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

Remote Diabetic Foot Temperature Monitoring for Early Detection of Diabetic Foot Ulcers: A Cost-Effectiveness Analysis

BACKGROUND

Foot temperature monitoring for the prevention and early detection of diabetic foot ulcers (DFU) is evidence-based and recommended in clinical practice. However, easy-to-use remote monitoring tools have been lacking, thereby preventing widespread adoption.

OBJECTIVE

To evaluate the cost-effectiveness of remote foot temperature monitoring (RFTM) (Siren's Neurofabric™ Diabetic socks) in addition to standard of care (SoC) versus SoC alone for early detection of DFU with diabetic neuropathy and a moderate to high risk of DFU.

METHODS

A payer perspective decision-tree analysis was conducted to compare expected DFU occurrence and subsequent amputation rates and costs between treatment strategies over one year. Inputs in the model were sourced from publicly available literature and relevant health technology assessments. One-way sensitivity analyses were performed for each model variable.

RESULTS

In the base-case scenario, RFTM plus SoC was a dominant strategy compared to SoC alone. RFTM plus SoC was associated with cost savings of $38,593 per additional ulcer avoided versus SoC alone, and $8027 per patient per year on average compared to SoC alone. These results were highly robust to one-way sensitivity analysis; all scenarios remained dominant if compliance was ≥13%.

CONCLUSION

RFTM is a cost-effective addition to SoC in patients with diabetic neuropathy at a moderate-to-high risk of DFU and subsequent amputation. Further, reduction in DFU and associated complications may result in improvements in the patient's quality of life and mental health. Future studies are needed to evaluate the compliance and reduction of DFU occurrence in patients on RFTM.

Quantitative Sensory Testing in pain assesment and treatment. Brief review and algorithmic management proposal

Quantitative Sensory Testing (QST) is used to globally analyze the nociceptive system in order to obtain a more objective understanding of pain perception. In recent years, QST has become a common tool in many pain clinics and anesthesiology departments worldwide. In 2013, the Neuropathic Pain Special Interest Group of the IASP put forward the first recommendations for conducting QST in clinical practice and research. However, the wide variety of QST methodologies and standards in the literature make it difficult to generalize the used of this tool in clinical practice. In this study, we present the basic concepts of QST, the type of tests and devices used, how they are applied, and the role of QST in anesthesiology and pain management.

Acupuncture as adjuvant therapy for diabetic foot: A protocol for systematic review

BACKGROUND

Diabetic foot (DF) problems are common throughout the world, about one-fourth of them develop a foot ulcer and serious cases would suffer from amputation, which seriously affects the patient's work and life. Previous studies indicated that acupuncture as adjuvant therapy would be effective in treating DF. However, these studies have no consistent results. Therefore, the aim of our study was to explore the efficacy and safety of acupuncture as adjuvant therapy for DF.

METHODS

The randomized controlled trials associated with acupuncture therapy (or as adjuvant therapy) for DF will be included. We will search 6 electronic databases relevant to health sciences, including PubMed, Embase, the Cochrane Library, the Chinese databases Sino-Med, CNKI, and WANFANG database. All searches were from databases inception to March 30, 2019. The primary outcomes are the total curative effective rate, and the hemodynamic parameter and adverse events will be deemed as secondary outcomes. The Stata15.1 software and Review Manager (RevMan 5.3; Cochrane Collaboration, Copenhagen, Denmark) will be used for analysis, to assess the bias risk, subgroup analysis, and data synthesis.

RESULTS

In this systematic review and meta-analysis, we will synthesize the studies to assess the safety and efficacy of acupuncture as adjuvant therapy for DF.

CONCLUSION

The summary of our study will clarify whether acupuncture as adjuvant therapy could be an efficient method for DF.

Degree of risk for foot ulcer due to diabetes: nursing assessment

OBJECTIVE

To classify the level of risk for foot ulcers in people with diabetes mellitus and identify their main predictive risk factors.

METHOD

Exploratory, descriptive study, in which patients were assessed in a municipal ambulatory of São Paulo through nursing consultation, following the guidelines of the International Consensus on the Diabetic Foot. Data were descriptively analyzed.

RESULTS

The analyzed population was composed of 50 longevous and retired people, with household income of up to two minimum wages, with dermato-neurofunctional risk factors and unfavorable clinical indicators, and 66% had Risk 1; 16% Risk 2; 6% Risk 3 and 12% Risk 4. Of this analyzed total, 96% never had their feet examined with the Semmes-Weinstein monofilament.

CONCLUSION

The data found indicate the importance of careful feet examination in people with diabetes by the nursing staff to identify future risks of ulcers and, thus, prevent them.

Changes in the vibration sensitivity and pressure pain thresholds in patients with burning mouth syndrome

OBJECTIVE

To investigate the presence of changes in vibration detection and pressure pain threshold in patients with burning-mouth syndrome (BMS).

DESIGN OF THE STUDY

Case-control study. The sample was composed of 30 volunteers, 15 with BMS and 15 in the control group. The pressure-pain threshold (PPT) and vibration-detection threshold (VDT) were examined. The clinical evaluation was complemented with the McGill Pain Questionnaire (MPQ), Douleur Neuropathique 4 (DN4) and Beck Depression and Anxiety Inventories (BDI and BAI, respectively).

RESULTS

BMS subjects showed a statistically significant higher PPT in the tongue (p = 0.002), right (p = 0.001) and left (p = 0.004) face, and a significant reduction of the VDT in the tongue (p = 0.013) and right face (p = 0.030). Significant differences were also found when comparing the PPT and the VDT of distinct anatomical areas. However, a significant interaction (group × location) was only for the PPT. BMS subjects also showed significantly higher levels of depression (p = 0.01), as measured by the BDI, compared to controls; and a significant inverse correlation between the VDT in the left face and anxiety levels was detected.

CONCLUSIONS

The study of somatosensory changes in BMS and its correlations with the clinical features as well as the levels of anxiety and depression expands current understanding of the neuropathic origin and the possible contribution of psychogenic factors related to this disease.

Cost-effectiveness of prevention and management of diabetic foot ulcer and amputation in a health resource-limited setting

BACKGROUND

The aim of the present study was to estimate the lifetime health and economic effects of different strategies of caring for diabetic foot in the Chinese setting.

METHODS

A mathematical model was developed to simulate the onset and progression of diabetic foot disease in patients with type 2 diabetes managed with optimal care and usual care. Clinical and utility data were obtained from the published literature. Direct medical costs and resource utilization in the Chinese healthcare setting were considered. Sensitivity analyses were undertaken to test the effects of a range of variables and assumptions on the results. Heath benefits and costs were the outcome measures assessed.

RESULTS

Compared with usual care, optimal care was a cost-saving option that exhibited lower costs with improved health benefits, including greater quality-adjusted life-years (QALYs) and reduced incidence of foot complications. The lifetime saving costs per additional QALY gained by optimal care were US$2015. The model outcome was most sensitive to the risk ratio of foot ulcers and amputation for optimal care over usual care.

CONCLUSIONS

Implementing guideline-based optimal care for diabetic foot is likely to be cost-effective in a health resource-limited setting.

Financial burden of diabetic foot ulcers to world: a progressive topic to discuss always

Diabetic foot complications are the most common occurring problems throughout the globe, resulting in devastating economic crises for the patients, families and society. Diabetic foot ulcers (DFUs) have a neuropathic origin with a progressive prevalence rate in developing countries compared with developed countries among diabetes mellitus patients. Diabetic patients that are of greatest risk of ulcers may easily be diagnosed with foot examination. Economic burden may be carefully examined. The budget costing must include both the clinical and social impact of the patients.

In-hospital costs of diabetic foot disease treated by a multidisciplinary foot team

BACKGROUND

The diabetic foot imposes significant burden on healthcare systems. Obtaining knowledge on the extent of the costs of diabetic foot ulcers (DFUs) is of value to health care researchers investigating cost-effectiveness of interventions that prevent these costly complications.

OBJECTIVES

To estimate the in-hospital costs associated with the treatment of DFUs by a multidisciplinary diabetic foot team.

METHODS

Persons with DFUs presenting to our team in 2013 and 2014 were followed and use of care was estimated. Exclusion criteria were a single visit only and ulcers above the ankle. Demographic data and per-person incremental clinical outcomes (e.g., healing with or without amputation and rehabilitation) were assessed. Resource use was identified, measured and multiplied by unit costs.

RESULTS

Eighty-nine persons were identified with 56 persons meeting the inclusion criteria (with 69 DFU episodes). The median in-hospital care was 17weeks (inter quartile range: 7-34). Average in-hospital costs were US$ 10,827 (range: 702-82,880) per DFU episode. Primary healed DFUs costs on average US$ 4830, single minor amputations on average US$ 13,580, multiple minor amputations on average US$ 31,835 and major amputations on average US$ 73,813 per episode. Costs differed significantly between groups (p<0.001).

CONCLUSION

DFUs are associated with substantial immediate and long-term in-hospital costs. Our study provides estimates of these costs, aiding researchers and health policy analysis.

The Potential Role of Sensory Testing, Skin Biopsy, and Functional Brain Imaging as Biomarkers in Chronic Pain Clinical Trials: IMMPACT Considerations

Valid and reliable biomarkers can play an important role in clinical trials as indicators of biological or pathogenic processes or as a signal of treatment response. Currently, there are no biomarkers for pain qualified by the U.S. Food and Drug Administration or the European Medicines Agency for use in clinical trials. This article summarizes an Initiative on Methods, Measurement, and Pain Assessment in Clinical Trials meeting in which 3 potential biomarkers were discussed for use in the development of analgesic treatments: 1) sensory testing, 2) skin punch biopsy, and 3) brain imaging. The empirical evidence supporting the use of these tests is described within the context of the 4 categories of biomarkers: 1) diagnostic, 2) prognostic, 3) predictive, and 4) pharmacodynamic. Although sensory testing, skin punch biopsy, and brain imaging are promising tools for pain in clinical trials, additional evidence is needed to further support and standardize these tests for use as biomarkers in pain clinical trials.

PERSPECTIVE

The applicability of sensory testing, skin biopsy, and brain imaging as diagnostic, prognostic, predictive, and pharmacodynamic biomarkers for use in analgesic treatment trials is considered. Evidence in support of their use and outlining problems is presented, as well as a call for further standardization and demonstrations of validity and reliability.

Poly-ADP-ribose polymerase inhibition enhances ischemic and diabetic wound healing by promoting angiogenesis

OBJECTIVE

Chronic nonhealing wounds are a major health problem for patients in the United States and worldwide. Diabetes and ischemia are two major risk factors behind impaired healing of chronic lower extremity wounds. Poly-ADP-ribose polymerase (PARP) is found to be overactivated with both ischemic and diabetic conditions. This study seeks a better understanding of the role of PARP in ischemic and diabetic wound healing, with a specific focus on angiogenesis and vasculogenesis.

METHODS

Ischemic and diabetic wounds were created in FVB/NJ mice and an in vitro scratch wound model. PARP inhibitor PJ34 was delivered to the animals at 10 mg/kg/d through implanted osmotic pumps or added to the culture medium, respectively. Animal wound healing was assessed by daily digital photographs. Animal wound tissues, peripheral blood, and bone marrow cells were collected at different time points for further analysis with Western blot and flow cytometry. Scratch wound migration and invasion angiogenesis assays were performed using human umbilical vein endothelial cells (HUVECs). Measurements were reported as mean ± standard deviation. Continuous measurements were compared by t-test. P < .05 was considered statistically significant.

RESULTS

A significant increase in PARP activity was observed under ischemic and diabetic conditions that correlated with delayed wound healing and slower HUVEC migration. The beneficial effect of PARP inhibition with PJ34 on ischemic and diabetic wound healing was observed in both animal and in vitro models. In the animal model, the percentage of wound healing was significantly enhanced from 43% ± 6% to 71% ± 9% (P < .05) by day 7 with the addition of PJ34. PARP inhibition promoted angiogenesis at the ischemic and diabetic wound beds as evidenced by significantly higher levels of endothelial cell markers (vascular endothelial growth factor receptor 2 [VEGFR2] and endothelial nitric oxide synthase) in mice treated with PJ34 compared with controls. Flow cytometry analysis of peripheral blood mononuclear cells showed that PARP inhibition increased mobilization of endothelial progenitor cells (VEGFR2⁺/CD133⁺ and VEGFR2⁺/CD34⁺) into the systemic circulation. Furthermore, under in vitro hyperglycemia and hypoxia conditions, PARP inhibition enhanced HUVEC migration and invasion in Boyden chamber assays by 80% and 180% (P < .05), respectively.

CONCLUSIONS

Delayed healing in ischemic and diabetic wounds is caused by PARP hyperactivity, and PARP inhibition significantly enhanced ischemic and diabetic wound healing by promoting angiogenesis.

Wound Care Algorithm: Diagnosis and Treatment

There has been a dramatic rise in the incidence of wounds in the United States. Chronic wounds are not only difficult and costly to treat, but also have a devastating impact on the patients, caregivers, and on society as a whole. Many factors influence the etiology of wounds. The goal of this article is to educate all types of healthcare providers on the evaluation process and the various available treatment options of chronic wounds. With the information presented in this article, providers will be able to achieve faster healing and hopefully decrease the total number of chronic and debilitating wounds.

Efficacy of the smartphone-based glucose management application stratified by user satisfaction

BACKGROUND

We aimed to assess the efficacy of the smartphone-based health application for glucose control and patient satisfaction with the mobile network system used for glucose self-monitoring.

METHODS

Thirty-five patients were provided with a smartphone device, and self-measured blood glucose data were automatically transferred to the medical staff through the smartphone application over the course of 12 weeks. The smartphone user group was divided into two subgroups (more satisfied group vs. less satisfied group) based on the results of questionnaire surveys regarding satisfaction, comfort, convenience, and functionality, as well as their willingness to use the smartphone application in the future. The control group was set up via a review of electronic medical records by group matching in terms of age, sex, doctor in charge, and glycated hemoglobin (HbA1c).

RESULTS

Both the smartphone group and the control group showed a tendency towards a decrease in the HbA1c level after 3 months (7.7%±0.7% to 7.5%±0.7%, P=0.077). In the more satisfied group (n=27), the HbA1c level decreased from 7.7%±0.8% to 7.3%±0.6% (P=0.001), whereas in the less satisfied group (n=8), the HbA1c result increased from 7.7%±0.4% to 8.1%±0.5% (P=0.062), showing values much worse than that of the no-smartphone control group (from 7.7%±0.5% to 7.7%±0.7%, P=0.093).

CONCLUSION

In addition to medical feedback, device and network-related patient satisfaction play a crucial role in blood glucose management. Therefore, for the smartphone app-based blood glucose monitoring to be effective, it is essential to provide the patient with a well-functioning high quality tool capable of increasing patient satisfaction and willingness to use.

Incidence, prevalence, costs, and impact on disability of common conditions requiring rehabilitation in the United States: stroke, spinal cord injury, traumatic brain injury, multiple sclerosis, osteoarthritis, rheumatoid arthritis, limb loss, and back pain

OBJECTIVE

To determine the relative incidence, prevalence, costs, and impact on disability of 8 common conditions treated by rehabilitation professionals.

DATA SOURCES

Comprehensive bibliographic searches using MEDLINE, Google Scholar, and UpToDate, (June, 2013).

DATA EXTRACTION

Two review authors independently screened the search results and performed data extraction. Eighty-two articles were identified that had relevant data on the following conditions: Stroke, Spinal Cord Injury, Traumatic Brain Injury, Multiple Sclerosis, Osteoarthritis, Rheumatoid Arthritis, Limb Loss, and Back Pain.

DATA SYNTHESIS

Back pain and arthritis (osteoarthritis, rheumatoid arthritis) are the most common and costly conditions we analyzed, affecting more than 100 million individuals and costing greater than $200 billion per year. Traumatic brain injury, while less common than arthritis and back pain, carries enormous per capita direct and indirect costs, mostly because of the young age of those involved and the severe disability that it may cause. Finally, stroke, which is often listed as the most common cause of disability, is likely second to both arthritis and back pain in its impact on functional limitations.

CONCLUSIONS

Of the common rehabilitation diagnoses we studied, musculoskeletal conditions such as back pain and arthritis likely have the most impact on the health care system because of their high prevalence and impact on disability.

Human acellular dermal wound matrix: evidence and experience

A chronic wound fails to complete an orderly and timely reparative process and places patients at increased risk for wound complications that negatively impact quality of life and require greater health care expenditure. The role of extracellular matrix (ECM) is critical in normal and chronic wound repair. Not only is ECM the largest component of the dermal skin layer, but also ECM proteins provide structure and cell signalling that are necessary for successful tissue repair. Chronic wounds are characterised by their inflammatory and proteolytic environment, which degrades the ECM. Human acellular dermal matrices, which provide an ECM scaffold, therefore, are being used to treat chronic wounds. The ideal human acellular dermal wound matrix (HADWM) would support regenerative healing, providing a structure that could be repopulated by the body's cells. Experienced wound care investigators and clinicians discussed the function of ECM, the evidence related to a specific HADWM (Graftjacket(®) regenerative tissue matrix, Wright Medical Technology, Inc., licensed by KCI USA, Inc., San Antonio, TX), and their clinical experience with this scaffold. This article distills these discussions into an evidence-based and practical overview for treating chronic lower extremity wounds with this HADWM.

A prospective study of 20 foot and ankle wounds treated with cryopreserved amniotic membrane and fluid allograft

We reviewed the background information and previous clinical studies that considered the use of allogeneic amniotic tissue and fluid (granulized amniotic membrane and amniotic fluid) in the treatment of chronic diabetic foot wounds. This innovation represents a relatively new approach to wound management by delivering a unique allograft of live human cells in a nonimmunogenic structural tissue matrix. Developed to fill soft tissue defects and bone voids and to convey antimicrobial and anti-inflammatory capabilities, granulized amniotic membrane and amniotic fluid does not require fetal death, because its procurement is performed with maternal consent during birth. In the present investigation, 20 chronic wounds (20 patients) that had been treated with standard wound therapy for a mean of 36.6 ± 31.58 weeks and with a mean baseline area of 10.15 ± 19.54 cm(2) were followed up during a 12-week observation period or until they healed. A total of 18 of the wounds (90%) healed during the 12-week observation period, and none of the wounds progressed to amputation. From our experience with the patients in the present case series, we believe that granulized amniotic membrane and amniotic fluid represents a useful option for the treatment of chronic diabetic foot wounds.

Screening patients at risk for diabetic foot ulceration: a comparison between measurement of vibration perception threshold and 10-g monofilament test

The aim is to compare the frequency of increased vibration perception threshold (VPT) with abnormal 10-g Semmes-Weinstein monofilament (SWF) testing in a non-selected diabetic population, and to assess the agreement between these two screening methods. VPT was measured using a neurothesiometer at the pulp of the hallux and 10-g SWF was applied on three plantar sites on each foot according to the guidelines of the International Working Group on the Diabetic Foot, in 400 consecutive diabetic patients. VPT was considered as abnormal if ≥25 V and SWF was considered as abnormal if the patient was unable to feel ≥2 applications at a single site. Both tests were normal in 240 patients (60%) and both abnormal in 78. In 21 patients, only SWF was abnormal whereas only VPT was abnormal in 61. As a whole, 160 patients (40%) were considered at risk for foot ulceration by VPT and/or SWF. Agreement between the two screening methods was only moderate with a kappa coefficient of 0·52 (95% CI: 0·43-0·60). Using VPT as a predictor for foot ulceration, the number of patients at risk is much higher than identified by SWF. This discrepancy might have potential effects on costs and prevention policies.

Progressive axonal dysfunction precedes development of neuropathy in type 2 diabetes

To evaluate the development of diabetic neuropathy, the current study examined changes in peripheral axonal function. Nerve excitability techniques were undertaken in 108 type 2 diabetic patients with nerve conduction studies (NCS), HbA(1c) levels, and total neuropathy score (TNS). Patients were categorized into two cohorts: patients with diabetes without neuropathy (DWN group [n = 56]) and patients with diabetes with neuropathy (DN group [n = 52]) and further into severity grade 0 (TNS 0-1 [n = 35]), grade 1 (TNS 2-8 [n = 42]), and grade 2/3 (TNS 9-24 [n = 31]). Results revealed that the DWN group had a significantly increased threshold, prolonged latency, and changes in excitability parameters compared with age-matched control subjects. Patients with neuropathy demonstrated significant alteration in recovery cycle parameters and depolarizing threshold electrotonus. Within the DWN cohort, there were significant correlations between HbA(1c) level and latency and subexcitability, whereas the estimated glomerular filtration rate correlated with superexcitability in patients with neuropathy. Furthermore, excitability parameters became progressively more abnormal with increasing clinical severity. These results suggest a spectrum of excitability abnormalities in patients with diabetes and that early axonal dysfunction may be detected prior to the development of neuropathy. As progressive changes in excitability parameters correlated to neuropathy severity, excitability testing may provide a biomarker of the early development and severity of diabetic neuropathy, providing insights into the pathophysiological mechanisms producing axonal dysfunction.

Results of a model analysis of the cost-effectiveness of liraglutide versus exenatide added to metformin, glimepiride, or both for the treatment of type 2 diabetes in the United States

BACKGROUND

Nearly half of all US patients with type 2 diabetes mellitus (T2DM) are unable to maintain adequate glycosylated hemoglobin (HbA₁(c)) control (ie, <7.0%).

OBJECTIVE

The aim of this work was to determine the long-term cost-effectiveness of incretin-based therapy with once-daily liraglutide (vs twice-daily exenatide) combined with metformin, glimepiride, or both for the treatment of T2DM.

METHODS

Patient data were obtained from the Liraglutide Effect and Action in Diabetes 6 (LEAD 6) trial. Baseline data included mean HbA₁(c) (8.15%), age (56.7 years), disease duration (8 years), sex, body mass index, blood pressure, lipid levels, cardiovascular and renal risk factors, and other complications. The IMS Center for Outcomes Research Diabetes Model was used to project and compare lifetime (ie, 35-year) clinical and economic outcomes for once-daily liraglutide 1.8 mg compared with twice-daily exenatide 10 (ig, each used as add-on therapy with maximum-dose metformin and/or glimepiride. Treatment-effect assumptions were also derived from the LEAD 6 trial. Transition probabilities, utilities, and complication costs were obtained from published sources. All outcomes were discounted at 3% per annum, and the analysis was conducted from the perspective of a third-party payer in the United States.

RESULTS

The base-case analysis indicated that, compared with exenatide, liraglutide add-on therapy was associated with a mean (SD) increase in life expectancy of 0.187 (0.250) years and an increase in qualityadjusted life-years of 0.322 (0.164) years. Compared with exenatide, total lifetime treatment costs for liraglutide were $12,956 higher, yielding an incremental costeffectiveness ratio (ICER) of $40,282. However, the costs of diabetes-related complications were lower with liraglutide than with exenatide ($49,784 vs $52,429, respectively). Sensitivity analysis indicated that setting patient HbA(1c) levels at the 95% upper limit reduced the ICER for liraglutide compared with exenatide to $33,086.

CONCLUSION

In this model analysis using published clinical data and current medication acquisition price assumptions, liraglutide (in combination with metformin and/or glimepiride) appeared to be cost-effective in the US payer setting over a 35-year time horizon.

Hyperspectral imaging in diabetic foot wound care

Diabetic foot ulceration is a major complication of diabetes and afflicts as many as 15 to 25% of type 1 and 2 diabetes patients during their lifetime. If untreated, diabetic foot ulcers may become infected and require total or partial amputation of the affected limb. Early identification of tissue at risk of ulcerating could enable proper preventive care, thereby reducing the incidence of foot ulceration. Furthermore, noninvasive assessment of tissue viability around already formed ulcers could inform the diabetes caregiver about the severity of the wound and help assess the need for amputation. This article reviews how hyperspectral imaging between 450 and 700 nm can be used to assess the risk of diabetic foot ulcer development and to predict the likelihood of healing noninvasively. Two methods are described to analyze the in vivo hyperspectral measurements. The first method is based on the modified Beer-Lambert law and produces a map of oxyhemoglobin and deoxyhemoglobin concentrations in the dermis of the foot. The second is based on a two-layer optical model of skin and can retrieve not only oxyhemoglobin and deoxyhemoglobin concentrations but also epidermal thickness and melanin concentration along with skin scattering properties. It can detect changes in the diabetic foot and help predict and understand ulceration mechanisms.

Receipt of care and reduction of lower extremity amputations in a nationally representative sample of U.S. Elderly

OBJECTIVE

To determine effectiveness of receipt of care from podiatrist and lower extremity clinician specialists (LEC specialists) on diabetes mellitus (DM)-related lower extremity amputation.

DATA SOURCES

Medicare 5 percent sample claims, 1991-2007.

STUDY DESIGN

Individuals with DM-related lower extremity complications (LECs) were followed 6 years. Visits with podiatrists, LEC specialists, and other health professionals were tracked to ascertain whether receipt of such care reduced the hazards of an LEC amputation.

DATA COLLECTION

Individuals were stratified based on disease severity, Stage 1--neuropathy, paresthesia, pain in feet, diabetic amyotrophy; Stage 2--cellulitis, charcot foot; Stage 3--ulcer; Stage 4--osteomyelitis, gangrene.

PRINCIPAL FINDINGS

Half the LEC sample died within 6 years. More severe lower extremity disease increased risk of death and amputation. Persons visiting a podiatrist and an LEC specialist within a year before developing all stage complications were between 31 percent (ulceration) and 77 percent (cellulitis and charcot foot) as likely to undergo amputation compared with individuals visiting other health professionals.

CONCLUSIONS

Individuals with an LEC had high mortality. Visiting both a podiatrist and an LEC specialist in the year before LEC diagnosis was protective of undergoing lower extremity amputation, suggesting a benefit from multidisciplinary care.

Limb salvage surgery and wound treatment in the establishment of globally standardized diabetes, amputation, and limb salvage centers to address lower extremity morbidity and mortality in Thailand

Diabetes and its consequences, particularly diabetic foot ulcerations and amputations, are increasing exponentially on a global level. Universal interest exists in the establishment of educational programs, clinics, and patient materials. However, the availability and skills needed to develop, implement, and consistently manage diabetes and related problems are lacking. This article reviews problems related to care of the diabetic foot, with a focus on Thailand as a model. Recommendations are made to assist with the development and implementation of limb salvage centers for the treatment of the at-risk diabetic foot. The guidelines presented may be applied to any countries where diabetic foot care is in the initial stages of development.

A simulation of the comparative long-term effectiveness of liraglutide and glimepiride monotherapies in patients with type 2 diabetes mellitus

STUDY OBJECTIVE

To project and compare long-term outcomes of morbidity and mortality, and costs of complications of type 2 diabetes mellitus from a randomized controlled trial of patients receiving liraglutide versus glimepiride monotherapy.

DESIGN

Mathematic simulation using the validated Center for Outcomes Research (CORE) Diabetes Model, calibrated to baseline patient characteristics from a short-term, randomized, controlled trial of liraglutide and glimepiride monotherapies (Liraglutide Effect and Action in Diabetes [LEAD]-3 trial) and using data from long-term outcomes studies.

SETTING

Simulated routine clinical practice.

PATIENTS

Seven hundred forty-six patients with type 2 diabetes who participated in the LEAD-3 trial, and three hypothetical cohorts of 5000 patients each that were based on the baseline characteristics of the patients in the LEAD-3 trial. The patients in the LEAD-3 trial were randomly assigned to monotherapy with liraglutide 1.2 mg/day (251 patients), liraglutide 1.8 mg/day (247 patients), or glimepiride 8 mg/day (248 patients).

MEASUREMENTS AND MAIN RESULTS

The impact of the three treatments for type 2 diabetes on survival and cumulative incidence of cardiovascular, ocular, or renal events and costs were estimated at three time periods: 10, 20, and 30 years. Simulations predicted improved survival for liraglutide 1.8 and 1.2 mg at all three time points compared with glimepiride. Survival benefits were greatest after 30 years of follow-up: 16.5%, 13.6%, and 7.3%, respectively. The frequency of nonfatal renal and ocular events was lower for both liraglutide doses than for glimepiride. The rate of neuropathies leading to first or recurrent amputation was higher for glimepiride compared with both liraglutide doses. The average cumulative cost/patient was higher for glimepiride compared with liraglutide 1.2 mg and liraglutide 1.8 mg.

CONCLUSION

With use of the CORE Diabetes Model and data from the LEAD-3 trial, long-term projected survival, diabetes complications, and costs favored liraglutide 1.2- and 1.8-mg monotherapies compared with glimepiride in the treatment of type 2 diabetes.

Self-monitoring of blood glucose (SMBG) for type 2 diabetes patients treated with oral anti-diabetes drugs and with a recent history of monitoring: cost-effectiveness in the US

OBJECTIVE

Stakeholders in the US and elsewhere are interested in country-specific and cohort-specific information with which to assess the long-term value of self-monitoring of blood glucose (SMBG) for patients with type 2 diabetes mellitus (T2DM) on oral anti-diabetes drugs (OADs). This study modeled the cost-effectiveness of SMBG at frequencies of once, twice, or three times per day for this population, and included those who had used SMBG in the prior year.

RESEARCH DESIGN AND METHODS

Based on clinical findings of a longitudinal Kaiser Permanente study, a validated model was used to project 40-year clinical and economic outcomes for SMBG at (averages of) once, twice, or three times per day versus no SMBG. Baseline HbA1c (7.6%), age and gender represented the Kaiser study 'prevalent' SMBG users cohort. Unit costs came primarily from a 2003 published article; inflated to US$2006. Outcomes were discounted at 3% per annum, with sensitivity analyses on discount rates and time horizons. Analyses were conducted from a third-party payer perspective in the US, including only direct costs.

MAIN OUTCOME MEASURES

Primary outcomes were differences in total costs, cumulative incidence of complications, quality-adjusted life years (QALYs); and incremental cost-effectiveness ratios (ICERs).

RESULTS

For patients using SMBG once, twice, or three times per day, relative risks over 40 years were lower for 14 of 16 complications and slightly higher for 2 complications. Compared to 'no SMBG,' QALYs increased with SMBG frequency: 0.047, 0.116, and 0.132 QALYs for SMBG once, twice, and three times per day, respectively. Some increased costs with SMBG were offset by reductions in costs for several diabetes-related complications. Corresponding ICERs were $26,206, $18,572 and $25,436/QALY gained. Results were most sensitive to time horizon, with SMBG not cost-effective over a 5-year simulation period.

CONCLUSIONS

Study limitations include the use of relatively short-term observational data, unknown levels of patient adherence, and assumptions regarding the duration of clinical effects. Results showed that compared to no SMBG, base case ICERs for each of the three SMBG frequencies examined were below $30,000, and that a portion of the increased costs associated with SMBG were offset by reductions in complication costs, and by modest increases in QALYs. Results add to the literature addressing the cost-effectiveness of SMBG as a component of care for T2DM patients on OADs, and in particular those with monitoring experience within the previous year.

Cost effectiveness of preventive screening programmes for type 2 diabetes mellitus in Germany

BACKGROUND

As in several other industrialized countries, Germany's statutory health insurance (SHI) is facing rising healthcare costs as well as the challenges caused by a double-aging society. The early detection and prevention of chronic diseases is considered a possible way to reduce the impact of these developments. However, controversy surrounds the costs and effects in terms of medical and financial outcomes of such programmes.

OBJECTIVE

To examine the cost effectiveness of screening for type 2 diabetes mellitus (T2DM) from the perspective of the German SHI. The screening programme was compared with the current status quo (i.e. diagnosis of T2DM in routine clinical care or after the occurrence of the first clinical symptoms). Prevention strategies after diagnosis of pre-diabetes encompassed lifestyle and metformin interventions.

METHODS

Effects of introducing screening for T2DM were assessed based on a Markov Monte Carlo microsimulation model. In contrast to a cohort model, this approach easily allows for detailed subgroup analysis accounting for the different characteristics of the general German population that would be targeted by the screening programme. Assessed endpoints included quality of life, lifetime costs, age at diabetes diagnosis, and incidence and age at occurrence of diabetes-related complications such as myocardial infarction, stroke, renal failure and blindness.

RESULTS

Screening for T2DM was cost effective in the general population by all commonly applied standards (euro562.54 per QALY for lifestyle intervention, euro325.44 per QALY for prevention with metformin [year 2006 values]) and even cost saving in the subgroup diagnosed with pre-diabetes and treated preventively. Occurrence of diabetes-related adverse events was reduced significantly and life expectancy was increased compared with no screening.

CONCLUSIONS

These results suggest that early detection and disease prevention may be cost effective in the long term. However, additional political measures are necessary to support implementation, as the German SHI is currently lacking the necessary long-term incentives to support preventive screening programmes.

Human skin wounds: a major and snowballing threat to public health and the economy

ABSTRACT In the United States, chronic wounds affect 6.5 million patients. An estimated excess of US$25 billion is spent annually on treatment of chronic wounds and the burden is rapidly growing due to increasing health care costs, an aging population and a sharp rise in the incidence of diabetes and obesity worldwide. The annual wound care products market is projected to reach $15.3 billion by 2010. Chronic wounds are rarely seen in individuals who are otherwise healthy. In fact, chronic wound patients frequently suffer from "highly branded" diseases such as diabetes and obesity. This seems to have overshadowed the significance of wounds per se as a major health problem. For example, NIH's Research Portfolio Online Reporting Tool (RePORT; http://report.nih.gov/), directed at providing access to estimates of funding for various disease conditions does list several rare diseases but does not list wounds. Forty million inpatient surgical procedures were performed in the United States in 2000, followed closely by 31.5 million outpatient surgeries. The need for post-surgical wound care is sharply on the rise. Emergency wound care in an acute setting has major significance not only in a war setting but also in homeland preparedness against natural disasters as well as against terrorism attacks. An additional burden of wound healing is the problem of skin scarring, a $12 billion annual market. The immense economic and social impact of wounds in our society calls for allocation of a higher level of attention and resources to understand biological mechanisms underlying cutaneous wound complications.

Large-fiber dysfunction in diabetic peripheral neuropathy is predicted by cardiovascular risk factors

OBJECTIVE

Diabetic large-nerve fiber dysfunction, as measured by vibration perception threshold (VPT), predicts foot ulceration, amputation, and mortality. Thus, determination of modifiable risk factors is of great clinical importance.

RESEARCH DESIGN AND METHODS

We assessed 1,407 patients with type 1 diabetes and a normal VPT participating in the EURODIAB Prospective Complications Study, at baseline mean +/- SD age of 32.7 +/- 10.2 years with diabetes duration of 14.7 +/- 9.3 years and follow-up of 7.3 +/- 0.6 years. VPT was measured using biothesiometry on the right big toe and medial malleolus. An abnormal result was defined as >2 SD from the predicted mean for the patient s age.

RESULTS

An abnormal VPT was associated with an increased incidence of gangrene, amputation, foot ulceration, leg bypass or angioplasty, and mortality (P < OR = 0.02). The incidence of abnormal VPT was 24% over the 7.3-year follow-up. Duration of diabetes and A1C significantly influenced the incidence of abnormal VPT (P < 0.0001). After correction for these, established risk factors for cardiovascular disease (CVD), including male sex (P = 0.0004), hypertension (P < 0.0001), total cholesterol (P = 0.002), LDL cholesterol (P = 0.01), smoking (P < 0.0001), weight (P < 0.0001), and diabetes complications (retinopathy [P = 0.0001], nephropathy [P = 0.01], and autonomic neuropathy [P = 0.001]), were all found to be significant risk factors. A previous history of CVD doubled the incidence of abnormal VPT.

CONCLUSIONS

This prospective study indicates that cardiovascular risk factors predict development of large-fiber dysfunction, which may account for the high mortality rate in patients with an abnormal VPT, and emphasizes the importance of early determination of VPT to detect subclinical neuropathy and to address cardiovascular risk factors.

A cost-effectiveness analysis of continuous subcutaneous insulin injection versus multiple daily injections in type 1 diabetes patients: a third-party US payer perspective

OBJECTIVE

To estimate the long-term cost-effectiveness of using continuous subcutaneous insulin infusion (CSII) compared with multiple daily injections (MDI) of insulin in adult and child/young adult type 1 diabetes mellitus (T1DM) patients from a third-party payer perspective in the United States.

METHOD

A previously validated health economic model was used to determine the incremental cost-effectiveness ratio (ICER) of CSII compared with MDI using published clinical and cost data. The primary input variable was change in HbA(1c), and was assumed to be an improvement of -0.9% to -1.2% for CSII compared with MDI for child/young adult and adults, respectively. A series of Markov constructs simulated the progression of diabetes-related complications.

RESULTS

CSII was associated with an improvement in quality-adjusted life-years (QALYs) gained of 1.061 versus MDI for adults and 0.799 versus MDI for children/young adults. ICERs were $16,992 and $27,195 per QALY gained for CSII versus MDI in adults and children/young adults, respectively. Improved glycemic control from CSII led to a lower incidence of diabetes complications, with the most significant reduction in proliferative diabetic retinopathy (PDR), end stage renal disease (ESRD), and peripheral vascular disease (PVD). The number needed to treat (NNT) for PDR was nine patients, suggesting that only nine patients need to be treated with CSII to avoid one case of PDR. The NNT for ESRD and PVD was 19 and 41, respectively.

CONCLUSIONS

Setting the willingness to pay at $50,000/QALY, the analysis demonstrated that CSII is a cost-effective option for patients with T1DM in the United States.

A cost-effectiveness analysis of pioglitazone plus metformin compared with rosiglitazone plus metformin from a third-party payer perspective in the US

OBJECTIVE

The long-term cost-effectiveness of using pioglitazone plus metformin (Actoplusmet dagger) compared with rosiglitazone plus metformin (Avandamet double dagger) in treating type 2 diabetes (T2DM) was assessed from a US third-party payer perspective.

RESEARCH DESIGN AND METHODS

Clinical efficacy (change in HbA(1c) and lipids) and baseline cohort parameters were extracted from a 12-month, randomized clinical trial (Derosa et al., 2006) evaluating the efficacy and tolerability of pioglitazone versus rosiglitazone, both in addition to metformin, in adult T2DM patients with insufficient glucose control (n = 96). A Markov-based model was used to project clinical and economic outcomes over 35 years, discounted at 3% per annum. Costs for complications were taken from published sources. Base-case assumptions were assessed through several sensitivity analyses.

MAIN OUTCOME MEASURES

Outcomes included incremental life-years, quality-adjusted life-years (QALYs), total direct medical costs, cumulative incidence of complications and associated costs, and incremental cost-effectiveness ratios (ICERs).

RESULTS

Compared to rosiglitazone plus metformin, pioglitazone plus metformin was projected to result in a modest improvement in 0.187 quality-adjusted life-years. Over patients' lifetimes, total direct medical costs were projected to be marginally lower with pioglitazone plus metformin (difference -$526.), largely due to reduced CVD complication costs. While costs were higher among renal, ulcer/amputation/neuropathy, and eye complications in the pioglitazone plus metformin group, the cost savings for CVD complications outweighed their economic impact. Pioglitazone plus metformin was found to be a dominant long-term treatment strategy in the US compared to rosiglitazone plus metformin. Sensitivity analyses showed findings to be robust under almost all scenarios, including short-term time horizons, 6% discounting, removal of individual lipid parameters, and modifications of patient cohort to more closely represent a US T2DM population. Pioglitazone plus metformin was no longer dominant with 0% discounting, with 25% reduction in its HbA(1c) effects, or with a 15% increase in its acquisition price.

CONCLUSIONS

Under a range of assumptions and study limitations around cohorts, clinical effects, and treatment patterns, this long-term analysis showed that pioglitazone plus metformin, when compared to rosiglitazone plus metformin, was a dominant treatment strategy within the US payer setting. Results were driven by the combination of modest differences in QALYs and modest savings in total complication costs over 35 years.

Long-term outcomes in patients with type 2 diabetes receiving glimepiride combined with liraglutide or rosiglitazone

Background

Poor control of type 2 diabetes results in substantial long-term consequences. Studies of new diabetes treatments are rarely designed to assess mortality, complication rates and costs. We sought to estimate the long-term consequences of liraglutide and rosiglitazone both added to glimepiride.

Methods

To estimate long-term clinical and economic consequences, we used the CORE diabetes model, a validated cohort model that uses epidemiologic data from long-term clinical trials to simulate morbidity, mortality and costs of diabetes. Clinical data were extracted from the LEAD-1 trial evaluating two doses (1.2 mg and 1.8 mg) of a once daily GLP-1 analog liraglutide, or rosiglitazone 4 mg, on a background of glimepiride in type 2 diabetes. CORE was calibrated to the LEAD-1 baseline patient characteristics. Survival, cumulative incidence of cardiovascular, ocular and renal events and healthcare costs were estimated over three periods: 10, 20 and 30 years.

Results

In a hypothetical cohort of 5000 patients per treatment followed for 30 years, liraglutide 1.2 mg and 1.8 mg had higher survival rates compared to the group treated with rosiglitazone (15.0% and 16.0% vs. 12.6% after 30 years), and fewer cardiovascular, renal, and ocular events. Cardiovascular death rates after 30 years were 69.7%, 68.4% and 72.5%, for liraglutide 1.2 mg, 1.8 mg, and rosiglitazone, respectively. First and recurrent amputations were lower in the rosiglitazone group, probably due to a 'survival paradox' in the liraglutide arms (number of events: 565, 529, and 507, respectively). Overall cumulative costs per patient, were lower in both liraglutide groups compared to rosiglitazone (US$38,963, $39,239, and $40,401 for liraglutide 1.2 mg, 1.8 mg, and rosiglitazone, respectively), mainly driven by the costs of cardiovascular events in all groups.

Conclusion

Using data from LEAD-1 and epidemiologic evidence from the CORE diabetes model, projected rates of mortality, diabetes complications and healthcare costs over the long term favor liraglutide plus glimepiride over rosiglitazone plus glimepiride.

Trial registration

LEAD-1 NCT00318422; LEAD-2 NCT00318461; LEAD-3 NCT 00294723; LEAD-4 NCT00333151; LEAD-5 NCT00331851; LEAD-6 NCT00518882.

An evidence-based model comparing the cost-effectiveness of platelet-rich plasma gel to alternative therapies for patients with nonhealing diabetic foot ulcers

OBJECTIVE

A cost-effectiveness analysis compared the potential economic benefit of an autologous, platelet-rich plasma (PRP) gel to alternative therapies in treating nonhealing diabetic foot ulcers.

DESIGN

An economic model used peer-reviewed data to simulate clinical and cost outcomes and quality-adjusted life-years (QALYs) associated with PRP gel and other treatment modalities.

PATIENTS

The model varies rates of healing, recurrence, infection, amputation, death, and associated costs for a hypothetical group of 200,000 patients with full-thickness, nonhealing diabetic foot ulcers for 5 years or until death.

MAIN OUTCOME MEASURES

The model simulates the clinical, cost, and QALY outcomes associated with PRP gel versus other modalities in treating nonhealing diabetic foot ulcers over a 5-year period.

MAIN RESULTS

The average 5-year direct wound care cost per modality and QALYs were PRP gel, $15,159 (2.87); saline gel, $33,214 (2.70); standard of care, $40,073 (2.65); noncontact kilohertz ultrasound therapy, $32,659 (2.73); human fibroblast-derived dermal substitute, $40,569 (2.65); allogenic bilayered culture skin substitute, $24,374 (2.79); bilayered cellular matrix, $37,340 (2.71); negative pressure wound therapy, $20,964 (2.81); and recombinant human platelet-derived growth factor BB, $47,252 (2.69).

CONCLUSION

Use of PRP gel resulted in improved quality of life and lower cost of care over a 5-year period than other treatment modalities for nonhealing diabetic foot ulcers. Although actual treatment outcomes may differ from those modeled, PRP gel represents a potentially attractive treatment alternative for insurers and health care providers to address the cost burden and health effects of nonhealing diabetic foot ulcers.

Long-term cost-effectiveness of pioglitazone versus placebo in addition to existing diabetes treatment: a US analysis based on PROactive

OBJECTIVE

To estimate the long-term cost-effectiveness of adding pioglitazone versus placebo to standard treatment in high-risk patients with type 2 diabetes.

METHODS

The validated CORE Diabetes Model was modified to project long-term clinical and cost outcomes associated with pioglitazone versus placebo, based on results from PROactive. The model retained basic structure and functionality, with interdependent Markov submodels, Monte Carlo simulation and user interface. Adjustments to submodels were made to accommodate the PROactive primary end points. The analysis was from the perspective of a third party US health-care payer perspective, projected over a lifetime horizon using a 3% annual discount.

RESULTS

Over a lifetime horizon, addition of pioglitazone was associated with increased life expectancy (0.237 life-years) and quality-adjusted life expectancy (QALE) [0.166 quality-adjusted life-years (QALYs)] versus placebo. Estimated long-term complication rates showed that pioglitazone reduced the number of events versus placebo for most outcomes. Lifetime total direct costs were marginally higher with pioglitazone versus placebo ($272,694 vs. $265,390, difference $7,305). The incremental cost-effectiveness ratio for pioglitazone versus placebo was $44,105 per QALY gained. Probabilistic sensitivity analysis indicated a 55% likelihood that pioglitazone would be considered cost-effective in the United States, with a willingness to pay of $50,000 per QALY gained.

CONCLUSIONS

The addition of pioglitazone to existing therapy in high-risk patients with type 2 diabetes was projected to improve life expectancy, QALE and complication rates compared with placebo. Addition of pioglitazone was in the range generally considered acceptable.

Pioglitazone versus rosiglitazone treatment in patients with type 2 diabetes and dyslipidemia: cost-effectiveness in the US

OBJECTIVES

Pioglitazone hydrochloride (Actos † ) and rosiglitazone maleate (Avandia ‡ ) are members of the thiazolidinedione (TZD) class of oral anti-diabetic drugs (OADs) and are used to treat type 2 diabetes mellitus (T2DM). Greater beneficial effects on lipids have been demonstrated with pioglitazone, however. Study objectives were to evaluate the long-term cost-effectiveness of pioglitazone compared to rosiglitazone in treating patients with T2DM and dyslipidemia, and determine the extent to which reported beneficial lipid effects of pioglitazone would improve clinical and economic outcomes through reduced macrovascular complications. † Actos is a trade name of Takeda Pharmaceuticals Co. Ltd., Deerfield, IL, US ‡ Avandia is a trade name of GlaxoSmithKline, Research Triangle, NC, US.

RESEARCH DESIGN AND METHODS

The validated CORE Diabetes Model (CDM) was used to simulate changes in glycosylated hemoglobin (HbA(1c)), complications, and direct medical costs. Baseline parameters came from a multi-center, double-blind trial comparing lipid and glycemic effects of pioglitazone (n = 400) and rosiglitazone (n = 402) among individuals with T2DM and untreated dyslipidemia. Sensitivity analyses examined the impact of cohort, clinical, and cost inputs on incremental cost effectiveness ratios (ICERs).

RESULTS

In the base case, pioglitazone was associated with mean (standard deviation [SD]) quality-adjusted life years (QALYs) of 7.476 (0.123) vs. 7.326 (0.128) for rosiglitazone. Pioglitazone had $3038 higher total direct costs, but $580 lower complication costs. Risks of four cardiovascular complications were reduced with pioglitazone (relative risks 0.860-0.942), while risks of 17 other complications were slightly higher (relative risks 1.001-1.056). The ICER for pioglitazone treatment was $20 171/QALY. Results were most sensitive to the effects of HbA(1c), high-density lipoprotein-cholesterol, overall lipid effects, and pioglitazone acquisition costs.

CONCLUSIONS

Study limitations include issues of generalizability of the trial patient population, as well as inability to capture non-adherence and variation in 'real-world' treatment patterns. Nevertheless, pioglitazone (when compared to rosiglitazone) was found to have long-term value as a treatment option for T2DM patients with dyslipidemia treated within the US payer setting.

Gender differences in the onset of diabetic neuropathy

OBJECTIVE

Diabetic neuropathy is one of the more common complications plaguing individuals with type 2 diabetes. The development and progression of such complications are responsible for much of the morbidity and mortality related to this disease. Few studies have evaluated age at onset of diabetic neuropathy between genders. A difference in the progression of diabetic neuropathy between men and women may exist. This investigation evaluated gender differences in the age at onset of neuropathy among patients with type 2 diabetes.

METHODS

The study, a retrospective chart analysis, reviewed 376 inpatient and outpatient medical records between January 2004 and January 2006 from a Cleveland, Ohio, hospital. Onset of neuropathy was determined by the date the neuropathy International Classification of Diseases, Ninth Revision code was first included in the medical chart; for this study, onset was equated with the date of first identification. Data were analyzed via a tailed independent t test.

RESULTS

Of the 376 inpatient and outpatient charts reviewed, 156 were for male patients and 220 were for female patients (41% and 59%, respectively). All patients had type 2 diabetes; however, 23% (n=86) required insulin therapy at the time of the study. Males developed neuropathic complications at 63 years, approximately 4 years earlier than did females (at 67 years). The t test revealed a statistically significant difference in age at onset of diabetic neuropathy between the male and female subjects.

CONCLUSIONS

This study demonstrates that the males in the study population developed neuropathy earlier than did the females. It may then be hypothesized that earlier interventions in the male population may improve disease outcomes.

Estimating the long-term cost-effectiveness of exenatide in the United States: an adjunctive treatment for type 2 diabetes mellitus

OBJECTIVES

This analysis provides an early estimate of the cost-effectiveness of adjunctive exenatide in treating type 2 diabetes mellitus in the United States. Data from pivotal phase III 30-week clinical trials and 52 weeks of their subsequent open-label extension studies (i.e., 82 weeks total) were used to project the effects of 30 years of adjunctive exenatide treatment.

METHODS

This analysis utilized a published and validated Markov model incorporating Monte Carlo simulation with tracker variables to estimate the clinical and cost outcomes of adding exenatide to a background of metformin and/or sulfonylurea treatment, with the effects of 30 years of adjunctive exenatide treatment (projected from data from 82 weeks of exenatide treatment) compared with no additional treatment beyond metformin and/or a sulfonylurea. Sensitivity analyses were performed on key clinical assumptions, discount rates, and shorter time horizons.

RESULTS

The base-case scenario (30 years of exenatide) yielded an incremental cost-effectiveness ratio (ICER) of $35,571. We found that shortening the time horizons and removing the lipid effects of exenatide had the greatest negative impact on ICERs when performing sensitivity analysis.

CONCLUSIONS

Our analysis demonstrated that exenatide used for 20 or 30 years compared with no additional treatment beyond metformin and/or a sulfonylurea is cost-effective in the adjunctive treatment of type 2 diabetes with an ICER less than $50,000 per life-year gained. Sensitivity analyses suggest that, in addition to sustained reduction in HbA(1c), the added clinical effects of improved lipid values, systolic blood pressure, and reduced body mass index all positively contributed to the cost-effectiveness of exenatide.

Application of Orem's Self-Care Deficit Theory and Standardized Nursing Languages in a Case Study of a Woman with Diabetes

PURPOSE

This paper aims to illustrate the process of theory-based nursing practice by presenting a case study of a clinical nurse specialist's assessment and care of a woman with type 2 diabetes.

DESIGN

Orem's self-care deficit theory and standardized nursing language, NANDA, NIC (Nursing Interventions Classification), and NOC (Nursing Outcomes Classification), guided assessment and the identification of outcomes and interventions related to the client's management of diabetes.

FINDINGS

Theory-based nursing care and standardized nursing language enhanced the client's ability to self-manage the chronic illness: diabetes.

CONCLUSION

Nursing theory and standardized nursing language enhance communication among nurses and support a client's ability to self-manage a chronic illness.

The diabetic foot

Diabetic foot problems are common throughout the world, resulting in major medical, social and economic consequences for the patients, their families, and society. Foot ulcers are more likely to be of neuropathic origin, and therefore eminently preventable. People at greatest risk of ulceration can easily be identified by careful clinical examination of the feet: education and frequent follow-up is indicated for these patients. When infection complicates a foot ulcer, the combination can be limb or life-threatening. Infection is defined clinically, but wound cultures assist in identifying the causative pathogens. Tissue specimens are strongly preferred to wound swabs for wound cultures. Antimicrobial therapy should be guided by culture results, and although such therapy may cure the infection, it does not heal the wound. Alleviation of the mechanical load on ulcers (offloading) should always be a part of treatment. Plantar neuropathic ulcers typically heal in 6 weeks with irremovable casting, because pressure at the ulcer site is mitigated and compliance is enforced. The success of other approaches to offloading similarly depends on the patients' adherence to the effectiveness of pressure relief.

Local biological factors that influence amputations in diabetic patients

Lower extremity amputation is one of the worst complications of diabetes, as it usually has a life expectancy that is below that of most cancers. Four local biologic factors-ulcer, ischemia, neuropathy, and infection-have been shown to be related to amputation. These factors interact with one another, such that neuropathy has been shown to cause ulcers and ischemia and to prevent the healing of ulcers. In addition, ischemia and neuropathy are independent risk factors for infection. More coordinated efforts are needed to create better grading schemes and therapeutic protocols.

Syme amputation for limb salvage: early experience with 26 cases

The Syme amputation is often overlooked as an alternative to below-knee amputation or above-knee amputation in cases of limb-threatening foot infections and gangrene. Even though the advantages of the Syme amputation over major amputation are well cited in the literature, many surgeons do not view this amputation as a viable option for limb salvage. We herein present our initial experience with this operation in a series of patients at imminent risk for major lower extremity amputation. This study included our initial 26 patients at high risk (92% had diabetes) with infection and/or significant peripheral arterial disease who underwent ankle disarticulation for limb salvage. Medical records were abstracted for pertinent demographic and clinical data. Variables of interest included diabetes status and duration, presence of peripheral arterial disease, infection, osteomyelitis, and gangrene. Our primary outcome variable was a healed amputation, whereas secondary outcomes included time to healing, subsequent major amputations, and complications. Despite prior recommendation for below-knee amputation or above-knee amputation in each of these patients, 50% remained healed at an average of 49.3 weeks of follow-up. Although 17 patients (65.4%) ambulated in a Syme prosthesis after healing of the original Syme operation, several patients went on to major amputation for progressive sepsis or recurrent ulcers, and 1 patient subsequently died. Because of the relatively small number of study subjects, we could find no significant predictors of success or failure of this procedure. However, all 10 patients eventually succumbing to major amputation and all 3 patients who died during follow-up had diabetes mellitus. At the end of follow-up, 46.2% (12/26) patients were functioning well in a Syme prosthesis. In this high-risk cohort of patients in whom major amputation had been recommended, we achieved a healing rate of 50% at an approximate 1-year follow-up. With the majority of patients having diabetes and peripheral vascular disease, we could not find any clear predictive factors for failure or successful outcome in this small population. Nonetheless, the Syme amputation deserves further study and consideration as a viable limb salvage option in patients threatened with major lower extremity amputation.

Therapy conversion to insulin detemir among patients with type 2 diabetes treated with oral agents: a modeling study of cost-effectiveness in the United States

The aim of this study was to gain a preliminary indication of the long-term clinical and economic implications of converting treatment for patients with type 2 diabetes to insulin detemir+/-oral hypoglycemic agents (OHAs) in a routine clinical practice setting in the United States. With the use of outcome data and patient characteristics reported from an ongoing prospective observational trial, a validated computer simulation model of diabetes was used to project the clinical and cost outcomes associated with therapy conversion to insulin detemir over a 35-y period from (1) OHA only, (2) neutral protamine Hagedorn insulin (NPH)+/-OHA, and (3) insulin glargine+/-OHA. Cost-effectiveness was assessed from a third-party healthcare payer perspective for the year 2005. Costs and clinical outcomes were discounted at a rate of 3%. Treatment with insulin detemir+/-OHA was associated with increases in quality-adjusted life expectancy of 0.309, 0.350, and 0.333 quality-adjusted life-years (QALYs) versus treatment with OHA alone, NPH+/-OHA, and insulin glargine+/-OHA, respectively. Increases in pharmacy costs were partially offset by reduced complications, rticularly renal complications and neuropathy. Projected incremental cost-effectiveness ratios were well within the range considered to represent good value in the United States, at $7412, $6269, and $3951 per QALY gained for treatment with Idet+/-OHA versus OHA alone, NPH+/-OHA, and Iglarg+/-OHA, respectively. On the basis of preliminary evidence of short-term improvements in glycemic control and reduced hypoglycemia, therapy conversion to insulin detemir+/-OHA from OHA alone, NPH+/-OHA, or insulin glargine+/-OHA was projected to increase quality-adjusted life expectancy and to represent a cost-effective treatment option in the United States.

The financial costs of healthcare treatment for people with Type 1 or Type 2 diabetes in the UK with particular reference to differing severity of peripheral neuropathy

AIMS

To characterize symptom severity of diabetic peripheral neuropathy (DPN) in people with diabetes and to characterize its association with healthcare resource use.

METHODS

The study was undertaken in Cardiff and the Vale of Glamorgan, UK. A postal survey was posted to subjects identified as having diabetes. Demography, quality of life (EQ-5D and SF-36) and symptoms of neuropathy (NTSS-6 and QOL-DN) data were collected. These data were linked to routine healthcare data coded into healthcare resource groups (HRGs) and subsequently costed according to UK National reference costs.

RESULTS

Survey responses were received from 1298 patients, a 32% response rate. For patients with a clinically confirmed diagnosis of DPN, the mean NTSS-6-SA score was 6.16 vs. 3.19 (P < 0.001). Duration of diabetes did not change across groups defined by severity of neuropathy symptoms, but mean HbA(1c) and body mass index values did increase with symptom severity (range 7.6-8.1%, P = 0.023; and 28.0-30.9 kg/m(2), P < 0.001, respectively). General linear modelling showed that the NTSS-6-SA score was a significant predictor of both annual health resource costs and yearly prescribed drug costs. On average, each 1-point increase in NTSS-6-SA score predicted a 6% increase in primary and secondary care costs and a 3% increase in log transformed drug costs.

CONCLUSION

This study demonstrated that severity of DPN symptoms was associated with increased healthcare resource use, thus costs.

Insulin therapy in type 2 diabetes patients failing oral agents: cost-effectiveness of biphasic insulin aspart 70/30 vs. insulin glargine in the US

OBJECTIVES

To project the long-term clinical and economic outcomes of treatment with biphasic insulin aspart 30 (BIAsp 70/30, 30% soluble and 70% protaminated insulin aspart) vs. insulin glargine in insulin-naïve type 2 diabetes patients failing to achieve glycemic control with oral antidiabetic agents alone (OADs).

METHODS

Baseline patient characteristics and treatment effect data from the recent 'INITIATE' clinical trial served as input to a peer-reviewed, validated Markov/Monte-Carlo simulation model. INITIATE demonstrated improvements in HbA1c favouring BIAsp 70/30 vs. glargine (-0.43%; p < 0.005) and greater efficacy in reaching glycaemic targets among patients poorly controlled on OAD therapy. Effects on life expectancy (LE), quality-adjusted life expectancy (QALE), cumulative incidence of diabetes-related complications and direct medical costs (2004 USD) were projected over 35 years. Clinical outcomes and costs were discounted at a rate of 3.0% per annum. Sensitivity analyses were performed.

RESULTS

Improvements in glycaemic control were projected to lead to gains in LE (0.19 +/- 0.24 years) and QALE (0.19 +/- 0.17 years) favouring BIAsp 70/30 vs. glargine. Treatment with BIAsp 70/30 was also associated with reductions in the cumulative incidences of diabetes-related complications, notably in renal and retinal conditions. The incremental cost-effectiveness ratio was $46 533 per quality-adjusted life year gained with BIAsp 70/30 vs. glargine (for patients with baseline HbA1c >/= 8.5%, it was $34 916). Total lifetime costs were compared to efficacy rates in both arms as a ratio, which revealed that the lifetime cost per patient treated successfully to target HbA1c levels of <7.0% and </= 6.5% were $80 523 and $93 242 lower with BIAsp 70/30 than with glargine, respectively.

CONCLUSIONS

Long-term treatment with BIAsp 70/30 was projected to be cost-effective for patients with type 2 diabetes insufficiently controlled on OADs alone compared to glargine. Treatment with BIAsp 70/30 was estimated to represent an appropriate investment of healthcare dollars in the management of type 2 diabetes.

The neuropathic diabetic foot

Diabetic foot problems are common throughout the world, and result in major medical, social and economic consequences for the patients, their families, and society. Foot ulcers are likely to be of neuropathic origin and, therefore, are eminently preventable. Individuals with the greatest risk of ulceration can easily be identified by careful clinical examination of their feet: education and frequent follow-up is indicated for these patients. When infection complicates a foot ulcer, the combination can be limb-threatening, or life-threatening. Infection is defined clinically, but wound cultures assist in identification of causative pathogens. Tissue specimens are strongly preferred to wound swabs for wound cultures. Antimicrobial therapy should be guided by culture results, and although such therapy may cure the infection, it does not heal the wound. Alleviation of the mechanical load on ulcers (offloading) should always be a part of treatment. Plantar neuropathic ulcers typically heal in 6 weeks with nonremovable casts, because pressure at the ulcer site is mitigated and compliance is enforced. The success of other approaches to offloading similarly depends on the patient's adherence to the strategy used for pressure relief.