What Studies Reveal About The Preventive Value Of Podiatric Care For Patients With Diabetes

Paul J. Liswood, DPM, FACFAS

The care podiatrists provide for patients with diabetes is essential, improves outcomes and saves money. That is the value we provide. Now we have data that demonstrates this value. Last year, two independent studies, one by Carls and colleagues and the other by researchers at Duke University, confirmed this truth.1,2

   As we embark on new healthcare delivery models and healthcare reform, this value will prove very important. The government and private insurance payers are looking to improve patient outcomes and lower healthcare costs. One of the most expensive, devastating and prevalent diseases is diabetes.

   Almost 24 million people have diabetes in the United States, incurring healthcare costs estimated at $174 billion annually.3 Foot ulcers and amputations were estimated to have cost the U.S. healthcare system $29 billion in 2007.4 Up to 25 percent of patients with diabetes will develop a foot ulcer during their lifetime.5 Researchers have reported costs for treating foot ulcers ranging between $7,439 and $20,622 per episode.6 Direct costs of major limb amputations — which are preceded by a foot ulcer 85 percent of the time — may be as high as $70,434.6 The lifetime costs of an amputation can be substantially higher than that. The annual incidence of lower extremity amputation is 5 to 8 per 1,000 patients with diabetes and the annual incidence of foot ulcerations in patients with diabetes is somewhere between 2 and 6.8 percent.6

   The high morbidity and mortality associated with foot ulcerations and amputations are well known. People with a history of a diabetic foot ulcer have a 40 percent greater 10-year mortality than people with diabetes alone, according to a study by Iversen and colleagues in 2009.7 Following a lower extremity amputation, up to 68 percent of patients will lose the contralateral limb within five years. The mortality rate following amputation is up to 50 percent between three and five years after an amputation. This poor prognosis is worse than that of many malignancies.5 (See “Comparing Five-Year Mortality Rates Of Amputation And Various Cancers” above at left.)

   Does the care provided by podiatrists improve the health of patients with diabetes and reduce healthcare costs? That is the question researchers asked in the study, “The Economic Value of Specialized Lower-Extremity Medical Care by Podiatric Physicians in the Treatment of Diabetic Foot Ulcers.”1

   Study researchers examined approximately half a million medical claims from patients with commercial insurance and patients with Medicare. The study focused on those patients who developed foot ulceration. Researchers subsequently made a comparison by looking at the year preceding ulceration to see if the patient saw a podiatrist, and examined outcomes and economic costs.1

   The results were compelling. Commercial insurance patients who saw podiatrists had a 28.8 percent lower risk of amputation and a 24.4 percent lower risk of hospitalization. Medicare patients had a 22.5 percent lower risk of amputation and a 13.7 percent lower risk of hospitalization if they were under the care of a podiatrist.1 (See “Do Podiatry Visits Reduce Hospitalization And Amputation In Patients With Diabetes?” at right.)

Study Shows Significant Cost Savings With Podiatric Care

But is there a cost savings realized if podiatrists are involved in the care of patients with diabetes? Yes, according to the study by Carls and co-workers.1 In the commercial insurance group, researchers saw an average savings of $19,686 per patient and an average savings of $4,271 per patient in the Medicare group when podiatrists were involved as part of the health care team. If you extrapolate this information out to populations who are at risk for a foot ulceration, the healthcare system could save $1.97 billion in the commercial insurance group and $1.53 billion in the Medicare group each year if these patients saw podiatrists. That would be a total savings to the U.S. healthcare system of $3.5 billion annually.1

   The study also showed that an investment in podiatry care yielded an exceptional cost savings. Every dollar invested in care by a podiatrist resulted in $27 to $51 of savings in the commercial insurance group and $9 to $13 of savings in the Medicare group.1 This is important information for healthcare policy makers.

Reducing The Risk Of Lower Extremity Amputations

A second study out of Duke University sought to determine the effectiveness of care from podiatrists and lower extremity clinician specialists in regard to diabetes-related lower extremity amputation.2 The researchers looked at Medicare 5 percent sample claims from 1991 to 2007, and stratified individuals based on disease severity.

   They found that patients visiting a podiatrist and a lower extremity clinician specialist within a year before developing all stage complications were between 31 and 77 percent as likely to undergo amputation in comparison to individuals visiting other health professionals.2 They concluded that visiting a podiatrist reduced the risk of lower extremity amputation in patients with diabetes. Once again, researchers demonstrated the value of care by podiatrists.2

   However, the true value of podiatry may be in preventing ulcerations and amputations in the first place. In 2008, Rogers, Lavery and Armstrong looked at the incidence of ulcers and amputations, and extrapolated that info out to the diabetic population in the U.S.6 They calculated cost per episode and created a model that showed U.S. lower extremity disease cost exposure of about $30.6 billion annually. Then they looked at practical reductions that clinicians could achieve with amputation prevention strategies. They reported that practical reductions of 48 to 73 percent for ulcers and 50 to 69 percent for amputations are possible. If this occurred, the savings could be $14.9 to $21.8 billion annually.6

Emphasizing The Importance Of Risk Classification

Although the above data is impressive, we should look to improve on these results. Podiatrists are uniquely trained and educated in providing diabetic foot examinations and risk assessments. Following a patient risk evaluation, podiatrists should assign a risk classification to the patient as outlined by the American Diabetes Association Foot Care Interest Group Task Force.8

   In the risk classification recommendations from Boulton and colleagues, risk category 0 is normal sensation and circulation with no deformity.8 Patient education would be appropriate and there should be annual visits. Risk category 1 is a loss of protective sensation. With these patients, podiatrists should consider prescription footwear, prophylactic surgery and patient education. Patient follow-up would be every three to six months.

   Risk category 2 is arterial disease with or without neuropathy. Podiatrists should obtain vascular consultation for these patients and schedule follow-up visits every two to three months. Risk category 3 would be a history of ulcer or amputation. These patients require follow-up every one to two months.8

   A qualified podiatrist should assign every patient with diabetes a risk classification. Individual podiatrists must take it upon themselves to perform the evaluations.

Final Notes

As doctors of podiatric medicine, it is all of our responsibilities to show the medical community, governmental agencies and insurance companies the important role podiatrists play as part of the healthcare team.

   The New York State Podiatric Medical Association, on which I serve as a trustee, has been on a campaign to do just that. We have presented the aforementioned study data to the New York State Health Commissioner as well as representatives of the governor’s office. We sent summary sheets of the study data to all New York State legislators. We have made presentations to insurance executives as well as health foundations. We are empowering our members with materials to speak to referring physicians and patients on the importance of podiatry care for patients with diabetes.

   However, it does not have to be only a large-scale effort by a state podiatry association to make a difference. All podiatrists could help get the word out. By educating the public and the medical community on what we do, podiatry’s role in patient care will expand. The goal is to have all patients with diabetes receiving lower extremity care from a podiatrist. Patients will benefit and the U.S. healthcare system will as well. The results will be significant cost savings, ulcer prevention and reductions in amputations.

   Dr. Liswood serves as a Trustee of the New York State Podiatric Medical Association. He is a member of a special task force created to inform governmental agencies, healthcare payers and the public about the results of the Thomson Reuters and Duke University data. Dr. Liswood is a Fellow of the American College of Foot and Ankle Surgeons.

1. Carls GS, Gibson TB, Driver VR, et al. The economic value of specialized lower-extremity medical care by podiatric physicians in the treatment of diabetic foot ulcers. J Am Podiatr Med Assoc. 2011;101(2):93-115.
2. Sloan FA, Feinglos MN, Grossman DS. Receipt of care and reduction of lower extremity amputations in a nationally representative sample of U.S. elderly. Health Serv Res. 2010;45(6 Pt 1):1740-1762.
3. Driver VR, Fabbi M, Lavery LA, Gibbons G. The costs of diabetic foot: the economic case for the limb salvage team. J Am Podiatr Med Assoc. 2010;100(5):335-341.
4. Rogers LC, Andros G, Caporusso J, et al. Toe and flow: essential components and structure of the amputation prevention team. J Am Podiatr Med Assoc. 2010;100(5):342-348.
5. Singh N, Armstrong DG, Lipsky BA. Preventing foot ulcers in patients with diabetes. JAMA. 2005;293(2):217-28.
6. Rogers LC, Lavery LA, Armstrong DG. The right to bear legs — an amendment to healthcare: how preventing amputations can save billions for the U.S. health care system. J Am Podiatr Med Assoc. 2008;98(2):166-168.
7. Iversen MM, Tell GS, Riise T, et al. History of foot ulcer increases mortality among individuals with diabetes: ten-year follow-up of the Nord-Trondelag health study, Norway. Diabetes Care. 2009;32(12):2193-9.
8. Boulton AJ, Armstrong DG, Albert SF, et al. Comprehensive foot examination and risk assessment: a report of the task force of the foot care interest group of the American Diabetes Association, with endorsement by the American Association of Clinical Endocrinologists. Diabetes Care. 2008:31(8):1679-85.

   For further reading, see “Emphasizing The Multidisciplinary Approach To Diabetic Limb Salvage” in the November 2008 issue of Podiatry Today or “Preventing Amputation In Patients With Diabetes” in the March 2008 issue.

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