The authors measured U.S. demographics, diabetes prevalence, epidemiological data, healthcare cost and economic data, formulating these factors into a Cost of Diabetes Model. The study notes the $327 billion in costs include $237 billion in direct medical costs and $90 billion in reduced patient productivity. The authors note the increase in diabetes prevalence and costs is primarily among people over 65, putting a cost burden on the Medicare program.
Frank Tursi, DPM, FACFAS, and Jakob Thorud, DPM, FACFAS, express alarm at the rising medical costs for diabetes. “In fact, this should be the wake-up alarm for all members of our profession each and every morning,” says Dr. Tursi, the Chief of Foot and Ankle Surgery at Our Lady of Lourdes Medical Center in Camden, NJ.
Dr. Tursi attributes the “profound increase” in costs for patients with diabetes to the increased prevalence of diabetes along with the associated increase in costs for treatment. As he notes, about 8 percent of the American population had been diagnosed with diabetes in 2017.
Dr. Thorud notes the study found the average annual medical expenditures for patients with diabetes increased to about $16,750 per year in 2017 (including $9,600 in direct costs for diabetes), medical costs that are about 2.3 times higher than the medical costs for patients without diabetes. He finds the rising cost per patient “concerning but not entirely surprising.” Medical outcomes tend to be worse in patients with diabetes, particularly those with complications like peripheral arterial disease, renal disease or neuropathy, according to Dr. Thorud, who is affiliated with Mercy Health System in Illinois.
Dr. Thorud says patients with diabetes have lower success rates for treatment, longer hospital stays, more procedures for complications or failed treatment, more office visits, additional medications and more time off work. For example, he says physicians need to “double everything” in terms of treatment, costs and recovery time for patients with diabetic neuropathy who have ankle fractures.
In regard to the rise in diabetes costs in such a short timeframe, Dr. Thorud says as physicians are more aware of those at risk for diabetes, new problems may be surfacing, there be more testing being conducted or patients may be living longer in sicker states. As he notes, the study says the most contribution to the rising costs occurred due to more prescription medications, more inpatient care and more office visits.
The best approach to slowing the increasing costs of caring for patients with diabetes would be to increase diabetes research, improve treatment paradigms and increase diabetes awareness programs to allow for early diagnosis, notes Dr. Tursi. He says this would improve outcomes and decrease costs.
To decrease costs, Dr. Thorud says avoiding wasteful spending should already be in practice in healthcare systems.
Dr. Thorud also recommends ordering appropriate tests only when indicated, having greater consideration for prescription medication cost and avoiding excessive use of industry-based “newest and greatest” products until data can support their use.
By Brian McCurdy, Managing Editor
A recent study in the Journal of Foot and Ankle Surgery finds that hemiarthroplasty offers better surgical outcomes than arthrodesis for first metatarsophalangeal joint (MPJ) osteoarthritis.
The study focused on 47 primary arthrodeses and 31 hemiarthroplasties for first MPJ osteoarthritis with a mean follow-up period of 8.3 years. The authors noted the mean post-op American Orthopaedic Foot and Ankle Society hallux metatarsophalangeal interphalangeal (AOFAS-HMI) score was 72.8 for arthrodesis patients and 89.7 for hemiarthroplasty patients with greater patient satisfaction after hemiarthroplasty. In addition, the study notes hemiarthroplasty patients resumed sports activities faster and both arthrodesis and hemiarthroplasty had similar costs.
Matthew Sorensen, DPM, FACFAS, cites advantages to hemiarthroplasty including the procedure’s joint sparing approach, which can provide predictable pain relief. He notes that minimal joint resection is required and adds that the technical component of implantation is relatively straightforward. The procedure also allows patients to maintain motion and wear various shoe gear, according to Dr. Sorensen, a Fellow in Reconstructive Foot and Ankle Surgery at the Weil Foot and Ankle Institute in Des Plaines, Ill.
However, Dr. Sorensen does note a few disadvantages with hemiarthroplasty. He says the procedure alone does not address the intrinsic pathobiomechanics causing the hallux limitus and cautions that the risk of failure/recurrence is high. Additionally, Dr. Sorenson notes a “perpetual risk” of implant subsidence and subsequent bone loss, which can create a difficult salvage scenario and a potential need for large intercalary bone grafting with further surgical intervention.
Dr. Sorensen most commonly performs first MPJ fusion, particularly in patients with late Grade 2 or 3 hallux limitus or severe hallux abductovalgus.
“(First MPJ fusion has) a predictable outcome that lasts for the remainder of life,” maintains Dr. Sorenson. “It does a great job of relieving pain and re-establishes medial column load sharing in an effort to mitigate lesser metatarsal overload.”
He notes arthrodesis patients can engage in ballistic activity such as running and jumping without fear of further joint compromise. Dr. Sorenson says two of his patients are marathon runners who continue to run marathons without pain after fusion. He does acknowledge that arthrodesis is a joint destructive procedure that can be difficult to perform.
By Brian McCurdy, Managing Editor
Perioperative cryotherapy can effectively prevent post-op necrosis and skin infections following surgery for calcaneal fractures, according to a new study in the Journal of Foot and Ankle Surgery.
The authors assessed 148 calcaneal fractures in 129 patients who had open reduction and internal fixation (ORIF). Forty-three patients had preoperative cryotherapy, 42 had perioperative cryotherapy and there were 44 control patients. The authors note that in comparison to control patients, both cryotherapy groups had fewer infections, higher Maryland Foot Scores, lower Visual Analogue Scale (VAS) scores and shorter hospitalizations. Those who had perioperative cryotherapy had fewer infections, higher Maryland Foot Scores and shorter hospitalizations but similar VAS scores in comparison with those who had pre-op cryotherapy, according to the study.
Keith Cook, DPM, FACFAS, believes cryotherapy has a role in reducing soft tissue edema following surgery or trauma. If cryotherapy can effectively reduce the edema following calcaneal fractures that are treated operatively or conservatively, it should be effective in reducing wound complications including surgical incision dehiscence, according to Dr. Cook, the Director of Podiatric Medical Education at University Hospital in Newark, N.J.
Dr. Cook concurs with the study that cryotherapy would be most effective during the perioperative period. He would use cryotherapy prior to surgical intervention to reduce the edema and then again post-op to keep the soft tissue edema controlled. However, he notes cryotherapy has been associated with inducing thermal injuries in some patients so one should use it carefully.
Immediately following a calcaneal fracture, Dr. Cook notes soft tissue edema and ecchymosis are common along with fracture blisters. He says surgical incision dehiscence and surgical site infections are common postoperatively. Dr. Cook adds that one can prevent these complications with proper placement of a lateral extensile incision, preserving the patient’s angiosomes, utilizing a no-touch technique when lifting and retracting the soft tissue flap to expose the fracture, and closing the incision with running absorbable skin sutures. For Dr. Cook, the best way to prevent wound complications is by utilizing a sinus tarsi (or minimal incision) approach to the fracture and/or percutaneous fixation.