Integrated care for the diabetic foot: impact on outcomes

Gerry RaymanIpswich HospitalSuffolk

The Ipswich Diabetic Foot Clinic

WoundWound

HealingHealing

Lose Lose footwearfootwear

Untreated Untreated InfectionInfection

AmputationAmputation Referred to Foot Clinic

Off-Off-loadingloadingOff-loading and Off-loading and treatment of treatment of infectioninfection

Replace Replace footwearfootwear

Screening to characterise risk

Pathways

Health care professional

Patients and carers

Coordination of Interventional procedures

Ipswich Diabetic Foot UnitMain Treatment Room

‘Hot Line’Patient held recordCommunity nurse

Community Podiatrist

Secondary Care

Diabetologist Podiatrist Orthotist Vascular & Orthopaedic surgeons Radiologist

Primary CareGPs Practice nurses Community nurses Podiatrists

DSN Senior Podiatrist

Foot ProtectionTeam

GP practices

In-patient service

Community Nurses

Multidisciplinary foot care team

Integrated care

Fast tracking

Possible admission routes for the acute diabetic foot

There needs to be a clear pathway for the acute diabetic foot

Am

pu

tati

on

rate

s p

er

100,0

00 g

en

. p

op

ula

tion Amputation rates 1995-2009 per 100,000

gen population

2.82

Organisation Population size

Year Change in major amputation rates

Estimated savings based on bed days alone(£200/d)

Ipswich Hospital NHS Trust

335,000 1997- 2009 Reduced by 75% £386,000/yr

Southampton 540,000 2003-2007 Reduced by 60% £754,000/yr

Middlesbrough 273,987 1995-2000 Reduced by 75% N/A

Northampton NHS Trust

350,000 1999-2002 Reduced by 53% N/A

Kings College Hospital

Inner city hospital-population not clearly defined

1990-2002 Estimated reduction >70% (difficult to assess as population not clearly defined)

N/A

UK Evidence for effectiveness of Multi-disciplinary foot teams and provision of inpatient foot care service

Larsson J, Eneroth M, Apelqvist J, Stenstrom A. Acta Orthop 2008

The trend of Total amputations in diabetes in Finland

Number of 1st Amputations per 10,000diabetics in Finland 1988-2002

Lepantalo 2006

Total Amputations (major and minor) per 10,000 diabetics

Trends in LEA in people with diabetes in England 1996-2005 (HES data)

• Type 1 Minor decreased 11.4%Major decreased

41.0%

• Type 2 Minor increased 95.0%Major increased

83.5%

Vamos EP; EASD 2009

Why is care patchy across the UK?

Not rocket science

Not on the agendaNot on the agenda

Not all plain sailing

• Loss of in patient foot nurse• Foot protection team not supported in primary care• Community podiatry not full integrated• Education of community staff relies on good will- no funding

Southampton 2003 -2007 (520 admissions)

0

10

20

30

40

50

60

2003 2004 2004 2005 2005 2006 2006 2007

LOSMajorMinor

LOS from 50 days to 18.5 daysMajor amputations reduced by 60%

Bed days –Invest to Save

1997-1998 2005-2006

Amputation 1680 477

Other foot 1307 579

Total 2987 1056

Reduction 65%

Saving ~£400,000

““I marvel that society would pay I marvel that society would pay a surgeon a large sum to a surgeon a large sum to remove a patient’s leg but remove a patient’s leg but nothing to save it”.nothing to save it”.

George Bernard ShawGeorge Bernard Shaw

““I marvel that the health service I marvel that the health service should continue wasting large should continue wasting large sums on the disasters arising sums on the disasters arising from poor diabetic foot care but from poor diabetic foot care but little or none to develop little or none to develop integrate services to prevent integrate services to prevent them in the first place” them in the first place”

Gerry Gerry RaymanRayman