Pé diabético: avaliação da evolução e custo hospitalar de pacientes internados no conjunto hospitalar de Sorocaba

Annual Direct Medical Costs of Diabetic Foot Disease in Brazil: A Cost of Illness Study

The aim of this study was to estimate the annual costs for the treatment of diabetic foot disease (DFD) in Brazil. We conducted a cost-of-illness study of DFD in 2014, while considering the Brazilian Public Healthcare System (SUS) perspective. Direct medical costs of outpatient management and inpatient care were considered. For outpatient costs, a panel of experts was convened from which utilization of healthcare services for the management of DFD was obtained. When considering the range of syndromes included in the DFD spectrum, we developed four well-defined hypothetical DFD cases: (1) peripheral neuropathy without ulcer, (2) non-infected foot ulcer, (3) infected foot ulcer, and (4) clinical management of amputated patients. Quantities of each healthcare service was then multiplied by their respective unit costs obtained from national price listings. We then developed a decision analytic tree to estimate nationwide costs of DFD in Brazil, while taking into the account the estimated cost per case and considering epidemiologic parameters obtained from a national survey, secondary data, and the literature. For inpatient care, ICD10 codes related to DFD were identified and costs of hospitalizations due to osteomyelitis, amputations, and other selected DFD related conditions were obtained from a nationwide hospitalization database. Direct medical costs of DFD in Brazil was estimated considering the 2014 purchasing power parity (PPP) (1 Int$ = 1.748 BRL). We estimated that the annual direct medical costs of DFD in 2014 was Int$ 361 million, which denotes 0.31% of public health expenses for this period. Of the total, Int$ 27.7 million (13%) was for inpatient, and Int$ 333.5 million (87%) for outpatient care. Despite using different methodologies to estimate outpatient and inpatient costs related to DFD, this is the first study to assess the overall economic burden of DFD in Brazil, while considering all of its syndromes and both outpatients and inpatients. Although we have various reasons to believe that the hospital costs are underestimated, the estimated DFD burden is significant. As such, public health preventive strategies to reduce DFD related morbidity and mortality and costs are of utmost importance.

Lower limb self-care among diabetic insulin users

Abstract Introduction: Lower limb neuropathy is one the complications of diabetes mellitus and the most common cause of lower limb amputation. Hence information and self-care advice should be provided to primary healthcare patients to prevent this condition. Objective: To explore insulin users’ knowledge of foot self-care. Methods: This quantitative, descriptive, exploratory study was conducted at a Family Health Unit Curitiba-PR of Curitiba, PR, Brazil. The study sample comprised 63 insulin users. Data were collected through a structured questionnaire. Results: Although they reported performing self-care activities, 67% (n = 42) of insulin users declared that they had never received any information on foot self-care. Conclusion: The adherence to self-care practices shown by respondents and the patient empowerment observed in this study indicate the effectiveness of the information on diabetes self-care imparted to patients registered at this health care unit in contributing to the promotion of quality of life.

Growth factors for treating diabetic foot ulcers

BACKGROUND

Foot ulcers are a major complication of diabetes mellitus, often leading to amputation. Growth factors derived from blood platelets, endothelium, or macrophages could potentially be an important treatment for these wounds but they may also confer risks.

OBJECTIVES

To assess the benefits and harms of growth factors for foot ulcers in patients with type 1 or type 2 diabetes mellitus.

SEARCH METHODS

In March 2015 we searched the Cochrane Wounds Group Specialised Register, The Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library), Ovid MEDLINE, Ovid MEDLINE (In-Process & Other Non-Indexed Citations, Ovid EMBASE and EBSCO CINAHL. There were no restrictions with respect to language, date of publication or study setting.

SELECTION CRITERIA

Randomised clinical trials in any setting, recruiting people with type 1 or type 2 diabetes mellitus diagnosed with a foot ulcer. Trials were eligible for inclusion if they compared a growth factor plus standard care (e.g., antibiotic therapy, debridement, wound dressings) versus placebo or no growth factor plus standard care, or compared different growth factors against each other. We considered lower limb amputation (minimum of one toe), complete healing of the foot ulcer, and time to complete healing of the diabetic foot ulcer as the primary outcomes.

DATA COLLECTION AND ANALYSIS

Independently, we selected randomised clinical trials, assessed risk of bias, and extracted data in duplicate. We estimated risk ratios (RR) for dichotomous outcomes. We measured statistical heterogeneity using the I(2) statistic. We subjected our analyses to both fixed-effect and random-effects model analyses.

MAIN RESULTS

We identified 28 randomised clinical trials involving 2365 participants. The cause of foot ulcer (neurologic, vascular, or combined) was poorly defined in all trials. The trials were conducted in ten countries. The trials assessed 11 growth factors in 30 comparisons: platelet-derived wound healing formula, autologous growth factor, allogeneic platelet-derived growth factor, transforming growth factor β2, arginine-glycine-aspartic acid peptide matrix, recombinant human platelet-derived growth factor (becaplermin), recombinant human epidermal growth factor, recombinant human basic fibroblast growth factor, recombinant human vascular endothelial growth factor, recombinant human lactoferrin, and recombinant human acidic fibroblast growth factor. Topical intervention was the most frequent route of administration. All the trials were underpowered and had a high risk of bias. Pharmaceutical industry sponsored 50% of the trials.Any growth factor compared with placebo or no growth factor increased the number of participants with complete wound healing (345/657 (52.51%) versus 167/482 (34.64%); RR 1.51, 95% CI 1.31 to 1.73; I(2) = 51%, 12 trials; low quality evidence). The result is mainly based on platelet-derived wound healing formula (36/56 (64.28%) versus 7/27 (25.92%); RR 2.45, 95% 1.27 to 4.74; I(2) = 0%, two trials), and recombinant human platelet-derived growth factor (becaplermin) (205/428 (47.89%) versus 109/335 (32.53%); RR 1.47, 95% CI 1.23 to 1.76, I(2)= 74%, five trials).In terms of lower limb amputation (minimum of one toe), there was no clear evidence of a difference between any growth factor and placebo or no growth factor (19/150 (12.66%) versus 12/69 (17.39%); RR 0.74, 95% CI 0.39 to 1.39; I(2) = 0%, two trials; very low quality evidence). One trial involving 55 participants showed no clear evidence of a difference between recombinant human vascular endothelial growth factor and placebo in terms of ulcer-free days following treatment for diabetic foot ulcers (RR 0.64, 95% CI 0.14 to 2.94; P value 0.56, low quality of evidence)Although 11 trials reported time to complete healing of the foot ulcers in people with diabetes , meta-analysis was not possible for this outcome due to the unique comparisons within each trial, failure to report data, and high number of withdrawals. Data on quality of life were not reported. Growth factors showed an increasing risk of overall adverse event rate compared with compared with placebo or no growth factor (255/498 (51.20%) versus 169/332 (50.90%); RR 0.83; 95% CI 0.72 to 0.96; I(2) = 48%; eight trials; low quality evidence). Overall, safety data were poorly reported and adverse events may have been underestimated.

AUTHORS' CONCLUSIONS

This Cochrane systematic review analysed a heterogeneous group of trials that assessed 11 different growth factors for diabetic foot ulcers. We found evidence suggesting that growth factors may increase the likelihood that people will have complete healing of foot ulcers in people with diabetes. However, this conclusion is based on randomised clinical trials with high risk of systematic errors (bias). Assessment of the quality of the available evidence (GRADE) showed that further trials investigating the effect of growth factors are needed before firm conclusions can be drawn. The safety profiles of the growth factors are unclear. Future trials should be conducted according to SPIRIT statement and reported according to the CONSORT statement by independent investigators and using the Foundation of Patient-Centered Outcomes Research recommendations.

Validação de intervenções de enfermagem em pessoas com diabetes mellitus

Estudo descritivo e exploratório que objetivou validar as intervenções de enfermagem propostas pela Nursing Interventions Classification para os diagnósticos de enfermagem: Integridade da pele prejudicada, Conhecimento deficiente e Controle ineficaz do regime terapêutico predominantes em pessoas com diabetes. Participaram 21 enfermeiros especialistas em diabetes mellitus no Brasil, em 2007. As intervenções de enfermagem que obtiveram a maior média ponderada foram cuidado com lesões: drenagem fechada, precauções circulatórias para o diagnóstico de enfermagem Integridade da pele prejudicada, ensino: processo de doença, ensino: medicação prescrita para o Conhecimento deficiente e ensino: processo de doença e ensino: dieta prescrita para Controle ineficaz do regime terapêutico. Dentre as 1005 atividades de enfermagem, 51% foram validadas como muitíssimo características pelos especialistas. Acredita-se que outros estudos devam ser conduzidos para ampliar a validação das intervenções de enfermagem em pessoas com diabetes mellitus no Brasil, buscando evidências científicas para o cuidado dessa clientela.

Hipertensão arterial e diabetes na Estratégia de Saúde da Família: uma análise da frequência de acompanhamento pelas equipes de Saúde da Família

O objetivo deste estudo foi avaliar a média anual do cadastro de diabetes e hipertensão e o correspondente nível de acompanhamento pelas equipes de saúde da 13ª Coordenadoria Regional de Saúde (13ª CRS). O estudo é do tipo descritivo-exploratório. Utilizou-se o teste t de Student para verificar diferenças entre o cadastro e o acompanhamento da hipertensão e diabetes para cada município. Considerou-se diferença estatisticamente significativa somente para p<0,05. O acompanhamento dos casos de hipertensão e de diabetes pelas equipes de saúde não correspondem à média anual de cadastro nos diferentes municípios da 13ª CRS. Os municípios da 13ª CRS apresentaram um menor nível de acompanhamento anual pelas equipes de saúde em relação à média geral de cadastros de hipertensão (cadastro: 37,3 ± 2,4 versus acompanhamento: 28,0 ± 2,1; P<0,05) e diabetes (cadastro: 7,2 ± 0,6 versus acompanhamento: 5,7 ± 0,5; P<0,05). Dentre os municípios analisados, Venâncio Aires apresentou o menor percentual de acompanhamento nos casos de hipertensão (50%) e diabetes (55%) em relação aos demais municípios. Verificou-se um reduzido acompanhamento de diabetes e hipertensão pelas equipes de saúde na 13ª CRS.

Predicted annual costs for inpatients with diabetes and foot ulcers in a developing country-a simulation of the current situation in Brazil

AIMS

The objective of this cost-of-illness analysis was to quantify the annual costs associated with hospital admission for people with diabetes and foot ulcers in Brazil.

METHODS

A hypothetical cohort was simulated using a decision tree model. Prevalence and incidence rates and clinical outcomes were estimated from published studies and applied to the general Brazilian population over 30 years. Costs were quoted in Brazilian real (BRL) and converted to US dollars ($US) at the 2008 currency exchange rate ($US1 = BRL 1.64). In the sensitivity analysis, we reduced and increased rates to assess the robustness of the cost estimates.

RESULTS

In this hypothetical cohort there are 6.48 million (95% confidence interval 4.47-7.12) Brazilians citizens with Type 2 diabetes. Each year, approximately 323,000 (89,500-484,500) of these people develop foot ulcers and almost 97,200 (17,900-169,600) require hospital admission as a result. Each year, almost 46,300 (8500-80,900) limb amputations and 12,400 (2300-21,700) deaths occur as a result of diabetic foot disease in Brazil. The annual cost associated with these hospital admissions is estimated to be almost $US264m ($US51m-461m). The estimated cost for patients with amputation is nearly $US128m ($US24.5m-222.3m).

CONCLUSIONS

Our model shows that the social and economic impact of diabetic foot disease in Brazil is high. Government decision makers should reflect on the current situation and provide organized foot care throughout the whole country.

[Nursing diagnoses for diabetic patients using insulin]

This is a descriptive study with a qualitative approach that has as objective to identify the nursing diagnoses of diabetic patients using insulin, having as inquiry method the study of multiple cases. The data were obtained by the researcher by means of physical examination and the technique of interview directed in the instrument based on the Orem's Self-Care Theory. After data collection, the diagnostic indentification was proceeded from the nominated nursing diagnoses of NANDA Taxonomy II, using Risner's reasoning diagnostic process. The identified nursing diagnoses with a higher frequency than 50% were six: impaired skin integrity (100%), risk for infection (100%), behavior of health search (57,2%), disturbed sleep (57,2%), chronic pain (57,2%) and risk for peripheral neurovascular dysfunction (57,2%). The application of the nursing process based in Orem and the importance of the identified diagnostic for clients nursing care were evidenced.

Perfil de diagnósticos de enfermagem em pessoas com diabetes segundo modelo conceitual de Orem

OBJETIVO: Identificar os diagnósticos de enfermagem em pessoas com diabetes mellitus, segundo o modelo conceitual de Orem. MÉTODOS: Participaram 31 pessoas com diabetes atendidas em um Centro Universitário de Pesquisa e Extensão, do interior paulista, em 2006. Os dados foram obtidos por meio de exame físico e entrevista dirigida de casos múltiplos. Os diagnósticos de enfermagem foram identificados segundo a Taxonomia II da NANDA, mediante o processo de raciocínio diagnóstico de Risner. RESULTADOS: Dos 37 diagnósticos de enfermagem, três apresentaram freqüência superior a 50%: controle ineficaz do regime terapêutico (67%), conhecimento deficiente (51%) e integridade da pele prejudicada (51%). Dezoito diagnósticos de enfermagem estavam relacionados aos requisitos para o autocuidado universal, preconizado por Orem CONCLUSÃO: Os diagnósticos de enfermagem mostraram-se indicadores diferenciados para guiar as ações educativas do enfermeiro com enfoque no desenvolvimento das habilidades de autocuidado para pessoas com diabetes.

Internações por pé diabético: comparação entre o custo direto estimado e o desembolso do SUS

Foram seguidas 109 internações de pacientes com diabetes e ulcerações nos pés na rede do Sistema Único de Saúde (SUS) em Sergipe, com o objetivo de estimar o custo direto hospitalar e comparar com os valores do desembolso do SUS. Os dados foram coletados desde a admissão até a alta ou o óbito dos casos incluídos, sendo anotadas as características clínicas dos pacientes e os desfechos das internações. Foram calculados o custo direto estimado e o desembolso do SUS. Todos eram portadores de diabetes tipo 2 e a maioria das ulcerações (64,2%) foram classificadas como Wagner 4 ou 5. Evoluíram com alta sem amputação 43 pacientes (39,4%) e 52 (47,7%) com alta após amputação. Evoluíram para óbito 14 pacientes (12,8%). O custo estimado variou de R$ 943,72 a R$ 16.378,85, com média de R$ 4.461,04. O valor do desembolso do SUS variou de R$ 96,95 a R$ 2.410,18, com média de R$ 633,97, cerca de sete vezes inferior. As menores defasagens entre os custos ocorreram nos pacientes assistidos no Hospital Beneficente e as maiores naqueles tratados com amputações menores.

Avaliação do conhecimento de medidas preventivas do pé diabético em pacientes de Rio Branco, Acre

O pé diabético é uma das principais complicações do diabetes mellitus (DM), de alto impacto sócio-econômico, caracterizado por lesões decorrentes de neuropatia, isquemia e infecção. Para analisar o conhecimento sobre medidas preventivas do pé diabético em portadores de DM tipo 2 (DM2) em instituição de saúde pública, Rio Branco, Acre, entre agosto/2002 e fevereiro/2003, foram avaliados 109 pacientes (71,6% do sexo feminino) quanto à história clínico-epidemiológica, dados demográficos, atitudes de controle do DM e cuidados preventivos do pé, antes e após aplicação de programa educativo (álbum seriado e folders). Houve melhora significativa do conhecimento sobre cuidados preventivos do pé diabético após o programa (p< 0,0001), assim como de atitudes de controle do DM (p< 0,0001). Conclui-se que a população avaliada desconhece as medidas preventivas do pé diabético e do controle glicêmico. A utilização de programas de educação, facilmente reprodutíveis nos centros de saúde, pode colaborar na redução das taxas de amputação de membros inferiores em pacientes com DM.