17_Chapter 11_Conclusion (14)

602 CHAPTER 11: CONCLUSION The foot has always been the forgotten child of medicine… It is a glamorous part of the body… For healthcare providers and patients …  It is an unglamorous part of the body to which they hardly give any attention Diabetic Foot  MOST feared complication – for the patients’ point of view  MOST devastating – for the doctors’ point of view India already faces a grave problem with the largest number of subjects with diabetes (approximately 72.9 million in the year 2017) and by the year 2045 it may be 134.3 million. That means almost 264.4 million legs are at risk of the diabetic foot, its ulcer and leading to amputations.  25% diabetics develop foot ulcers in their life time Diabetic foot ulcers are common – in fact, 1 in 4 people with diabetes will develop at least one ulcer post -diagnosis. In Indian scenario, there are 60% people are undiagnosed. Due to long standing undiagnosed uncontrolled diabetes, they are prone to have micro as well as macrovascular complications at the time of diagnosis. 50% of newly diagnosed people with the diabetes have one of the complications at the time of the diagnosis. Even patients present to the clinics with the burned ulcer due to thermal burn injury on back side of the bike due to slippage of the footwear and603 they don’t feel the heat of the silencer. So, there are many cases reported with non healing ulcer at the time of the 1 st visit. Among the all complication of the diabetes, Foot complications are among the most serious and costly complications of diabetes. Diabetic foot is the commonest indication of the hospitalisation and it requires longest hospital stay. In 2007, one third of diabetes costs were estimated to be linked to foot ulcers. Compared to people with diabetes without foot ulcers, the cost of care for people with diabetes and with foot ulcers is 5.4 times higher in the year of the first episode and 2.6 times higher in the year of the second episode of foot ulcer. Mor eover, among patients with foot ulcers, costs for treating those with the highest grade ulcers were eight times higher compared to treatment of the lowest grade foot ulcers. According to International Diabetes Federation (IDF), in year 2017, 7 9% of adults with diabetes are living in low – and middle -income countries. Mostly these countries have poor health / medical insurance support from insurance industry or government and so diabetes and diabetic foot complications are the major burden to these countries citizens. An ulcer for mation is beginning of the end …  85% of the amputations are preceded by trivial foot ulcer Amputation in people with diabetes is 10 to 20 times more common compared to those of non -diabetic people. 75% of all leg amputations happen in people with diabetes . After unilateral below knee or above ankle leg amputation, five year mortality is 80 %. About 1 million people loose a leg, every year, due to diabetes. Every 30 seconds a lower limb (leg) or604 part of a lower limb is lost to amputation somewhere in the world as a consequence of diabetes.  Up to 85% of the amputations are preventable with com prehensive management Th e key elements of preventive care include: annual examination of the feet by health care providers to determine risk factors for ulceration, subsequent examination of high -risk feet at each patient visit, patient education about daily self -care of the feet and careful glucose management. The awareness and education about Diabetes , diabetes foot problem and Diabetes related other complications are must. Primarily, based on the outcome of the study and considering the high prevalence of diabetic foot complications in all profile of the diabetic individuals from th e time of the diagnosis to as diabetes advances; we venture to give following recommendations: AT THE COMMUNITY LEVEL As India has no subsidized, coordinated diabetes care programme, the need of the hour is a drastic change in our approach with more emphasis on the preventive aspects of diabetes for the benefit o f the community. Preventive measures for diabetes must be initiated in India at least before the diabetes sets in to any complications occur in order t o decrease the spiraling cost of diabetes to the citizens of India.605 The first step towards combating rising rates of diabetes leg amputations, we must act on public awareness about diabetes and its risk factors, particularly the outcomes of the diabetes . Community education about diabetes, diabetes risk factors, it s preventions and diabetes c omplication preventions along with healthy diet, recommended physical activity, weight -stress management and regular preventive hygiene – health care are strongly recommended. The social media campaigns (Facebook, Wh atsapp, Twitter, etc) can be support for the mass public awareness . Projects like FOCUS on FEET , to create awareness for the diabetes and foot care should be encouraged. The need of the hour is early screening for diabetes and its complications in the population and institution s as prev entive measures at an early age to the high risk individuals or diabetics. The target population has to be defined for this purpose. The characteris tics of people with diabetic foot often include older age individual with positive family history along with longer diabetic duration , presence of hyp ertension, diabetic retinopathy or smoking history. The early preventive actions to be taken in these individuals from cessation of smoking to glycemic control along with other comorbidities control / treatment . There is an urgent need to develop a cost -effective prot ocol for diabetes care aimed at improving disease control and diabetes complication prevention. W hich can prevent, delay or limit the development of complications in both Type 1 and Type 2 diabetes. Such a protocol like PROJECT SHRAVAN must be integrated into patient care by making the family member of the patient as an important team member for the patient diabetes and foot complications prevention as w ell as managemen t. The606 training of the family member along with empowerment and continues monitoring can play a key role in the foot care of the patients with diabet es. Building support group team whic h includes diabetes educator, podiatry nurse, dietician , counsellor , psychologist, podiatry footwear maker, etc. to prevent the 1st amputation to occur. As needing the 1st amputa tion is a poor prognostic sign and 28% to 51% of these pa tients require a 2 nd amputation within 5 years. The Support group can meet on regular bases to share their learning and experience from their daily clinical pract ice which can be implemented at the community level. The TRAIN THE COBBLER project is evolved from the support group meeting and these cobbler s can be vary handful from the early bedside screening for th e peripheral vascular disease and neuropathy to preventive and therapeutic footwear production. At the community level, ther e should be mass feet washing ceremony display. W hich represents the importance of the feet care in diabetes and create the awareness for the diabetes and diabetes foot complica tions ’ prevention. AT HEALTH CARE PROVIDER LEVEL Majority of higher level leg amputations in diabetes are due to preventable and inadequately treated foot ulcers . There should be a structur ed diabetic foot management protoco l incorporated into both undergraduate and postgraduate medica l education. Education, supported by an appropriate incentive programme, is pa rticularly im portant for the General Practitioners (GPs) / Primary Care Provider / Family physicians; who play a key role in the care of patients with diabetes. On same value s607 based the TRAIN THE FOOT TRAINERS program is created for the PHC doctors or the doctors of the areas where no availability of the podiatry or su pper speciality facilities and to man age the foot problem at primary level. AT HEALTH CARE INSTITUE LEVEL There is also a need to improve case record maintenance / develop registries and perf orm outcomes research to define standards and identify patients at risk. Through registry b y identify ing the patient at risk , the focus on th e importance of early diagnosis, lifestyle changes – training and regular monitoring to reduce the burden of complications can be given. Promoting the self -routine foot care and glycemic monitoring regularly would prevent the cost of the diabetes complication in the se individuals . This integrated approach would help provide better care early in the course of the disease and reduce the rate of complications and associated costs for all patients, regardless of education and/or income. AT HEALTH CARE GOVERNANCE LEVEL The current thrust of health care services in India is towards the treatment and prevention of communicable disease. This needs to be reviewed and an added impetus towards preventing and treating non -communicable diseases is the need of the hour. To be cost effective, diabetes health care should be linked with health care to control risk factors like hypertension, dyslipidemia, tobacco and alcohol abuse etc. For this purpose, the health care professional should receive additional training and this can yield rich dividends at a low cost.608 With such a health care delivery system, one would achieve, improved patient adherence to medical regimens, enhanced patient confidence, improved utilization of effective treatments with proper glycemic control, reduction of ischemic heart disease, decreased progression to blindness, decreased progression to renal failure and less number of lower extremity amputations. This wou ld also cause a shift in overall health utilization from amputation and high cost complication related hospitalizations to low cost preventive services. AT THE CLINIC LEVEL Loss of the limb is the outcome of the treatment in major part of India due to lack of comprehensive multi -discipli nary team approach. That results into both the economic burden and loss quality of life experienced by a diabetic individual could be attributed to its morbidity associated with either diabetic foot problem, non healing ulcer or amputation. In view of the high prevalence of micro -macrovascular complications and associated risk factors in diabetics in India, there is a need for scre ening all diabetics for complications at the time of diagnosis and annually thereafter. This includes retinal screening for detecting retinopathy, microalbuminuria for diabetic nephropathy, examination of pedal pulses and peripheral doppler for peripheral vascular disease, 12 lead electrocardiography for coronary artery disease and if indicated Treadmill and Echocardiography as well as a complete foot examination including monofilament testing and biothesiometry for diabetic neuropathy. The study highlight s the ne ed of the organised comprehensive multi -disciplinary teamed diabetes foot care clinics / centres to reduce foot complications and amputations609 by up to 85%. As diabetic treatment continuous for life so regular check – ups are required to avoid or restrict co -morbidities attached to diabetes. The early approaches for preve ntion of complications should target glycemic control, hypertension control and control of dyslipidemia. Such a multi factorial approach is necessary to prevent complicati on. As intensive blood glucose management (HbA1c