The Cost of the Diabetic Foot
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1 The Cost of the Diabetic Foot Jonathan Labovitz, DPM Associate Professor Western University of Health Sciences Pomona, CA, USA Medical Director Foot & Ankle Center Western University of Health Sciences Pomona, CA, USA
2 Disclosures Speaker s Bureau: None Stockholder: None Honorarium: None Grant/Research Support: None Consultant: Volcano Corporation Medical/Scientific Boards: None
3 The Diabetes Burden Diabetic spends 2.3x more than non-diabetic $1 of every $5 spent on diabetic patient $1 of every $10 spent on diabetes Diabetes costs Direct costs Prevalence % Change 26% $116 B $176 B 51.7% Overall Cost 40% Cost of Complications Cardiovascular/PAD 28-31% Neurological 30% Ettaro L, et al. Pharmacoeconomics 2004; ADA Diabetes Care 2008
4 The Diabetes Burden: DFU Costs 29.1 MM DM prevalence CDC 2014 (all ages, 2012) 4% $5,391 DFU prevalence 1-7% annually Cost per Episode Fife C. Wounds 2012 What happens when diabetes prevalence is 1 in 3 Americans in 2050? $6.3 B Annual cost of DFU 1-7% = $1.6 B - $10.9 B CDC. National Diabetes Statistics Report, 2014
5 Cost of the Diabetic Foot What makes up the cost? Inpatient vs. Outpatient Complications Technology
6 Inpatient vs. Outpatient DM with complications 1.4% of national costs ($5.38B) Medicare = approx. 1/2 of costs Healthcare spending: Acute care All-cause = nearly 33% Diabetes mellitus = 50% ED visits (2010) Neurological Peripheral Circulatory % DM ED visits 36% (675,000) 0.8% (94,000) % DM Admit from ED 41% 1.5% Source: HCUP Statistical Briefs #160, 2013; HCUP Statistical Briefs #167, 2013
7 $/per patient (in $100) Inpatient vs. Outpatient Change in U.S. Spending in Diabetes Mellitus % 15% ER/OTHER $/unit OUTPATIENT Volume 20 24% INPATIENT $/unit 55% RX Volume & $/unit 0 Excess $ Inpt. Outpt. Rx % of growth Zhuo X, et al. Diabetes Care 2015
8 Inpatient vs. Outpatient Hospitalization main cost driver in diabetic foot? 9-20% of DFU require hospitalization Accounts for 74-84% of total costs Hunt NA. Plastic Reconstr Surg 2011; Hicks CW. J Vasc Surg 2014
9 The complications Diagnosis Neurological Peripheral circulation Diabetic foot ulcer Infection Co-morbidities Chronic diseases Renal disease Severity Controlled vs. Uncontrolled PAD vs. CLI DPN vs. Charcot Procedures Imaging tests Amputations
10 Diagnosis & Co-morbidities Foot related complications 337,932 Diabetic foot Higher costs with a diabetic foot complication $17,373 vs. $9, % 18.8% 1,461,398 DM normal foot LOS 84.0% 1.75x mortality during hospital stay Unpublished data - CA OSHPD Public Discharge Files
11 Diagnosis & Co-morbidities The Diabetic Foot N Cost LOS Chronic conditions Mortality No complication 1,461,398 $ 9, % Complication 337,932 $ 17, % % Difference 74.5% 84.0% 83.0% 74.6% The Hemodialysis Effect DM no complication DM + complication DM + DPN DM + PAD DM + DFU DM + Infection (-) HD $ 9,958 $ 17,373 $ 13,673 $ 20,579 $ 18,977 $ 16,783 (+) HD $ 12,779 $ 26,222 $ 16,473 $ 27,610 $ 26,987 $ 28,381 % Difference 28.3% 50.9% 20.5% 34.2% 42.2% 69.1% Unpublished data - CA OSHPD Public Discharge Files
12 Diagnosis & Co-morbidities Cost and Utilization by Diagnosis DM + complication DM + DPN DM + PAD DM + DFU DM + Infection n 337, ,204 60,790 80, ,044 Cost $ 17,373 $13,673 $20,579 $18,977 $16,783 LOS Chronic Conditions Amputation 10.0% 4.3% 24.6% 22.7% 20.6% Mortality 1.2% 0.5% 1.3% 0.9% 0.6% Unpublished data - CA OSHPD Public Discharge Files
13 Diagnosis & Co-morbidities Diabetic Foot Ulcers Most expensive chronic wound ($5,391 per patient) 2x cost of other chronic ulcers Cost drivers: Rx (systemic Abx, pain meds) Comorbidities (renal failure, 2 comorbidities) Current tobacco Inpatient costs ($13,258) Increasing mean cost/patient YoY Factors: Increased co-morbidities, revascularization, minor LEA Likely sicker patient population with greater attempt at limb salvage Fife C., Wounds 2012; Hicks CW. J Vasc Surg 2014
14 Diagnosis by Diagnosis 2 nd highest readmission rate DM readmissions w/out complications 80 with complications Gangrene Readmit/1, % readmit DM w/out complications Skin/SubQ infections Peripheral artherosclerosis DM with complications Chronic ulcer skin Gangrene DM with complications % Readmitted Percentage readmitted Source: HCUP Statistical Briefs #154, Readmissions to U.S. Hospitals by Procedure, 2010
15 Procedures: Amputations Amputation N Cost LOS Amputation 31,919 $28, No Amputation 1,735,492 $12, Minor 23, 769 $26, Major 13,726 $34, % of amputations needed multiple OR visits LOS 47.2% Hospital charges 60.2% Unpublished data - CA OSHPD Public D/C Files ; Ashry et al. 1998
16 Procedures: Revascularization PAD, No revascularization Revascularization Amputation Endovascular Surgical Minor Major COST $ 15,540 $ 37,589 $ 39,552 $ 26,214 $ 34,671 Revascularization Revascularization (endovascular or bypass) ± limb salvage is costeffective compared to amputation Improved years of function Improved years of limb salvage Improved QALY Barshes 2012; Barshes 2014
17 % Readmitted Procedures by Procedure Highest readmission rate (30 most common procedures) Lower extremity amputation 11 th highest readmission rate by procedure 19.1% 28,394 readmissions Debridement wound, infection, or burn % Readmitted LEA Debridement LE vascular bypass Amputation of lower extremity Medicare Medicaid Private Uninsured Source: HCUP Statistical Briefs #154, Readmissions to U.S. Hospitals by Procedure, 2010
18 Severity Diabetic Foot Ulcers Grade Cost Statistically significant Vascular (Adequate vs. Inadequate) Age (<65 v 65+) Progress higher severity (No progress vs. Yes progress) I $ 1,892 $ 1,716 $ 2,433 $ 2,772 $ 1,597 $ 1,892 $ 14,009 II $ 4,345 $ 3,269 $ 6,762 $ 5,776 $ 3,756 $ 3,848 $ 30,381 III $ 12,255 $ 11,258 $ 14,003 $ 14,518 $ 10,861 $ 9,083 $ 30,528 IV/V $ 27,721 $ 11,686 $ 34,845 $ 33,502 $ 25,518 Average $ 13,065 $ 5,218 $ 23,372 $ 16,390 $ 11,925 $ 3,063 $ 20,136 N = 2,253 22% progressed to higher grade ulcer 24% ulcer-related hospitalization = 77% of charges 30% amputation rate Stockl K, et al. Diabetes Care 2004
19 Severity: DPN vs. Charcot Foot Amputations Minor Major Complication n Cost n Cost DPN 6,869 $ 22,932 1,566 $ 31,110 Charcot Foot 423 $ 28, $ 32,084 Cost and Adjusting for Chronic Disease DPN Charcot Foot Difference # chronic conditions (6.8%) Cost of chronic disease $ 18,118 $21,242 $ 3,124 (17.2%) Each additional chronic disease contributes $ in total costs in DPN patients (R 2 =0.798) Adjusted cost $ 18,717 $ 21,242 $ 2,525 (13.9%) Other significant cost drivers in Charcot: DFU, Infection, Osteomyelitis Poster Presentation: Diabetic Limb Salvage Meeting, Washington, DC 2014
20 Technology Does technology drive the cost of care? Medical technology explains 27-48% of healthcare spending The trade-off Expedited recovery vs. Cost of medical advancement Smith S, et al. Health Affairs 2013
21 Technology: Skin graft substitutes Modeling Cost Effectiveness Study Graft Economics
22 Technology: Skin graft substitutes Resource utilization 159 Apligraf (cm 2 ) Graft Size Cost Minimization (not CEA) Grafts/person 97.1% purchased applied EpiFix ,546 Apligraf 6.2 Epifix (cm 2 ) Cost/person % 154 purchased applied EpiFix Apligraf $1,669 $9,216 Zelen CM, Gould L, Serena, TE, et al. Int Wound 2014.
23 Technology: Negative Pressure Significant decrease in resource utilization caused decrease cost despite expense of equipment - Apelqvist, AM J Surg, Inpt LOS Procedures Outpt visits Dressing Δ Cost/pt 8 wks tx 4 41 (Cost in $1,000s) Avg. cost to heal MWT NPWT Other studies Revenue neutral (NPWT = higher material cost, lower nursing time) Apelqvist J, et al., 2008, Braackenburg A, et al., 2006; Moues CM, et al., 2005
24 Dollars and Sense: Personal cost Depression prevalence in diabetic inpatient care in CA, Inpatient foot complications ± depression No foot complication 6.4% 5.6% increased cost Foot complication 11.1% 0.0% 10.0% 20.0% LOS 31.2% longer Depression prevalence 10.7% % in outpatient DFU (Vileikyte 2009; Vedhara K, 2010) Unpublished data - CA OSHPD Public Discharge Files
25 Dollars and Sense: Personal cost Opportunity Costs Financial hardship a major issue DFU 50-79% unemployed or unable to work HRQOL Diabetes lower than general population Higher than most other chronic illness Presence of complications is most important variable Foot ulcers/foot infections lower all physical and psychosocial domains Active ulcer lower QoL than healed ulcer or minor amputation Van Acker K, et al., 2014; Hogg FRA, et al., 2012; Goodridge D, et al. 2005
26 Increasing prevalence expect higher total costs Inpatient, severity of health, Rx, and amputations drive costs High personal & societal cost
27 The Cost of the Diabetic Foot Jonathan Labovitz, DPM Associate Professor Western University of Health Sciences Pomona, CA, USA Medical Director Foot & Ankle Center Western University of Health Sciences Pomona, CA, USA
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