This is an important topic and I can
understand the cost savings, as many people with type 2 diabetes are
not aware of diabetic foot ulcers (DFU). Fortunately, the members of our
support group do and great effort to prevent DFU is a continual thing
with the members. Several members have had them discovered early and
they were properly treated to prevent amputations.
Does an ounce of prevention beat a pound of cure? Our support group members believe this and have
witnessed the successes of several of the members in avoiding
amputations.
According to the ADA, treatment of
diabetic foot ulcers (DFUs) along with associated infections, below
the knee amputations, and surgeries to revascularize the lower limbs
account for a significant portion of the costs incurred in the
treatment of diabetes. Yet, with the frequency of occurrence of these
complications, there are very few studies that drive the paradigm
toward either primary prevention (avoiding DFUs entirely) or
secondary/tertiary measures (efficient treatment of DFUs in those who
are not aware [secondary]/are aware [tertiary] of diabetic ulcers),
which are combined into a single term (secondary prevention) for
purposes of the article.
Sadly, utilization of primary
prevention of these complications is spotty in most health care
systems, and implementation of secondary prevention is often delayed
in patients with DFUs. It is speculated that one reason little
attention is paid to these secondary measures may be the concern over
a “small return on the investment” in trying to prevent
amputations, an attitude that certainly appears to be both
counter-intuitive and counterproductive. An attempt to show
otherwise was made by N.R. Barshes et al. who utilized a Markov model
demonstrating the probability of significant cost savings
attributable to otherwise less costly preventive measures.
The idea of the Markov model allows
prediction of transition from one condition to another, with the
understanding that the probability of any transition is only
dependent on the current condition, but not any past condition, and
that these conditions exist over a continuum. A simple example would
be the states of untreated, treated, and final outcomes (cure,
amputation, or death, the latter two of which would be considered
“inescapable” outcomes, where return to the state immediately
prior is not possible). Barshes looked at 1,000 repeated simulations
of 100,000 hypothetical diabetes patients with no current or
historical DFU, over a period of five years in 1-month intervals.
Each month, each “patient” would exist in one of six clinical
states: no DFU, uninfected DFU, infected DFU, limb loss, healed DFU,
and all-cause death. Based on available clinical data, the patients
were stratified into low, moderate, and high risk, and transition
probabilities for moving from state to state each month were assigned
(for example, the chance of transitioning from no DFU to initial DFU
event in moderate risk patients was 0.3%, while the chance of limb
loss in undertreated DFU in high risk was 3.1%).
Each of the simulations was run with
transitions occurring over five years (60 months/transitions), and
the outcome probabilities were pooled. Each outcome was assigned a
monthly cost estimate (for example, the median monthly cost of a
healed DFU was $45, infected DFU $12,955, and major limb amputation
such as BKA $38,934). Remember, each of these costs were per case,
not the total population.
By applying costs of both primary and
secondary preventive measures to all levels of risk-presenting
patients (low to high), cost thresholds, at which at least 90% of
simulations demonstrated savings, were established. An example was a
measure that decreased the occurrence of DFU by 10% (0.90 RR),
costing $50 per person and would have greater than a 90% probability
of reducing amputations (at almost $39K) in diabetes patients at a
cost that is equal or even lower than the standard of care, compared
to no preventive care. The same 10% reduction in moderate- to
high-risk patients from preventive care costs $125 per patient, with
increases in cost as risk reduction also increases, yet said costs
are considerably less than the outcome of amputation. For the
purpose of this discussion, these results have been simplified.
The lack of programs designed to
prevent/eliminate DFUs is troubling, this in spite of the known
impact these DFUs have on amputation requirements, increasing
healthcare costs, and overall quality of life. The paucity of such
programs, even in larger academic healthcare centers, may be related
to the perception of a clear lack of economic benefit. Studies have
been few and far between, and prior Markov models have not
demonstrated a potential for overall savings, where cost
effectiveness has been shown. The difference in this study from past
offerings is this one looked at differing degrees of effectiveness
(risk reductions ranging from 5% to 25%), assigning costs to each and
determining a likely cost threshold for determining the need for
preventive measures.
One important limitation stated by the
authors was separating low-risk from moderate- to high-risk patients,
which may cause those higher risk populations to lose favor due to
increased costs of prevention. An examination of the overall
population as a whole would have been warranted to help support
better utilization of prevention of diabetic foot ulcers and
subsequent complications. If little else, there is certainly a need
to encourage preventive programs as a means to reduce these high
costs of care.
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