Huge Burden of Foot Ulcers Doubles Diabetes Costs in US

Becky McCall

March 13, 2014

Diabetic foot ulcers impose a substantial burden on public and private payers in the United States, doubling care costs per patient compared with diabetic patients without foot ulcers.

Ulcer care adds around US $9 billion to $13 billion to the direct yearly costs associated with diabetes itself, according to a new study examining the annual, per-patient burden of diabetic foot ulcers, published in the March issue of Diabetes Care.

"The incremental healthcare costs associated with diabetic foot ulcers are approximately twice that attributable to treating diabetes itself," said Brad Rice, PhD, from Analysis Group, Boston, Massachusetts, who led the research, with coauthors from Analysis Group and Organogenesis, Canton, Massachusetts.

"Patients with diabetic foot ulcers can require considerable amounts of healthcare resources, but little is known about the burden of diabetic foot ulcers imposed on the US healthcare system and payers," Dr. Rice told Medscape Medical News in an interview.

As such, the main motivation for the study was to provide a robust, current estimate of the incremental clinical and economic burden of diabetic foot ulcers — above and beyond any existing medical conditions.

"We used geographically diverse, real-world data on healthcare services and costs and controlled for a broad set of underlying differences between patients with a diabetic foot ulcer and a diabetes control population," he explained.

More Hospitalization Costs for Private Patients With Ulcers

According to the study authors, diabetic foot ulcers are estimated to occur in up to 25% of patients with diabetes. They often require extensive healing time and, if they do not heal, this leads to a risk of severe and costly outcomes, including infections and amputations.

Dr. Rice and coauthors analyzed data sets from 27,878 matched pairs of Medicare and 4536 matched pairs of privately insured patients with either type 1 or type 2 diabetes over a 12-month follow-up period. They examined clinical care and related costs and found that annual incremental healthcare costs ranged from $11,710 to $16,883 per patient with a foot ulcer, or as high as $13 billion nationally, in addition to the costs associated with diabetes itself.

In addition, the investigators found that employed, privately insured patients with a diabetic foot ulcer incurred over $3200 in annual work-loss costs due to disability and medically related absenteeism.

A comparison of time spent in public vs private healthcare showed that those patients with diabetic foot ulcers experienced more days hospitalized (+138.2% Medicare, +173.5% private), more days requiring home healthcare (+85.4% Medicare, +230.0% private), more emergency-department visits (+40.6% Medicare, +109.0% private), and more outpatient/physician-office visits (+35.1% Medicare, +42.5% private) than matched controls.

Of those with diabetic foot ulcers, 3.8% of Medicare and 5.0% of privately insured patients underwent lower-limb amputations in the study.

The research was not designed to make statistical comparisons between the 2 populations, but there was a key difference between them in terms of the breakdown of healthcare costs by type of care, specifically with regard to hospitalizations.

"While they are a cost driver for both patient populations, hospitalizations accounted for approximately two-thirds of the total healthcare cost differential among privately insured patients with diabetic foot ulcers," said Dr. Rice.

"Relative to privately insured patients, Medicare-insured diabetic foot ulcers patients had higher portions of the differential coming from other places of service, including outpatient, home health, and the emergency department," he noted.

Wake-up Call to Take Chronic Wounds Seriously in Diabetes

According to the American Diabetes Association, the annual cost of diabetes, which affects 22.3 million people in the United States, was $245 billion in 2012. This figure comprises $176 billion in excess healthcare expenditures and $69 billion in reduced workforce productivity.

Dr. Rice stressed that diabetic foot ulcers impose a substantial burden on the US healthcare system, beyond that associated with treating diabetes itself.

"We hope these findings will raise awareness of the costs associated with this condition, as such knowledge may help optimize wound management, including better monitoring and targeted early intervention with appropriate treatments to identify and heal these wounds as quickly as possible, which could in turn avoid some severe and costly outcomes."

Commenting on the findings, Geoff MacKay, president and CEO of Organogenesis, a company that makes Food and Drug Administration–approved, living, cell-based treatments for diabetic foot ulcers, who also contributed to the report, said chronic wounds need to be taken more seriously by the healthcare system in general and by patients and their family members in particular.

Upon diagnosis, patients should receive education and training about proper foot care and how to spot potential problems as soon as they occur, he noted.

"Oftentimes, patients with diabetes experience neuropathy, and if patients are not aware of this, they can walk around with injuries, cuts, and sores on their feet for weeks and months without noticing," he observed.

He said he hopes this study will serve as a wake-up call. "More attention should be given to patients with chronic, nonhealing wounds, and specialized care should be initiated early and aggressively, as this has been shown to reduce healing time and complications," he concluded.

Dr. Rice reported no relevant financial relationships other than consulting for Organogenesis, which contributed research funding to the study. Mr. MacKay is president and CEO of Organogenesis. Disclosures for the coauthors are listed in the article.

Diabetes Care. 2014;37:651-658. Abstract

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