This document outlines a proposal to establish a Diabetic Foot Center of Tel Aviv (DCTA) to provide comprehensive and coordinated care for patients with diabetic foot ulcers (DFU). The DCTA will bring together specialists from various fields including endocrinology, podiatry, vascular surgery, infectious disease, and others. This multidisciplinary "toe and flow" approach aims to promptly assess, treat, and prevent DFUs through a protocol-based team effort in order to reduce amputations and their related burdens. The roles and contributions of each specialist are described. Benefits of the DCTA include faster access to coordinated care, improved outcomes, and potential cost savings.

1. OGANIZING MEDICAL CARE
FOR DFS PATIENT
Michael Knizhnik,
Rabin M.C., Israel
Almaty
4 July 2014

2. ?

3. The Diabetic Foot Ulcer
• Ulceration due to neuropathy and
repetitive trauma, often complicated by
infection and ischemia.
• Host resolution impaired by
immunopathy and peripheral arterial
disease.

4. Diabetic Foot Ulcers
• 85% of amputations preceded by DFU.
• 25% of diabetics will develop DFU.
• 2.0-6.8% a year.
• 9-17% experience 2nd amp same year.
• 25-68% within 5 years.
• 5 yr mortality after amputation is 46%

5. Diabetic Foot Ulcers
• Accounts for 20% of the $174 Billion
yearly expenditure on diabetic healthcare
$34.8B.
• # of diabetic amputees in US expected to
double by 2050.
• Post amputation status carries financial
burden of cost of prostheses, mobility
devices, and disability.
• Amputation reduces life expectancy.

6. Causes of Delayed Treatment
of DFU
• Patient unawareness/denial/fear.
• Primary physician not removing socks and
shoes during checkups.
• Offloading shoes not widely prescribed.
• Underestimation of severity of infection.
• Lack of recognition of repairable arterial
blockages.
•Mills et al: The Diabetic foot:Consequences of Delayed treatment and referral, Southern Med J 1991, 84:970-974l

7. DFU in Israel
• Estimate at least 500,000 Diabetics
• Another 500,000 undiagnosed
• # increasing with aging population
• 20% of population (7.6 M) >65
• 10% of these are diabetic, 4% DFU/year
• Estimate 6,000 DFU/year,2,500 Gush Dan.

8. Roots of the Problem:
• Delay in identifying the problem (patient and
physician).
• Time lost during fragmented, inappropriate
care, resulting in avoidable amputation.
• Inability of public system to match demands
of increasing prevalence of DFU.

9. Healing of DFU is a steep,
slippery slope
• Fragmented care evokes tale of
Sisyphus pushing a rock up a hill
repeatedly.
• Integrated “toe and flow” approach
reduces incidence of amputations, and
rescues Sisyphus.
• This will be done by establishing the
foot center in Tel Aviv.
•Mills JI, Armstoring DG, Andros G:Rescuing Sisyphus:The team approach to amputation prevention:J Vasc Surg 2010;52:1S-2S

10. TEAM WORK
interventional radiologist
vascular surgeon
orthopaedist
podiatrcardiologist
endocrinologist
?
plastic surgeon

11. The “Toe and Flow” Concept
of the Diabetic Foot Team

12. Diabetic Foot Center of Tel
Aviv
• DCTA will be a comprehensive multispecialty center of
excellence providing prompt, protocol based preventive
care and treatment for the Diabetic Foot.
• Endocrinology, Infectious Disease, Podiatry, Orthopedics,
Endovascular and Vascular Surgery, Plastic Surgery,
Dietician, Exercise Physiologist, Diabetic nurse/educator,
psychologist.
• Cardiologist, Nephrologist and Opthamologist will be
available for consultation

13. The Stairway to Amputation

14. The S Curve for Likelihood of
Healing

15. Approach of DCTA-1
• Initial evaluation by diabetologist and
podiatrist to include staging/control of DM,
assessment of feet for evidence of
neuropathy, ischemia and infection.
• Referral to appropriate specialist who will
see patient within 24-48 hours.
• Strict flow sheet protocol to be followed.

16. Approach of DFCTA-2
• Primary physician will receive copies of
consultations, lab results and treatments.
• Regular meetings will be held to discuss
problematic patients, consider changes to
protocol, and discuss potential new
treatments.
• DCTA intends to actively publish.

17. Role of the Diabetologist
• Conductor of the orchestra.
• Initial evaluation of the patient.
• Responsible for subsequent triage to other
specialists.
• Optimize glucose control.

18. Role of Infectious Disease
Specialist
• Provide appropriate antimicrobial
therapy.
• Confirm adequacy of resolution of
infection.
• Assess need for PICC placement for IV
antibiotics, which will be done within
24-48 hr notice.
• Assist in identifying borderline patients
requiring immediate surgery.

19. Role of the Podiatrist
• Manage off loading in the center
• Primary provider for wound healing
treatments performed in center.
• Manager of preventive care.
• Off site surgery when indicated.

20. Off Loading
• Simple first step in healing/preventing
ulcer.
• Not widely used in Israel.
• Can be done in the center during initial
visit to podiatrist.
• Together with debridement, often all
that is needed.

21. Podiatric/Orthopedic Methods
for wound healing
• Debridement
• Non surgical interventions (ozone
therapy, soft laser, wound
vacuum,artificial skin,etc).
• Surgical off loading.
• Foot sparing amputation.

22. Diabetic “small vessel
disease”
• Misconception of an angiopathy distal to the
palpable pedal pulse which is therefore not
amenable to revascularization.
• Based on single amputation study done in
1959 which has been refuted.
• In fact small vessels of the foot often spared in
diabetics, and the clinically relevent changes
occur at the macroarterial level.

23. Role of Endovascular Specialist
• Interpret non invasive studies
performed in center.
• Interpret CTA, MRA performed
elsewhere.
• Perform diagnostic angiography and
endovascular repair.
• Liason with vascular surgeon when
endovascular repair is not an option.

24. Advantages of Screening
• Occult PVD (ABI < 0.9) is an accepted
coronary disease equivalent marker.
• Elevated ABI in diabetics (>1.3) is also
associated with decreased long term survival.
• Early detection can increase survival by
signalling need for risk factor control and
coronary and cerebrovascular screening.

25. Endovascular Therapy
• Advanced techniques such as atherectomy
and drug eluting balloon angioplasty allow
for treatment of long calcified tibial lesions,
as well as popliteal disease at the knee joint,
which is a “no stent zone”.

26. Distal Bypass
• Although less durable and more time
consuming than aortofemoral and popliteal
bypass, the grafts usually remain open long
enough to heal the ulcer, after which graft
surveillance and secondary endovascular
interventions can be performed, along with
aggressive preventive care.

27. Role of Exercise Physiologist
• Work in concert with the
endocrinologist, at the very first stage
of referral.
• Prescribe and monitor individualized
exercise protocol designed to improve
exercise capacity, reduce cardiovascular
risk profile, and improve quality of life.
• Explain to patient the importance of the
above, in order to increase motivation
and compliance.

28. Concept of Business Plan
• Concept is for global fee (monthly or per
DFU).
• This will cover all services provided at the
center.
• Procedures/surgeries performed outside will
not be included.
• Viability of this concept will be assessed by
business plan, once we have the data for a
proforma.

29. Benefits to Patient
• Faster assessment of wound care
healing status
• Faster access to multispecialist care
under one roof.
• Foundation for lifetime surveillance.

30. Benefits for
Partnering/Contracting Insurers
• Link to team of specialists to effectively
manage pts with complex
comorbidities.
• Leadership role in information
dissemination, enhance identity as a
leader.
• Savings on hospitalization costs.
• Patient satisfaction. Attraction to join
kupa.

31. ?