ECONOMIC CONSIDERATIONS FOR FOOT ULCERS Studies on foot-ulcer-related conditions usually report only direct patient costs or charges such as outpatient visits, procedures, pharmaceuticals and hospitalisations, since indirect costs (value of lost income from work, pain, suffering and family burden) are difficult to measure.
Two studies assessed the economic impact of ulcers and amputations, and followed the lesion from the onset of the ulcer episode to each lesion’s final resolution.
Ramsey conducted a nested case, control study in a large health maintenance organisation (HMO) that involved 8905 patients with diabetes.
Of this group, 514 individuals developed one or more foot ulcers, and 11% of these patients required amputation.
Costs were computed for the year prior to the ulcer and the two years following the ulcer, for both cases and controls.
The excess cost attributed to foot ulcers and their sequelae averaged $27 987 per patient for the 2-year period following ulcer presentation.26 Apelqvist followed 314 patients across their ulcer episode, and reported healing was achieved in ≤2 months in 54% of patients, in 3, 4 months in 19% of patients and in ≥5 months in 27% of patients.
There were 63% of patients who healed without surgery at an average cost of $6664.
Lower limb amputation was required for 24% of patients at an average cost of $44 790.
The 13% of patients who died prior to final ulcer resolution were excluded from this analysis.
The proportion of all costs that were related to hospitalisation was 39% among ulcer patients and 82% among amputees.69 Direct costs for US patients with private insurance are available from the Medstat group, who manages a large US integrated administrative claims system affiliated with private health insurance plans.
Table 1.6 shows reimbursement to hospitals for patients with selected foot conditions by Diagnostic Related Group (DRG).
For example, for DRG 271, i.e. skin ulcers, patients with private insurance averaged 11-day hospitalisation at a cost of $11 638, while those whose coverage was Medicare had an average 7.3-day length of stay and an average
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Table 1.6 Reimbursement to hospitals for patients with and without diabetes, 2002
Medstat (private) Medicare Average Average reimbursement reimbursement DRG Condition LOS (in $) LOS (in $)
277 Cellulitis, age >17 with complications 4.8 6 823 5.7 4 000 278 Cellulitis, age >17 without complications 3.4 4, 426 4.2 2 192 271 Skin ulcers 11.0 11 638 7.3 5 227 238 Osteomyelitis 5.9 9 913 8.7 7 376
Source: Medstat group, Thompson Corporation, 200570 ; Centers for Medicare and Medicaid Services, 200571 . DRG, Diagnostic Related Group; LOS, length of stay.
hospital reimbursement of $5227 according to the Centers for Medicare and Medicaid Services.
Payment for the health care providers is not included in these figures.70,71 In summary, foot ulcer prevalence and incidence is increasing globally and is challenging to measure, due to a lack of outpatient- and clinic-based surveillance systems.
Peripheral neuropathy and its sequelae, a long duration of diabetes and peripheral vascular disease are the most consistent risk factors for predicting a foot ulcer.
Re-ulceration occurs in about 60% of persons with prior ulcers and is more common among those with more severe peripheral neuropathy, increased alcohol consumption, poorer blood glucose control and delays in seeking ulcer care.
Costs are high to the patient and the health care system.