FINANCIAL SUPPORT KEY FOR DIABETES FOOT CARE

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

• 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

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

• 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

• Self expenditure
• Charity – potentially a non self
fuelling way of solving health care
issues

Two Thirds of Healthcare Spending is out of Pocket,
0% 10% 20% 30% 40% 50% 60%
PP
PC/NC
OP
PHC
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.

• 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,
• 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.

• 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.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

WHY DIABETIC FOOT
INFECTIONS ARE TREATED
LATE?

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
0
10
20
30
40
50
60
70
80
90
1st Qtr 2nd Qtr 3rd Qtr 4th Qtr
East
West
North

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.
1. 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.

FINANCIAL SUPPORT KEY FOR DIABETES FOOT CARE

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