>> Since 2011, 1,439 insured people suffering from diabetic foot syndrome have been cared for in the “DFS care program” by 26 doctors at 16 locations, with some blind spots spread across the Berlin city area. With success: According to the 2015 survey of insured people by AOK Nordost, more than 90 percent of participants in the care program were satisfied, positive evaluation results were published in MVF in 2016 and the MSD health award was accepted in the same year. Does this make the world okay? Not even close!
The top management of the fund has been thinking about this for years, says Dr. Werner Wyrwich, Head of Indications at AOK Nordost, possible options for improving care: This starts with the regional expansion of selective contracts, continues through a stronger representation of the DFS care approach in the DMP Diabetes and extends to “rolling out” into standard care through KV remuneration agreements. The problem is that in Germany there is no mechanism of any kind that would help to transfer innovative care improvements - which have clearly shown that they work - into standard care. What makes matters worse is that there is no obligation for the health insurance companies to adopt positively evaluated care approaches (for example in the form of a license) and then make these available to their own insured persons. The text of the law simply states that the insured person is entitled to medical treatment, including medical, dental and psychotherapeutic treatment, the supply of medicines, bandages, remedies and aids, home nursing care, hospital treatment and medical rehabilitation services and other services count. According to Section 12 SGB V, these services only have to meet the cost-effectiveness requirement and must therefore be sufficient, appropriate and economical and must not exceed what is necessary. In connection with this so-called “cost-effectiveness requirement”, many statutory health insurance companies are of the opinion that there is no entitlement to the best possible care, but only to adequate basic care.
Not the AOK Nordost. “We have employees with a high level of understanding for the patients insured by our fund,” says Wyrwich, proud of “having employees who deal with a topic like DFS in depth.” So intensively that when they were evaluating routine data, they noticed that there must be something wrong in the DMP documentation if either a patient had to be amputated with documented Wagner stage 0, or with high Wagner stages such as 4 (see Fig. 1) no amputations occur.
“In the more in-depth analysis of the data, we were able to determine,” continued Wyrwich, “that around 1,000 of our insured persons could not be proven to have their feet examined once.” But this also means that the foot status is not, contrary to the requirements of the corresponding DMP was collected regularly, the documentation was either completely missing or implausible and as a result the actually necessary referrals to specialist doctors did not take place.
One possibility would of course have been to relaunch the AOK Nordost diabetes type 2 disease management program in order to be able to set certain qualitative priorities. According to Wyrwich, the serious disadvantage of DMP is the lack of leeway given to health insurance companies and service partners by the “very rigid legal regulations” and which therefore offers limited opportunities to make individual adjustments. In addition, DMP contracts in the statutory health insurance system are usually concluded across health insurance companies - this often leads to a minimal consensus that does not adequately take regional peculiarities into account. Selective contracts, on the other hand, definitely have this potential and the opportunity to address supply-specific problems in order to “provide the right measures for the right insured people “the right partners” to develop.
Based on the PDCA cycle (Plan, Do, Check, Act), measures were therefore developed on the basis of reliable data and their implementation was undertaken: now with permanent individual contracts with - as of today - 26 established Berlin doctors who contractually focus on two main main goals committed to: avoiding amputations and reducing the recurrence rate. These doctors currently care for almost 1,440 insured people at 16 locations.
One of these doctors is Dr. med. Ralf-Uwe Häußler, owner of the certified diabetes foot clinic at Teltower Damm, who like the previous speakers – Dr. Dirk Hochlenert from the Outpatient Center for Diabetology, Endoscopy and Wound Healing in Cologne, who spoke about the “ups and downs of 15 years of network work” - emphasized the urgency of the problem: “We expect 16,000 people with a wound from the diabetic foot per year alone Berlin,” emphasized Häußler, who reported on his daily work. Among other things, with a patient who came to him and thus made his first contact with a certified and specialized diabetes foot clinic. “You can see that not only is the third toe missing, but also the metatarsal head,” explains the doctor using a very impressive picture:
“Overall, this foot has already been extremely changed by the visible amputation,” Häußler pointed out not only the missing toe, but also the typical claw-toe shape and said, shaking his head: “And so this patient comes to us for the first time! First of all, it keeps you from spitting, doesn’t it?”
When asked by the audience, Häußler explained that the patient had not previously been treated in a specialized facility, although theoretically a contractual solution in Berlin would have been available to him. “We have to find solutions precisely for such patients,” is the doctor’s first demand. After what was, at least according to the patient, a minor injury, he went to an emergency room and was then admitted to a clinic for 20 days, which was then followed by 23 days of geriatric rehabilitation. Despite expensive vacuum bandages, he still came to Häußler's practice with his feet open. And indeed: two and a half months later, the foot had healed and the patient would like to say goodbye to normality again; but – says Häußler – “that’s exactly where he’s not allowed to go”. Although the patient is no longer in the active stage of his illness, he is now in the inactive stage.
That's exactly why, in Häußler's opinion, such a patient is an example of structural problems in DFS care. Because: This patient had never previously received adequate training on his DFS. Although this is included in the DMP training, it was held at some point when enrolling in this program and has since been long forgotten. Häußler: “This brings us straight to our Berlin DMP and its shortcomings.” This does not contain a follow-up training agreement, an individual training agreement or even a repeat training agreement, as is quite common in other KVs. Hence Häußler's second demand: "This urgently needs to be improved so that we can also accommodate such patients."
What made things even more difficult for this patient was that there was no standard shoe and insole care, and there was probably no vascular intervention before the ulcer developed - and when everything was too late - there was no initial quick wound care. Häußler: “Then it’s not all that surprising that something like this goes wrong.” All the more so because this patient has not been trained to immediately go to a specialist practice for foot problems (preferably certified) if he has a supposed minor or minor injury to visit.
“The biggest problem with this patient was the lack of interdisciplinary, multiprofessional and cross-sector treatment,” said Häußler. And this is even more important for patients with or beginning to develop DFS, who are often only partially adherent to therapy because they are exposed to it due to their polyneuropathy, the so-called body island atrophy. Due to this gradual change in sensitivity, coupled with increasing insensitivity to pain, DFS is a “ticking time bomb”. Häußler: “It is only the ulcer infection that makes the detonator active and the macroangiopathy then leads to an explosion.” This development can be observed more often when a patient is not adequately connected to a certified diabetes foot clinic. But: Not just in any diabetological practice (or a clinic) without the necessary know-how that has to be acquired specifically.
“What should be done?” Häußler asked rhetorically, because he immediately gave the answer himself: “What is needed is to strengthen standard care, taking all professional groups and professions into account.” There is an approach for this in the model contract of the National Association of Statutory Health Insurance Physicians on the DFS but “unfortunately it has not yet reached our KV”, with which he cleverly refers to the “encrusted institutions” already mentioned by previous speakers. What is also necessary is the regular integration of qualified outpatient and individual inpatient foot care facilities as network centers under the premise of “promoting and challenging”. Especially the latter, because the practitioners must be required to have proven qualifications. And support because well-functioning DMPs are particularly important because they form the basis for the work of the specialist practices and thus also the basis for the foot clinic.
Which led to Häußler's third demand: "We need functioning diabetes DMPs at all levels of care at reasonable conditions." Care in the area of diabetes and DFS in Berlin is based on DMPs for diabetes mellitus type 2, which are now fourteen years old, for which the fees have never been adjusted: And this despite the fact that, for example, assistants working in doctors' offices now earn 32 percent more on average across all salary groups and even 55 percent more in the East. Häußler: “And we doctors still receive the same fee rates for our work as we did back then.”
This demand is all the more understandable because the work of Häußler and his 25 colleagues in the add-on contract is worthwhile for patients and the health insurance company. According to the credo “limb preservation first”, the effort is more expensive in the short term compared to amputations, but in the medium and especially long term the better care is also more economical.
According to a publication of the results of the “Diabetic Foot Syndrome” care program as part of an add-on contract from AOK Nordost (MVF 03/2016), the risk of amputation increases:
• with non-participation in the contract at 16 %
• with each age group around 12 %
• in men compared to women by 29 %
• for previously amputated insured persons by 149 %
• in those requiring insulin around 31 %
• for insured people with PAD around 8 %.

In fact, 129 amputations occurred in the intervention group (IG), although mathematically the number of expected amputations was 152. This means that the incidence rates for the first amputations (in 100 person-years) are 7.7 in the IG and 13.3 in the control group (CG) - so the incidence rates could be almost halved!
Dr. Sandra Feldt, who was responsible for evaluating the contract when she was still working for AOK Nordost, and who presented the data to the participants in the “Translations Conference” out of her old ties to her ex-employer.
The evaluation showed that there were savings for patients with wounds that exceeded the program costs, although - naturally with such interventions - more costs were incurred in the prophylaxis phase for the enrolled patients.
It should be noted, however, that the enrolled patients had characteristics of more advanced diabetes, for example, they were more insulin dependent and required more hospital stays. That is why the additional costs observed in prophylaxis largely had nothing to do with diabetic foot and would have arisen for these patients even without a DFS care module.”
However, this would need to be examined more closely in follow-up studies to further explore the role of certain confounders - such as the variable “insulin requirement”, as this is often associated with higher severity and/or longer duration of diabetes in diabetics, which will influence various outcome parameters .
Nevertheless, said Prof. Dr. Dr. Alfred Holzgreve, the Director of Clinical Research and Academic Teaching of the Vivantes Network for Health, who, after a detailed discussion with the plenum and audience, took on the difficult task of preparing an initial agreement on the DFS on an ad hoc basis: “With regard to the evidence, no one contradicted that is already enough to demand a translation into standard care, which is exactly what HTW, DGIV and MVF will now prepare and agree with the participants of the conference and the members of the DGIV in the coming weeks." <<

from:
MVF editor-in-chief Peter Stegmaier <<