"The Burden of Diabetes in Underserved Populations."

Ace Anglin, M.S., DPMChief of Podiatric Medicine & Surgery

Health Services Incorporated

OBJECTIVESExplain the Burden of DiabetesI. Discuss how patient and caregiver can teach

Self Management of the Diabetic Foot.II. Explain the Podiatrist Role as a Diabetic

EducatorIII. Remove the Barriers that prevent patients

from being “Compliant” with Treatment.IV. Identify Feet “At-Risk” for Amputation

The Burden of Diabetes

My current practice with the underserved includes educating elderly, diabetics with Medicare about the Burden of Diabetes

“Burden of Diabetes”

Health Services Incorporated Montgomery, ALBernell Mapp, CEO Julian McIntyre, MD Medical Director

Nonprofit AL FQHC with 10 Health Centers.Provides for over 30,000 residents Montgomery County.

• 3,000 Diabetics (10% Diabetic)

• Annual Visit 90,000.

• African American (52.5%)

• Caucasians (45%)

• Latino’s (1.4%)

• Asians (1.2%)

• Native Americans 0.9%

• Sliding scale Patient fees discount for services.

Burden of Diabetes, U.S.20.8 million has Diabetes (ADA)

• 130,000 amputations a year (1/30 Sec) 67% due Diabetes

• 50% Amputation unnecessary (CDC)

• 50% Amputees undergo second amputation.

• 50% Amputees Die 2-5 years After Amputation.

• Diabetes costs this country $85 billion a year in total health care expenditures.

The Burden of Diabetes in Alabama:

• AL, had the highest rate

• Diabetes (JAMA, 03).

• 10.5% have Diabetes

•

•Comparison AL to CA:Population CA = 36 MillionPopulation AL = 4.5 Million2 Million Diabetics CA639,000 Diabetics AL

Explain the Podiatrist’s role in diabetic education? Teaching & Performing Foot Examinations!

Podiatrist Main role in diabetic education must center on amputation prevention

just as the Ophthalmologist role must be prevention of blindness.

Partnerships which are beneficial to the diabetic underserved population?

Lower Extremity Amputation Prevention (LEAP)

• Patient Education Self-management skills is the second component of the LEAP Program.

• Once patients are taught simple self-management techniques, they assumes personal responsibility and becomes a full partner with the health care team in preventing foot problems.

Describe self-management programs. Lower Extremity Amputation Prevention (LEAP)

Provider refer all diabetics for Comprehensive foot exam Comprehensive exam include Vascular, Dermatological,

Biomechanical & Neurological Testing all Diabetics Neurological testing all diabetics to determine risk level Foot exam every 2-3 months (High risk patients) Foot exam every 6-12 months (Low risk patients) Extra Depth Shoes all Low risk patients Custom Mold shoes or Extra depth Shoes High risk patient Patient education on amputation prevention all Diabetics Debridement of Fungal nails and/or Callous

Effectiveness of LEAP:Louisana State Univ. Health Sciences Center 3/98

I. Reduction in foot-related ulcer days 49%

II. Reduction in hospitalizations 89%

III. Reduction in emergency room visits 81%

IV. Reduction in antibiotic prescriptions 57%

V. Reduction in foot operations 87%

VI. Reduction lower-extremity amputations 79%

VII.Reduction in Missed workdays 70%

CONCLUSIONS of LSU Cohort Study:

Large reduction in foot related Complications after first year of comprehensive preventive foot care.

Diabetes Care 23:1339–1342, 2000

What Makes People really make a change in their lifestyle to control their disease? Pain!!

What stops them from changing? Neuropathy!!

Pain!!1. Painlessness Make Diabetes

Destructive!

2. Diabetics will walk 10 miles without changing Strides.

3. Diabetics Do not Limp!

4. Diabetics wear Shoes Too Tight!!

• “Understanding the Gift of Pain”

Amputation Risk: 1. Patients with Absent

pedal pulses

1. Patients with Foot deformity

2. Patients with Prior amputation

3. Patients with Loss of protective sensation (LOPS)

4. Elderly Diabetics

Sensory ExamSemmes-Weinstein monofilament

Free monofilaments

www.bphc.hrsa.dhhs.gov/leap/

How open are elderly diabetics to receiving information about making life style changes? For Example Diabetic Shoes.

What’s the compliance rate for patients wearing say… Diabetic Shoes as opposed to regular walking shoes?

Compliance rate for patients wearing diabetic shoes are low. Recurrence of diabetic foot ulcers, even in specialty foot

clinics, is often very high, ranging from 25 to 80% per year.

• Specialty diabetic foot clinics have been shown to reduce the incidence of ulceration and amputation in high-risk patients.

• Often these foot clinics provide protective shoes and insoles, foot-specific education, and advanced clinical care. These clinics usually deliver services that are well above the local community standard

The Burden of Diabetes

Black

5

Age-adjusted rate per 1,000

10

15

Obj. 5-10

I = 95% confidence interval. *Age adjusted to the 2000 standard population. †Age-specific rates are not age-adjusted. NOTE: Includes any amputation of lower limb. For NHDS data prior to 2000, only one race category was recorded; reporting more than one race was not an option. For NHIS data prior to 1999, respondents reported one or more races and identified one race as best representing their race. Respondents were asked to select one or more races starting in 1999 (NHIS) or 2000 (NHDS), although more than one race selection was not used for 1999 NHIS data in order to be consistent with 1997-1998 data. Data for the single race categories shown are for persons who reported only one racial group. SOURCE: National Hospital Discharge Survey (NHDS) and National Health Interview Survey (NHIS), CDC, NCHS.

Race*

0White Female Male <65 65-74

Age†

1997-99

Total* 75+

2001-0320

Decrease desired

Lower Extremity Amputations Among Persons With Diabetes

2010 Target: 2.9

Gender*

Barriers for Underserved Obtaining Diabetic (Extra Depth Shoes)

1.Treadsafe (Wal-Mart) 2.Tom McCann (K-Mart)Medicare Therapeutic Shoe Bill, May 1993

Success stories on educating diabetics, especially

elderly diabetes from underserved populations? • EXTRA!! EXTRA!!

November is National Diabetes Month

Come Get Your Free Foot Exam!!

Success stories on educating diabetics, especially

elderly diabetes from underserved populations? FACT:

55% of diabetic amputations occur in patients older than 65 years of age.

EXTRA!! EXTRA!!

August is National Foot Health Month

Come Get Your Free Foot Exam!!

Success stories on educating underserved elderly diabetics populations? The publication of the first self management book on diabetic foot care

and amputation prevention. www.savingthediabeticfoot.com

www.amazon.com

Advice on Diabetic Self-Management

10 Steps to Healthy Feet • Step #1. Have your doctor check your feet regularly.

• Step #2. Wear the right shoes and socks. Never go barefoot.

• Step #3. Check your feet every day.

• Step #4. Treat cuts, scrapes and blisters. See your doctor if a wound does not heal.

• Step #6. Cut your toenails correctly. See a Podiatrist if your nails are too thick or ingrown.

• Step #7. Treat athlete's foot.

• Step #8. Get proper treatment for calluses and corns.

• Step #9. Avoid heating pads and hot water foot soaks.

• Step #10. Take action to improve your circulation.

• High blood pressure, high cholesterol levels and smoking can harm the circulation in your feet and keep sores from healing. Ask your doctor for help

if you have any of these problems.

Advice on Diabetic Self Management? The Burden of Diabetes in Underserved Populations

“Self-management is the cornerstone of diabetes

treatment. Unfortunately, persons with diabetes are not equipped to deal with the long

term self-management requirements of diabetes”.

Alabama Behavioral Risk Factor

Surveillance System Data

Multidisciplinary Approach (Team Approach)Paul Brand, MD

“A Man’s Got to Know His Limitations”Clint Eastwood

• Patient• Family• Internal Medicine• Nurse, Social Worker• Cardiology/ Nephrology• Endocrinologist• Infectious Disease• Orthopedic Surgeon • Podiatric Surgeon

• Home Health Worker

• Community Organization

• Vascular Surgeon

• Wound Care Specialist

• Nutritionist

• Pedorthist

• PT/ OT

• Family Medicine

Advice on Diabetic Self Management? The Burden of Diabetes in Underserved Populations

“The challenge to any Disciplines

caring for the Diabetic Foot is that there can be no turf wars, recognizing

instead strengths to achieve success”

Gary Gibbons, MD

Harvard Medical School

Burden of Diabetes:

Let the Strong Bear the Infirmities of the Weak Romans 15:1