Prevention of diabetes related amputations in an American Indian community using staged diabetes management

Track 5. Diabetes Care Organisation

Pm35 F’revention of Diabetes Related Amputations in an American Indian Community Using Staged Diabetes Management GREGG D. SIMONSON’, Steve Rith-Najarian’, Charmaine Braunchaud’, Oran Beaulieu*, Craig Valvatine’, Roger S. Mazze ’ ’ International Diabetes Centel; Minneapolis, MN, United States of America; 2 Indian Health Service, MN, United States of America The purpose of this study was to evaluate the impact of practice guidelines and algorithms designed to screen for, and manage foot complications associated with diabetes mellitus in an American Indian population seeking care in a community based clinic in Northern Minnesota, USA. The primary study endpoints were lower extremity amputation (LEA) rates and estimated cost associated with the intervention relative to standard care. LEAS were tracked over a 1Cyear period using a diabetes registry and were divided into 4 study periods. During the “Standard Care” period (1986-1989). patients received foot screening and care at the discretion of their primary care provider. During the “Public Health” period (1990-1993). routine foot screening coupled with simple preventative measures were performed on those at highest risk for foot complications. Starting in 1994, Staged Diabetes Management (SDM), a comprehensive set of practice guidelines and algorithms for the prevention and management of foot complications was implemented. During the “SDM” period (1994-1996), a foot care team was established to screen all individuals for foot complications, provide orthotics, and aggressively manage foot ulcers according to the SDM guidelines and algorithms. Starting in 1997, vascular surgery and pedorthic consultants provided local outreach clinics in what was called the “SDM-Outreach” period (1997-1999). The annual incidence rates are shown below: Period

standard car-e Public He&b SDM SDM-Outreach *x2 compared

person-yr.

#cases

at Risk

OfLEA

1464 1544 1314 1779

42 33

with Standard

20 13

LEA/1000 DM Patient-yrs 29 21 I5 7

PW.Xnt Change

p-vabJe*

-25%

0.24

-47%

0.016 0.0001

-75%

Care period.

The estimated annual excess medical cost for foot care provided as part of SDM program implementation was determined and compared to the cost savings associated with reduced LEA. Comparing the Standard Care period with the SDM and SDM-Outreach periods revealed a cost savings of $370,090 (18%) and $442,000 (22%), respectively. Implementation of the SDM foot program, improved foot screening and outreach, targeted preventative care and established uniform wound care guidelines and algorithms. This resulted in a 75% reduction in LEA and significant cost savings compared with standard diabetes foot care.

P1586 Two-Year Experience of Community-Based Outpatient Diabetic Foot Care Clinic in Moscow OLEG V. UDOVICHENKO, M&hail B. Antsiferov, Tatyana G. Kurtseva, Ivan I. Dedov. National Research Centre for Endocrinology, Moscow, Russian Federation Diabetic foot care in regions with poorly established foot care system is usually performed by different specialists (endocrinologists, surgeons, orthopedists, etc.) who work without proper coordination and often are not well qualified in this field. Multidisciplinary foot care teams exist in 8 Moscow hospitals for several years but predominant form of their activity is in-patient care. In order to improve foot care efficacy and to put qualified medical service closer to patient specialized local outpatient clinics were organized in some regions of the city. South-Western region is a typical district of Moscow city with 1,3 million population and 14567 people with diabetes. Local diabetic foot clinic

s409

& Economics

(with 1 diabetologist specialized in this field and 1 nurse) was organized there in 1997. The main goals of the clinic activity are management of diabetic foot lesions, preventive intervention in high-risk patients, education of patients and healthcare professionals. Patients referred to this clinic were selected by 25 primary care endocrinologists of the district on base of high risk or presence of foot lesions. Number of patients admitted was 560 last year. About 25% of them had foot ulcers or other ‘major’ foot problems; rest 75% had minor foot problems, neuropathic and ischemic pains, etc. Preventive interventions were recommended for high-risk patients. Of all patients with foot ulcers, 19% required hospitalization; the rest underwent ambulatory-based treatment with 91% healing rate. Average treatment duration was 44 (6-130) days. Year Number of amputations (all levels) Amputation incidence (per loo0 diabetic patients)

1996

1997

1998

54 3.6

67 4.3

37

1999 29

2.5

2.0

The main result of the foot clinic activity is a decrease of amputation rate in this area by 49%, that is very close to St. Vincent Declarationgoals (see table; the clinic was organised at the end of 1997). These data demonstrate importance of implementation of local foot care system in Moscow.

P1587 Screening for ‘Qpe 2 Diabetes in the Pittsburgh Community LINDA M. SIMINERIO ’ , Janice Zgibor ’ , Susan Zimecki *. ’ Endocrine, University of Pittsburgh, Pittsburgh, PA, United States ofAmerica; ‘Public Relations, UPMC Health System, Pittsburgh, PA, United States of America In the U.S., approximately 16 million people have diabetes, with only 10.3 million diagnosed. Major risk factors include: older age; obesity; race and family history. Reports have shown that distribution of characteristics and risk factors of nondiabetics screened include: age in yrs.(lS-39)49%; (40-64)36% and (>65)16% with 15.6% having a parent with diabetes.The ratio of undiagnosed females(F)5 1.3% to males(M)48.7% is similar. In Pennsylvania (PA), 1.1 million people have diabetes of whom approximately 379,500 remain undiagnosed.Studies have found that type 2 diabetes onset occurs -10 years before diagnosis and that complications often already exist. Substantial evidence demontrates that detection and intervention will improve the prognosisIn an effort to find those undiagnosed, heighten awareness, assess follow-up, and gain insight into participant’s risk factors and characteristics, the University of Pittsburgh Diabetes Institute sponsored 10 glucose screenings. A campaign that included announcements at work-sites and churches, television, radio, and newspaper was used to promote the program. Sites and individuals screened included: 1 health center(41);l hospital cafeteria(70); 2 churches(70); 2 supermarkets(61); 1 university health fair(105); 2 city office(l56) and the city court(l50) buildings. 718 individuals were screened for risk factors with the ADA risk test. Of these, 653 (7 l%F/29%M)had random capillary blood glucoses performed by trained nurses on the Sure Step meterIndividuals were recommended to have follow-up if a fasting glucose 2 126 or non-fasting 2 140mg/dl,Of the 653 tested: 23% were 265 yrs.; 48% were overweight; and 30% had a parent with diabetes. Excluding those with already diagnosed diabetes, glucose results of those tested were 18(9F/9M):140-200 and 11(4F/7M):?200 mg/dl. Based on the protocol, 6% of the 653 tested received telephone contact of whom all reported follow-up except one who could not be reached and one who refused contact. Findings support that women are more likely to seek preventive health screening, despite accessibility of service to all. Follow-up was excellent.In the Pittsburgh community compared to other US screening data, people 565 yrs.were more likely and men less likely to be screened, however, 50% of those who met protocol for follow-up were malesRates of reported obesity and having a parent with diabetes were high. The health fair, city office and court buildings attracted the most partici-