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Moon KC, Cha JH, Han SK, Son JW. Developing a Practical Tool for Predicting Wound Healing Outcomes of Patients with Diabetic Forefoot Ulcers: Focus on Vasculopathy and Infection. Adv Skin Wound Care 2024; 37:95-101. [PMID: 38241452 DOI: 10.1097/asw.0000000000000090] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2024]
Abstract
OBJECTIVE To develop a preliminary risk scoring system to predict the prognosis of patients with diabetic forefoot ulcers based on the severity of vasculopathy and infection, which are the major risk factors for amputation. METHODS Forefoot was defined as the distal part of the foot composed of the metatarsal bones and phalanges and associated soft tissue structures. The degree of vasculopathy was graded as V0, V1, or V2 according to transcutaneous partial oxygen tension values and toe pressure. The degree of infection was graded as I0, I1, or I2 according to tissue and bone biopsy culture results. The risk scores were calculated by adding the scores for the degree of vasculopathy and infection and ranged from 0 to 4. Wound healing outcomes were graded as healed without amputation, minor amputation, or major amputation. The authors evaluated wound healing outcomes according to risk scores. RESULTS As the risk score increased, the proportion of patients who underwent both major and minor amputations increased (P < .001). In the multivariate logistic analysis, the odds ratios of amputation also increased as the risk score increased. Patients with a risk score of 4 were 75- and 19-fold more likely to undergo major and minor amputations, respectively, than patients with a risk score of 0 (P = .006 and P < .001). CONCLUSIONS The risk score can be used as an indicator to predict the probability of amputation in patients with diabetic forefoot ulcers.
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Affiliation(s)
- Kyung-Chul Moon
- At Korea University Medical Center, Seoul, South Korea, Kyung-Chul Moon, MD, PhD, is Clinical Associate Professor, Department of Plastic Surgery; Ji-Hwan Cha, MD, is Plastic Surgery Resident; Seung-Kyu Han, MD, PhD, is Professor, Department of Plastic Surgery; and Ji-Won Son, RN, is Plastic Surgery Nurse
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Muacevic A, Adler JR. Effectiveness of Telemedicine for the Management of Foot Ulcers in People With Diabetes: A Meta-Analysis. Cureus 2022; 14:e30634. [PMID: 36439575 PMCID: PMC9683114 DOI: 10.7759/cureus.30634] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/22/2022] [Indexed: 01/25/2023] Open
Abstract
Treatment of diabetes-related foot ulcers presents great pressure on the healthcare system in terms of management strategy and allocation of resources. Telemedicine can be used to treat diabetic foot ulcers more effectively. This meta-analysis aims to evaluate the impacts of telemedicine on the treatment of diabetic foot ulcers. The current meta-analysis was conducted as per the reported guidelines of the Preferred Reporting Items for Systematic Review and Meta-analysis (PRISMA) statement. Two reviewers independently searched for relevant articles using PubMed, EMBASE, and the Cochrane Database of Systematic Reviews from inception to 31 August 2022, assessing the impacts of telemedicine on the treatment of diabetic foot ulcers. The primary outcomes assessed in the current meta-analysis included the percentage of foot ulcers healed and the time of healing foot ulcers within 12 months. Secondary outcomes included the percentage of amputation (minor and major) and all-cause mortality. A total of six studies were included in the current meta-analysis enrolling 1876 patients with diabetic foot ulcers. No difference was there between the two groups in terms of the number of patients whose ulcer healed (risk ratio (RR): 1.01, 95% confidence interval (CI): 0.93-1.09), time to healing of wound within 12 months (mean difference: -0.07, 95% CI: -0.31-0.17), the incidence of amputation (RR: 0.73, 95% CI: 0.54-1.00), and all-cause mortality (RR: 0.99, 95% CI: 0.42-2.37). In conclusion, the study found that telemedicine is non-inferior to standard care in terms of reducing healing time and the number of patients with ulcer healing within 12 months. The study also found that the incidence of amputation is also lower in patients assigned to the telemedicine group compared to patients in the control group and no significant differences were reported in terms of mortality.
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Abstract
ABSTRACT In this case report, the treatment of a patient with a diabetic foot ulcer on his left foot was interrupted by the novel coronavirus 2019 pandemic lockdown in India. The author guided the patient via telephone and online services. Based on the history given by the patient, the lesion started as blistering from improperly fitted footwear that then evolved into multiple infected ulcerations on the dorsal surface of the great toe (osteomyelitis with septic arthritis of the joint). Based on a radiograph and other photographs of the foot lesions, the author prescribed amoxicillin/clavulanic acid in combination with linezolid for 2 weeks. Further, the author guided the patient to dress the wound at home using a medical-grade honey-based product. With no option for an outpatient visit, the author guided the patient to use a plastic ruler and place it below the toe during each dressing. Healing (complete epithelialization) was achieved within 4 weeks.
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Macauley M, Adams G, Mackenny P, Kubelka I, Scott E, Buckworth R, Biddiscombe C, Aitkins C, Lake H, Matthews V, Ashraff S, Ashwell S. Microbiological evaluation of resection margins of the infected diabetic foot ulcer. Diabet Med 2021; 38:e14440. [PMID: 33113230 DOI: 10.1111/dme.14440] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2020] [Accepted: 11/23/2020] [Indexed: 01/22/2023]
Abstract
AIM To evaluate the impact of surgical debridement on the microbiology of resection margins of an infected diabetic foot ulcer and to compare the use of marginal sampling as a guide for antimicrobial therapy. METHODS Forty consecutive participants were studied. Tissue samples from infected diabetic foot ulcers were obtained at first contact by podiatrists. After surgical debridement to macroscopically healthy tissue, multiple samples were obtained from the margins of the residuum and also from excised non-viable tissue. Debridement was done by a single surgeon. Bacterial species were classified according to pathogenic potential a priori into Red Group-Definite pathogen causing infection, Yellow Group-Likely to be causing infection if present in more than one specimen and Green Group -Commensals, not causing infection. RESULTS There was a relative reduction of 49% (p = 0.002) in bacteria in the most pathogenic (red) group, and 59% (p = 0.002) in the yellow group in podiatry samples compared with resection specimen. Positive cultures from margins of the residuum were observed in 75% of cases. There was a relative reduction of 67% (p = 0.0001) in bacteria in the red and 48% (p = 0.06) in the yellow group in marginal samples from the residuum compared with podiatry samples. CONCLUSIONS After surgical debridement to healthy tissue, positive cultures from marginal tissue samples provided vital information on the presence of pathogenic bacteria. This allowed antibiotics to be individualised post-surgical debridement.
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Affiliation(s)
- Mavin Macauley
- Diabetes and Endocrinology, South Tees Hospitals NHS Trust, Middlesbrough, Teesside, UK
| | - George Adams
- Diabetes and Endocrinology, South Tees Hospitals NHS Trust, Middlesbrough, Teesside, UK
| | - Paul Mackenny
- Diabetes and Endocrinology, South Tees Hospitals NHS Trust, Middlesbrough, Teesside, UK
- Orthopaedic Department Hartlepool, North Tees and Hartlepool NHS Foundation Trust, Hartlepool, UK
| | - Igor Kubelka
- Diabetes and Endocrinology, South Tees Hospitals NHS Trust, Middlesbrough, Teesside, UK
| | - Emma Scott
- Diabetes and Endocrinology, South Tees Hospitals NHS Trust, Middlesbrough, Teesside, UK
| | - Rebecca Buckworth
- Diabetes and Endocrinology, South Tees Hospitals NHS Trust, Middlesbrough, Teesside, UK
| | - Claire Biddiscombe
- Diabetes and Endocrinology, South Tees Hospitals NHS Trust, Middlesbrough, Teesside, UK
| | - Christopher Aitkins
- Diabetes and Endocrinology, South Tees Hospitals NHS Trust, Middlesbrough, Teesside, UK
| | - Hannah Lake
- Diabetes and Endocrinology, South Tees Hospitals NHS Trust, Middlesbrough, Teesside, UK
| | - Vicky Matthews
- Diabetes and Endocrinology, South Tees Hospitals NHS Trust, Middlesbrough, Teesside, UK
| | - Suhel Ashraff
- Diabetes and Endocrinology, South Tees Hospitals NHS Trust, Middlesbrough, Teesside, UK
| | - Simon Ashwell
- Diabetes and Endocrinology, South Tees Hospitals NHS Trust, Middlesbrough, Teesside, UK
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Ramanathan B, Duraisamy R, Venkatramanasami BTD, Abbas MK, Balamurugan A. Association of glycaemic status and outcomes in diabetic foot problems: a retrospective evidence from South India. J Basic Clin Physiol Pharmacol 2021; 33:155-162. [PMID: 33618439 DOI: 10.1515/jbcpp-2020-0198] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2020] [Accepted: 10/30/2020] [Indexed: 11/15/2022]
Abstract
OBJECTIVES Emerging shreds of evidence indicates that the risk of diabetic foot ulcer and associated morbidity can be reduced through the intensive glycemic control. There are very few studies which assessed the effects of glycemic control on diabetic foot problems among Indian patients. We aimed to assess the effect of glycemic control on the outcomes of diabetic foot problems among adult type 2 diabetes (T2DM) patients with foot ulcers. METHODS A cross sectional study was conducted among the T2DM patients from a tertiary care teaching hospital in South India. The demographic characters, risk factors, treatment characters, glycemic status were collected among the patients and analyzed against the outcomes of diabetic foot ulcers by reviewing their medical records. Descriptive statistics were used to present the data. The Chi-square test and ANOVA were used for was used for the categorical variables and continuous parameters to identify the factors affecting the outcomes, respectively. All analysis was performed in SPSS v21. RESULTS Out of the 100 participants included in the study, 70% were male. The majority (78%) were from an age group of 40 to 70 years, and the mean age was found to be 59.91 ± 10.6 years. The mean duration of diabetes was 9.66 years. Only ankle-brachial Index score (p=0.001) was significantly associated with the type of ulcers, whereas other factors not (p>0.05). A high level of average HbA1c, BMI, ABI index and poor glycemic status was associated with a significant debridement strategy and longer duration of hospitalization; however, it was not substantial. CONCLUSION Our study inferred that poor glycemic status is associated with a significant debridement strategy and longer duration of hospitalization. However, these findings need to be strengthened with adequately powered prospective studies.
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Affiliation(s)
- Balamurugan Ramanathan
- Department of General Medicine, Karuna Medical College, Vilayodi, Chittur, Palakkad, Kerala, India
| | - Ramesh Duraisamy
- Department of General Medicine, Coimbatore Medical College & Hospital, Coimbatore, Tamilnadu, India
| | | | - Manoj Kumar Abbas
- Kovai Diabetes Speciality Centre & Hospital, Coimbatore, Tamilnadu, India
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Hellstrand S, Sundberg L, Karlsson J, Zügner R, Tranberg R, Hellstrand Tang U. Measuring sustainability in healthcare: an analysis of two systems providing insoles to patients with diabetes. ENVIRONMENT, DEVELOPMENT AND SUSTAINABILITY 2021; 23:6987-7001. [PMID: 32863737 PMCID: PMC7445797 DOI: 10.1007/s10668-020-00901-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/17/2019] [Accepted: 07/21/2020] [Indexed: 05/04/2023]
Abstract
There is an increasing demand to quantify the footprints, ecological, economic and social, in terms of the effect of different interventions in healthcare. The aim of this study was to compare two systems providing patients with diabetes with insoles in terms of their ecological, economic and social footprints. Prefabricated insoles (PRI) were compared with custom-made insoles (CMI). Using a welfare-economic monetary approach, costs were estimated for (1) treatment, (2) travelling to and from the hospital in terms of both fuel and time consumed by the patients and (3) society through emissions contributing to climate change. The proportion of patients/year that could be supplied within the same budget, for each individual treatment, was calculated. The cost of the insoles was 825 SEK (PRI) and 1450 SEK (CMI), respectively. The cost, mean value/patient due to the consumption of patients' time at the department, was 754 SEK (PRI) and 1508 SEK (CMI), respectively. Emissions, in terms of CO2 equivalent, were 13.7 (PRI) and 27.4 (CMI), respectively. Using PRI, a total of 928 patients could be provided/year compared with 500 patients if CMI are used. By using PRI, the cost/treatment was reduced by 46%. The cost of treatment dominated and the cost of time consumed by patients were also substantial. The societal cost of contributing to climate change was of low importance. By using PRI, the needs of 86% more patients could be met within the same budget. Using these methods, the contribution of healthcare systems to the 17 Sustainable Development Goals approved by the UN can be quantified.
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Affiliation(s)
| | - L. Sundberg
- Gothenburg Diabetes Association, Mellangatan 1, 413 01 Göteborg, Sweden
| | - J. Karlsson
- The Department of Orthopaedics, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Göteborgsvägen 31, 43180 Mölndal, Sweden
| | - R. Zügner
- The Department of Orthopaedics, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Göteborgsvägen 31, 43180 Mölndal, Sweden
| | - R. Tranberg
- The Department of Orthopaedics, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Göteborgsvägen 31, 43180 Mölndal, Sweden
| | - Ulla Hellstrand Tang
- The Department of Orthopaedics, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Göteborgsvägen 31, 43180 Mölndal, Sweden
- The Department of Prosthetics and Orthotics, Sahlgrenska University Hospital, Falkenbergsgatan 3, 412 85 Göteborg, Sweden
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Hosseini ES, Bhattacharjee M, Manjakkal L, Dahiya R. Healing and monitoring of chronic wounds: advances in wearable technologies. Digit Health 2021. [DOI: 10.1016/b978-0-12-818914-6.00014-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
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Liette MD, Crisologo PA, Johnson LJ, Henning JA, Rodriguez-Collazo ER, Masadeh S. A Surgical Approach to Location-specific Neuropathic Foot Ulceration. Clin Podiatr Med Surg 2021; 38:31-53. [PMID: 33220743 DOI: 10.1016/j.cpm.2020.09.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
The management of pedal ulcerations is often challenging because of a failure to correct underlying biomechanical deformities. Without correcting the biomechanical driving force creating the increased plantar pressures, it is unlikely for routine wound care to provide lasting solutions to pedal ulcerations. Patients with diabetes often experience glycosylation of their tendons, leading to contracture and pursuant deformity, creating imbalanced pressure distributions and eventual plantar ulceration. This article evaluates the efficacy of various lower extremity tendon transfers to balance the foot and redistribute plantar pressures to prevent or heal ulceration.
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Affiliation(s)
- Michael D Liette
- University of Cincinnati Medical Center, 231 Albert Sabin Way, ML 0513, Cincinnati, OH 45276, USA
| | - Peter A Crisologo
- University of Cincinnati Medical Center, 231 Albert Sabin Way, ML 0513, Cincinnati, OH 45276, USA
| | - Lance J Johnson
- University of Cincinnati Medical Center, 231 Albert Sabin Way, ML 0513, Cincinnati, OH 45276, USA
| | - Jordan A Henning
- University of Cincinnati Medical Center, Staff Podiatrist Cincinnati Veterans Affairs Medical Center, 580 Walnut Street, Apt 803, Cincinnati, OH 45202, USA
| | - Edgardo R Rodriguez-Collazo
- Department of Surgery, Presence Saint Joseph Hospital, Adults & Pediatric Ilizarov Limb Deformity Correction, Peripheral Nerve Reconstructive Microsurgery, 2913 North Commonwealth Avenue, Chicago, IL 60657, USA
| | - Suhail Masadeh
- University of Cincinnati Medical Center, Director of Podiatric Surgery Residency University of Cincinnati Medical Center, Cincinnati Veteran Affairs Medical Center, 231 Albert Sabin Way, ML 0513, Cincinnati, OH 45276, USA.
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Albright RH, Joseph RM, Wukich DK, Armstrong DG, Fleischer AE. Is Reconstruction of Unstable Midfoot Charcot Neuroarthropathy Cost Effective from a US Payer's Perspective? Clin Orthop Relat Res 2020; 478:2869-2888. [PMID: 32694315 PMCID: PMC7899431 DOI: 10.1097/corr.0000000000001416] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2020] [Accepted: 06/26/2020] [Indexed: 01/31/2023]
Abstract
BACKGROUND Charcot neuroarthropathy is a morbid and expensive complication of diabetes that can lead to lower extremity amputation. Current treatment of unstable midfoot deformity includes lifetime limb bracing, primary transtibial amputation, or surgical reconstruction of the deformity. In the absence of a widely adopted treatment algorithm, the decision to pursue more costly attempts at reconstruction in the United States continues to be driven by surgeon preference. QUESTIONS/PURPOSES To examine the cost effectiveness (defined by lifetime costs, quality-adjusted life-years [QALYs] and incremental cost-effectiveness ratio [ICER]) of surgical reconstruction and its alternatives (primary transtibial amputation and lifetime bracing) for adults with diabetes and unstable midfoot Charcot neuroarthropathy using previously published cost data. METHODS A Markov model was used to compare Charcot reconstruction and its alternatives in three progressively worsening clinical scenarios: no foot ulcer, uncomplicated (or uninfected) ulcer, and infected ulcer. Our base case scenario was a 50-year-old adult with diabetes and unstable midfoot deformity. Patients were placed into health states based on their disease stage. Transitions between health states occurred annually using probabilities estimated from the evidence obtained after systematic review. The time horizon was 50 cycles. Data regarding costs were obtained from a systematic review. Costs were converted to 2019 USD using the Consumer Price Index. The primary outcomes included the long-term costs and QALYs, which were combined to form ICERs. Willingness-to-pay was set at USD 100,000/QALY. Multiple sensitivity analyses and probabilistic analyses were performed to measure model uncertainty. RESULTS The most effective strategy for patients without foot ulcers was Charcot reconstruction, which resulted in an additional 1.63 QALYs gained and an ICER of USD 14,340 per QALY gained compared with lifetime bracing. Reconstruction was also the most effective strategy for patients with uninfected foot ulcers, resulting in an additional 1.04 QALYs gained, and an ICER of USD 26,220 per QALY gained compared with bracing. On the other hand, bracing was cost effective in all scenarios and was the only cost-effective strategy for patents with infected foot ulcers; it resulted in 6.32 QALYs gained and an ICER of USD 15,010 per QALY gained compared with transtibial amputation. As unstable midfoot Charcot neuroarthropathy progressed to deep infection, reconstruction lost its value (ICER USD 193,240 per QALY gained) compared with bracing. This was driven by the increasing costs associated with staged surgeries, combined with a higher frequency of complications and shorter patient life expectancies in the infected ulcer cohort. The findings in the no ulcer and uncomplicated ulcer cohorts were both unchanged after multiple sensitivity analyses; however, threshold effects were identified in the infected ulcer cohort during the sensitivity analysis. When the cost of surgery dropped below USD 40,000 or the frequency of postoperative complications dropped below 50%, surgical reconstruction became cost effective. CONCLUSIONS Surgeons aiming to offer both clinically effective and cost-effective care would do well to discuss surgical reconstruction early with patients who have unstable midfoot Charcot neuroarthropathy, and they should favor lifetime bracing only after deep infection develops. Future clinical studies should focus on methods of minimizing surgical complications and/or reducing operative costs in patients with infected foot ulcers. LEVEL OF EVIDENCE Level II, economic and decision analysis.
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Affiliation(s)
- Rachel H Albright
- R. H. Albright, The Dartmouth Institute, Geisel School of Medicine, Hanover, NH, USA
| | - Robert M Joseph
- R. M. Joseph, A. E. Fleischer, Department of Podiatric Medicine and Radiology, Dr. William M. Scholl College of Podiatric Medicine at Rosalind Franklin University of Medicine and Science, North Chicago, IL, USA
| | - Dane K Wukich
- D. K. Wukich, Department of Orthopaedic Surgery, UT Southwestern Medical Center, Dallas, TX, USA
| | - David G Armstrong
- D. G. Armstrong, Southwestern Academic Limb Salvage Alliance, Department of Surgery, Keck School of Medicine at University of Southern California, Los Angeles, CA, USA
| | - Adam E Fleischer
- R. M. Joseph, A. E. Fleischer, Department of Podiatric Medicine and Radiology, Dr. William M. Scholl College of Podiatric Medicine at Rosalind Franklin University of Medicine and Science, North Chicago, IL, USA
- A. E. Fleischer, Weil Foot and Ankle Institute, Mount Prospect, IL, USA
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Chan BC, Campbell KE. An economic evaluation examining the cost-effectiveness of continuous diffusion of oxygen therapy for individuals with diabetic foot ulcers. Int Wound J 2020; 17:1791-1808. [PMID: 33189100 PMCID: PMC7754389 DOI: 10.1111/iwj.13468] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2020] [Revised: 07/02/2020] [Accepted: 07/07/2020] [Indexed: 01/02/2023] Open
Abstract
Continuous delivery of oxygen therapy has been observed to improve healing for individuals with an advanced diabetic foot ulcer (DFU). However, this intervention requires the purchasing of an oxygen delivery device and moist dressings. It is unknown whether this upfront financial investment represents good value for money. Thus the aim of this project is to evaluate the cost-effectiveness of treating advanced DFU using continuous delivery of oxygen compared with negative pressure wound therapy from the perspective of the public health care payer in Ontario, Canada. A microsimulation model was constructed with inputs from peer-reviewed journal publications and publicly available reports. The 5-year costs and quality-adjusted life-years were compared between treatment and comparator. Sensitivity analyses were conducted to evaluate the robustness of results. The model predicted that continuous delivery of oxygen would cost $4800 less compared with negative pressure wound therapy and increased quality-adjusted life years by 0.025. Lower cost and improved outcomes were observed in most scenario analyses. The results of this economic evaluation suggest that CDO therapy may reduce health care economic burden with a modest increase in quality of life outcomes. Health care decision-makers should consider the inclusion of CDO for the treatment of DFU.
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Affiliation(s)
- Brian C.‐F. Chan
- KITE – Toronto Rehabilitation InstituteUniversity Health NetworkTorontoCanada
- Institute of Health Policy, Management and EvaluationUniversity of TorontoTorontoCanada
| | - Karen E. Campbell
- School of Physical Therapy, Faculty of Health ScienceWestern UniversityLondonCanada
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Crawford F, Chappell FM, Lewsey J, Riley R, Hawkins N, Nicolson D, Heggie R, Smith M, Horne M, Amanna A, Martin A, Gupta S, Gray K, Weller D, Brittenden J, Leese G. Risk assessments and structured care interventions for prevention of foot ulceration in diabetes: development and validation of a prognostic model. Health Technol Assess 2020; 24:1-198. [PMID: 33236718 PMCID: PMC7768791 DOI: 10.3310/hta24620] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Diabetes-related foot ulcers give rise to considerable morbidity, generate a high monetary cost for health and social care services and precede the majority of diabetes-related lower extremity amputations. There are many clinical prediction rules in existence to assess risk of foot ulceration but few have been subject to validation. OBJECTIVES Our objectives were to produce an evidence-based clinical pathway for risk assessment and management of the foot in people with diabetes mellitus to estimate cost-effective monitoring intervals and to perform cost-effectiveness analyses and a value-of-information analysis. DESIGN We developed and validated a prognostic model using predictive modelling, calibration and discrimination techniques. An overview of systematic reviews already completed was followed by a review of randomised controlled trials of interventions to prevent foot ulceration in diabetes mellitus. A review of the health economic literature was followed by the construction of an economic model, an analysis of the transitional probability of moving from one foot risk state to another, an assessment of cost-effectiveness and a value-of-information analysis. INTERVENTIONS The effects of simple and complex interventions and different monitoring intervals for the clinical prediction rules were evaluated. MAIN OUTCOME MEASURE The main outcome was the incidence of foot ulceration. We compared the new clinical prediction rules in conjunction with the most effective preventative interventions at different monitoring intervals with a 'treat-all' strategy. DATA SOURCES Data from an electronic health record for 26,154 people with diabetes mellitus in one Scottish health board were used to estimate the monitoring interval. The Prediction Of Diabetic foot UlcerationS (PODUS) data set was used to develop and validate the clinical prediction rule. REVIEW METHODS We searched for eligible randomised controlled trials of interventions using search strategies created for Ovid® (Wolters Kluwer, Alphen aan den Rijn, the Netherlands), MEDLINE, EMBASE and the Cochrane Central Register of Controlled Trials. Randomised controlled trials in progress were identified via the International Standard Randomised Controlled Trial Number Registry and systematic reviews were identified via PROSPERO. Databases were searched from inception to February 2019. RESULTS The clinical prediction rule was found to accurately assess the risk of foot ulceration. Digital infrared thermometry, complex interventions and therapeutic footwear with offloading devices were found to be effective in preventing foot ulcers. The risk of developing a foot ulcer did not change over time for most people. We found that interventions to prevent foot ulceration may be cost-effective but there is uncertainty about this. Digital infrared thermometry and therapeutic footwear with offloading devices may be cost-effective when used to treat all people with diabetes mellitus regardless of their ulcer risk. LIMITATIONS The threats to the validity of the results in some randomised controlled trials in the review and the large number of missing data in the electronic health record mean that there is uncertainty in our estimates. CONCLUSIONS There is evidence that interventions to prevent foot ulceration are effective but it is not clear who would benefit most from receiving the interventions. The ulceration risk does not change over an 8-year period for most people with diabetes mellitus. A change in the monitoring interval from annually to every 2 years for those at low risk would be acceptable. FUTURE WORK RECOMMENDATIONS Improving the completeness of electronic health records and sharing data would help improve our knowledge about the most clinically effective and cost-effective approaches to prevent foot ulceration in diabetes mellitus. STUDY REGISTRATION This study is registered as PROSPERO CRD42016052324. FUNDING This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 24, No. 62. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Fay Crawford
- NHS Fife, R&D Department, Queen Margaret Hospital, Dunfermline, UK
- The Sir James Mackenzie Institute for Early Diagnosis, The School of Medicine, University of St Andrews, St Andrews, UK
| | - Francesca M Chappell
- Neuroimaging Sciences, Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
| | - James Lewsey
- Neuroimaging Sciences, Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
| | - Richard Riley
- Research Institute for Primary Care and Health Sciences, Keele University, Keele, UK
| | - Neil Hawkins
- Health Economics and Health Technology Assessment (HEHTA), Institute of Health & Wellbeing, University of Glasgow, Glasgow, UK
| | - Donald Nicolson
- NHS Fife, R&D Department, Queen Margaret Hospital, Dunfermline, UK
| | - Robert Heggie
- Health Economics and Health Technology Assessment (HEHTA), Institute of Health & Wellbeing, University of Glasgow, Glasgow, UK
| | - Marie Smith
- Library & Knowledge Service, Victoria Hospital, NHS Fife, Kirkcaldy, UK
| | | | - Aparna Amanna
- NHS Fife, R&D Department, Queen Margaret Hospital, Dunfermline, UK
| | - Angela Martin
- Diabetes Centre, Victoria Hospital, NHS Fife, Kirkcaldy, UK
| | - Saket Gupta
- Diabetes Centre, Victoria Hospital, NHS Fife, Kirkcaldy, UK
| | - Karen Gray
- NHS Fife, R&D Department, Queen Margaret Hospital, Dunfermline, UK
| | - David Weller
- Usher Institute, University of Edinburgh, Edinburgh, UK
| | - Julie Brittenden
- Institute of Cardiovascular & Medical Sciences, University of Glasgow, Glasgow, UK
| | - Graham Leese
- Diabetes and Endocrinology, Ninewells Hospital, NHS Tayside, Dundee, UK
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12
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Isaac AL, Swartz TD, Miller ML, Short DJ, Wilson EA, Chaffo JL, Watson ES, Hu H, Petersen BJ, Bloom JD, Neff NJ, Linders DR, Salgado SJ, Locke JL, Horberg MA. Lower resource utilization for patients with healed diabetic foot ulcers during participation in a prevention program with foot temperature monitoring. BMJ Open Diabetes Res Care 2020; 8:8/1/e001440. [PMID: 33055233 PMCID: PMC7559055 DOI: 10.1136/bmjdrc-2020-001440] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2020] [Revised: 09/11/2020] [Accepted: 09/17/2020] [Indexed: 12/20/2022] Open
Abstract
INTRODUCTION We assessed the impact of a diabetic foot ulcer prevention program incorporating once-daily foot temperature monitoring on hospitalizations, emergency department and outpatient visits, and rates of diabetic foot ulcer recurrence and lower extremity amputations for patients with recently healed foot ulcers. RESEARCH DESIGN AND METHODS In this retrospective analysis of real-world data, we enrolled 80 participants with a healed diabetic foot ulcer in a year-long foot ulcer recurrence prevention program. Four outpatient centers within a large integrated healthcare system in the USA contributed to enrollment. We evaluated diabetic foot-related outcomes and associated resource utilization for participants during three periods: the 2 years before the program, the year during the program, and after the program ended. We reported unadjusted resource utilization rates during the program and the periods before and after it. We then adjusted rates of outcomes in each phase using an interrupted time series approach, explicitly controlling for overall trends in resource utilization and recurrence during the three periods. RESULTS Our unadjusted data showed high initial rates of resource utilization and recurrence before enrollment in the program, followed by lower rates during the program, and higher rates of resource utilization and similar rates of recurrence in the period following the end of the program. The adjusted data showed lower rates of hospitalizations (relative risk reduction (RRR)=0.52; number needed to treat (NNT)=3.4), lower extremity amputations (RRR=0.71; NNT=6.4), and outpatient visits (RRR=0.26; absolute risk reduction (ARR)=3.5) during the program. We also found lower rates of foot ulcer recurrence during the program in the adjusted data, particularly for wounds with infection or greater than superficial depth (RRR=0.91; NNT=4.4). CONCLUSIONS We observed lower rates of healthcare resource utilization for high-risk participants during enrollment in a diabetic foot prevention program incorporating once-daily foot temperature monitoring. TRIAL REGISTRATION NUMBER NCT04345016.
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Affiliation(s)
- Adam L Isaac
- Mid-Atlantic Permanente Medical Group, Rockville, Maryland, USA
- Foot and Ankle Specialists of the Mid-Atlantic LLC, Rockville, Maryland, USA
| | | | - Mark L Miller
- Mid-Atlantic Permanente Medical Group, Rockville, Maryland, USA
| | - Daniel J Short
- Mid-Atlantic Permanente Medical Group, Rockville, Maryland, USA
| | | | - Jamie L Chaffo
- Mid-Atlantic Permanente Medical Group, Rockville, Maryland, USA
| | - Eric S Watson
- Mid-Atlantic Permanente Research Institute, Rockville, Maryland, USA
| | - Haihong Hu
- Mid-Atlantic Permanente Research Institute, Rockville, Maryland, USA
| | | | | | | | | | | | - Jessica L Locke
- Mid-Atlantic Permanente Medical Group, Rockville, Maryland, USA
| | - Michael A Horberg
- Mid-Atlantic Permanente Medical Group, Rockville, Maryland, USA
- Mid-Atlantic Permanente Research Institute, Rockville, Maryland, USA
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13
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Syed MH, Salata K, Hussain MA, Zamzam A, de Mestral C, Wheatcroft M, Harlock J, Awartani D, Aljabri B, Verma A, Razak F, Verma S, Al-Omran M. The economic burden of inpatient diabetic foot ulcers in Toronto, Canada. Vascular 2020; 28:520-529. [PMID: 32379584 DOI: 10.1177/1708538120923420] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE Diabetic foot ulcer, which often leads to lower limb amputation, is a devastating complication of diabetes that is a major burden on patients and the healthcare system. The main objective of this study is to determine the economic burden of diabetic foot ulcer-related care. METHODS We conducted a multicenter study of all diabetic foot ulcer patients admitted to general internal medicine wards at seven hospitals in the Greater Toronto Area, Canada from 2010 to 2015, using the GEMINI database. We compared the mean costs of care per patient for diabetic foot ulcer-related admissions, admissions for other diabetes-related complications, and admissions for the top five most costly general internal medicine conditions, using the Ontario Case Costing Initiative. Regression models were used to determine adjusted estimates of cost per patient. Propensity-score matched analyses were performed as sensitivity analyses. RESULTS Our study cohort comprised of 557 diabetic foot ulcer patients; 2939 non-diabetic foot ulcer diabetes patients; and 23,656 patients with the top 5 most costly general internal medicine conditions. Diabetic foot ulcer admissions incurred the highest mean cost per patient ($22,754) when compared to admissions with non-diabetic foot ulcer diabetes ($8,350) and the top five most costly conditions ($10,169). Using adjusted linear regression, diabetic foot ulcer admissions demonstrated a 49.6% greater mean cost of care than non-diabetic foot ulcer-related diabetes admissions (95% CI 1.14-1.58), and a 25.6% greater mean cost than the top five most costly conditions (95% CI 1.17-1.34). Propensity-scored matched analyses confirmed these results. CONCLUSION Diabetic foot ulcer patients incur significantly higher costs of care when compared to admissions with non-diabetic foot ulcer-related diabetes patients, and the top five most costly general internal medicine conditions.
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Affiliation(s)
- Muzammil H Syed
- Faculty of Science, McMaster University, Hamilton, Canada.,Division of Vascular Surgery, St. Michael's Hospital, Toronto, Canada
| | - Konrad Salata
- Division of Vascular Surgery, St. Michael's Hospital, Toronto, Canada.,Department of Surgery, University of Toronto, Toronto, Canada
| | - Mohamad A Hussain
- Division of Vascular Surgery, St. Michael's Hospital, Toronto, Canada.,Department of Surgery, University of Toronto, Toronto, Canada
| | | | - Charles de Mestral
- Division of Vascular Surgery, St. Michael's Hospital, Toronto, Canada.,Department of Surgery, University of Toronto, Toronto, Canada.,Diabetes Action Canada, Toronto, Canada
| | - Mark Wheatcroft
- Division of Vascular Surgery, St. Michael's Hospital, Toronto, Canada.,Department of Surgery, University of Toronto, Toronto, Canada
| | - John Harlock
- Department of Surgery, Hamilton General Hospital, Hamilton, Canada.,Division of Vascular Surgery, Hamilton General Hospital, Hamilton, Canada
| | - Deana Awartani
- Department of Surgery, King Saud University, Riyadh, Kingdom of Saudi Arabia
| | - Badr Aljabri
- Division of Vascular Surgery, St. Michael's Hospital, Toronto, Canada.,Department of Surgery, King Saud University, Riyadh, Kingdom of Saudi Arabia
| | - Amol Verma
- Division of General Internal Medicine, St. Michael's Hospital, Toronto, Canada
| | - Fahad Razak
- Division of General Internal Medicine, St. Michael's Hospital, Toronto, Canada
| | - Subodh Verma
- Division of Vascular Surgery, St. Michael's Hospital, Toronto, Canada.,Division of Cardiac Surgery, St. Michael's Hospital, Toronto, Canada
| | - Mohammed Al-Omran
- Division of Vascular Surgery, St. Michael's Hospital, Toronto, Canada.,Department of Surgery, University of Toronto, Toronto, Canada.,Diabetes Action Canada, Toronto, Canada.,Department of Surgery, King Saud University, Riyadh, Kingdom of Saudi Arabia
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14
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Risk factors for plantar foot ulcer recurrence in patients with diabetes - A prospective pilot study. J Tissue Viability 2020; 29:135-137. [PMID: 32044183 DOI: 10.1016/j.jtv.2020.02.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2019] [Revised: 12/30/2019] [Accepted: 02/01/2020] [Indexed: 01/13/2023]
Abstract
INTRODUCTION Diabetic foot ulcer (DFU) is a complication of diabetes mellitus (DM) with established recurrence risk factors evaluating patients from United States or Europe. There are scarce studies in developing countries about these risks. The aim of this study was to evaluate risk factors associated with DFU recurrence in a Brazilian prospective cohort. MATERIALS AND METHODS A prospective cohort of patients with healed DFU followed from January 2014 to June 2017 in Curitiba, Brazil. Periodic home visits from a specialist nurse in DFU were performed during the period of the study to evaluate recurrence of ulcer. The presence of risk factors in the group of patients that developed an ulcer in the follow-up period was compared with the presence of these factors in the group of patients without recurrence. At enrollment, 35 subjects presented a previous ulcer distal with complete healing to follow-up. RESULTS From 35 patients, 15 were male (43%) and the mean age was of 65.8 ± 10.9 years (48-85 year). Most patients were married with a low income (<US$ 250/month). The mean BMI was 26.5 ± 5.6 kg/cm2. Seventy-four percent (26/35) had another comorbidity. The mean duration of DM until ulcer was 14.6 ± 5.2 years. The global mortality during the study (3 years) was 14%. The DFU recurred in 23 patients (65.7%). Both groups had similar findings, except by lower income (<US$ 250/month) in the group of recurrent DFU. CONCLUSION Recurrence of DFU is frequent and associated with low familiar income in a pilot Brazilian study.
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15
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Fu XL, Ding H, Miao WW, Mao CX, Zhan MQ, Chen HL. Global recurrence rates in diabetic foot ulcers: A systematic review and meta-analysis. Diabetes Metab Res Rev 2019; 35:e3160. [PMID: 30916434 DOI: 10.1002/dmrr.3160] [Citation(s) in RCA: 60] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2018] [Revised: 02/22/2019] [Accepted: 03/17/2019] [Indexed: 12/23/2022]
Abstract
Recurrence rates of diabetic foot ulcers vary widely in the published literature. The aim of this systematic review is to estimate recurrence rates of diabetic foot ulcers. We did a PubMed search and performed a review of reference lists for studies reporting recurrence of diabetic foot ulcers. The weighted relative risk (RR) and corresponding 95% confidence interval (CI) for recurrence was estimated. Forty-nine studies reporting recurrence of diabetic foot ulcers were included. A pooled estimate for recurrence rate was 22.1% per person-year (py) (95% CI, 19.0-25.2%). Recurrence rate was 24.9% per py in Europe (95% CI, 20.0%-29.7%), 17.8% per py in North America (95% CI, 12.7%-22.9%), 16.9% per py in Africa (95% CI, 4.7%-29.0%), and 17.0% per py in Asia (95% CI, 11.1%-23.0%). Turkey had the highest recurrence rate of 44.4% per py (95% CI, 24.9%-63.9%), and Bangladesh had the lowest of 4.3% per py (95% CI, 2.3%-6.3%). Recurrence rates of diabetic foot ulcers before 2002, between 2002 and 2008, and after 2008 were 22.2% per py (95% CI, 17.6%-26.8%), 21.9% per py (95% CI, 17.0%-26.8%), and 21.8% per py (95% CI, 16.3%-27.2%), respectively. Recurrence rates of diabetic foot ulcers are high. Recurrence rates vary widely in different regions and have decreased recently. More attention towards recurrence of diabetic foot ulcers is urgently required.
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Affiliation(s)
- Xue-Lei Fu
- Bachelor Student. School of Nursing, Nantong University, Nantong, China
| | - Hui Ding
- Bachelor Student. School of Nursing, Nantong University, Nantong, China
| | - Wei-Wei Miao
- Bachelor Student. School of Nursing, Nantong University, Nantong, China
| | - Chun-Xing Mao
- Bachelor Student. School of Nursing, Nantong University, Nantong, China
| | - Min-Qi Zhan
- Bachelor Student. School of Nursing, Nantong University, Nantong, China
| | - Hong-Lin Chen
- School of Public Health, Nantong University, Nantong, China
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16
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Mairghani M, Jassim G, Elmusharaf K, Patton D, Eltahir O, Moore Z, Sorensen J. Methodological approaches for assessing the cost of diabetic foot ulcers: a systematic literature review. J Wound Care 2019; 28:261-266. [DOI: 10.12968/jowc.2019.28.5.261] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
Objective: To evaluate the methodological approaches used to assess the cost consequences of diabetic foot ulcers (DFUs) in published scientific papers. Method: A systematic literature search was conducted in PubMed, Embase, Scopus, Web of Science and CINAHL. English language papers reporting on the cost of DFUs were identified. Additionally, bibliographies were inspected to identify other relevant cost studies. Following the PRISMA guidance, the review identified the study design, epidemiological approach, analytical perspective and data collection approach in each of the included studies. Results: Relatively few studies of the cost consequences of DFUs were found (n=27). Most studies were conducted in Western countries with only five studies from countries in Asia and Africa. The identified studies used different study designs, epidemiological approaches, data collection strategies, and data sources, which in turn made a systematic comparison of cost estimates difficult. Detailed descriptions of the applied costing method and other methodological aspects were often limited or absent. Many studies only reported costs from a health-care payer's perspective and disregarded the costs to patients, their families and wider society. Conclusion: The costs of DFUs have been assessed using a wide range of different methodological approaches often restricted to the healthcare payer's perspective. Therefore, the cost analyses may fail to consider the true societal costs of DFUs.
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Affiliation(s)
| | - Ghufran Jassim
- Senior Lecturer, Royal College of Surgeons in Ireland, Bahrain
| | - Khalifa Elmusharaf
- Senior Lecturer, Graduate Entry Medical School, University of Limerick, Limerick
| | - Declan Patton
- Director of Research, Senior Lecturer, Royal College of Surgeons in Ireland, Dublin
| | - Omer Eltahir
- Registrar, MCh Scholar, Royal College of Surgeons in Ireland, Dublin
| | - Zena Moore
- Professor of Nursing, Head of Department, Royal College of Surgeons in Ireland, Dublin
| | - Jan Sorensen
- Director of Healthcare Outcomes Research Centre, Healthcare Outcomes Research Centre, Royal College of Surgeons in Ireland, Dublin
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17
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Muhammad FY, Pedro LM, Suleiman HH, Uloko AE, Gezawa ID, Adenike E, Ramalan M, Iliyasu G. Cost of Illness of Diabetic Foot Ulcer in a Resource Limited Setting: A Study from Northwestern Nigeria. J Diabetes Metab Disord 2018; 17:93-99. [PMID: 30918841 DOI: 10.1007/s40200-018-0344-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2018] [Accepted: 07/25/2018] [Indexed: 01/02/2023]
Abstract
Introduction Diabetic foot ulcer is a major complication of diabetes with a high economic cost of managing. Data from resource limited setting will bring to light how patients in these localities suffer financially in addition to poverty and lack of health insurance. This study estimated cost of illness among patients with diabetic foot ulcer in northwestern Nigeria. Methods It was a hospital based cross-sectional study. Questionnaire was used to take the bio data and medical history. Direct medical, direct non-medical and indirect cost were estimated. Result Majority of the patients were males with the mean age of 59.3 ± 15.1 yrs. About 60% of the patients earn less than $100 monthly. The total cost of illness of diabetic foot ulcer was estimated at $140,735.56 (median = $1381.55[IQR 1002.42-]). Direct cost of illness was $107,797.06 (median = $1023.27[IQR 773.93-1568]), while the indirect cost was $32,938.49 (median = $209.90[IQR 128.74-357.08]). Out of pocket payment accounted for 90% of the payment. Conclusion The cost of diabetic foot ulcer is very exorbitant and the patients affected are mostly poor, unemployed and the breadwinners of their families.
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Affiliation(s)
| | | | | | - Andrew E Uloko
- 1Department of Medicine, College of Health Science, Bayero University, Kano, PMB 3011 Nigeria
| | - Ibrahim D Gezawa
- 1Department of Medicine, College of Health Science, Bayero University, Kano, PMB 3011 Nigeria
| | | | - Mansur Ramalan
- 5Department of Medicine, Aminu Kano Teaching Hospital, Kano, Nigeria
| | - Garba Iliyasu
- 1Department of Medicine, College of Health Science, Bayero University, Kano, PMB 3011 Nigeria
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18
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Khalifa WA. Risk factors for diabetic foot ulcer recurrence: A prospective 2-year follow-up study in Egypt. Foot (Edinb) 2018; 35:11-15. [PMID: 29753996 DOI: 10.1016/j.foot.2017.12.004] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2017] [Revised: 12/18/2017] [Accepted: 12/23/2017] [Indexed: 02/04/2023]
Abstract
OBJECTIVES To determine the frequency of diabetic foot ulcer recurrence and its potential risk factors. METHODS This study included 93 patients with type 2 diabetes and followed for 2 years after primary healed foot ulceration. Demographic, diabetes related, comorbid and ulcer related variables were investigated as risk factors. Multiple logistic regression analysis was used to identify independent risk factors. RESULTS 61.3% of patients had recurrent ulcers particularly in the forefoot (33.3%) and big toe (24.6%). Peripheral neuropathy, peripheral arterial disease or both were reported in 69%, 12% and 19% of feet with recurrent ulcers respectively. In multivariate analysis, the significant independent potential risk factors for recurrence of foot ulcers were smoking (P=0.040), poor glycemic control [HbA1c cutoff of 10%] (P=0.010), peripheral neuropathy with lost ankle reflex (P=0.0001), peripheral arterial disease (P=0.0001) and previous ulcer location (P=0.050). CONCLUSION The frequency rate of recurrent diabetic foot ulceration in patients with type 2 diabetes is high particularly in the first year despite regular follow-up and patient education.
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Affiliation(s)
- Walaa A Khalifa
- Department of Internal Medicine, Endocrinology and Diabetes Unit, Assiut University, Assiut, Egypt.
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19
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Chandra V, Glebova NO, Salvo NL, Wu T. Partnerships Between Podiatrists and Vascular Surgeons in Building Effective Wound Care Centers. J Am Podiatr Med Assoc 2017; 107:471-474. [PMID: 28829154 DOI: 10.7547/17-144] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
This practice memo, a collaborative effort between the Young Physicians' Program of the American Podiatric Medical Association (APMA) and the Young Surgeons Committee of the Society for Vascular Surgery (SVS), is intended to aid podiatrists and vascular surgeons in the early years of their respective careers, especially those involved in the care of patients with chronic wounds. During these formative years, learning how to successfully establish an inter-professional partnership is crucial in order to provide the best possible care to this important patient population.
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Affiliation(s)
- Venita Chandra
- Department of Vascular Surgery, Stanford University, Stanford, CA. Society for Vascular Surgery Young Surgeons Committee
| | - Natalia O. Glebova
- Department of Surgery, University of Colorado, Aurora, CO. Society for Vascular Surgery Young Surgeons Committee
| | - Nichol L. Salvo
- APMA Young Physicians' Leadership Panel, Podiatry Section and Podiatry Residency Program, Atlanta VA Medical Center, Decatur, GA
| | - Timothy Wu
- Division of Vascular Surgery Young Surgeons Committee, Rutgers New Jersey Medical School, Newark, NJ. Society for Vascular Surgery Young Surgeons Committee
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20
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Chandra V, Glebova NO, Salvo NL, Wu T. Partnerships between podiatrists and vascular surgeons in building effective wound care centers. J Vasc Surg 2017; 66:902-905. [PMID: 28842074 DOI: 10.1016/j.jvs.2017.06.071] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
This practice memo, a collaborative effort between the Young Physicians' Program of the American Podiatric Medical Association and the Young Surgeons Committee of the Society for Vascular Surgery, is intended to aid podiatrists and vascular surgeons in the early years of their respective careers, especially those involved in the care of patients with chronic wounds. During these formative years, learning how to successfully establish an interprofessional partnership is crucial to provide the best possible care to this important population of patients.
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Affiliation(s)
- Venita Chandra
- Division of Vascular Surgery, Stanford University, Stanford, Calif
| | - Natalia O Glebova
- Division of Vascular Surgery & Endovascular Therapy, University of Colorado, Aurora, Colo
| | - Nichol L Salvo
- Podiatry Section, Atlanta VA Medical Center, Decatur, Ga
| | - Timothy Wu
- Division of Vascular Surgery, Rutgers New Jersey Medical School, Newark, NJ.
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21
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Sehlo MG, Alzahrani OH, Alzahrani HA. Illness invalidation from spouse and family is associated with depression in diabetic patients with first superficial diabetic foot ulcers. Int J Psychiatry Med 2017; 51:16-30. [PMID: 26681233 DOI: 10.1177/0091217415621032] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
OBJECTIVES (1) To assess the prevalence of depressive disorders in a sample of diabetic patients with their first superficial diabetic foot ulcer. (2) To evaluate the association between illness invalidation from spouse, family, and depressive disorders in those patients. METHODS Depressive disorders and severity were diagnosed by the Structured Clinical Interview for DSM-IV Axis Ι disorders, clinical version, and the spouse and family scales of the Illness Invalidation Inventory, respectively (3*I). Physical functioning was also assessed using the Physical Component of The Short Form 36 item health-related quality of life questionnaire. RESULTS The prevalence of depressive disorders was 27.50% (22/80). There was a significant decrease in physical health component summary mean score and a significant increase in ulcer size, Center for Epidemiologic Studies-Depression Scale, spouse discounting, spouse lack of understanding, and family discounting mean scores in the depressed group compared to the non-depressed group. Higher levels of spouse discounting, spouse understanding, and family discounting were significant predictors of diagnosis of depressive disorders and were strongly associated with increased severity of depressive symptoms in diabetic patients with first superficial diabetic foot ulcers. Poor physical functioning was associated with increased depressive symptom severity. CONCLUSION This study demonstrated that illness invalidation from spouse and family is associated with diagnosis of depressive disorders and increased severity of depressive symptoms in diabetic patients with first superficial diabetic foot ulcers.
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Affiliation(s)
- Mohammad G Sehlo
- Department of Medicine, Psychiatry Unit, King Abdulaziz University, Jeddah, Saudi Arabia Mohammad Hussein Al-Amoudi Chair for Diabetic Foot Research, King Abdulaziz University, Jeddah, Saudi Arabia Department of Psychiatry, Zagazig University, Zagazig, Egypt
| | - Owiss H Alzahrani
- Mohammad Hussein Al-Amoudi Chair for Diabetic Foot Research, King Abdulaziz University, Jeddah, Saudi Arabia
| | - Hasan A Alzahrani
- Mohammad Hussein Al-Amoudi Chair for Diabetic Foot Research, King Abdulaziz University, Jeddah, Saudi Arabia Division of Vascular Surgery, King Abdulaziz University, Jeddah, Saudi Arabia
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22
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Roze S, de Portu S, Smith-Palmer J, Delbaere A, Valentine W, Ridderstråle M. Cost-effectiveness of sensor-augmented pump therapy versus standard insulin pump therapy in patients with type 1 diabetes in Denmark. Diabetes Res Clin Pract 2017; 128:6-14. [PMID: 28432898 DOI: 10.1016/j.diabres.2017.02.009] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2016] [Revised: 01/09/2017] [Accepted: 02/07/2017] [Indexed: 10/20/2022]
Abstract
AIMS The use of continuous subcutaneous insulin infusion (CSII) in type 1 diabetes (T1D) has increased in recent years. Sensor-augmented pump therapy (SAP) with low glucose suspend (LGS) (allowing temporary suspension of insulin delivery if blood glucose level falls below a pre-defined threshold level) provides additional benefits over CSII alone, but is associated with higher acquisition costs. Therefore, a cost-effectiveness analysis of SAP+LGS versus CSII in patients with T1D was performed. METHODS Analyses were performed using the CORE Diabetes Model in two different patient cohorts in Denmark, one with hyperglycemia at baseline and one with increased risk for hypoglycemic events. Clinical input data were sourced from published literature. The analysis was performed over a lifetime time horizon from a societal perspective. Future costs and clinical outcomes were discounted at 3% per annum. RESULTS In patients who were hyperglycemic at baseline the use of SAP+LGS versus CSII resulted in improved quality-adjusted life expectancy (12.44 versus 10.99 quality-adjusted life years [QALYs]) but higher mean lifetime costs (DKK 2,027,316 versus DKK 1,801,293) leading to an incremental cost-effectiveness ratio (ICER) of DKK 156,082 per QALY gained. For patients at increased risk for hypoglycemic events the ICER for SAP+LGS versus CSII was DKK 89,868 per QALY gained. CONCLUSIONS The ICER for SAP+LGS versus CSII falls below commonly cited willingness-to-pay thresholds. Therefore, in Denmark, the use of SAP+LGS is likely to be considered cost-effective relative to CSII for patients with T1D who are either hyperglycemic, despite CSII use, or who experience frequent severe hypoglycemic events.
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Affiliation(s)
| | - S de Portu
- Medtronic International Sàrl, Tolochenaz, Switzerland
| | - J Smith-Palmer
- Ossian Health Economics and Communications, Basel, Switzerland.
| | - A Delbaere
- Medtronic International Sàrl, Tolochenaz, Switzerland
| | - W Valentine
- Ossian Health Economics and Communications, Basel, Switzerland
| | - M Ridderstråle
- Lund University, Skåne University Hospital, Malmö, Sweden
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Clokie M, Greenway AL, Harding K, Jones NJ, Vedhara K, Game F, Dhatariya KK. New horizons in the understanding of the causes and management of diabetic foot disease: report from the 2017 Diabetes UK Annual Professional Conference Symposium. Diabet Med 2017; 34:305-315. [PMID: 28029181 DOI: 10.1111/dme.13313] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/22/2016] [Indexed: 01/24/2023]
Abstract
Diabetes-related foot disease remains a common problem. For wounds, classic teaching recommends the treatment of any infection, offloading the wound and ensuring a good blood supply, as well as ensuring that the other modifiable risk factors are addressed and optimized. There remain, however, several questions about these and other aspects of the care of diabetes-related foot disease. Some of these questions are addressed in the present report; in particular, the impact of newer technologies in the identification of any organisms present in a wound, as well as the use of novel approaches to treat infections. The use of new remote sensing technology to identify people at risk of developing foot ulceration is also considered, in an attempt to allow early intervention and prevention of foot ulcers. The psychological impact of foot disease is often overlooked, but with an increasing number of publications on the subject, the cause-and-effect role that psychology plays in foot disease, such as ulcers and Charcot neuroarthropathy, is considered. Finally, because of heterogeneity in diabetic foot studies, comparing results is difficult. A recently published document focusing on ensuring a standardized way of reporting foot disease trials is discussed.
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Affiliation(s)
- M Clokie
- Department of Infection, Immunity and Inflammation, University of Leicester, Leicester, Rhondda Cynon Taf
| | - A L Greenway
- Department of Infection, Immunity and Inflammation, University of Leicester, Leicester, Rhondda Cynon Taf
| | - K Harding
- Medical School, Cardiff University, Heath Park, Cardiff, Rhondda Cynon Taf
| | - N J Jones
- Welsh Wound Innovation Centre, Rhodfa Marics, Ynysmaerdy, Rhondda Cynon Taf
| | - K Vedhara
- Department of Health Psychology, Division of Primary Care, Nottingham University, Nottingham, UK
| | - F Game
- Department of Diabetes, Derby Teaching Hospitals NHS Foundation Trust, Derby, UK
| | - K K Dhatariya
- Elsie Bertram Diabetes Centre, Norfolk and Norwich University Hospitals NHS Foundation Trust, Norwich, UK
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24
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Nemcová J, Hlinková E, Farský I, Žiaková K, Jarošová D, Zeleníková R, Bužgová R, Janíková E, Zdzieblo K, Wiraszka G, Stepien R, Nowak-Starz G, Csernus M, Balogh Z. Quality of life in patients with diabetic foot ulcer in Visegrad countries. J Clin Nurs 2017; 26:1245-1256. [DOI: 10.1111/jocn.13508] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/07/2016] [Indexed: 12/01/2022]
Affiliation(s)
- Jana Nemcová
- Jessenius Faculty of Medicine in Martin; Comenius University in Bratislava; Martin Slovak Republic
| | - Edita Hlinková
- Jessenius Faculty of Medicine in Martin; Comenius University in Bratislava; Martin Slovak Republic
| | - Ivan Farský
- Jessenius Faculty of Medicine in Martin; Comenius University in Bratislava; Martin Slovak Republic
| | - Katarína Žiaková
- Jessenius Faculty of Medicine in Martin; Comenius University in Bratislava; Martin Slovak Republic
| | - Darja Jarošová
- Faculty of Medicine; University of Ostrava; Ostrava Czech Republic
| | | | - Radka Bužgová
- Faculty of Medicine; University of Ostrava; Ostrava Czech Republic
| | - Eva Janíková
- Faculty of Medicine; University of Ostrava; Ostrava Czech Republic
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Abstract
BACKGROUND The Amputation Prevention Initiative is a project conducted jointly by the Massachusetts Public Health Association and the Massachusetts Podiatric Medical Society that seeks to study methods to reduce nontraumatic lower-extremity amputations from diabetes. METHODS To determine the rate of diabetes-related lower-extremity amputations in Massachusetts and identify the groups most at risk, hospital billing and discharge data were analyzed. To examine the components of the diabetic foot examination routinely performed by general practitioners, surveys were conducted in conjunction with physician meetings in Massachusetts (n = 149) and in six other states (n = 490). RESULTS The average age-adjusted number of diabetes-related lower-extremity amputations in 2004 was 30.8 per 100,000 and 5.3 per 1,000 diabetic patients in MA, with high-risk groups being identified as men and black individuals. Among the general practitioners surveyed in Massachusetts, only 2.01% reported routinely conducting all four key components of the diabetic foot examination, with 28.86% reporting not performing any components. CONCLUSIONS These findings suggest that many general practitioners may be failing to perform the major components of the diabetic foot examination believed to prevent foot ulcers and lower-extremity amputations.
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Affiliation(s)
- Emily A Cook
- Division of Podiatric Surgery, Mount Auburn Hospital, Harvard Medical School, Cambridge, MA
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Wang C, Yan X, Smith M, Kochhar K, Rubin M, Warren SM, Wrobel J, Lee H. A unified framework for automatic wound segmentation and analysis with deep convolutional neural networks. ANNUAL INTERNATIONAL CONFERENCE OF THE IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. ANNUAL INTERNATIONAL CONFERENCE 2016; 2015:2415-8. [PMID: 26736781 DOI: 10.1109/embc.2015.7318881] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Wound surface area changes over multiple weeks are highly predictive of the wound healing process. Furthermore, the quality and quantity of the tissue in the wound bed also offer important prognostic information. Unfortunately, accurate measurements of wound surface area changes are out of reach in the busy wound practice setting. Currently, clinicians estimate wound size by estimating wound width and length using a scalpel after wound treatment, which is highly inaccurate. To address this problem, we propose an integrated system to automatically segment wound regions and analyze wound conditions in wound images. Different from previous segmentation techniques which rely on handcrafted features or unsupervised approaches, our proposed deep learning method jointly learns task-relevant visual features and performs wound segmentation. Moreover, learned features are applied to further analysis of wounds in two ways: infection detection and healing progress prediction. To the best of our knowledge, this is the first attempt to automate long-term predictions of general wound healing progress. Our method is computationally efficient and takes less than 5 seconds per wound image (480 by 640 pixels) on a typical laptop computer. Our evaluations on a large-scale wound database demonstrate the effectiveness and reliability of the proposed system.
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Smith SR, Reed JF. Prevalence of Mixed Infections in the Diabetic Pedal Wound: A Perspective Based on a National Audit. INT J LOW EXTR WOUND 2016; 1:125-8. [PMID: 15871962 DOI: 10.1177/1534734602001002007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Foot infections can have disastrous consequences in the life of a diabetic. The treatment of the pedal wound demands a great deal of resources. This retrospective study was formulated to determine the incidence of polymicrobial infections. The National Hospital Discharge Survey was used to gather data regarding cultures from diabetic foot infections. Codes from surgery were used because intraoperative cultures are the most reliable. It was observed that Staphylococcus Aureus is the most frequently responsible inciting organism; regarding polymicrobial infections, Staphylococcus and Streptococcus were the most common combination found. Incidence of anaerobes and gram negatives was low. This information tells a clinician that very broad-spectrum antibiotics would most commonly not be necessary, putting the impetus on the doctors to clinically assess a wound and prescribe the most appropriate antibiotic selection.
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Affiliation(s)
- Stacey R Smith
- Department of Podiatry and Research Institute, St. Lukes Hospital & Health Network, Bethlehem, Pennsylvania 18015, USA.
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28
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Santema TB, Poyck PPC, Ubbink DT. Skin grafting and tissue replacement for treating foot ulcers in people with diabetes. Cochrane Database Syst Rev 2016; 2:CD011255. [PMID: 26866804 PMCID: PMC6464524 DOI: 10.1002/14651858.cd011255.pub2] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
BACKGROUND Foot ulceration is a major problem in people with diabetes and is the leading cause of hospitalisation and limb amputations. Skin grafts and tissue replacements can be used to reconstruct skin defects for people with diabetic foot ulcers in addition to providing them with standard care. Skin substitutes can consist of bioengineered or artificial skin, autografts (taken from the patient), allografts (taken from another person) or xenografts (taken from animals). OBJECTIVES To determine the benefits and harms of skin grafting and tissue replacement for treating foot ulcers in people with diabetes. SEARCH METHODS In April 2015 we searched: The Cochrane Wounds Specialised Register; the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library); Ovid MEDLINE; Ovid MEDLINE (In-Process & Other Non-Indexed Citations); Ovid EMBASE and EBSCO CINAHL. We also searched clinical trial registries to identify ongoing studies. We did not apply restrictions to language, date of publication or study setting. SELECTION CRITERIA Randomised clinical trials (RCTs) of skin grafts or tissue replacements for treating foot ulcers in people with diabetes. DATA COLLECTION AND ANALYSIS Two review authors independently extracted data and assessed the quality of the included studies. MAIN RESULTS We included seventeen studies with a total of 1655 randomised participants in this review. Risk of bias was variable among studies. Blinding of participants, personnel and outcome assessment was not possible in most trials because of obvious differences between the treatments. The lack of a blinded outcome assessor may have caused detection bias when ulcer healing was assessed. However, possible detection bias is hard to prevent due to the nature of the skin replacement products we assessed, and the fact that they are easily recognisable. Strikingly, nearly all studies (15/17) reported industry involvement; at least one of the authors was connected to a commercial organisation or the study was funded by a commercial organisation. In addition, the funnel plot for assessing risk of bias appeared to be asymmetrical; suggesting that small studies with 'negative' results are less likely to be published.Thirteen of the studies included in this review compared a skin graft or tissue replacement with standard care. Four studies compared two grafts or tissue replacements with each other. When we pooled the results of all the individual studies, the skin grafts and tissue replacement products that were used in the trials increased the healing rate of foot ulcers in patients with diabetes compared to standard care (risk ratio (RR) 1.55, 95% confidence interval (CI) 1.30 to 1.85, low quality of evidence). However, the strength of effect was variable depending on the specific product that was used (e.g. EpiFix® RR 11.08, 95% CI 1.69 to 72.82 and OrCel® RR 1.75, 95% CI 0.61 to 5.05). Based on the four included studies that directly compared two products, no specific type of skin graft or tissue replacement showed a superior effect on ulcer healing over another type of skin graft or tissue replacement.Sixteen of the included studies reported on adverse events in various ways. No study reported a statistically significant difference in the occurrence of adverse events between the intervention and the control group.Only two of the included studies reported on total incidence of lower limb amputations. We found fewer amputations in the experimental group compared with the standard care group when we pooled the results of these two studies, although the absolute risk reduction for amputation was small (RR 0.43, 95% CI 0.23 to 0.81; risk difference (RD) -0.06, 95% CI -0.10 to -0.01, very low quality of evidence). AUTHORS' CONCLUSIONS Based on the studies included in this review, the overall therapeutic effect of skin grafts and tissue replacements used in conjunction with standard care shows an increase in the healing rate of foot ulcers and slightly fewer amputations in people with diabetes compared with standard care alone. However, the data available to us was insufficient for us to draw conclusions on the effectiveness of different types of skin grafts or tissue replacement therapies. In addition, evidence of long term effectiveness is lacking and cost-effectiveness is uncertain.
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Affiliation(s)
- Trientje B Santema
- Academic Medical Centre at the University of AmsterdamDepartment of SurgeryMeibergdreef 9Room G4‐132AmsterdamNetherlands1105 AZ
| | - Paul PC Poyck
- Royal Brisbane and Women's HospitalDepartment of Vascular SurgeryButterfield StreetBrisbaneHerston, QueenslandAustralia4029
| | - Dirk T Ubbink
- Academic Medical Center at the University of AmsterdamDepartment of SurgeryMeibergdreef 9, room G4‐184PO Box 22700AmsterdamNetherlands1100 DE
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Rasmussen BSB, Yderstraede KB, Carstensen B, Skov O, Beck-Nielsen H. Substantial reduction in the number of amputations among patients with diabetes: a cohort study over 16 years. Diabetologia 2016; 59:121-129. [PMID: 26590707 DOI: 10.1007/s00125-015-3781-7] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2015] [Accepted: 09/11/2015] [Indexed: 10/22/2022]
Abstract
AIMS/HYPOTHESIS The aim of this study was to describe the trends in rates of amputation among individuals with and without diabetes. METHODS We studied amputation rates in the County of Funen (approximately 0.5 million residents) during the period 1996-2011. Amputations were identified from the hospital administrative system, diabetes status by linkage with the Danish National Diabetes Register, and mortality and population data by extraction from Statistics Denmark. Amputation rates were analysed using proportional hazard models. We analysed the incidence of the first amputation at each level as well as the incidence of further amputations, subdivided by level of amputation. RESULTS During the period 1996-2011, a total of 2,832 amputations were performed, of which 1,285 were among patients with diabetes and 1,547 among individuals without diabetes. Relative to persons without diabetes, patients with diabetes had an HR for below-ankle amputations (BAAs) of 14.7 for men and 7.5 for women, and for from-ankle-to-knee amputations (BKAs) of 7.6 and 8.4 for men and women, respectively. For above-knee amputations (AKAs) the numbers were 4.0 for men and 3.7 for women. We found an annual reduction in BAA rates among patients with diabetes of 9.8%, and the annual reduction in BKA for patients with diabetes was 15.1%. CONCLUSIONS/INTERPRETATION The amputation rate in patients with diabetes is still several-fold higher than in persons without diabetes, but the improvements in diabetes care in recent years have resulted in a steady decline in amputation rates among patients with diabetes from this Danish cohort.
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Affiliation(s)
- Benjamin S B Rasmussen
- Department of Medical Endocrinology, Odense University Hospital Denmark, Sdr. Boulevard 29, 5000, Odense C, Denmark.
| | - Knud B Yderstraede
- Department of Medical Endocrinology, Odense University Hospital Denmark, Sdr. Boulevard 29, 5000, Odense C, Denmark
| | | | - Ole Skov
- Department of Orthopaedic Surgery, Odense University Hospital, Odense, Denmark
| | - Henning Beck-Nielsen
- Department of Medical Endocrinology, Odense University Hospital Denmark, Sdr. Boulevard 29, 5000, Odense C, Denmark
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30
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May M, Hahn S, Tonn C, Engels G, Hochlenert D. Decrease in (Major) Amputations in Diabetics: A Secondary Data Analysis by AOK Rheinland/Hamburg. J Diabetes Res 2016; 2016:6247045. [PMID: 26881254 PMCID: PMC4736381 DOI: 10.1155/2016/6247045] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2015] [Accepted: 12/02/2015] [Indexed: 12/02/2022] Open
Abstract
AIM In two German regions with 11.1 million inhabitants, 6 networks for specialized treatment of DFS were implemented until 2008. Data provided for accounting purposes was analysed in order to determine changes in the rate of diabetics requiring amputations in the years before and after the implementation. METHOD Data covering 2.9 million people insured by the largest insurance company between 2007 and 2013 was analysed by the use of log-linear Poisson regression adjusted for age, gender and region. RESULTS The rate of diabetics needing major amputations fell significantly by 9.5% per year (p < 0.0001) from 217 to 126 of 100,000 patients per year. The rate of diabetics needing amputations of any kind fell from 504 to 419 of 100,000 patients per year (p = 0.0038). DISCUSSION The networks integrate health care providers in an organised system of shared care. They educate members of the medical community and the general public. At the same time, a more general disease management program for people with diabetes was implemented, which may also have contributed to this decrease. At the end of the observation period, the rate of diabetics requiring amputations was still high. For this reason, further expansion of organised specialized care is urgently needed.
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Affiliation(s)
- Melanie May
- AOK Rheinland/Hamburg, Die Gesundheitskasse, Unternehmensbereich Ambulante Versorgung, Geschäftsbereich Selektivverträge, Kasernenstrasse 61, 40213 Düsseldorf, Germany
- *Melanie May:
| | - Sebastian Hahn
- AOK Rheinland/Hamburg, Die Gesundheitskasse, Unternehmensbereich M-RSA/Finanzen/Controlling, Geschäftsbereich Controlling, Kasernenstrasse 61, 40213 Düsseldorf, Germany
| | - Claudia Tonn
- AOK Rheinland/Hamburg, Die Gesundheitskasse, Unternehmensbereich Ambulante Versorgung, Geschäftsbereich Selektivverträge, Kasernenstrasse 61, 40213 Düsseldorf, Germany
| | - Gerald Engels
- Chirurgische Praxis am Bayenthalgürtel, Bayenthalgürtel 45, 50968 Köln, Germany
- Ltd. Arzt Abteilung, Wundchirurgie St. Vinzenz Hospital Köln, Merheimer Strasse 221, 50733 Köln, Germany
| | - Dirk Hochlenert
- Centrum für Diabetologie, Endoskopie und Wundheilung, Merheimer Strasse 217, 50733 Köln, Germany
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Cárdenas MK, Mirelman AJ, Galvin CJ, Lazo-Porras M, Pinto M, Miranda JJ, Gilman RH. The cost of illness attributable to diabetic foot and cost-effectiveness of secondary prevention in Peru. BMC Health Serv Res 2015; 15:483. [PMID: 26503154 PMCID: PMC4623251 DOI: 10.1186/s12913-015-1141-4] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2014] [Accepted: 10/12/2015] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND Diabetes mellitus is a public health challenge worldwide, and roughly 25% of patients with diabetes in developing countries will develop at least one foot ulcer during their lifetime. The gravest outcome of an ulcerated foot is amputation, leading to premature death and larger economic costs. METHODS This study aimed to estimate the economic costs of diabetic foot in high-risk patients in Peru in 2012 and to model the cost-effectiveness of a year-long preventive strategy for foot ulceration including: sub-optimal care (baseline), standard care as recommended by the International Diabetes Federation, and standard care plus daily self-monitoring of foot temperature. A decision tree model using a population prevalence-based approach was used to calculate the costs and the incremental cost-effectiveness ratio (ICER). Outcome measures were deaths and major amputations, uncertainty was tested with a one-way sensitivity analysis. RESULTS The direct costs for prevention and management with sub-optimal care for high-risk diabetics is around US$74.5 million dollars in a single year, which decreases to US$71.8 million for standard care and increases to US$96.8 million for standard care plus temperature monitoring. The implementation of a standard care strategy would avert 791 deaths and is cost-saving in comparison to sub-optimal care. For standard care plus temperature monitoring compared to sub-optimal care the ICER rises to US$16,124 per death averted and averts 1,385 deaths. CONCLUSION Diabetic foot complications are highly costly and largely preventable in Peru. The implementation of a standard care strategy would lead to net savings and avert deaths over a one-year period. More intensive prevention strategies such as incorporating temperature monitoring may also be cost-effective.
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Affiliation(s)
- María Kathia Cárdenas
- CRONICAS Centre of Excellence in Chronic Diseases, Universidad Peruana Cayetano Heredia, Av. Armendariz 497, Lima 18, Miraflores, Peru.
| | | | | | - María Lazo-Porras
- CRONICAS Centre of Excellence in Chronic Diseases, Universidad Peruana Cayetano Heredia, Av. Armendariz 497, Lima 18, Miraflores, Peru.
- Unidad de Conocimiento y Evidencia, Universidad Peruana Cayetano Heredia, Lima, Peru.
| | - Miguel Pinto
- Servicio de Endocrinología, Hospital Nacional Cayetano Heredia, Lima, Peru.
- Facultad de Medicina "Alberto Hurtado", Universidad Peruana Cayetano Heredia, Lima, Peru.
| | - J Jaime Miranda
- CRONICAS Centre of Excellence in Chronic Diseases, Universidad Peruana Cayetano Heredia, Av. Armendariz 497, Lima 18, Miraflores, Peru.
- Facultad de Medicina "Alberto Hurtado", Universidad Peruana Cayetano Heredia, Lima, Peru.
| | - Robert H Gilman
- CRONICAS Centre of Excellence in Chronic Diseases, Universidad Peruana Cayetano Heredia, Av. Armendariz 497, Lima 18, Miraflores, Peru.
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.
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Rasmussen BSB, Froekjaer J, Bjerregaard MR, Lauritsen J, Hangaard J, Henriksen CW, Halekoh U, Yderstraede KB. A Randomized Controlled Trial Comparing Telemedical and Standard Outpatient Monitoring of Diabetic Foot Ulcers. Diabetes Care 2015; 38:1723-9. [PMID: 26116717 DOI: 10.2337/dc15-0332] [Citation(s) in RCA: 66] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2015] [Accepted: 06/06/2015] [Indexed: 02/03/2023]
Abstract
OBJECTIVE The role of telemedical monitoring in diabetic foot ulcer care is still uncertain. Our aim was to compare telemedical and standard outpatient monitoring in the care of patients with diabetic foot ulcers in a randomized controlled trial. RESEARCH DESIGN AND METHODS Of the 736 screened individuals with diabetic foot ulcers, 401 met the eligibility criteria and were randomized between October 2010 and November 2014. The per-protocol telemedical monitoring consisted of two consultations in the patient's own home and one consultation at the outpatient clinic. Standard practice consisted of three outpatient clinic visits. The three-visit cycle was repeated until study end point. The study end points were defined as complete ulcer healing, amputation, or death. RESULTS One hundred ninety-three individuals were randomized to telemedical monitoring and 181 to standard care. Demographics were similar in both groups. A cause-specific Cox proportional hazards model showed no difference in individuals monitored through telemedicine regarding wound healing (hazard ratio 1.11 [95% CI 0.87, 1.42], P = 0.42) or amputation (0.87 [0.54, 1.42], P = 0.59). We found a higher mortality incidence in the telemedical monitoring group compared with the standard outpatient monitoring group (8.68 [6.93, 10.88], P = 0.0001). CONCLUSIONS The findings of no significant difference regarding amputation and healing between telemedical and standard outpatient monitoring seem promising; however, for telemedical monitoring, a higher mortality throws into question the role of telemedicine in monitoring diabetic foot ulcers. Further studies are needed to investigate effects of telemedicine on mortality and other clinical outcomes and to identify patient subgroups that may have a poorer outcome through telemedical monitoring.
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Affiliation(s)
| | - Johnny Froekjaer
- Department of Orthopaedic Surgery, Odense University Hospital, Odense, Denmark
| | - Mads R Bjerregaard
- Department of Medical Endocrinology, Odense University Hospital, Odense, Denmark
| | - Jens Lauritsen
- Department of Orthopaedic Surgery, Odense University Hospital, Odense, Denmark
| | - Joergen Hangaard
- Department of Internal Medicine, Odense University Hospital, Odense, Denmark
| | - Claus W Henriksen
- Department of Orthopaedic Surgery, Kolding Hospital, Kolding, Denmark
| | - Ulrich Halekoh
- Epidemiology, Biostatistics and Biodemography, University of Southern Denmark, Odense, Denmark
| | - Knud B Yderstraede
- Department of Medical Endocrinology, Odense University Hospital, Odense, Denmark
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Smart bandage with wireless connectivity for uric acid biosensing as an indicator of wound status. Electrochem commun 2015. [DOI: 10.1016/j.elecom.2015.03.018] [Citation(s) in RCA: 186] [Impact Index Per Article: 20.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
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Lázaro-Martínez JL, Aragón-Sánchez J, Alvaro-Afonso FJ, García-Morales E, García-Álvarez Y, Molines-Barroso RJ. The best way to reduce reulcerations: if you understand biomechanics of the diabetic foot, you can do it. INT J LOW EXTR WOUND 2014; 13:294-319. [PMID: 25256280 DOI: 10.1177/1534734614549417] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Foot ulcer recurrence is still an unresolved issue. Although several therapies have been described for preventing foot ulcers, the rates of reulcerations are very high. Footwear and insoles have been recommended as effective therapies that prevent the development of new ulcers; however, the majority of studies have analyzed their effects in terms of reducing peak plantar pressure rather than ulcer relapse. Knowledge of biomechanical considerations is low, in general, in the team approach to diabetic foot because heterogeneous professionals having competence in recurrence prevention are involved. Assessment of biomechanical alterations define a foot type position; examining foot structure and recording plantar pressure could help in appropriate insole and footwear prescription and design. Patient education and compliance should be taken into consideration for better therapy success. When patients suffer from rigid deformities or have undergone an amputation, surgical offloading should be considered as an alternative.
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36
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Waaijman R, de Haart M, Arts MLJ, Wever D, Verlouw AJWE, Nollet F, Bus SA. Risk factors for plantar foot ulcer recurrence in neuropathic diabetic patients. Diabetes Care 2014; 37:1697-705. [PMID: 24705610 DOI: 10.2337/dc13-2470] [Citation(s) in RCA: 140] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVE Recurrence of plantar foot ulcers is a common and major problem in diabetes but not well understood. Foot biomechanics and patient behavior may be important. The aim was to identify risk factors for ulcer recurrence and to establish targets for ulcer prevention. RESEARCH DESIGN AND METHODS As part of a footwear trial, 171 neuropathic diabetic patients with a recently healed plantar foot ulcer and custom-made footwear were followed for 18 months or until ulceration. Demographic data, disease-related parameters, presence of minor lesions, barefoot and in-shoe plantar peak pressures, footwear adherence, and daily stride count were entered in a multivariate multilevel logistic regression model of plantar foot ulcer recurrence. RESULTS A total of 71 patients had a recurrent ulcer. Significant independent predictors were presence of minor lesions (odds ratio 9.06 [95% CI 2.98-27.57]), day-to-day variation in stride count (0.93 [0.89-0.99]), and cumulative duration of past foot ulcers (1.03 [1.00-1.06]). Significant independent predictors for those 41 recurrences suggested to be the result of unrecognized repetitive trauma were presence of minor lesions (10.95 [5.01-23.96]), in-shoe peak pressure <200 kPa with footwear adherence >80% (0.43 [0.20-0.94]), barefoot peak pressure (1.11 [1.00-1.22]), and day-to-day variation in stride count (0.91 [0.86-0.96]). CONCLUSIONS The presence of a minor lesion was clearly the strongest predictor, while recommended use of adequately offloading footwear was a strong protector against ulcer recurrence from unrecognized repetitive trauma. These outcomes define clear targets for diabetic foot screening and ulcer prevention.
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Affiliation(s)
- Roelof Waaijman
- Department of Rehabilitation Medicine, Academic Medical Centre, University of Amsterdam, Amsterdam, the Netherlands
| | - Mirjam de Haart
- Department of Rehabilitation Medicine, Academic Medical Centre, University of Amsterdam, Amsterdam, the Netherlands
| | - Mark L J Arts
- Department of Rehabilitation Medicine, Academic Medical Centre, University of Amsterdam, Amsterdam, the Netherlands
| | - Daniel Wever
- Department of Rehabilitation, Medisch Spectrum Twente, Enschede, the Netherlands
| | - Anke J W E Verlouw
- Department of Rehabilitation, Maxima Medical Centre, Veldhoven, the Netherlands
| | - Frans Nollet
- Department of Rehabilitation Medicine, Academic Medical Centre, University of Amsterdam, Amsterdam, the Netherlands
| | - Sicco A Bus
- Department of Rehabilitation Medicine, Academic Medical Centre, University of Amsterdam, Amsterdam, the Netherlands
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Augustin M, Herberger K, Kroeger K, Muenter KC, Goepel L, Rychlik R. Cost-effectiveness of treating vascular leg ulcers with UrgoStart(®) and UrgoCell(®) Contact. Int Wound J 2014; 13:82-7. [PMID: 24618370 DOI: 10.1111/iwj.12238] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2013] [Revised: 12/20/2013] [Accepted: 01/07/2014] [Indexed: 11/30/2022] Open
Abstract
Although chronic wounds have a high socio-economic impact, data on comparative effectiveness of treatments are rare. UrgoStart(®) is a hydroactive dressing containing a nano-oligosaccharide factor (NOSF). This study aimed at evaluating the cost-effectiveness of this NOSF-containing wound dressing in vascular leg ulcers compared with a similar neutral foam dressing (UrgoCell(®) Contact) without NOSF. Cost-effectiveness analysis from the perspective of the German statutory health care system was performed using a decision tree model for a period of 8 weeks. Cost and outcome data were derived from the clinical study 'Challenge' suggesting a response rate (≥40% wound size reduction) of UrgoStart(®) of 65·6% versus 39·4% for the comparator. In the treatment model, effect-adjusted costs of €849·86 were generated after 8 weeks for treatment with UrgoStart(®) versus €1335·51 for the comparator resulting in an effect-adjusted cost advantage of €485·64 for UrgoStart(®) . In linear sensitivity analyses, the outcomes were stable for varying assumptions on prices and response rates. In an 8-week period of treatment for vascular leg ulcers, UrgoStart(®) shows superior cost-effectiveness when compared with the similar neutral foam dressing without any active component (NOSF). As demonstrated within a randomised, double-blind clinical trial, UrgoStart(®) is also more effective in wound area reduction than the neutral foam dressing. Wound healing was not addressed in this clinical trial. Follow-up data of 12 months to allow for reulceration assessment were not generated.
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Affiliation(s)
- Matthias Augustin
- Institute and German Center for Health Services Research in Dermatology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Katharina Herberger
- Institute and German Center for Health Services Research in Dermatology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | | | | | - Lisa Goepel
- Institute and German Center for Health Services Research in Dermatology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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Hoffmann F, Claessen H, Morbach S, Waldeyer R, Glaeske G, Icks A. Impact of diabetes on costs before and after major lower extremity amputations in Germany. J Diabetes Complications 2013; 27:467-72. [PMID: 23746556 DOI: 10.1016/j.jdiacomp.2013.05.001] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2012] [Revised: 05/02/2013] [Accepted: 05/03/2013] [Indexed: 01/22/2023]
Abstract
AIMS To compare direct medical costs 1 year before up to 3 years after first major lower extremity amputation (LEA) between patients with and without diabetes. METHODS We used health insurance claims data and included patients with a first major LEA between 2005 and 2009. Costs for hospitalization, rehabilitation, outpatient care, outpatient drug prescriptions, non-physician services, durable medical equipment and long-term care were assessed. We estimated cost ratios (CR) for diabetes status using generalized linear models adjusted for age, sex, amputation level, care dependency as well as observation time and mortality within the corresponding period and costs before LEA. RESULTS We included 444 patients with first major LEA (58.3% had diabetes), 71.8% were male and the average age was 69.1 years. Total mean costs for 1 year before LEA were higher in patients with diabetes (24,504 vs. 18,961 Euros), which was also confirmed by the multivariate analysis (CR: 1.27; 95% CI: 1.06-1.52). Costs up to 24 weeks after LEA were virtually the same in both groups (36,686 vs. 35,858 Euros), but thereafter differences increase again with higher costs for diabetics. Costs for 3 years after LEA were 115,676 vs. 92,862 Euros, respectively (CR: 1.26; 95% CI: 1.12-1.42). Hospitalizations accounted for more than 50% of total costs irrespective of diabetes status and period. CONCLUSIONS Costs up to 24 weeks after first major LEA are mainly driven by the amputation itself irrespective of diabetes. Thereafter, costs for diabetic patients were higher again, which underlines the importance of studying long-term costs.
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Affiliation(s)
- Falk Hoffmann
- University of Bremen, Centre for Social Policy Research, Division Health Economics, Health Policy and Outcomes Research, Postfach 33 04 40, D-28334, Bremen, Germany.
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Dual-isotope SPECT/CT impact on hospitalized patients with suspected diabetic foot infection. Nucl Med Commun 2013; 34:877-84. [DOI: 10.1097/mnm.0b013e32836370a6] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
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Rasmussen A, Bjerre-Christensen U, Almdal TP, Holstein P. Percutaneous flexor tenotomy for preventing and treating toe ulcers in people with diabetes mellitus. J Tissue Viability 2013; 22:68-73. [DOI: 10.1016/j.jtv.2013.04.001] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2012] [Revised: 02/28/2013] [Accepted: 04/16/2013] [Indexed: 01/12/2023]
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Arts MLJ, Waaijman R, de Haart M, Keukenkamp R, Nollet F, Bus SA. Offloading effect of therapeutic footwear in patients with diabetic neuropathy at high risk for plantar foot ulceration. Diabet Med 2012; 29:1534-41. [PMID: 22913552 DOI: 10.1111/j.1464-5491.2012.03770.x] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
AIMS Custom-made therapeutic footwear is often prescribed to patients with diabetic neuropathy, foot deformity and a healed plantar foot ulcer. Offloading these feet is important to prevent ulcer recurrence. The aim was to evaluate the offloading effect of custom-made footwear in these patients. METHODS In 171 patients with diabetic neuropathy (336 feet) with foot deformity and a recently healed plantar foot ulcer, plantar pressures walking barefoot and inside new custom-made footwear were measured. At the previous ulcer location and at locations of highest barefoot pressure attributable to the deformity, in-shoe pressures were compared with non-deformed feet. The footwear was considered effective in offloading when in-shoe peak pressure at these locations was < 200 kPa. RESULTS Mean in-shoe peak pressures ranged between 211 and 308 kPa in feet with forefoot deformity (vs. 191-222 kPa in non-deformed feet) and between 140 and 187 kPa in feet with midfoot deformity (vs. 112 kPa in non-deformed feet). Offloading was effective in 61% of all feet with deformity, 81% of feet with midfoot deformity, 44% of feet with forefoot deformity and 62% of previous ulcer locations. Inter-subject variability in measured in-shoe plantar pressure was large. CONCLUSIONS Offloading in custom-made footwear is often not sufficiently achieved in high-risk diabetic feet with deformity. Highest offloading success rates were seen at known high-risk locations such as previous ulcer locations and Charcot feet, the lowest success rates in forefoot deformities. Together with the large inter-subject variability in pressure outcomes, this emphasizes the need for evidence-based prescription and evaluation procedures to assure adequate offloading.
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Affiliation(s)
- M L J Arts
- Department of Rehabilitation, University of Amsterdam, Amsterdam, The Netherlands.
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Abstract
Diabetic foot is a leading cause of admission, amputation, and mortality in diabetic patients. A multidisciplinary team approach is highly recommended for the management of patients with foot problems. To heal diabetic foot ulcers, all methods have to be conducted step by step under an efficient program, and all specialists should be well organized also, which was confirmed by the 2 cases described in this article.
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Affiliation(s)
- Yufeng Jiang
- The 306 Hospital of Chinese PLA, Beijing, China
- Chinese PLA General Hospital, Beijing, China
- Burns Institute, The First Affiliated Hospital of Chinese PLA General Hospital, Beijing, China
| | | | - Xiaobing Fu
- Chinese PLA General Hospital, Beijing, China
- Burns Institute, The First Affiliated Hospital of Chinese PLA General Hospital, Beijing, China
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Augustin M, Brocatti LK, Rustenbach SJ, Schäfer I, Herberger K. Cost-of-illness of leg ulcers in the community. Int Wound J 2012; 11:283-92. [PMID: 23020710 DOI: 10.1111/j.1742-481x.2012.01089.x] [Citation(s) in RCA: 92] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
Leg ulcer management is complex, time-consuming and of high socio-economic importance. Data on cost-of-illness in leg ulcer care are sparse. The objective of this study was to evaluate the cost-of-illness in leg ulcer treatment in the metropolitan area of Hamburg. About 147 institutions involved in wound care participated in a cross-sectional study. Patients consecutively recruited underwent a standardised interview and clinical examination. Main economic outcomes were direct, indirect and intangible costs from a societal perspective. Five hundred and two patients with a mean age of 71 years and mean wound duration of 9 years were enrolled. Annual total costs summed up to a mean of 9060€ /patient/year (8288€ direct, 772€ indirect costs). Direct costs carried by statutory health insurances amounted to 7680€ , patients themselves paid on average 607€. Leg ulcer is associated with high costs for health insurances, patients and the society. Exploratory predictor analyses suggest that early, interprofessional disease-management could lower treatment costs.
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Affiliation(s)
- Matthias Augustin
- Institute for Health Services Research in Dermatology and Nursing, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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Dageforde LA, Bream PR, Moore DE. Hemodialysis Reliable Outflow (HeRO) device in end-stage dialysis access: a decision analysis model. J Surg Res 2012; 177:165-71. [DOI: 10.1016/j.jss.2012.04.041] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2012] [Revised: 04/09/2012] [Accepted: 04/18/2012] [Indexed: 11/17/2022]
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Leung PC, Pang SY, Wong ELY, Cheng KF. Inflammatory state of type II diabetic patients with chronic ulcers in response to herbal treatment. Foot (Edinb) 2012; 22:181-5. [PMID: 22463944 DOI: 10.1016/j.foot.2012.03.001] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2009] [Revised: 03/02/2012] [Accepted: 03/02/2012] [Indexed: 02/04/2023]
Abstract
BACKGROUND Type II diabetic patients easily develop ulcers over their feet which heal with great difficulties and not infrequently, end up in amputations. In the quest for innovative means to avoid amputation, herbal medicine has been used in China to heal ulcers. METHOD A randomized placebo controlled clinical trial involving 80 patients was conducted to test whether a herbal formula taken orally could help to preserve the ulcerated leg. Other parameters measured included granulation maturation time, skin temperature and circulation, and tumor necrosis factor alpha (TNF-α). RESULTS showed a 85% limb rescue with the herbal treatment group showing superiority over placebo group. TNF-α decline was observed with gradual ulcer healing and the herbal supplement group showed a more impressive decline (p=0.037).
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Affiliation(s)
- P C Leung
- Department of Orthopaedics & Traumatology, The Chinese University of Hong Kong, Hong Kong.
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Dubský M, Jirkovská A, Bem R, Fejfarová V, Skibová J, Schaper NC, Lipsky BA. Risk factors for recurrence of diabetic foot ulcers: prospective follow-up analysis in the Eurodiale subgroup. Int Wound J 2012; 10:555-61. [PMID: 22712631 DOI: 10.1111/j.1742-481x.2012.01022.x] [Citation(s) in RCA: 128] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Few studies have examined factors associated with diabetic foot ulcer (DFU) recurrence. Using data from patients enrolled in the prospective Eurodiale DFU study, we investigated the frequency of and risk factors for DFU recurrence after healing during a 3-year follow-up period. At our site, 93 Eurodiale-enrolled patients had a healed DFU. Among these, 14 were not alive; of the remaining 79 patients we enrolled 73 in this study. On entry to the Eurodiale study, we assessed demographic factors (age, sex and distance from hospital); diabetes-related factors [duration, and glycated haemoglobin (HbA1c) levels]; comorbidities (obesity, renal failure, smoking and alcohol abuse) and DFU-related factors [peripheral arterial disease, ulcer infection, C-reactive protein (CRP) and; foot deformities]. During the 3-year follow-up period, a DFU had recurred in 42 patients (57.5%). By stepwise logistic regression of findings at initial DFU presentation, the significant independent predictors for recurrence were plantar ulcer location [odds ratio (OR) 8.62, 95% confidence interval (CI) 2.2-33.2]; presence of osteomyelitis (OR 5.17, 95% CI 1.4-18.7); HbA1c > 7.5% ([DCCT], OR 4.07, 95% CI 1.1-15.6) and CRP > 5 mg/l (OR 4.27, 95% CI 1.2-15.7). In these patients with a healed DFU, the majority had a recurrence of DFU during a 3-year follow-up period, despite intensive foot care. The findings at diagnosis of the initial DFU were independent risk factors associated with ulcer recurrence (plantar location, bone infection, poor diabetes control and elevated CRP) and define those at high risk for recurrence, but may be amenable to targeted interventions.
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Affiliation(s)
- Michal Dubský
- Diabetes Centre, Institute for Clinical and Experimental Medicine, Prague, Czech Republic Department of Internal Medicine, University Hospital Maastricht, Maastricht, The Netherlands General Medical Service, VA Puget Sound Health Care System, Department of Medicine, University of Washington, Seattle, WA, USA
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Abstract
The treatment of diabetic foot ulceration is complex with multiple considerations often leading to limb amputation. This article presents the usefulness of a multidisciplinary approach along with an algorithm to manage and salvage diabetic foot ulcers from amputation. This algorithm is a step-by-step guide to manage the diabetic foot ulcer and can help one in the selection of patients for limb salvage reconstruction.
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Affiliation(s)
- Joon Pio Hong
- Department of Plastic Surgery, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43-gil, Songpagu, Seoul 138-736, Korea.
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Hastings MK, Mueller MJ, Sinacore DR, Strube MJ, Crowner B, Johnson JE, Racette BA. Botulinum toxin effects on gasatrocnemius strength and plantar pressure in diabetics with peripheral neuropathy and forefoot ulceration. Foot Ankle Int 2012; 33:363-70. [PMID: 22735277 PMCID: PMC3747956 DOI: 10.3113/fai.2012.0363] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND High forefoot plantar pressure is associated with plantar ulcers in people with diabetes and peripheral neuropathy. The purpose of this pilot study was to determine the safety and efficacy of botulinum toxin A injected into the gastrocnemius-soleus muscles to reduce muscle strength and plantar pressure. METHODS This double blind, randomized clinical trial studied 17 people with diabetes mellitus, peripheral neuropathy and a forefoot plantar ulcer. Subjects were randomized into one of three groups receiving gastrocnemius-soleus muscle injections on the involved side with; 1) Saline (n = 5, weight =99± 21 kg), 2) 200-units of Botox® (n = 7, weight = 101± 5 kg), or 3) 300-units of Botox® (n = 5, weight = 129± 22 kg). Botox® dose was converted to units/kg, the majority received between 1.9 and 2.4 units/kg (n = 11) and one 3.2 units/kg. Plantarflexor peak torque and forefoot peak plantar pressure were quantified prior and 2 weeks post-injection. RESULTS There were no complications from the injections. Plantarflexor peak torque on the involved side increased in the placebo and 300 groups (3± 4 Nm and 6± 10 Nm, respectively) and decreased -8± 11 Nm in the 200 group. There was no relationship between units/kg of Botox® for each subject and change in plantarflexor peak torque. Forefoot peak plantar pressure did not change in the placebo and 300 groups (0± 11 and 0± 5 N/cm(2), respectively) and decreased -4± 16 N/cm2 (4%) for the 200 group. CONCLUSION There were no adverse events associated with the Botox® injections. This study was unable to determine the dose to consistently reduce plantarflexor strength and forefoot plantar pressure. Additional research is needed to investigate diabetes mellitus specific physiological changes and their impact of BoNT-A effectiveness in order to guide appropriate dosing.
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Cavanagh P, Attinger C, Abbas Z, Bal A, Rojas N, Xu ZR. Cost of treating diabetic foot ulcers in five different countries. Diabetes Metab Res Rev 2012; 28 Suppl 1:107-11. [PMID: 22271734 DOI: 10.1002/dmrr.2245] [Citation(s) in RCA: 114] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
Most estimates in the literature for the economic cost of treating a diabetic foot ulcer (DFU) are from industrialized countries. There is also marked heterogeneity between the complexity of cases considered in the different studies. The goal of the present article was to estimate treatment costs and costs to patients in five different countries (Chile, China, India, Tanzania, and the United States) for two hypothetical, but well-defined, DFUs at the extreme ends of the complexity spectrum. A co-author, who is a treating physician in the relevant country, was asked to choose treatment plans that represented the typical application of local resources to the DFU. The outcomes were pre-defined as complete healing in case 1 and trans-tibial amputation in case 2, but the time course of treatment was determined by each investigator in a manner that would be typical for their clinic. The costs, in local currencies, for each course of treatment were estimated with the assistance of local hospital administrators. Typical reimbursement scenarios in each country were used to estimate the cost burden to the patient, which was then expressed as a percentage of the annual per capita purchasing power parity-adjusted gross domestic product. There were marked differences in the treatment plans between countries based on the availability of resources and the realities of local conditions. The costs of treatment for case 1 ranged from Int$102 to Int$3959 in Tanzania and in the United States, respectively. The cost for case 2 ranged from Int$3060 to Int$188,645 in Tanzania and in the United States, respectively. The cost burden to the patient varied from the equivalent of 6 days of average income in the United States for case 1 to 5.7 years of average annual income for case 2 in India. Although these findings do not take cost-effectiveness into account, they highlight the dramatic economic burden of a DFU for patients in some countries.
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Affiliation(s)
- Peter Cavanagh
- Department of Orthopaedics and Sports Medicine, The University of Washington, Seattle, WA 98195, USA.
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