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How Australia can reduce diabetes-related amputations

Pete Lazzarini and Shan Bergin write:

Diabetes is arguably the nation’s greatest public health challenge, affecting over one million Australians.

People with diabetes have high sugar levels in the blood which can damage nerves and blood vessels. In the legs, this damage can cause a lack of feeling and poor circulation to the feet, both of which can lead to foot ulcers, infections and eventually amputations. Foot disease affects more Australians than any other major diabetes complication, aside from cardiovascular disease.

Consider this: if every Australian with diabetes and foot disease formed a city they would fill Canberra. If everyone in a hospital tonight with a diabetic foot ulcer was admitted to one hospital they would fill Canberra Hospital. And there are enough Australians scheduled for a diabetes-related amputation today to make up the entire Canberra Raiders rugby league team.

Our study, published this week in the Journal of Foot & Ankle Research, confirms that far from improving, Australian diabetes amputation rates (amputations per 100,000 people) have increased 30% over the past decade.

Australia ranks poorly by international standards. While there are nine diabetes amputations per 100,000 people in the United Kingdom and an average of 12 in the developed world, ours is the second worst in the developed world, with 18 amputations per 100,000 people.

We can do more to reduce the rates of diabetes amputations and prevent the social and financial toll it takes on our community.

Lessons from abroad

Studies consistently show it’s possible to reduce diabetes foot-related amputations, hospitalisation and costs by 50% to 85% when best practice strategies are implemented. The United Kingdom and the Netherlands, for instance, have amputation rates about half of ours because these strategies are embedded into their health systems.

Put simply, these strategies focus on making sure doctors, nurses and, importantly, podiatrists work together as a team and use the best treatment tools. Podiatrists are health professionals who are specially trained to manage foot disease and research suggests are a lynchpin to managing diabetes foot disease.

Multidisciplinary foot care teams, and better use of podiatrists, have been consistently shown to prevent and heal many more foot ulcers than professionals working on these problems alone. The Netherlands has actually shown the more teams and podiatrists you have, the less amputations and hospitalisations you get.

But these teams also need the best tools to treat these problems. These include more effective wound dressings and devices to offload pressure such as moon boots, casts, insoles and special shoes.

This all sounds expensive. But large economic studies have found that if you paid for the best diabetes teams and tools in the world, and still only prevented 25% of these amputations and hospitalisations, the health system would still be ahead financially. This surplus comes from saving $13,000 per foot ulcer admission and $26,000 per amputation that you were paying before. And in human terms, untold harm is avoided.

Attempts to solve the problem

Studies in locations as diverse as Melbourne and Mt Isa have shown the same big reductions in amputation and hospitalisation, when using these same simple “teams and tools” strategies.

The Australian government even recommended these same “cost saving” strategies in the inaugural strategic diabetes report back in 1998 and claimed we could expect a 50% amputation reduction in a decade.

No less than ten expert national groups have since recommended these same strategies. And the National Health and Medical Research Council (NHMRC) endorsed the research base of these strategies in national diabetes foot guideline recommendations – twice. Yet, rates of diabetic amputation continue to rise.

So what’s the hold up? Unfortunately, only one half of these NHMRC diabetes foot guideline recommendations are funded by Medicare. Yet, in contrast, all the NHMRC guideline recommendations for other diabetes complications are Medicare funded.

Simple solutions

The first step is to publicly fund all NHMRC-guideline researched recommendations for diabetes foot management as they are (and rightly so) for other diabetes complications. The Medicare funding of these recommendations will provide the incentive for the many more foot teams and tools we so urgently need in our communities.

We also need to publish an annual national diabetes amputation rate. Studies suggest publishing these rates has driven change in other nations.

In fact, international groups are now monitoring national diabetes amputation rates as a key performance indicator of an “effective (national) health system”. So maybe it’s time for an Australian mydiabetes or myfoot website.

We’ve just seen the Denticare debate produce a much needed $4bn investment in Australia’s dental problem. It wouldn’t take a tenth of that invested into a national diabetes foot care program to prevent countless avoidable diabetes hospitalisations and amputations.

It’s time for a “Footicare” debate to break the silence on this national health challenge.

* Pete Lazzarini is Senior Research Fellow, School of Clinical Sciences at Queensland University of Technology, Shan Bergin is Senior Podiatrist at Dandenong Hospital Diabetic Foot Unit and High Risk Foot Clinic at Southern Health

This article was first published on The Conversation. A reminder to Croakey readers that TC articles are freely available for republishing under a creative commons licence.

The Conversation

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Australian Palliative Care Conference
2018 conferences
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