Half of amputations carried out by the HSE are preventable
Today, TDs heard that 50% of lower limb amputation surgery carried out by the HSE in 2008 could have being prevented.
Lower limb amputation is one of the potential complications of long term poorly controlled diabetes further aggravated by the absence of regular screening of diabetes patients at risk of foot complications and the lack of early intervention by podiatrists in those patients requiring specific treatments.
In 2008, 338 diabetes patients had lower limb amputation procedures accounting for 50% of the total number of procedures carried out with 29 of those patients of working age, all of which were potentially preventable. At an inpatient cost of approximately €30,000 per procedure, the cost to the exchequer of carrying out this procedure on diabetes patients was €1.1m in 2008.
In each of the previous three years the costs were €1m for 334 patients in 2007, €852k for 284 patients in 2006 and €954k for 318 patients in 2005 respectively.
When ongoing direct outpatient costs, social welfare costs, housing alteration costs etc are added to this figure the final cost to the Exchequer is huge and unnecessary.
At the presentation by the Diabetes Federation of Ireland, TDs were informed of a new model of care that would prevent this level of lower limb amputations in people with diabetes.
Consultant Endocrinologist Dr Sean Dinneen of Galway University Hospital proposed a model of care that would see a podiatrist linked to each diabetes clinic who would train their local GP practice nurses to undertake routine foot screening and quickly refer patients at risk thus ensuring early and timely intervention and recovery.
In his ongoing Diabetic Foot Research study in Galway, preliminary findings suggest that identification of the at-risk foot does not require intense training or high-tech equipment. Screening assessments can be easily performed in 15 to 20 minutes by trained practice nurses as part of the patient’s annual check-up.
However, it is important that this service is seen as the first step of an integrated diabetes footcare pathway. It is vital that primary care staff have the back-up of community podiatry services and the specialist diabetes footcare team so that high risk patients can be managed appropriately and patients referred for emergency care of active foot lesions can receive prompt specialist treatment.
The report of the HSE’s Diabetes Expert Advisory Group (DEAG) recommends that for the population of Ireland a total of 90 to 100 full time podiatrists are needed for diabetes footcare. This works out at 2 x WTE podiatrists (for diabetes) per 100,000 of total population
However, cognisant of the current economic climate, the DEAG recommended that there should be an immediate priority to fund 1 WTE podiatrist in each hospital diabetes centre around the country giving a total of 20 new positions. Using the proposed model of care this would provide a focussed foot service in many parts of the country. The cost of this would €1,569,040 (just over €1.5m) per annum.
Dr Dinneen said “we are not looking for new money here. All we are asking is for the Department of Health and the HSE to seriously look at this model of care as a creative option that will provide podiatry resources at the coal face to prevent unnecessary lower limb amputations in diabetes patients each year”.
Last year, the Government supported the setting up of the first School of Podiatry in the country. This is being delivered as a joint effort between NUI Galway and the HSE. There are approximately 25 students per year attending the school who will need jobs on graduation or the system will lose them to other national health services.
The most common cause of hospitalisation among patients with diabetes is diabetic foot disease (ulcer, infection, deformity, advances neuropathy and amputation). These are the most costly complication of diabetes.
Foot disease affects mobility, quality of life and is associated with a high risk of lower limb amputation. The risk of amputation in a patient with diabetes is 20 to 40 times higher than a non-diabetic patient.
Dr Diarmuid Smith, Consultant Endocrinologist and Chair of the Diabetes Section of the Irish Endocrine Society said “it makes sound economical and medical sense to put this model of care into place now. The money is already being spent but at the wrong end of the healthcare chain. If this money was spent as a preventative measure rather than as a reactionary measure, diabetes patients would be so much healthier”.
Deputy Ciaran Lynch TD who organised the presentation added “What is frightening is that year on year, diabetes patients account for around 45-50% of the total number of patients requiring lower limb amputations in the country. More shocking is that it accounts for more than a third of patients under 65 years of age requiring amputations which in most probability could have being avoided if there was access to appropriate podiatry care. Here we have eminent consultants showing us a straightforward cost effective solution to fix this issue. I will be taking this up with Minister for Health and Children as a matter of urgency”.
The Diabetes Community sees the development of diabetes podiatry services as a key and immediate priority in a National Diabetes Service Framework. The HSE report recommends the creation of 20 full time podiatrists (one per hospital diabetes centre nationwide). Yet nothing is being done to implement this recommendation.
The Diabetes Federation of Ireland also provided free diabetes screening to Dail Members and Leinster House staff as part of numerous events to mark World Diabetes Day.