Thursday, March 10, 2011

The Economics of Limb Salvage in Diabetes

The January issue of the Plastic & Reconstructive Surgery included a supplement:  Current Concepts in Wound Healing: Update 2011.  One of the articles (first reference below) discusses the economics of limb salvage in diabetes.  An important topic.

Consensus panels have recommended that optimal preventive foot care should include education of the patient and health care workers, therapeutic shoes and insoles, and regular foot care as part of a multispecialty program.

After their initial introduction, the authors broke down their article into the following sections (bold emphasis is mine):

Cost and Impact of Prevention

…..In contrast, Ortegon et al. did not report results based on risk groups. These authors reported an improvement in quality-adjusted life-years and costs for all groups combined. The incremental cost-effectiveness ratio (1999 U.S. dollars) was $12,169 to $220,100 per quality-adjusted life-year gained, depending on the estimated effectiveness of ulcer prevention. The cost-effectiveness increased as the effectiveness of prevention increased. In the model of Ortegon et al., optimal foot care was only cost-effective if greater than 40 percent of foot ulcerations were prevented.

Cost of Diabetic Foot Ulcers

The average cost of diabetic foot ulcer treatment ranges from $3609 to $27,721.  …….

A small percentage of foot ulcers account for the majority of health care costs. For example, 9 to 20 percent of diabetic foot ulcers require hospitalization.  The major cost in treating diabetic foot ulcers is inpatient care, accounting for 74 to 84 percent of total costs.

Cost of Wound Technology

Many of the studies that compare the cost of new technologies for diabetic foot ulcers are sponsored by industry …..

There are two bioengineered tissue products that are U.S. Food and Drug Administration approved. Dermagraft (Advanced BioHealing, Westport, Conn.) is tissue-engineered human dermis, and Apligraf (Organogenesis, Inc., Canton, Mass.) is a bilayered product of dermis and epidermis. Both products are designed for multiple applications. Therefore, the expense of therapy is increased because of repeat treatments, but the cost-effectiveness is enhanced by reductions in costly complications such as infections and amputations. …..

The projected average yearly costs for Dermagraft were 15 percent higher than treatment of patients with good wound care; however, the cost per healed diabetic foot ulcer was less than with good wound care ($77,703 versus $73,380 converted from euros using historical exchange rates for 2007). …..

Negative-pressure wound therapy ……….The average direct costs of patients who were treated for at least 8 weeks was $27,270 for patients treated with negative-pressure wound therapy and $36,096 for patients treated with good wound care. The biggest differences in the cost of care were attributable to hospitalization ($7823) and treating infections ($15,749).  ……….

Cost of Peripheral Vascular Disease

…….It has been debated for years whether a primary amputation or revascularization procedure is more cost-effective. The rationale for early amputation assumes that the patients will be able to rehabilitate with a prosthetic and walk independently. For many patients, this is not true. Among unilateral amputees with vascular disease, successful rehabilitation is achieved in 47 to 66 percent of patients.   Several studies suggest that the cost of revascularization is less than or similar to amputations when the costs of rehabilitation and prosthetic limbs are included. For instance, Raviola et al. and Mackey et al. reported that the cost of amputations was $24,700 and $26,142 and the cost of revascularization was $23,500 and $27,081 in 1985 and 1984 U.S. dollar values, respectively.

Postoperative complications, revisions, and length of hospitalization are the primary expenses in revascularization. Raviola et al. reported that the average cost of uncomplicated revascularization was $20,300. The cost of graft revision was 41 percent higher ($28,700), and when bypass failed, the cost of amputation was $42,200. ……….

Interventions for Peripheral Vascular Disease

Revascularization of the lower extremity entails two areas of treatment: endovascular interventions and open surgical revascularization. The cost effectiveness of these procedures involves the cost of the initial procedure, the need for revisions, and the long-term success of the procedures. Lombardi et al. found endovascular procedures to be safe and cost-effective when performed in an outpatient setting. This creates immediate cost savings over open procedures. The length of stay for open procedures ranges from 3.9 to 7.4 days. ……..

Revascularization of the foot through a pedal artery may not always be possible with endovascular techniques; thus, the cost comparison is not appropriate for many limb salvage patients with diabetes.

 

 

Their conclusion:

More research is needed in this area, for several reasons. There are very few prospective data that evaluate the cost of limb preservation in patients with diabetes and lower extremity complications. Also, most of the data are based on models sponsored by the wound care industry, and much of this information is 10 years old or more. Finally, technological advances have changed what treatment costs and what we consider appropriate therapy. To understand the cost-effectiveness of limb salvage, the actual costs need to be evaluated as part of randomized clinical trials or prospective longitudinal studies that eliminate narrow inclusion criteria often seen in phase III clinical trials.

 

 

 

REFERENCES

The Economics of Limb Salvage in Diabetes; Hunt, N. A.; Liu, G. T.; Lavery, L. A.; Plastic & Reconstructive Surgery. 127():289S-295S, January 2011; doi: 10.1097/PRS.0b013e3181fbe2a6

Discussion: The Economics of Limb Salvage in Diabetes; Driver, Vickie R.; Yao, Min; Plastic & Reconstructive Surgery. 127():296S-297S, January 2011; doi: 10.1097/PRS.0b013e318203a47c

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