The impact of comorbidities on inpatient Charcot neuroarthropathy cost and utilization

Prevention and Management Strategies for Diabetic Neuropathy

Diabetic neuropathy (DN) is a common complication of diabetes that is becoming an increasing concern as the prevalence of diabetes rapidly rises. There are several types of DN, but the most prevalent and studied type is distal symmetrical polyneuropathy, which is the focus of this review and is simply referred to as DN. It can lead to a wide range of sensorimotor and psychosocial symptoms and is a major risk factor for diabetic foot ulceration and Charcot neuropathic osteoarthropathy, which are associated with high rates of lower limb amputation and mortality. The prevention and management of DN are thus critical, and clinical guidelines recommend several strategies for these based on the best available evidence. This article aims to provide a narrative review of DN prevention and management strategies by discussing these guidelines and the evidence that supports them. First, the epidemiology and diverse clinical manifestations of DN are summarized. Then, prevention strategies such as glycemic control, lifestyle modifications and footcare are discussed, as well as the importance of early diagnosis. Finally, neuropathic pain management strategies and promising novel therapies under investigation such as neuromodulation devices and nutraceuticals are reviewed.

Statins and renal disease progression, ophthalmic manifestations, and neurological manifestations in veterans with diabetes: A retrospective cohort study

Background

Statins increase insulin resistance, which may increase risk of diabetic microvascular complications. Little is known about the impact of statins on renal, ophthalmologic, and neurologic complications of diabetes in practice. The objective of this study was to examine the association of statins with renal disease progression, ophthalmic manifestations, and neurological manifestations in diabetes.

Methods

This is a retrospective cohort study, new-user active comparator design, that included a national Veterans Health Administration (VA) patients with diabetes from 2003 to 2015. Patients were age 30 years or older and were regular users of the VA with data encompassing clinical encounters, demographics, vital signs, laboratory tests, and medications. Patients were divided into statin users or nonusers (active comparators). Statin users initiated statins and nonusers initiated H2-blockers or proton pump-inhibitors (H2-PPI) as an active comparator. Study outcomes were: 1) Composite renal disease progression outcome; 2) Incident diabetes with ophthalmic manifestations; and 3) Incident diabetes with neurological manifestations.

Results

Out of 705,774 eligible patients, we propensity score matched 81,146 pairs of statin users and active comparators. Over a mean (standard deviation) of follow up duration of 4.8 (3) years, renal disease progression occurred in 9.5% of statin users vs 8.3% of nonusers (odds ratio [OR]: 1.16; 95% confidence interval [95%CI]: 1.12–1.20), incident ophthalmic manifestations in 2.7% of statin users vs 2.0% of nonusers (OR: 1.35, 95%CI:1.27–1.44), and incident neurological manifestations in 6.7% of statin users vs 5.7% of nonusers (OR: 1.19, 95%CI:1.15–1.25). Secondary, sensitivity, and post-hoc analyses were consistent and demonstrated highest risks among the healthier subgroup and those with intensive lowering of LDL-cholesterol.

Conclusions

Statin use in patients with diabetes was associated with modestly higher risk of renal disease progression, incident ophthalmic, and neurological manifestations. More research is needed to assess the overall harm/benefit balance for statins in the lower risk populations with diabetes and those who receive intensive statin therapy.

Investigating the Use of Denosumab in the Treatment of Acute Charcot Neuroarthropathy

Charcot neuroarthropathy is a devastating condition, most commonly affecting poorly controlled diabetic patients with peripheral neuropathy. Pharmacological options for the condition are currently limited. The purpose of this study was to investigate the potential of Prolia® (denosumab) as a safe and feasible option in the treatment of acute Charcot neuroarthropathy. A total of 7 consecutive subjects were enrolled and followed for 1 year. Subjects received a single one-time injection of denosumab 60 mg. Subjects also received standard of care treatment, which included total contact casting, restricted weightbearing status, and biweekly office visits until normalization of the skin temperature gradient. Overall, the pharmaceutical treatment was generally well-tolerated. One subject developed a diabetic foot infection with cellulitis of the contralateral lower extremity, which occurred following the 6-month follow-up visit and which resolved with oral antibiotics One subject identified transient muscle pain in the same upper extremity which received the injection. Subjects were found to exit the acute phase of the condition at an average of 52.00 ± 17.89 days after their injection, which was defined by normalization of skin temperature to within 2°C of the contralateral foot. Treatment of acute Charcot neuroarthropathy with denosumab was well-tolerated in this open-label, pilot study. The clinical outcomes suggest that the medication may be efficacious, though a larger sample size would be needed to confirm these preliminary results. An adequately-powered, randomized, controlled study may be an appropriate follow-up.

A randomised feasibility study of serial magnetic resonance imaging to reduce treatment times in Charcot neuroarthropathy in people with diabetes (CADOM): a protocol

BACKGROUND

Charcot neuroarthropathy is a complication of peripheral neuropathy associated with diabetes which most frequently affects the lower limb. It can cause fractures and dislocations within the foot, which may progress to deformity and ulceration. Recommended treatment is immobilisation and offloading, with a below knee non-removable cast or boot. Duration of treatment varies from six months to more than 1 year. Small observational studies suggest that repeated assessment with magnetic resonance imaging improves decision-making about when to stop treatment, but this has not been tested in clinical trials. This study aims to explore the feasibility of using serial magnetic resonance imaging without contrast in the monitoring of Charcot neuroarthropathy to reduce duration of immobilisation of the foot. A nested qualitative study aims to explore participants' lived experience of Charcot neuroarthropathy and of taking part in the feasibility study.

METHODS

We will undertake a two-arm, open study and randomise 60 people with a suspected or confirmed diagnosis of Charcot neuroarthropathy from five NHS, secondary care multidisciplinary Diabetic Foot Clinics across England. Participants will be randomised 1:1 to receive magnetic resonance imaging at baseline and remission up to 12 months, with repeated foot temperature measurements and X-rays (standard care plus), or standard care plus with additional three-monthly magnetic resonance imaging until remission up to 12 months (intervention). Time to confirmed remission of Charcot neuroarthropathy with off-loading treatment (days) and its variance will be used to inform sample size in a full-scale trial. We will look for opportunities to improve the protocols for monitoring techniques and the clinical, patient-centred and health economic measures used in a future study. For the nested qualitative study, we will invite a purposive sample of 10-14 people able to offer maximally varying experiences from the feasibility study to take part in semi-structured interviews to be analysed using thematic analysis.

DISCUSSION

The study will inform the decision whether to proceed to a full-scale trial. It will also allow deeper understanding of the lived experience of Charcot neuroarthropathy, and factors that contribute to engagement in management and contribute to the development of more effective patient-centred strategies.

TRIAL REGISTRATION

ISRCTN, ISRCTN74101606. Registered on 6 November 2017.

Surgical treatment of midfoot Charcot neuroarthropathy with osteomyelitis in patients with diabetes: a systematic review

OBJECTIVE

A wide range of clinical presentations of Charcot neuroarthropathy of the foot with concomitant osteomyelitis in patients with diabetes has been described. Existing literature provides an equally diverse list of treatment options. The purpose of this systematic review was to assess the outcomes specifically for the surgical management of midfoot Charcot neuroarthropathy with osteomyelitis in patients with diabetes.

METHOD

A systematic review was conducted by three independent reviewers using the following databases and search engines: Cumulative Index of Nursing and Allied Health Literature (CINAHL), Cochrane Library, EMBASE (Excerpta Medica dataBASE), Google Scholar, Ovid, PubMed and Scopus. Search terms used were: Charcot neuroarthropathy, osteoarthropathy, neuro-osteoarthropathy, neurogenic arthropathy, osteomyelitis, midfoot, foot, ankle, diabetes mellitus, ulceration, wound, infection, surgical offloading, diabetic reconstruction, internal fixation, external fixation. Studies meeting the following criteria were included: English language studies, studies published from 1997-2017, patients with diabetes mellitus surgically treated for Charcot neuroarthropathy of the midfoot (specified location) with concomitant osteomyelitis, with or without internal and/or external fixation, follow-up period of six months or more postoperatively, documentation of healing rates, complications, and need for revisional surgery. Studies which were entirely literature reviews, descriptions of surgical-only technique and/or cadaveric studies, patients without diabetes, studies that did not specify location of osteomyelitis and Charcot neuroarthropathy, and treatment proximal to and including Chopart's/midtarsal joint specifically talonavicular, calcaneocuboid, subtalar, ankle were excluded.

RESULTS

A total of 13 selected studies, with a total of 114 patients with diabetes of which 56 had surgical treatment for midfoot Charcot neuroarthropathy with osteomyelitis, met the above inclusion criteria and were used for data extraction.

CONCLUSION

Surgical intervention for midfoot Charcot neuroarthropathy with osteomyelitis in patients with diabetes demonstrated a relatively high success rate for a range of procedures including debridement with simple exostectomy, arthrodesis with or without internal or external fixation, and advanced soft tissue reconstruction. However, this systematic review emphasises the need for larger, better designed studies to investigate the efficacy and failure rates of surgical treatment in this group of patients.

Excess Cost and Healthcare Resources Associated With Delayed Diagnosis of Charcot Foot

The purpose of the present study was to demonstrate the effect of a delayed diagnosis of Charcot foot on acute care cost and usage. We used International Classification of Disease, Ninth Revision, Clinical Modification codes, and the California Office for Statewide Health Planning and Development 2009 to 2012 public patient discharge files to identify patients with type 2 diabetes mellitus and Charcot foot. The costs and length of stay were compared for those with a diagnosis of Charcot foot on admission compared with those who received a delayed diagnosis of Charcot foot before discharge. Patient demographic data, diagnoses often mistaken for Charcot foot, and procedures often performed for Charcot foot were assessed to determine the potential effect on costs and length of stay in Charcot foot subjects. A delayed Charcot foot diagnosis was associated with 10.8% greater inpatient costs and 12.1% longer length of stay. These patients required greater resource usage owing to the significantly greater number of procedures performed. A significantly greater number of patients underwent lower extremity amputation when the diagnosis was delayed, resulting in a 30.4% increase in costs and 31.6% longer length of stay. A greater rate of diabetic foot ulcers, foot infections, and osteomyelitis was also observed; however, the cost was only affected by osteomyelitis, and the length of stay was not significantly affected. A delayed diagnosis of Charcot foot at admission resulted in significantly increased acute care costs and longer lengths of stay.

Costs and Length of Stay of Hospitalizations due to Diabetes-Related Complications

BACKGROUND

Diabetes mellitus (DM) has become a significant worldwide public health problem and economic burden because a great proportion of healthcare costs has been spent on the treatment of DM and its related complications. The aim of this study was to examine the costs and length of stay (LoS) of hospitalizations due to diabetes-related complications in Taiwan.

METHODS

This study is a retrospective claim database analysis using the Longitudinal Cohort of Diabetes Patients, with 2012 used as the base year. The hospitalization costs and LoS per admission were estimated for each complication of interest using data from the LHDB 2004 to 2012 cohorts. The presence of eight DM-related complications were identified using the ICD-9-CM codes and procedure codes. ANOVA was used to examine the relationships of diabetes duration with the LoS and costs of the complications.

RESULTS

A total of 27,473 DM patients who were hospitalized in 2012 due to one of the examined DM-related complications were identified. The most common complications that caused the hospitalizations were nonfatal stroke (34.7%) and nonfatal ischemic heart disease (IHD) (28.7%). Amputation was the complication with the longest hospital stay, with a mean ± SD of 21.6 ± 14.1 days, followed by nonfatal stroke (13.6 ± 11.3), ulcer (12.7 ± 11.8), and fatal IHD (12.2 ± 13.6). The complications with the greatest hospitalization cost were fatal IHD (mean = TWD 306,209.8; median = TWD 221,417.0; 1TWD = 0.034USD) and fatal myocardial infarction (mean = TWD 272,840.1; median = TWD 174,008).

CONCLUSIONS

This study indicates that DM-related complications are associated with significant hospital LoS and costs. The study results could be useful for economic evaluations of diabetes treatments and the estimation of the overall economic impact of diabetes.

Healthcare costs and utilization of diabetes-related complications in Taiwan: A claims database analysis

To estimate the healthcare utilization and costs of major diabetes mellitus (DM)-related complications in Taiwan in the year of first occurrence and in subsequent years.This study is a retrospective claim database analysis using the longitudinal cohort of diabetes patients (LHDB) with 2012 as the base year. Occurrences of 8 DM-related complications of interest were identified using the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes. Annual healthcare costs and utilization of these DM-related complications in the LHDB cohorts of the years 2004 to 2009 were examined, and the generalized linear model was used to estimate annual total healthcare costs for each complication.DM patients with complications were more likely to have at least 1 emergency room (ER) visit and at least 1 hospitalization (both P < .001), and they also had more outpatient visits, higher hospitalization costs, higher outpatient costs, and higher ER costs (all P < .001) than those without. The mean annual total healthcare cost of the patients with DM-related complications was US $4189, whereas the mean annual cost of those patients without complication was $1424 (P < .001). The complications with the greatest event costs were amputation ($7877; 95% confidence interval [CI]: $6628-$9322) and fatal MI ($4067; 95% CI: $3001-$5396) while the complication with the greatest state costs was end-stage renal disease (ESRD) ($2228; 95% CI: $2155 to $2302).DM-related complications could significantly increase healthcare utilization and costs. The results of this study provide data that are useful for local economic evaluations of DM treatments.

Extract critical factors affecting the length of hospital stay of pneumonia patient by data mining (case study: an Iranian hospital)

MOTIVATION

Pneumonia is a prevalent infection of lower respiratory tract caused by infected lungs. Length of stay (LOS) in hospital is one of the simplest and most important indicators in hospital activity that is used for different purposes. The aim of this study is to explore the important factors affecting the LOS of patients with pneumonia in hospitals.

METHODS

The clinical data set for the study were collected from 387 patients in a specialized hospital in Iran between 2009 and 2015. Patients discharge summary includes their demographic details, reasons for admission, prescribed medications for the patient, the result of laboratory tests, and length of treatment.

RESULTS AND CONCLUSIONS

The proposed model in the study demonstrates the way various scenarios of data processing impact on the scale efficiency model, which points to the significance of the pre-processing in data mining. In this article, some methods were utilized; it is noteworthy that Bayesian boosting method led to better results in identifying the factors affecting LOS (accuracy 95.17%). In addition, it was found that 58% of patients younger than 15 years old and 74% of the elderly within the age range of 74-88 were more vulnerable to pneumonia disease. Also, it was found that the Meropenem is a relatively more effective medicine compared to other antibiotics which are used to treat pneumonia in the majority of age groups. Regardless of the impact of various laboratory findings (including CRP, ESR, WBC, NA, K), the patients LOS decreased as a result of Meropenem.

Management of Osteomyelitis and Bone Loss in the Diabetic Charcot Foot and Ankle

Bone loss and destruction due to diabetic Charcot neuroarthropathy (CN) and osteomyelitis of the foot and ankle is a challenging clinical condition when lower extremity preservation is considered. Resection and excision of osteomyelitis and associated nonviable soft tissue can lead into large osseous and soft tissue defects that will most likely need the utilization of bone grafting and subsequent arthrodesis for stability and anatomic alignment. In the diabetic population with peripheral neuropathy, osseous instability can lead to subsequent lower extremity deformity, ulceration, infection and/or amputation. This article reviews the surgical approach in the presence of diabetic CN and concomitant osteomyelitis.

Hospitalization for Charcot neuroarthropathy in diabetes: A population study in Italy

AIMS

To provide data on hospitalization and incidence rates of Charcot neuroarthropathy (CN) and its relation to lower limbs' amputations/revascularizations in population with diabetes of Italy as well as of one of its regions (Tuscany).

METHODS

Hospitalizations with CN diagnosis (codes ICD-9-CM: 7130, 7135, 7138) have been recorded in people with diabetes over years 2003-2013 in Italy and 2008-2015 in Tuscany. Amputations, peripheral vascular disease, revascularizations and infections were likewise evaluated.

RESULTS

Between 2003 and 2013 CN hospitalizations were very infrequent in Italy ranging between 14×100,000 and 11×100,000 patients with diabetes. In Tuscany they declined to a minimum of 7×100,000 patients in 2015, after a previous increase to a maximum of 22×100,000 (p=NS for both). Yearly CN incidence remained constant in Italy, declining in Tuscany to a minimum of 3.4×100,000 diabetic patients in 2015 (p=0.047). CN patients were younger and with longer length of hospital stay than those with non-Charcot diabetic foot (p<0.05 for both). Amputation and infection rates were manifold higher in CN patients than in those with non-Charcot diabetic foot, while the revascularization rate was similar in both.

CONCLUSIONS

Over last decade, in Italy and Tuscany yearly CN incidence and hospitalization rates concerned only a small percentage of patients, remaining constant over years and declining in Tuscany in the last couple of years. CN was significantly associated to younger age, longer hospital stay and greater risk of amputations and infections while the need of revascularization was similar to that of non-Charcot diabetic foot.

Diabetic osteoarthropathy care in Sweden - Need for improvement: A national inventory

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79% of the clinics had no guidelines for managing patients with osteoarthropathy.

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Only two clinics presented acceptable guidelines.

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Plain X-ray, was the common diagnostic method.

Aims

Osteoarthropathy, a rare foot complication in patients with diabetes mellitus, calls for immediate and optimal management to prevent irreversible bone/joint destruction and risk of amputation. Awareness of the condition and adequate guidelines would minimize the consequences and the costs, both for the patient and for the society. We investigated the diabetic osteoarthropathy care in Swedish orthopedic clinics.

Methods

A questionnaire was distributed to 63 Swedish hospitals with emergency department for orthopedic patients. There was a 95% response rate.

Results

Most of the respondents (79%) specified absence of established procedures including guidelines for managing patients with osteoarthropathy. The most common diagnostic method was clinical diagnosis and plain X-ray (95%). MRI or scintigraphy was used by 19% and 10.5% respectively. As treatment method, 84% used a total contact cast, while 38% used orthoses. Treatment duration <3 months was reported in 4%, 3–6 months in 53% and 6–12 months in 28% of the clinics. Four clinics reported treatment duration >12 months and two clinics provided no treatment.

Conclusion

Our national inventory indicates a need for improvement in knowledge as well as guidance and organization at orthopedic clinics regarding optimal care of patients with diabetic osteoarthropathy.

Conservative and Pharmacologic Treatments for the Diabetic Charcot Foot

Charcot neuroarthropathy is a disabling complication of diabetic neuropathy. Prolonged immobilization in a total contact cast (TCC) is among the main treatments. Education of health care professionals in the application of TCC together with well-conducted clinical trials are required to overcome its frequent underuse. There are no established pharmacologic therapies to treat this condition; however, there is an overwhelming need for a new therapeutic approach. Novel targeted drug delivery systems are required to prevent the pathologic bone and joint destruction of the Charcot neuroarthropathy and this may lead to an improved outcome in diabetic patients with this condition.