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Diabetic foot care in China: challenges and strategy
Comment
Diabetic foot care in China: challenges and strategy The known prevalence of diabetes in China has increased rapidly in the past few decades, from 0·67% in 1980 to 9·7% in 2008. In China, about 92 million people have diabetes and 145 million people have prediabetes.1 Among people with diabetes, diabetic foot disease is becoming a serious burden, which not only affects patients’ quality of life, but also poses a major challenge to the Chinese health-care system. Unfortunately, national epidemiological data for diabetic foot ulcers and amputation in China are not available, so we refer to survey data from tertiary hospitals in this Comment. In 1998, results from a multicentre epidemiological study of inpatients with chronic wounds in China suggested that the leading cause of chronic cutaneous wounds was trauma (67%), with diabetic foot ulcers a fairly uncommon cause (<5%).2 In a similar study done a decade later, diabetic foot ulcers had become the leading cause of chronic cutaneous wounds, implicated in 32·6% of cases, with trauma and burns causing 23·8% of cases.3 This is not only because prevalence of diabetic foot uclcer has drastically increased, but also because patients with diabetes live much longer with more intensive and comprehensive treatment, and diabetic foot ulcers are more common in elderly patients. Additionally, burn prevalence is now much lower in China, and diabetic foot ulcers receive more attention because foot care and protection have been promoted nationwide for the past two decades. Diabetic foot disease is the leading cause of lowerextremity amputation in patients with diabetes worldwide.4 Most diabetic foot ulcers in China are neuroischaemic; purely neuropathic ulcers or ulcers complicating Charcot foot deformity are uncommon.5,6 Based on survey data from 2010,7 27·3% of amputations in tertiary hospitals were in patients being treated for diabetic foot disease—this proportion increases to 56·5% when emergency amputations, such as those caused by traffic accidents, are excluded. The average direct medical cost for hospital care of patients with diabetic foot disease in China in 2004 was about US$1850 per person,5 which is about twice as high as the medical cost for patients admitted to hospital with other complications of diabetes in both China and the USA.8 By 2012, this cost had increased to $2685 per person.6 www.thelancet.com/diabetes-endocrinology Vol 4 April 2016
Data suggest a geographical divide in the prevalence of diabetic foot disease, which is more severe and more common in north China than in south China, with a higher proportion of patients undergoing amputations in the north than in the south (9·5% vs 2·8%).9 Patients with diabetic foot disease in the north have a higher risk of overt macrovascular and microvascular disease than do those in the south.9 The lower income and education level, coupled with more prevalent and heavier smoking, colder weather, and less exercise in the north than in the south might partly account for these differences.10 Nearly 40% of patients with diabetes in China who have had an amputation (including minor and major amputations) die within 5 years of the procedure;11 this statistic is similar to, or lower than, estimates for some European and North American countries, although 5-year mortality of patients with diabetic foot ulcers varied greatly across studies; cardiovascular disease was the leading cause of death for these patients.4 As in many other countries in Asia and elsewhere, neither professional podiatrist colleges nor podiatry hospital departments exist in China. Similarly, no onestop clinics exist for patients with diabetic foot ulcers. Patients are seen by doctors from various departments, including diabetes, orthopaedics, vascular medicine, plastic surgery, and dermatology. The therapeutic results can vary widely because of lack of knowledge, poor availability of tools for effective debridement, off-loading tissue repair, and peripheral artery intervention in different departments, and a dearth of multidisciplinary care. A multidisciplinary approach for diabetic foot disease has been established in very few tertiary hospitals in China. As part of this multidisciplinary care, surgeons are involved earlier in the disease process to ensure effective wound debridement and peripheral artery patency. Because of earlier surgical intervention, minor amputations (below the ankle) increased from 10·2% of patients with diabetic foot ulcer in 2004 to 17·2% of cases in 2012, whereas major amputations (above the ankle) decreased from 5·9% to 2·3% of cases in the same period.6 Another issue in China is late presentation. Some patients tragically lose the limb because they are 297
Comment
transferred to a multidisciplinary department too late. Fortunately, this state of affairs is improving; the average duration of foot ulcer in patients before admission to a tertiary hospital was 6 months in 2004, but only 1 month in 2012.6 Traditional beliefs and poor economic conditions in some regions can also impede treatment for patients with diabetic foot disease. Patients with mild diabetic foot ulcers might be self-treated at home or poorly managed in primary community health-care centres until severe infection or gangrene develops. Patients with toe gangrene and infection often refuse early minor amputation only for the disease to progress such that major amputation is needed. Finally, medical insurance policies in China are not appropriate for patients with diabetic foot disease, since they cover only short-term stays in hospital and do not cover the cost of therapeutic shoes and some dressings. Patients with diabetic foot disease tend to need longterm inpatient care, often including treatment for various other complications such as severe infection, peripheral artery disease, and kidney disease. Medical insurance coverage is low, and the proportion of costs covered differs in different parts of the country. Several programmes have been initiated to tackle the burden of diabetic foot disease in China. Since 2005, an annual national forum on diabetic foot disease and related disorders supported by the Chinese Diabetes Society has brought together more than 6000 Chinese and international professionals from various disciplines, including specialists in diabetes, orthopaedics, vascular medicine, and plastic surgery, in addition to burn specialists, radiologists, and nurses. The Chinese Tissue Repair Society has developed a 3-year training programme in wound care in China, sponsored by the World Diabetes Foundation and the Coloplast Access to Healthcare Foundation. The project focuses on training physicians and nurses in wound care for patients with diabetic foot ulcers and other chronic skin wounds. During the past 2 years, 915 physicians and 703 nurses from more than 200 hospitals in 21 provinces have been trained. About 1200 patients per month, on average, have benefited from this project. In total, 13 hospitals have become training bases to continue the education programme. Publications in China are also helping to educate a wider group of professionals than can be reached 298
through these courses. International guidelines are increasingly being translated into Chinese and distributed widely. Chinese guidelines and consensus documents have also been produced, based on international and Chinese experience. Additionally, the Chinese Diabetic Foot Group published a manual in 201412 for the standardised prevention, treatment, and management of diabetic foot disease. Diabetic foot disease is difficult to treat, but it is preventable and can be cured if diagnosed early and treated in time. The Chinese Diabetic Foot Group will intensify its cooperation with international organisations and Chinese societies such as The Chinese Tissue Repair Society to develop national and regional databases, further train doctors and nurses, and promote the standardised prevention, diagnosis, and treatment of diabetic foot disease across the various levels of the Chinese health-care system. *Zhangrong Xu, Xingwu Ran Diabetes Centre, The 306th Hospital of PLA, Beijing 10010, China (ZX); and Endocrinology Department, Southwest Hospital of Sichuan University, Chengdu, China (XR) [email protected] ZX is the honorary chairman and XR is the chairman of the Chinese Diabetic Foot Group. 1
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Yang W, Lu J, Weng J, et al, for the China National Diabetes and Metabolic Disorders Study Group. Prevalence of diabetes among men and women in China. N Eng J Med 2010; 362: 1090–101. Fu X, Sheng Z, Cherry GW, Li Q. Epidemiological study of chronic dermal ulcers in China. Wound Repair Regen 1998; 6: 21–27. Jiang Y, Huang S, Fu X, et al. Epidemiology of chronic cutaneous wounds in China. Wound Repair Regen 2011; 19: 181–88. Apelqvist J. Epidemiology of diabetic foot disease and etiology of ulceration. In: Hinchiliffe RJ, et al. eds. The Diabetic Foot. London: JP Medical, 2014: 3–9. Wang AH, Zhao S, Li Q, Xu ZR. A multicenter survey on the diabetic foot and medical economics in China. Chin J Endocrinol Metab 2005; 21: 496–99 (in Chinese). Ban Y, Ran X, Yang C, et al. Comparison of clinical characteristics and medical costs of patients with diabetic foot ulcer between 2004 and 2012 in China. Chin J Diabetes Mellitus 2014; 6: 499–503 (in Chinese). Wang A, Xu Z, Mu Y, Ji L. Clinical characteristics and medical costs in patients with diabetic amputation and nondiabetic patients with nonacute amputation in central urban hospitals in China. Int J Low Extrem Wounds 2014; 13: 17–21. Rice JB, Desai U, Cummings A KG, et al. Burden of diabetic foot ulcers for Medicare and private insurers. Diabetes Care 2014; 37: 651–58. Wang YZ, Wang AH, Zhao S, et al. The differences on the diabetic foot risk factors in the south and north of China. Zhonghua Yi Xue Za Zhi 2007; 87: 1817–20 (in Chinese). Yang GH, Li Q, Hsia J. Prevalence of smoking in China in 2010. N Enl J Med 2011; 365: 2649–70. Li X, Xiao T, Wang Y, et al. Incidence, risk factors for amputation among patients with diabetic foot ulcer in a Chinese tertiary hospital. Diabetic Res Clin Prac 2011; 93: 26–30. Xu Z, Ran X, eds. The standardized diagnosis and treatment on diabetic foot disease. Beijing: People’s Military Medical Press, 2014 (in Chinese).
www.thelancet.com/diabetes-endocrinology Vol 4 April 2016
Diabetic foot care in China: challenges and strategy The known prevalence of diabetes in China has increased rapidly in the past few decades, from 0·67% in 1980 to 9·7% in 2008. In China, about 92 million people have diabetes and 145 million people have prediabetes.1 Among people with diabetes, diabetic foot disease is becoming a serious burden, which not only affects patients’ quality of life, but also poses a major challenge to the Chinese health-care system. Unfortunately, national epidemiological data for diabetic foot ulcers and amputation in China are not available, so we refer to survey data from tertiary hospitals in this Comment. In 1998, results from a multicentre epidemiological study of inpatients with chronic wounds in China suggested that the leading cause of chronic cutaneous wounds was trauma (67%), with diabetic foot ulcers a fairly uncommon cause (<5%).2 In a similar study done a decade later, diabetic foot ulcers had become the leading cause of chronic cutaneous wounds, implicated in 32·6% of cases, with trauma and burns causing 23·8% of cases.3 This is not only because prevalence of diabetic foot uclcer has drastically increased, but also because patients with diabetes live much longer with more intensive and comprehensive treatment, and diabetic foot ulcers are more common in elderly patients. Additionally, burn prevalence is now much lower in China, and diabetic foot ulcers receive more attention because foot care and protection have been promoted nationwide for the past two decades. Diabetic foot disease is the leading cause of lowerextremity amputation in patients with diabetes worldwide.4 Most diabetic foot ulcers in China are neuroischaemic; purely neuropathic ulcers or ulcers complicating Charcot foot deformity are uncommon.5,6 Based on survey data from 2010,7 27·3% of amputations in tertiary hospitals were in patients being treated for diabetic foot disease—this proportion increases to 56·5% when emergency amputations, such as those caused by traffic accidents, are excluded. The average direct medical cost for hospital care of patients with diabetic foot disease in China in 2004 was about US$1850 per person,5 which is about twice as high as the medical cost for patients admitted to hospital with other complications of diabetes in both China and the USA.8 By 2012, this cost had increased to $2685 per person.6 www.thelancet.com/diabetes-endocrinology Vol 4 April 2016
Data suggest a geographical divide in the prevalence of diabetic foot disease, which is more severe and more common in north China than in south China, with a higher proportion of patients undergoing amputations in the north than in the south (9·5% vs 2·8%).9 Patients with diabetic foot disease in the north have a higher risk of overt macrovascular and microvascular disease than do those in the south.9 The lower income and education level, coupled with more prevalent and heavier smoking, colder weather, and less exercise in the north than in the south might partly account for these differences.10 Nearly 40% of patients with diabetes in China who have had an amputation (including minor and major amputations) die within 5 years of the procedure;11 this statistic is similar to, or lower than, estimates for some European and North American countries, although 5-year mortality of patients with diabetic foot ulcers varied greatly across studies; cardiovascular disease was the leading cause of death for these patients.4 As in many other countries in Asia and elsewhere, neither professional podiatrist colleges nor podiatry hospital departments exist in China. Similarly, no onestop clinics exist for patients with diabetic foot ulcers. Patients are seen by doctors from various departments, including diabetes, orthopaedics, vascular medicine, plastic surgery, and dermatology. The therapeutic results can vary widely because of lack of knowledge, poor availability of tools for effective debridement, off-loading tissue repair, and peripheral artery intervention in different departments, and a dearth of multidisciplinary care. A multidisciplinary approach for diabetic foot disease has been established in very few tertiary hospitals in China. As part of this multidisciplinary care, surgeons are involved earlier in the disease process to ensure effective wound debridement and peripheral artery patency. Because of earlier surgical intervention, minor amputations (below the ankle) increased from 10·2% of patients with diabetic foot ulcer in 2004 to 17·2% of cases in 2012, whereas major amputations (above the ankle) decreased from 5·9% to 2·3% of cases in the same period.6 Another issue in China is late presentation. Some patients tragically lose the limb because they are 297
Comment
transferred to a multidisciplinary department too late. Fortunately, this state of affairs is improving; the average duration of foot ulcer in patients before admission to a tertiary hospital was 6 months in 2004, but only 1 month in 2012.6 Traditional beliefs and poor economic conditions in some regions can also impede treatment for patients with diabetic foot disease. Patients with mild diabetic foot ulcers might be self-treated at home or poorly managed in primary community health-care centres until severe infection or gangrene develops. Patients with toe gangrene and infection often refuse early minor amputation only for the disease to progress such that major amputation is needed. Finally, medical insurance policies in China are not appropriate for patients with diabetic foot disease, since they cover only short-term stays in hospital and do not cover the cost of therapeutic shoes and some dressings. Patients with diabetic foot disease tend to need longterm inpatient care, often including treatment for various other complications such as severe infection, peripheral artery disease, and kidney disease. Medical insurance coverage is low, and the proportion of costs covered differs in different parts of the country. Several programmes have been initiated to tackle the burden of diabetic foot disease in China. Since 2005, an annual national forum on diabetic foot disease and related disorders supported by the Chinese Diabetes Society has brought together more than 6000 Chinese and international professionals from various disciplines, including specialists in diabetes, orthopaedics, vascular medicine, and plastic surgery, in addition to burn specialists, radiologists, and nurses. The Chinese Tissue Repair Society has developed a 3-year training programme in wound care in China, sponsored by the World Diabetes Foundation and the Coloplast Access to Healthcare Foundation. The project focuses on training physicians and nurses in wound care for patients with diabetic foot ulcers and other chronic skin wounds. During the past 2 years, 915 physicians and 703 nurses from more than 200 hospitals in 21 provinces have been trained. About 1200 patients per month, on average, have benefited from this project. In total, 13 hospitals have become training bases to continue the education programme. Publications in China are also helping to educate a wider group of professionals than can be reached 298
through these courses. International guidelines are increasingly being translated into Chinese and distributed widely. Chinese guidelines and consensus documents have also been produced, based on international and Chinese experience. Additionally, the Chinese Diabetic Foot Group published a manual in 201412 for the standardised prevention, treatment, and management of diabetic foot disease. Diabetic foot disease is difficult to treat, but it is preventable and can be cured if diagnosed early and treated in time. The Chinese Diabetic Foot Group will intensify its cooperation with international organisations and Chinese societies such as The Chinese Tissue Repair Society to develop national and regional databases, further train doctors and nurses, and promote the standardised prevention, diagnosis, and treatment of diabetic foot disease across the various levels of the Chinese health-care system. *Zhangrong Xu, Xingwu Ran Diabetes Centre, The 306th Hospital of PLA, Beijing 10010, China (ZX); and Endocrinology Department, Southwest Hospital of Sichuan University, Chengdu, China (XR) [email protected] ZX is the honorary chairman and XR is the chairman of the Chinese Diabetic Foot Group. 1
2 3 4
5
6
7
8 9
10 11
12
Yang W, Lu J, Weng J, et al, for the China National Diabetes and Metabolic Disorders Study Group. Prevalence of diabetes among men and women in China. N Eng J Med 2010; 362: 1090–101. Fu X, Sheng Z, Cherry GW, Li Q. Epidemiological study of chronic dermal ulcers in China. Wound Repair Regen 1998; 6: 21–27. Jiang Y, Huang S, Fu X, et al. Epidemiology of chronic cutaneous wounds in China. Wound Repair Regen 2011; 19: 181–88. Apelqvist J. Epidemiology of diabetic foot disease and etiology of ulceration. In: Hinchiliffe RJ, et al. eds. The Diabetic Foot. London: JP Medical, 2014: 3–9. Wang AH, Zhao S, Li Q, Xu ZR. A multicenter survey on the diabetic foot and medical economics in China. Chin J Endocrinol Metab 2005; 21: 496–99 (in Chinese). Ban Y, Ran X, Yang C, et al. Comparison of clinical characteristics and medical costs of patients with diabetic foot ulcer between 2004 and 2012 in China. Chin J Diabetes Mellitus 2014; 6: 499–503 (in Chinese). Wang A, Xu Z, Mu Y, Ji L. Clinical characteristics and medical costs in patients with diabetic amputation and nondiabetic patients with nonacute amputation in central urban hospitals in China. Int J Low Extrem Wounds 2014; 13: 17–21. Rice JB, Desai U, Cummings A KG, et al. Burden of diabetic foot ulcers for Medicare and private insurers. Diabetes Care 2014; 37: 651–58. Wang YZ, Wang AH, Zhao S, et al. The differences on the diabetic foot risk factors in the south and north of China. Zhonghua Yi Xue Za Zhi 2007; 87: 1817–20 (in Chinese). Yang GH, Li Q, Hsia J. Prevalence of smoking in China in 2010. N Enl J Med 2011; 365: 2649–70. Li X, Xiao T, Wang Y, et al. Incidence, risk factors for amputation among patients with diabetic foot ulcer in a Chinese tertiary hospital. Diabetic Res Clin Prac 2011; 93: 26–30. Xu Z, Ran X, eds. The standardized diagnosis and treatment on diabetic foot disease. Beijing: People’s Military Medical Press, 2014 (in Chinese).
www.thelancet.com/diabetes-endocrinology Vol 4 April 2016