Diabetes mellitus has become an economic and healthcare burden both domestically and globally due to its exponential rise, and podiatric physicians are generally well aware of the devastating statistics associated with the disease process. It is a global epidemic with 600 million people expected to be affected worldwide over the course of the next 25 years.1
In the United States specifically, at least 10 percent of the population has either diabetes or pre-diabetes.2 Health care spending in the United States approached nearly $2.8 trillion in 2012 with $176 billion spent on diabetes.2,3 Every 30 seconds or so in the world, physicians amputate a lower limb secondary to the sequelae of the diabetes mellitus disease process.4
These statistics and costs reflect the public health management and bureaucratic pitfalls, and concerns often associated with this disease. With this in mind, let us highlight some of the cost considerations for patients with diabetes and areas where podiatric physicians might have an effect.
What Hospital Admissions And Unplanned Readmissions Cost
As the number of individuals affected by diabetes has continued to rise, there have also been associated increases in hospital admissions/discharges and related expenditures for patients with diabetes. For example, hospital admissions associated with diabetes increased from 4.6 million in 2001 to 5.5 million in 2009.5 Karagoz and colleagues report that the number of discharges relating to the diabetic foot, pedal ulcerations, peripheral arterial disease, infection and/or neuropathy doubled from 445,000 in 1988 to 890,000 in 2007.1
The American Diabetes Association has reported that direct medical costs are approximately 2.3 times greater in patients with diabetes in comparison to patients without diabetes.2 Hicks and coworkers found a mean adjusted cost of care for patients with diabetic foot ulcerations of $9,397 per admission, and this was substantially higher in those with concomitant infection.5
In a review of Medicare beneficiaries, patients with diabetic foot ulcerations were likely to have a mean of 13.8 office visits and a mean number of 0.25 hospitalizations annually.6 About 5 percent of those patients went on to readmission specifically for another diabetic foot ulceration and the overall rate of readmission (for any reason) was a massive 33.4 percent.
Readmissions might occur secondary to any number of different potential causes. Holscher and colleagues sought to determine unplanned readmission rates in a study of patients receiving care at a multidisciplinary setting for diabetic foot infections.7 One of the most common factors contributing to readmission in this study was worsening of the ulceration, causing 41 percent of readmissions within a 30-day period. This was followed by 15 percent of readmissions in 30 days due to vascular-related complications, 10 percent due to gastrointestinal-related complications, 8 percent due to cardiac-related complications and 8 percent due to acute renal injury.7
What The 30-Day Hospital Readmission Data Reveals
Our group has recently performed an internal quality improvement/performance improvement project evaluating readmission rates of patients originally admitted with diabetic foot tissue loss.8 We found an unplanned 30-day readmission rate of 12.7 percent for our patients. Those who had a 30-day readmission:
• were somewhat more likely to wait one day longer prior to their first surgical intervention (four days versus three days);
• were more likely to have had their final podiatric procedure left open (57.1 percent) as opposed to having primary closure (38.6 percent);
• more often had cardiac disease (48.6 percent versus 34.7 percent of patients who did not have cardiac disease); and
• more often had pulmonary disease (29.7 percent versus 18.7 percent).
Those who had a 30-day readmission were somewhat less likely to have a podiatric procedure performed during their index admission (18.9 percent versus 26.3 percent); be discharged with negative pressure wound therapy (4.3 percent versus 13.6 percent); and be discharged with antibiotics (39.3 percent versus 59.5 percent).
We also evaluated length of hospital stay.8 Patients with relatively longer hospital stays were more likely to have had a podiatric procedure performed during their admission (81 percent) versus those with shorter stays (49.4 percent); have a vascular procedure during their admission (44.4 percent versus 6.8 percent); have had a podiatric procedure left open as opposed to having primary closure (54.3 percent versus 29.3 percent); and be discharged to a nursing facility as opposed to home (56.8 percent versus 19.3 percent).
This is an area where podiatric physicians can likely have a significant effect. This is potentially important irrespective of patient care as length of hospital stay and 30-day readmission rates are common and easily evaluated outcome measures by hospital administrations. To some degree, we have changed our management of these inpatients with efforts to primarily close as many debridements and partial foot amputations as possible (as opposed to leaving an open packed wound requiring home wound care); pushing for immediate vascular intervention if indicated versus a “wait and see” approach; and doing our best to ensure that we discharge patients on appropriate antibiotics and with realistic outpatient care and a follow-up plan (“realistic” being the operative word).
Recognizing The Impact Of Social Factors On Healthcare
The aftercare of a hospital admission and even the circumstances leading up to an admission also play vital roles in determining the economic burden of diabetic foot disease. One must consider social characteristics, such as age, education, income, employment, social support, family and community safety, and the circumstances in which people are born, grow up, live and work, particularly in urban areas such as North Philadelphia where our hospital is located. Per the Philadelphia Vital Statistics Report, Philadelphia is the poorest of the 10 largest cities in the U.S. with nearly one out of three residents and two out of five children living below the poverty line.9 Often one of the most challenging parts of healthcare is simply gaining consistent access to it. Barriers to healthcare access include the cost of the care itself, lack of insurance, limited primary care capacity and the disparate geographic availability of services. These all play a large role in the progression of the disease and the development of sequelae.
With the aforementioned factors as considerations, let us now imagine that a patient with uncontrolled diabetes, limited access to healthcare and a relative lack of education on disease management ends up in the emergency room for a diabetic foot infection, and has a subsequent partial foot amputation. What is next? One might say healing actually begins when the actual hospital stay is over. Therefore, these patients often require skilled nursing services and close outpatient follow-up including wound care in order to make a recovery without recurrence.
How Wound Care Management Factors Into Healthcare Costs
Roughly 4 percent of the total cost of hospital care expenditures involves wound care management with some predicting that this will cost around $18.5 billion by 2021.3 One of the frequently used modalities in diabetic wound care is negative pressure wound therapy (NPWT). Research has demonstrated that NPWT is a valuable resource in improving post-op outcomes, reducing hospital stays by allowing management of wounds in the outpatient setting, expediting healing times and ultimately allowing the patient to return to activities of daily living in a timelier manner.3
However, as with any wound healing modality, there are associated costs to consider. When considering the costs of NPWT, there are four primary expenditure considerations. One should consider the daily rental costs of the portable vacuum machine, the cost per suction canister, the cost per sponge/adhesive dressing package and the cost of labor for dressing changes.3
A retrospective review of 2,132 patients treated with NPWT between July 1, 1999 and June 30, 2014 at the University of Chicago Medical Center demonstrated an average daily cost of $94.01.3 In a further breakdown of the component costs, researchers determined the suction rental cost to be approximately $66.37 per day whereas the cost per sponge dressing and canister was $30.10 per day. This is not an insignificant daily cost but interestingly, this use of NPWT might be more cost conscious than an alternative of basic local wound care as a randomized controlled trial demonstrated.10
Pertinent Considerations With Discharge Planning
Another consideration is the manual labor cost for bandage changes and this may take two forms, largely determined by the patient’s ultimate disposition upon leaving the hospital. When discharging a patient home, one often contacts a home health agency to initiate skilled nursing home care. Skilled nursing care comprises a majority (55 percent) of the home health services Medicare beneficiaries utilize.11 In 2008, Medicare expenditures on home health agency services (including home health aides, physical, occupational and speech therapy) totaled $16.9 million with the average payment per patient of approximately $2,800.11 Total Medicaid home health expenditures from 2006 totaled $4.6 billion.11
Alternatively, a patient might be deemed a candidate for placement in a skilled nursing facility instead of discharge to home. Skilled nursing facilities offer skilled nursing care and rehabilitation services, such as physical and occupational therapy and speech-language pathology services following an acute care hospital stay. However, this skilled labor does come at a steep cost. In 2008, the Medicare program spent $49.9 billion on post-acute services.11 Similarly, Medicaid spent $56.3 billion in 2008 on nursing home care.11 It is interesting to note that skilled nursing facilities may cost twice that of normal nursing facilities. One study estimates the cost per day of a skilled nursing facility to be $330 versus $148.62 for a general nursing facility.11
This is once again an area where podiatric physicians might exert positive influence with respect to cost. Physicians should be closely involved in discharge planning of their patients with explicit input on the requirements for postoperative patients from a wound care and functional perspective. This should include sensible decision making with respect to what type of wound care is absolutely required instead of preferred, the frequency of dressing changes needed and realistic offloading plans. Physicians should have reasonable discussions with patients and caregivers about how often outpatient visits might be realistically scheduled and what the barriers are to these visits (i.e. transportation, caregiver work schedules, frequency of home nursing visits, etc.).
One should also tailor specific interventional outpatient therapies with all of these considerations. The photo above at left demonstrates the foot of a patient who suffered a major complication secondary to inappropriate follow-up after an appropriate therapy. Although NPWT might have been a reasonable recommendation for this specific wound initially, it in fact had negative consequences because social considerations prevented appropriate follow-up care. In retrospect, these considerations seemed fairly obvious but they were not readily appreciated because of a relatively passive approach to discharge planning.
We hope this information helps podiatric physicians understand how their medical decision making affects the economic realities associated with the treatment of diabetic foot disease.
Dr. Magodia is a first-year resident at the Temple University Hospital Podiatric Surgical Residency Program.
Dr. Skolnik is a first-year resident at the Temple University Hospital Podiatric Surgical Residency Program.
Dr. Meyr is a Clinical Associate Professor and the Residency Program Director of the Department of Podiatric Surgery at Temple University School of Podiatric Medicine and Temple University Hospital. He is a Fellow of the American College of Foot and Ankle Surgeons.
1. Karagöz G, Kadanali A, Ozturk S, et al. The analysis of the cost and amputation rates of hospitalized diabetic foot infection patients. Int J Diabetes Developing Countries. 2017; 37(2):201-205.
2. American Diabetes Association. Economic costs of diabetes in the US in 2012. Diabetes Care. 2013; 36(4):1033-1046.
3. Kim JJ, Franczyk M, Gottlieb LJ, Song DH. Cost-effective alternative for negative pressure wound therapy. PRS Global Open. 2017; 5(2):e1211.
4. Boulton AJM, Vileikyte L, Ragnarson-Tennvall G, Apelqvist J. The global burden of diabetic foot disease. Lancet. 2005; 366(9498):1719-24.
5. Hicks CW, Selvarajah S, Mathioudakis N, et al. Burden of infected diabetic foot ulcers on hospital admissions and costs. Ann Vasc Surg. 2016; 33:149-158.
6. Margolis DJ, Malay DS, Hoffstad OJ, et al. Economic burden of diabetic foot ulcers and amputations. Data Points Publication Series. Available at https://www.ncbi.nlm.nih.gov/books/NBK65152/ . Published 2011.
7. Holscher CM, Hicks CW, Canner JK, et al. Unplanned 30-day readmission in patients with diabetic foot wounds treated in a multidisciplinary setting. J Vasc Surg. 2017; 67(3):876–86.
8. Cardenas V, Seo K, Sheth S, Meyr AJ. Factors influencing 30-day readmission rates for patients presenting to the emergency department with lower extremity tissue loss. Presented at the 2017 American College of Foot and Ankle Surgeons Annual Scientific Conference. Available at: https://www.acfas.org/Education-and-Professional-Development/Annual-Scientific-Conference/Posters/ACFAS-Online-Posters/ .
9. Philadelphia Department of Public Health. Philadelphia Vital Statistics Report. Available at http://www.phila.gov/health/commissioner/DataResearch.html . Published 2010.
10. Apelqvist J, Armstrong DG, Lavery LA, Boulton AJ. Resource utilization and economic costs of care based on a randomized trial of vacuum-assisted closure therapy in the treatment of diabetic foot wounds. Am J Surg. 2008; 195(6):782-8.
11. Grabowski. Post-acute and long-term care: A primer on services, expenditures and payment methods. U.S. Department of Health and Human Services. Harvard Medical School. Available at https://aspe.hhs.gov/basic-report/post-acute-and-long-term-care-primer-services-expenditures-and-payment-methods . Published June 2010.