1. DIABETIC FOOT CARE IN BRAZIL: ACHIEVEMENTS AND CHALLENGES
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DIABETIC FOOT CARE IN BRAZIL: ACHIEVEMENTS AND CHALLENGES
Dr Hermelinda Pedrosa
Director
Department of the Diabetic Foot
Brazilian Diabetes Society

2. Diabetic Foot: Where we were ?
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Diabetic Foot: Where we were ?

3. Diabetes National Programme Implementation - 1988
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Diabetes National Programme Implementation
Targets:
Set up basic diabetes teams:
primary /secondary care
Establish multidisciplinary teams:
tertiary care - public hospitals
Manual de Diabetes. Ministério da Saúde, ISBN

4. What about diabetic foot care ?
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What about diabetic foot care ?

5. 1990’s: depressing situation in Brazil
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Low interest in foot problems
Diabetic foot care: restricted to surgical interventions (vascular, orthopedist)
Lack of specialist foot clinics
Scarce orthotics and foot material
High major amputation rates
No podiatrists
Pedrosa HC et al. É possível salvar o pé diabético ? Arq Bras Endoc Metab, 1991.
Spiechler E, Spiechler D, Forti AC, et al. OPAS Bulletin, 2001

6. Hospital stay UK and USA 25 - 21 days International Consensus
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UK and USA days
International Consensus
(average) days
CEPEDF – 90 days
(Brasilia)
IWGDF, 1999; Miziara MDY, Dias MSO, Farias L, Pedrosa HC, 1991

7. Strategies: Save the Diabetic Foot Project implementation
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Strategies: Save the Diabetic Foot Project implementation

8. Implementation To set up a specialist foot clinic
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To set up a specialist foot clinic
To train health professionals on foot exam and care
To get the policymakers and hospital endocrine staff to understand the diabetic foot devastation
1990´s – diabetic foot approach started to be linked to the hospital diabetes team

9. Costs: the best approach to policy makers
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Costs: the best approach to policy makers
Ulcer and amputations (US $):
Ulcer + amputation 30,000-60,000
Primary Ulcer ,000-10,000
Brazil-RS ,000
2005 : R$ ,00

10. Setting up a foot team: Without a podiatrist – a remarkable barrier ?
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Setting up a foot team: Without a podiatrist – a remarkable barrier ?

11. How to motivate professionals? foot workshops
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How to motivate professionals? foot workshops
Foot exam – screening techniques
Basic podiatry procedures
Ulcer management
Education – family, carers
Organization of care*
Prevention – Practical Guidelines*
* Practical Guidelines – International Consensus, IWGDF – International Working Group on the Diabetic Foot

12. Setting up a multidisciplinary team
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Basic podiatry care: nurses join the project
Berry BL, Black JA. What is chiropody / podiatry ?
The Foot. 1992; 2: 59-60

13. Basic foot kit : simple and affordable
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Tuning fork, hammer, cotton wool, pin, monofilament, ecodoppler
Goniometer (physiotherapy staff)

14. Foot exam: mandatory Neuropathic foot Ischaemic foot
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Neuropathic foot
Foot exam:
mandatory
Ischaemic foot
Neuroischaemic foot

15. Specialist interdisciplinary team Family health programme
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Organization of care
Targets:
Primary care integration
Referral and contra referral system
Hospital
Specialist interdisciplinary team
Health Centre
Family health programme

16. 15/04/2017
Achievements

17. Sala Professor Andrew Boulton
(new structure inauguration – 1999)
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18. Hospital Foot Team 02 13 1992 Diabetologist
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Hospital Foot Team
1992
Diabetologist
Nurses and Nurse Aid (Helpers)
2005
Diabetologists / Medical residents
Social Worker
Dietitians
Physiotherapists
Vascular Surgeons
Orthopaedist
Physiatrist
Orthotists
Dermatologist
Infectious Disease Specialist
Plastic Surgeon
Psychiatrist 02 13

19. Trends towards reduction = 77%
Major amputations ( )
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Trends towards reduction = 77%
Note: Data - LEAS protocol and guidelines - data collection restricted to the reference hospital (Pedrosa HC et al. Diabetes Monitor, 2004)

20. according to level of procedure
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Amputation rate:
according to level of procedure
Note: Data - LEAS protocol and guidelines on data collection restricted to the reference hospital (Pedrosa HC et al. Diabetes Monitor, 2004)

21. 15/04/2017
Insole provision:
Total = Increase = 687.7%

22. Workshops and project demonstration: 1992/2005
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Workshops and project demonstration: 1992/2005
Workshops 37
Workshop attendees*
4.035
National Congress
Regional Seminars 21
National Congress, Regional Seminars attendees**
4.950
mean attendance: workshop = 100; meetings = 200
total attendance estimated : 9.000
Ministry of Health, Brazíl; Brazilian Diabetes Society,
Foot Department, 2005

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25. Brazilian version* XIII Brazilian Congress of Diabetes Rio de Janeiro,
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Brazilian version*
XIII Brazilian Congress of Diabetes
Rio de Janeiro,
October
10-14th, 2001
* issues

26. Brazilian Diabetes Society Journal
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Brazilian Diabetes Society Journal
Diabetic Foot Forum*
(*since 2001)

27. The good news, the bad news: What are the challenges ?
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The good news, the bad news: What are the challenges ?

28. 2002 – 2005: main problems PAD: late diagnosis confirmation
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PAD: late diagnosis confirmation
Revascularisation: scarce
Long hospital stay
Footwear: not available (yet)
Prosthetic provision: too late
(6 months)
High amputation rates
No podiatrists yet

29. Official Plans for 2005 - 2006 Ministry of Health / SBD
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Official Plans for
Ministry of Health / SBD
Formation: Diabetic Foot Task Force Group*
Podiatry Course ? (US and UK support)*
Practical Guidelines – Primary Care
Basic care teams training: (FHP**)
Outpatients Foot Clinics: improve structure
* Support: Ministry of Health – SBD; * IDF / WDF
**Family Health Programme

30. National Campaign – Logo: a sensibization approach
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Logo – Ministry of Health