The health care costs of diabetic peripheral neuropathy in the US

Changing the Natural History of Diabetic Neuropathy: Incidence of Ulcer/Amputation in the Contralateral Limb of Patients With a Unilateral Nerve Decompression Procedure

The natural history of diabetes neuropathy is progressive and irreversible loss of sensibility in the feet, leading to ulceration and/or amputation in 15% of patients. The prevalence of neuropathy is more than 50% in those who have been diabetic for 20 years. Decompression of the tibial and peroneal nerves in those with diabetic neuropathy improves sensation in 70% of patients. The impact of this surgery on the development of ulcers and amputations in both the operated and the contralateral, nonoperated limb was evaluated in a retrospective analysis of 50 patients with diabetes a mean of 4.5 years (range, 2-7 years) from the date of surgery. No ulcers or amputations occurred in the index limb of these patients. In contrast, there were 12 ulcers and 3 amputations in 15 different patients in contralateral limbs. This difference was significant at P < 0.001. It is concluded that decompression of lower extremity nerves in diabetic neuropathy changes the natural history of this disease, representing a paradigm shift in health care costs.

Foot Problems in Diabetes: An Overview

Diabetes is the leading cause of nontraumatic lower-extremity amputations in the United States. Most amputations are preceded by an ulcer, and ulcers are costly in their own right. Most ulcers are neuropathic in etiology and plantar in location. They occur typically at sites of high mechanical loading because of repetitive trauma in people with loss of pain sensation. In an adequately perfused limb, such ulcers are not difficult to heal. When they are properly mechanically off-loaded, approximately 90% of these wounds heal in approximately 6 weeks. The reference standard off-loading device is the total contact cast, but other reasonably efficacious methods exist. Screening and implementation of preventive measures in the high-risk patient are highly recommended and can reduce the incidence of ulceration. All patients with diabetes should be screened annually for loss of protective sensation, with the 10-g Semmes-Weinstein monofilament being the easiest tool to use. Education to prevent complications should be implemented for all patients with loss of protective sensation.

Reversal of Diabetic Peripheral Neuropathy and New Wound Incidence: The Role of MIRE

OBJECTIVE

To determine if improved foot sensitivity to the Semmes-Weinstein 10-g (5.07) monofilament, originally impaired because of diabetic peripheral neuropathy, might be associated with a reduced incidence of new diabetic foot wounds.

DESIGN

Retrospective cohort study using a health status questionnaire.

SUBJECTS

Sixty-eight individuals over age 64 with diabetes, diabetic peripheral neuropathy, and loss of protective sensation who had clinically demonstrable increases in foot sensation to the Semmes-Weinstein monofilament after treatment with monochromatic near infrared photo energy.

MAIN RESULTS

After reversal of diabetic peripheral neuropathy following treatment with monochromatic near infrared photo energy, only 1 of 68 patients developed a new diabetic foot wound, for an incidence of 1.5%. Comparatively, the incidence previously reported in the Medicare-aged population with diabetes was 7.3%.

CONCLUSIONS

Improved foot sensitivity to the Semmes-Weinstein monofilament in patients previously suffering from loss of protective sensation due to diabetic neuropathy appears to be associated with a lower incidence of new diabetic foot ulcers when compared with the expected incidence in the Medicare-aged population with diabetes.

CLINICAL RELEVANCE

Therapeutic interventions that effectively improve foot sensitivity that has been previously diminished due to diabetic peripheral neuropathy may substantially reduce the incidence of new foot wounds in the Medicare-aged population with diabetes.

Predicted costs and outcomes from reduced vibration detection in people with diabetes in the U.S

OBJECTIVE

The ability to perceive vibration (vibration detection) has been shown to be a good predictor of the long-term complications of diabetic peripheral neuropathy (DPN). We aimed to estimate the predicted complications and costs for the U.S. health care system associated with reduced vibration detection (vibration perception threshold >or=25 V), estimated using a quantitative sensory testing device.

RESEARCH DESIGN AND METHODS

A Markov model was constructed for a hypothetical cohort of people with DPN. The model was run over a 10-year period using Monte Carlo simulations to estimate disease progression, predicted costs, and complications according to vibration detection levels.

RESULTS

The average individual with reduced vibration detection incurs approximately five times more direct medical costs for foot ulcer and amputations, yields 0.18 fewer quality-adjusted life-years, and lives for approximately 2 months less than an average individual with normal vibration detection.

CONCLUSIONS

The treatment of foot ulceration and amputation is time-consuming and expensive. If individuals with reduced vibration detection could be identified, then preventative care could be concentrated on those patients, potentially saving valuable resources and improving health outcomes.