William Jeffcoate, MB, BChir compares and contrasts diabetic foot care in the United States and the United Kingdom. Dr Jeffcoate focuses on amputation rates in these countries and how each country is combating diabetic foot disease.
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William Jeffcoate, MB, BChir
Foot Ulcer Trials Unit, City Hospital
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Robert Frykberg: I’d like to introduce you all to Dr. William Jeffcoate who's going to give the Third Annual Paul Brand Memorial lecture, The Diabetic Foot Syndrome, A British Perspective. So let’s welcome Dr. Jeffcoate.
William Jeffcoate: Thank you Bob for that really generous and thoroughly undeserved introduction. I do actually have a tremendous sense of both humility and gratitude, humility both for having my name linked with Dr. Paul Brand but also in being invited to give this talk in his memory. Gratitude not just for the invitation but also for the fantastic hospitality, which I've enjoyed. And so having had my supper, I've now got to sing for it. Trouble is that when I sing, I'm occasionally a little bit provocative and if I am provocative, please bear with me and just pass it off as one of those funny things people do over there. I'm not really trying to be critical. I'm really just trying to stimulate thought and underneath it all of course is a continuing thing that drives me and that is the need for evidence of our job coming back which I’ll come back to and I'm afraid I'm going to disappoint you, Bob. I'm not going to talk about osteo. My life is all Charcot. But maybe tomorrow. Now when is my slides going to come? There we go. So I was asked to talk about The Diabetic Foot Syndrome, A British Perspective. I already have a problem with slide transfers which is what is parts in parcel of my - there we go. So The Diabetic Foot Syndrome, A British Perspective I guess is much the same as in American perspective. We see these things all the time plus of course Charcot foot and gangrene. It’s dealing with this complex multifaceted, complex etiological syndrome, series of different wounds which fascinates us. Fascinates us mainly because lots of other people, majority of healthcare professionals aren’t in the slide has been interested at all. Fascinates us because they are so frustrating and management is incredibly difficult and of course so uncertain. It’s been said many times and I’ll say it again. There is no denying that the management of the diabetic foot syndrome is definitely the Cinderella of diabetes care. And if diabetes is the Cinderella of medical care, then the foot would obviously come to the bottom of the heap. I like to think of when I'm talking about the ugly sisters, the cardiology and cancer, undertake all the people’s attention and all people’s money and poor old Cinderella is sitting down there in the ashes. But I want to introduce a new concept about this Cinderella, and that’s the fairy godmother, who I'm going to use to impersonate science. Because unless we actually look not just at the literature but look at the evidence from the literature and that’s what they care for and the way we assess the evidence which is presented to us and actually really improve the evidence base for what we do, then we’re not really going to drag the diabetic foot syndrome out of its present slough. The fairy godmother here portrayed by Walt Disney is a little bit plump really, whereas actually the evidence base is depressingly thin. But without the fairy godmother, the syndrome is not going to get to the ball. But I was asked to talk not just about diabetic foot syndrome but specifically about the British perspective, a British perspective. That’s my perspective. I'm not saying I speak for everybody else. Now there are differences across between the US and the UK. Perhaps the most critical one is the National Health Service established as the UK was rising like phoenix I could say as the ashes of the sycamore wore. This is Aneurin Bevan who was the administrator of health at the time.
He said the collective principle is the society can legitimately call themselves civilized if a sick person is denied medical aid because of lack of means. And of course this has got tremendous direct relevance to Obamacare, but I won’t comment on that in any more detail except to say that while your country is perhaps going down the road to which many people feel perhaps it should, our country is going in completely the opposite direction led by misguided politicians who are trying to break out the NHS and successfully are breaking up the NHS and converting it into an insurance-based healthcare system which will be inevitably divisive. End of political speech. Not quite the end. It was applause for what I said or applause for finishing it?
If it was for finishing it, I'm going to disappoint you. I did work for 10 years as contributing editor to The Lancet which might be why they publish my paper on there. Shocker, you never know, Bob. I, in that position, did have the privilege of being able to write commentaries from time to time. This one I wrote, I've been fighting this battle against the British government, not very successful impact with having a success at all for an awful long time and wrote this one when they force through a new contract for UK consultants and this was the title of it. I'm pleased to say, this was the most downloaded article from The Lancet in the whole of 2004. I'm rather proud of that. Care and despair in the UK NHS followed in 2005 and then mismanagement was a prelude to privatization in the UK just in 2006. The UK press has been depressingly deaf to these messages but this is last I think to wake up to what exactly they're going to need in the UK NHS, sadly far too late. But that’s because of this. That is the end of my political message. While we have the NHS, we have a healthcare system which has a quality of access and is free at the point of delivery. As far as foot syndrome is concerned, it does mean that when you're working in secondary care, you're likely to see an unselected population because by and large, secondary care centers will be looking after circumscribed population. London is a little bit different. But by and large, most the places you do is to look after a community as it were. You also have less variable and more consistent followup with people being less likely to phone up a different specialist as they're not entirely happy with how things are going. Also because we have a countrywide system, we also have countrywide databases such as the hospital episodes, statistic database. So it means that you can get realistic measures of outcomes when it’s relevant and I’ll come back to that at the end. Going back briefly to Cinderella and looking up costs just for evidences is really very thorough work which was undertaken two years ago by health economists in the UK. It costs something between 600 million pounds and 700 million pounds in the UK, it’s a billion dollars, which is 0.7 of the total healthcare budget of the NHS. That is a staggering proportion considering the way which is largely neglected by most healthcare professionals. So let’s carry on with the compare and contrast between the US and the UK. And I got this off the web and I acknowledged the source there, and I looked at this Union Flag or Union Jack, where these so-called names apply. I thought, that’s not right. This company can’t be British, but actually it is British. But they got it wrong. Just for your education, the Union Jack is a very funny shape and it has these white bits adjacent to the red bits but that is symmetrical and you’ve got to get it the way around us, the flagpole side and the broad white bit and the broad white bit and they’ve got it wrong there. So right in this. Alright, end of education episode. There are differences between your country and mine and in particular, it relates to the role of podiatrists, the thing where of course the majority in this country are surgically trained and in our country, foot care and diabetes is nearly always led by diabetologists who are not surgically trained. There are exceptions. But by and large, that is true and often working with more podiatrists, they tend not to be surgically trained. There were very small minority of.
So surgery is not part of the armamentarium of the frontline team and this is actually quite interesting because it does mean, look there is a completely different focus in the way the thoughts that are going through the minds of the carers when presented with the clinical problem. But the question is, do these differences matter. Let’s look at amputation statistics. Amputation is not the best measures as I’ll go on and describe a little bit in a second. But it’s actually just about the only thing that people do measure. Now what things do contribute to amputations? Well, racial and social factors, poor management of diabetes through the proceeding 15, 20 years or the person has gotten here obviously whether they smoke or not, they're more likely to have macrovascular disease, all sorts of comorbidities and other predisposing factors which might preserve, predispose them to trauma. Variable screening that detect risk even more variable, by which I mean almost nonexistent, system as it systematic attempts to try and reduce the risk to the foot once it has been identified. Then of course many ulcers are precipitated by an accident. Accidents by definition cannot be prevented. So if you can’t prevent it with education, and so you're always going to have this sort of unknown factor which you will come at some stage which will stop the onset of foot disease activity. Then the other factors which might contribute to the loss of the limb is the way in which the disease is managed in the early phases. But if a patient ignore it and hoping it would go away, which is what I would do, or do they go along straight long to their doctor and knock on the door and say, “Please can I be seen,” which is what people ought to do. And then it’s a matter of who sees them and what advice they give them, where they are given flu drops and sent, I suppose, and asked to come back in a week and then give med again. But where of course they should be referred to early specialist referral, and yet that doesn’t often happen. If they're seen by nonspecialist in secondary care then you also proceeds the need to refer people for early specialist assessment. Infection of course definitely makes things worse and then finally at the bottom of the ladder, you’ve got the specialist management and specialist services. So all sorts of things will contribute sort of some of those limb or not. So is it a good measure the quality of care? Well it’s quite a good measure really of the overall quality of care available to the person and community they live in. But the poor measure of the care of the individual clinician or the team, the clinician works and we have to remember, amputation isn’t a treatment. Now if we’re looking at cancer now of the colon, we don’t count colectomies. We don’t count mastectomies. We look at other measures which are realistic measures of the outcome of the natural history of disease and yet in the case of the foot, we count amputations. You know that’s not only, not a measure of the outcome, an endpoint of natural history but for so many people, early amputation may be the preferred treatment and the correct treatment. For others, amputation may never be ambulated even though the limb we know cannot be saved but it’s just not in their best interest. So following that introduction, what about amputation? The actual statistics themselves, who we wrote a paper 10 years or so ago looking at all the evidence we could find relating to the incidences of amputation all over the world and the literature and there are various tables. This is the one which relates to LEA. In other words, major plus minor amputations and all the different places. We selected populations which was studied more or less in the 1990s. The variation in incidence of LEA was 200-fold from the highest to the lowest. This obviously doesn’t mean all of Louisiana obviously. But particular high risk group in that particular study. But whatever the group or however you select the populations, there is 200-fold. Those data from Spain have never been repeated. They're very, very low. But even if perhaps unfairly we don’t consider that, it’s still a hundred fold. There's an enormous variation in the incidence of LEA worldwide. But when you look at the list, you have to be able to care for and the results must be expressed in terms of the at-risk population.
It has to be expressed in terms of people with diabetes. It doesn’t mean people with at-risk feet. It means in terms of the diabetes population. In many communities, people don’t know what the diabetes population is. They might know what the local population or the total population is, but that’s no good because we know the incidence and the prevalence of diabetes is increasing very fast. It’s very difficult then to get a meaningful impression of what the incidence of amputation in known diabetes is. So it has to be expressed in terms of the population of diabetes. It also should be from an unselected population. In other words, well what is the unselected population. I have a grievance about the term LEA. I think it doesn’t make sense at all to compare major amputation and minor amputation. Minor is done to save a foot, major is done to remove a foot which cannot be saved. It seems bunkers to combine the two and yet it is ever so popular. It gives you a bigger number of course and so it looks good in the first paragraph, the introduction or in grand applications. But medically, I think it’s meaningless. I suspect that 9/10 of the audience disagree with me. Major amputation is therefore what I tend to concentrate on and again, there are varying definitions of major but I prefer the one of above the ankle. If you got healthcare provider there, one of the disadvantages of not having an nationalized health service is that you are limited to healthcare provider data. They are inherently selected as you know full well. So go back to these tables and that paper I wrote 10 years ago. I now just look at the major amputations. You can see that the incidence of these were the only papers we could find relating to it. Again, the incidence of major amputation per thousand people with diabetes at risk per year range from 0.06 in this one study in Madrid. Sorry, those are both the same study, 234 per thousand and then higher incidences in particular groups in the US. So assessment to the published data, so I've been through all those but let’s just look at this last one now, healthcare provider data inherently selected, whether it’s VA, whether it’s Medicare, whether it’s particular institutions. And you can’t extrapolate from those necessarily. The information which is most useful when you look at those is when comparisons are made within that system which is being studied. If we look at the issue of regional variation in the incidence of amputation, Jim Wrobel produced this paper in 2001 referring to major amputation, Medicare people throughout the US and you can see there were light bits and there were dark bits. Dark bits are higher incidence and the white bits are better incidence, lower incidence. But overall he found that between the HRRs, there was an 8.6-fold variation between them in the incidence of major amputation and overall the incidence of amputation was 3.83 per thousand. We have much more recently looked at this in the UK and we looked at PCTs, primary care trustees who administered groups which link general practitioners in the UK in the sort of birth of this quasi-market and privatization which is on the way. There's buying and selling and business. When we compared the incidence of major amputation between PCTs in the UK, we found there was tenfold variation between the lowest and the highest. Here the highest are in dark red and the lowest are white or pale yellow. This is a staggering statistic. We've certainly hit the BBC News. In this sense, in your country and my country share appallingly high and surprising variation in the incidents of limb loss for diabetes. But when you undertake orders like this, it’s not to find fault with people. It’s not to punish them or to praise them but what we’re really looking for is reasons why the variation exists. Because if we can eliminate variation, then we will find that the performance of clear medical services overall will improve and outcome will be better. Now there are some associations which we know are linked to amputation, social deprivation is one, and show you some of the UK data coming from the UK National Diabetes which are returned to towards the end.
Looking at the quintiles of deprivation based on people’s post code, ZIP code or where they live and you'll see that when compared with the least deprived quintile, those in the first, second and third quintile was significantly more likely to lose a limb as a result of diabetes even though access to primary care is equal in our country at least, thought to be. Then we brought the issue of race, we’re very familiar with those. But you may not know and you may not have seen the UK data. If you compare the incidence of major amputation with white ethnic groups as one, the incidence in South Asians, that’s people basically racially from the Indian subcontinent, India, Pakistan, Bangladesh, you will see that their incidence is 1/4 of white Caucasians and blacks is a 1/2. This of course contrast quite markedly with the US data. There had been many papers showing the incidence of limb loss in racial minorities is higher than it is in Caucasians in the US. This is a recent one looking at the Medicare population, a very large number of people of whom 12.7% were African Americans. That population was divided into low risk and high risk foot groups and the prevalence of people who have an amputation who are African American was 64% in one group and 72% in the other. Staggeringly high when the prevalence was only 12.7 in the total population. I think there's a problem there which presumably relates to social deprivation and access to effective primary care but it’s important that obviously it must be tackled. So they're independent associations with social, they're independent in UK and social deprivation and race, although race goes both ways but other factors may also be important in explaining this variation which we have in the incidence of limb loss. In particular, it’s decision making. We believe decision making by us. I showed you this graph at the beginning and there were four census in the UK. These four census where we have the data from the 1990s on the incidence of amputation all took part in an international study ran by a prominent diabetologist called George Alberti and because he was based in UK, he gave one of his boys the job of looking at local places in the northeast in particular and recruiting them into this international study. When they just looked at the UK data, they found that the incidence of LEA varied fourfold between Leicestershire and Middlesbrough. The people at least were intrigued with this and after the study was published looked into the reasons why this might be and they produced cases which they’ve presented to the vascular surgeons in three of the four centers, the four center wouldn’t actually play ball. When they looked at the results of the three centers, they found that the opinions of the vascular surgeons differed significantly in how the people ought to be managed and they concluded variations in clinical decision making made by vascular surgeons that do most of the amputations in the UK giving the same patient a likely to explain at least a part of the reserved geographical variation. That’s been very politely worded for meaning the vascular surgeons actually differ in their opinions quite considerably. In the US, David Margolis produced this other paper just over a year ago, or just two years ago in which he looked and it’s called location, location, location using again the Medicare data and looking at HRRs and this is the map across the US where the good high spots and low spots. What he did was to pair adjacent high spots and to pair the adjacent low spots and when one high spot was next door to another high spot, he produced a map of hotspots which is where there is a very high particular incidence of limb loss for diabetes. I just went the wrong way. On the other hand, there are areas including Arizona where the incidence found diabetes seems to be particularly low and he extrapolated from this and draw the conclusion that actually this might be because you’ve got groups of doctors acting there who've all been trained in a particular area or at least have their identical practice reinforced by working with local colleagues.
This neighborhood effect could easily have an effect on how modulating people’s professional opinions. Another particular detail which isn't directly relevant to the main thread of what I'm saying is this high-low amputation thing which came out, Jim Wrobel, David Armstrong, I've forgotten the third author just under 10 years ago suggesting that if you, and again they looked at the Medicare data, an awful lot of minors and an awful lot majors and they actually looked at the ratio of majors to minors and they found that in some places you had a very high incidence of high amputations. In other words, major amputation compared with minors. In others, they were more or less equal or in that sort of half. So half as many. There was a direct correlation now. Value was quite low but because the numbers were so enormous the P value was very high. They drew this, they suggest, well this is evidence that if you do more minor amputations, you will actually save the limb, which is loadable except if you look at the UK, it doesn’t apply. So this was again the data we did collecting data which in 2007, 2010 and annualizing them and this shows major amputation per thousand people with diabetes up there and minor amputation per thousand people with diabetes and each of these is a PCT. So it’s the geographical thing again. You'll see, there's a direct correlation. In other words, the high-low rule doesn’t apply in this country and in fact, the reverse is true in the UK. There are areas where people do a lot of operations whether it’s minor or major and there are other areas where they don’t do a lot of operations. This might be a factor contributing to variation in amputation. So we've got variation in both US and UK partly explained by differences in race and deprivation. Other factors I'm not too sure about. But we believe to a large extent differences in the training, the culture and beliefs of us. What are we going to do about it? Well, it would be nice to know how good we are, who here thinks their service is good? Who here knows their service is good? Two brave souls.
Doesn’t include me. I'm the faintest idea how good our service is. Who knows they're bad?
Yeah, well you're not going to put your hand up anyway. We don’t know. We can believe but we don’t know unless we have systemically compared with other centers and maybe the two who put out their hands have. So how good are we? How are we better worse than in other service? How much are differences if we do find differences better or worse? Are they related to our beliefs and how can we find out? Well, we can compare performance with other centers. We did one a few years ago where we looked at different centers and we looked in these different centers in different countries and starting with Karachi. Pakistan is a particular country which is where one of those where if you have a diabetic foot problem, it is just a disaster. There's no health service. Eighty percent of the population earn less than US $2 a day. The average total family spending is $49 a month, that's a total extended family spend $49 a month on everything. If they get a simple, superficial, infected lump or neuropathic ulcer, that will cost them $15, which is of course a third or whatever it is of their family expenditure. If they’ve got an infected deep wound, an ischemic infected deep wound, then the cost is five months of the total family expenditure. It is a complete disaster for an impoverished community. When you look at these differences between us, you'll see that this country has a very high prevalence of type 2. They tend to be younger and most of the other things are the same expect loss to followup. People who try and study especially in this particular unit in a private hospital which does its best to provide a good service, a third of that population are lost. Darussalam was formed as a socialist state of course by [indecipherable] [30:00].
It is now still largely socialist. They still have high prevalence of type 2, still low age population. But people cannot afford the antibiotics. They're entitled to see a doctor, but they can’t afford the achievements which they have to have, and so they also have a very high DNA rate. We compared it with [indecipherable] [30:21] in North Germany and him obviously much more similar communities to our own so you got an older population. This is actually a private Catholic hospital where Stephan Morbach works. I'm not sure if that’s the reason for high because it’s a Catholic religious hospital, whether that’s the reason why there are more women than we’re used to seeing because nearly always two to one in most areas that are done. But look at this, the incidence of resolved of amputation, 19% compared with ours, 8%. Persisting unhealed at 12 months, zero. So that makes me think, well maybe they're right. Maybe I just keep on tethering and I'm not actually providing the best service for these people. So that's comparing service with other centers. You can also compare performance with overtime. This is the chart I showed you in the beginning of major amputations per 10,000 at risk in the 1990s. We’ve got Middlesbrough, Medicare, Jim Wrobel study and Ipswich. Middlesbrough is a sort of fairly not well-off town up there served by a single hospital. Ipswich is a bit of a mixed population but also served by a single hospital. So they were serving the whole community. Middlesbrough was one of the four centers involved in that international study. They were so horrified that they were so high. They set about setting up a specialist foot care unit. In 1995, the incidence of ulceration and limb loss was three per thousand. In four years, they reduced it to 0.76. They didn’t have any schmancy fancy products. They didn’t have new radiologists. They just change the way they were working and they made sure that people saw them quickly and that they together work as a team and induce this tremendous change. They weren’t the only one exactly the same year, Ipswich four per thousand per year. In five years to 2000, they dropped the incidence to 0.6 and that was maintained for a further five years, to 2005. In other words, by exactly the same, and this is more evidence that actually when there are highs and lows, of the extent to which it actually reflects our behavior. If we can just change our behavior in the space for a couple of months, change the way our services give and you have this traumatic of change effects on clinical service. I'm going to skip over that one. So, the average incidence of major amputation in England now is about one per thousand and it was three in a bit. When I showed you this chart of variation, I didn’t draw your attention to the key, it’s variation but within a much, much lower range than the numbers we were talking about in the mid-1990s. Recent data in diabetes care, last Christmas showing those data from Scotland and collected in a different way, exactly the same. And in the USA also has been a four, from three in a bit, down to 1.3. These are the latest data I could find from CDC. BKAs were in green, AKAs are in the yellow and it’s just those numbers we’re talking about and living at midfoot surgery and toes and just looking at those and that’s why the 1.3. In fact, looking at this chart, it looks like more than 1.3 but that’s the number they came up with. But it’s still come down appreciably. But when you look at these numbers coming down, the apparent improvement in the incidence of amputation and people with diabetes, you got to remain, remember an awful lot of other things have been happening in the last 15 years, in particular there's much more systematic screening for diabetes in different countries and therefore much more detection of early diabetes, not so bad diabetes and that can obviously have an impact on such a thing if you're trying to express the incidence of amputation against your total population and people with known diabetes. Also people have been changing the way in which we make the diagnosis. It’s becoming increasingly more stringent, in other words, people with lesser degrees of glucose intolerance are now called diabetes and that’s also would have an impact on this declining incidence.
But the main message is that if we can minimize variation, outcome will improve still further and I think we ought to be down at about 0.6 or 0.7. Nationalized health service, I'm conscious I've gone on too long Bob, is that alright? You're not going to shoot me for two minutes, two minutes. Nationalized health service makes you technically feasible to carry out countrywide data. We have a national diabetes ordered in England and Wales which actually collects data from GPs electronic records. They're anonymized. That gives us a profile of 80% of people, 88% of all people in the UK, sorry in England and Wales who are known to have diabetes. We’re now in this new year we hope we’re anticipating government confirmation of funding which we've been promised will be starting a collection of data on the management of every person with foot disease in the UK, we’ll be able to link that with data on the structure of healthcare where they’ll manage and on the demographic data which we already have and that will give us the information that we need to provide comprehensive data on every episode in England and Wales linking eventually to reduction in incidence of amputation. So it’s a recap, we have different services. Yours is more surgical at the frontline than ours is. We have a National Health Service for the moment. When you analyze amputation data, you got to be very careful about what you look at. There is tenfold variation incidence in major amputation in the UK and there's 8.6-fold or there was in the USA. But the overall number is declining rapidly. When this variation that race plays a part, deprivation declaration plays a part, well I believe that actually medical opinions play a much greater part and that’s why I'm going to finish. Thank you very much.