FINANCIAL SUPPORT FOR AMPUTATION PREVENTION DR ARUN BAL PRESIDENT DIABETIC FOOT SOCIETY OF INDIA

ST.VINCENT`S DECLARATION TO REDUCE THE MAJOR AMPUTAIONS DUE TO DIABETES BY 50% IN 5 YEARS Dr.bal

INDIA …on the TOP of the world 30 million diabetics 60 million feet at potential risk

REALITIES 40,000 lower extremity amputation per year Commonest indication is infected neuropathic foot potentially prevetable

LACUNAE IN THE PRESENT SYSTEM NO SCREENING PROCESS PODIATRY----NON EXISTENT ORTHOTICS----RARELY AVAILABLE TEAM APPROACH LACKING GRADUATE AND POST GRADUATE CURRICULUM INADEQEUT MULTIPLE DISCIPLINES OF MEDICINE CONVERGE

SOCIO ECONOMIC FACTORS Bare foot walking Inappropriate footwear Lack of awareness in patients & doctors Late reference to specialty centers – painless state, 50% Population stays in rural area – law of inverse care applies 1. quality and poverty, 2. reaching a good facility within reach in time 40% population stays in 1 room tenements Inadequate sanitary facilities Inadequate off loading due to lack of facilities

COMPONENTS OF FINANCIAL SUPPORT FOR AMPUTATION PREVENTION COST OF regular monitoring of foot and diabetes drugs foot wear loss of income hospitalization dressings vascular surgery rehabilitation after foot salvage surgery change in the job/employment Training & Education

Cost of Hospitalization Every hospitalization for foot infection cost Rs.25-30000/- Multiple hospitalizations are required for deformed foot/ dysvascular Foot Major component of hospital cost is for investigations and drugs Medicinal costs are usually 15-20% of the total costs of hospitalization

Cost of Drugs Insulin Oral Hypoglycemic Anti Lipid Anti Platelet Anti Hypertensive For neuropathic Symptoms Antibiotics

Cost of regular monitoring Diabetes: Blood Sugar Estimation Allied Tests e.g.- Lipids, Renal, Cardiac Imaging

Cost of Footwear Needs replacement frequently due to increase shear force Increases with advanced neuropathy Material Cost Cost of manufacture is variable Lack of easy availability of off the shelf footwear Customized footwear aids like Charcot Walker

Cost of loss of income Temporary Loss Permanent change/loss of job due to foot salvage surgery Loss of income of care giver

Cost of Dressings Commercial dressings are costly Lack of home wound care facilities Travel Cost Hospital Charges Medical Charges Lack of availability of ready to use dressings packs

Scientific evidence and studies

Cost of Healing infected Ulcer 17000 US$ Cost of Amputattion 33000 US$ Ragnarson Tennvall G, Apelqvist J. IHE, the Swedish Institute for Health Economics, Lund, Sweden. Cost of Healing infected Ulcer 17000 US$ Cost of Amputattion 33000 US$ Smith D, Cullen MJ, Nolan JJ Department of Endocrinology, St James's Hospital, Dublin, Ireland. 23489 IRISH POUND EXPENDITURE ON EACH HOSPITAL ADMISSION FOR FOOT ULCER

Costs, costs Monica Maria Ortegon, MD1,2, William Ken Redekop, PHD2 and Louis Wilhelmus Niessen, PHD2 1 Netherlands Institute of Health Sciences, Erasmus University, Rotterdam, the Netherlands 2 Institute for Medical Technology Assessment, Erasmus University, Rotterdam, the Netherlands The lifetime costs of management of the diabetic foot following guideline-based care resulted in a cost per QALY gained of <$25,000, even for levels of preventive foot care as low as 10%. The cost-effectiveness varied sharply, depending on the level of foot ulcer reduction attained.

Costs Potential economic benefits of lower-extremity amputation prevention strategies in diabetes. Ollendorf DA, Kotsanos JG, Wishner WJ, Friedman M, Cooper T, Bittoni M, Oster G. Policy Analysis Incorporated, Brookline, Massachusetts, USA. The total potential economic benefits (discounted at 5%) of strategies to reduce amputation risk ranged from $2,900 to $4,442 per person with a history of foot ulcer over 3 years. Benefits were highest for educational interventions. Most benefits were found to accrue among individuals aged > or = 70 years.

Team approach toward lower extremity amputation prevention in diabetes RG Frykberg Harvard Medical School, Beth Israel Deaconess Medical Center, Boston, MA, USA. Cost of prevention are more likely to to prevent higher costs of treatment among veterans.

Realities of financial support for amputation prevention in India Higher level amputation is cheaper than amputation prevention by foot salvage surgery in India The issue is – many more amputees will be dead in a few years

Employer reimbursement Self expenditure Charity Components of current available financial supports for amputation prevention Insurance Employer reimbursement Self expenditure Charity Public Sector Healthcare

In next 20 years cost of amputation prevention has to be borne by insurance to make adequate social impact

Health Insurance Coverage in India Schemes & Beneficiaries (in Million) State Insurance Scheme (ESIS) 25.3 Central Government Health Scheme 4.3 Railways Health Scheme 8.0 Defence Employees 6.6 Ex-servicemen 7.5 Mining and Plantations (public sector) 4.0 Health Insurance (public sector non-life companies) 10.0

Health Insurance Coverage in India SchemesBeneficiaries (in Million) Health Insurance (private sector non-life companies) 0.8 Health Segment of Life Insurance Companies (public and private) 0.23 State Sponsored Schemes<0.50 Employers run facilities/reimbursement schemes of private sector 6.0 Employers run facilities/reimbursement schemes of public sector<8.0C Community Health Scheme 3.0 Total85.0

HEALTH INSURANCE Limited Coverage Majority Schemes do not cover preexisting diabetes Major Private health Insurance companies not active players Diabetic Foot as a complication is usually excluded.

HEALTH INSURANCE Quality of services Purposes for which used Final run off still to privateers Overall sub-optimality with islands of excellences

Components of current available financial supports for amputation prevention A dozen private companies in health insurance business, community specific, area specific or trade specific coverage, ?decline over time Yashaswini – The force and charisma of one man moving the otherwise inert government system Should happen without it

Components of current available financial supports for amputation prevention Self expenditure Charity – potentially a non self fuelling way of solving health care issues

Two Thirds of Healthcare Spending is out of Pocket, PHC : Public Clinic /Primary Health Care Centres OP : Other Private – includes both qualified and others PC/NC : private Clinic / nursing home PP : Private Practitioner Source: CII –McKinsey & Company, Healthcare In India: The Road Ahead, CII and McKinsey & Company, New Delhi, 2002, p. 38.

Components of current available financial supports for amputation prevention Public Sector Healthcare – PHCs archaic, non evolving invariant model, conceptually woefully limited capacity vis a vis huge task profile, unmotivated and needs scrapping, out of tune with changing economic states of people,

NRHM – the CHC based model Talks of public private partnerships, Components of current available financial supports for amputation prevention NRHM – the CHC based model Talks of public private partnerships, Talks of user fees Under automatic criticism of left wing

Create Public-Private Partnership. Models Options Successful Examples Contract out Services Contract out non-clinical hospital service (e.g., catering, laundry) Contract out clinical hospital services (e.g. radiology, pathology : Karnataka: Cleaning, maintenance and waste management contracted out in 82 hospitals. Tamil Nadu: High technology services in major teaching hospitals contracted out. Private Management of Public Facilities Private management of primary facilities. Private management of public hospitals. Tamil Nadu: Management of PHCs by corporate houses with large presence in the area. Gujarat: PHCs in one district managed by SEWA. Source: CII –McKinsey & Company, Healthcare In India: The Road Ahead, CII and McKinsey & Company, New Delhi, 2002, p. 183.

Components of current available financial supports for amputation prevention Employer reimbursement – varies with the health of the business, has procedural / conceptual confusions, eg. nature of packages, choice of facility,

IS COMMUNITY DIABETES WORKER A SOLUTION? Going back to the PHC profile with an additional new task Separate cadre arising out of NGOs, Problems of self sustaining mechanism Second level back up is a fundamental need grossly inadequately answered in Public Health System

WHAT WE NEED TO DO TO ACHIEVE THE OBJECTIVES OF ST WHAT WE NEED TO DO TO ACHIEVE THE OBJECTIVES OF ST.VINCENTS DECLARATION?

Cost Effective High Quality Solutions Preventive Foot Care Clinics Preventive Foot Wear facilities Home Wound Care Facility Making paramedics as a nodal person Evolve Community Insurance Schemes for Amputation Prevention Develop cheap cost effective technology for diabetic foot wound care Studies related cost of amputation prevention

Cost Effective High Quality Solutions Common sense, common place restructuring of public health care delivery Intelligent, non demotivating regulation of private sector, particularly on quality assurance and wastes of huge money

THANK YOU

WHY DIABETIC FOOT INFECTIONS ARE TREATED LATE?

NO COMPLAINT NO EXAMINATION Dr.bal

HIGH INDEX OF SUSPICION Dr.bal

Costs, costs Monica Maria Ortegon, MD1,2, William Ken Redekop, PHD2 and Louis Wilhelmus Niessen, PHD2 1 Netherlands Institute of Health Sciences, Erasmus University, Rotterdam, the Netherlands 2 Institute for Medical Technology Assessment, Erasmus University, Rotterdam, the Netherlands guideline-based care resulted in improved life expectancy, gain of quality-adjusted life-years (QALYs), and reduced incidence of foot complications. The lifetime costs of management of the diabetic foot following guideline-based care resulted in a cost per QALY gained of <$25,000, even for levels of preventive foot care as low as 10%. The cost-effectiveness varied sharply, depending on the level of foot ulcer reduction attained.

Costs, costs

Costs Redekop W.K.1; McDonnell J.1; Verboom P.1; Lovas K.2; Kalo Z.2 Source: PharmacoEconomics, Volume 21, Number 16, 2003, pp. 1171-1183(13) Treatment with Apligraf® plus GWC resulted in a 12% reduction in costs over the first year of treatment compared with GWC alone. The increased ulcer-free time coupled with a reduced risk of amputation to a large extent offset the initial costs of the product.

Costs Redekop W.K.1; McDonnell J.1; Verboom P.1; Lovas K.2; Kalo Z.2 Source: PharmacoEconomics, Volume 21, Number 16, 2003, pp. 1171-1183(13) Treatment with Apligraf® plus GWC resulted in a 12% reduction in costs over the first year of treatment compared with GWC alone. The increased ulcer-free time coupled with a reduced risk of amputation to a large extent offset the initial costs of the product.

Amputation Prevention Initiative in South India Positive impact of foot care education Vijay Viswanathan, MD, PHD, Sivagami Madhavan, BSC, Seena Rajasekar, BA, Snehalatha Chamukuttan, MSC, DSC and Ramachandran Ambady, MD, PHD, DSC, FRCP Among the 1,259 group 3 subjects who came for follow-up, 718 (57%) strictly followed the advice given and 541 (43%) did not. Ulcers present during the recruitment had healed in 585 (82%) subjects who followed the advice, but in only 269 (50%) subjects who did not. A significantly larger proportion of subjects who did not follow the advice developed new problems (26%) and required surgical procedures (14%) compared with those who followed the advice (5 and 3%, respectively)

Team approach toward lower extremity amputation prevention in diabetes RG Frykberg Harvard Medical School, Beth Israel Deaconess Medical Center, Boston, MA, USA. Health care costs to prevent ulcers and amputations appear to reduce the probability that veterans with high risk feet will incur costs to treat ulcers and amputations in a given fiscal year. However, prior prevention costs do not affect the level of costs to treat ulcers and amputations if some treatment costs are incurred.

Diabetes mellitus and nontraumatic lower extremity amputation in black and white Americans: the National Health and Nutrition Examination Survey Epidemiologic Follow-up Study, 1971-1992. Resnick HE; Valsania P; Phillips CL During the study period, 158 LEAs occurred among 108 subjects. While black subjects constituted 15.2% of the cohort, they represented 27.8% of the subjects with amputation (P = .002). The 20-year age-adjusted rate ratio of first LEAs for black subjects-white subjects was 2.14. Regression analyses confirmed the importance of diabetes mellitus as a key LEA risk factor. The association between prevalent diabetes mellitus and LEA risk was substantially higher (relative risk [RR], 7.19; 95% confidence interval [CI], 4.61-11.22) than that for incident diabetes mellitus (RR, 3.15 [CI, 1.84-5.37]), highlighting the importance of diabetes mellitus duration on LEA risk. While preliminary analyses adjusted for age and diabetes indicated a significant association between race and LEA risk (RR, 1.93 [95% CI, 1.26-2.96]), the effect of race diminished (RR, 1.49 [95% CI, 0.95-2.34]) following adjustment for education, hypertension, and smoking

Why bother educating the multi-disciplinary team and the patient--the example of prevention of lower extremity amputation in diabetes. Boulton AJ Amongst all the long-term complications of diabetes it is believed that foot ulceration and amputation are the most preventable: small studies have suggested that more than 50% of amputations should be avoidable by screening and appropriate education. There is ample evidence that simple non-invasive screening tests are not being carried out in many diabetic clinics--one study confirmed that poor patient care was responsible for 50% of heel ulcers in a hospital setting. There is a similar lack of awareness of potential problems in many 'at risk' diabetic patients. Thus, simple screening of diabetic patients should be routine clinical practice: those identified as being at 'high risk' of foot, problems should receive appropriate education in protective foot care. The rewards are potentially great, and include the realization of the St. Vincent target, a 50% reduction in amputation.