46%

35%

60%

Toe & Metatarsal

Below KneeNo Education

Education

University Hospital of Geneva 1979-1989. All comparisons p<0.001. Assal JP et al. Diabete Metab 1993.