Cost‐effectiveness of guideline‐based care provision for patients with diabetes‐related foot ulcers: A modelled analysis using discrete event simulation

Zhang, Yuqi; Carter, Hannah; Lazzarini, Peter A; Cramb, Susanna; Pacella, Rosana; Netten, Jaap J. van; Cheng, Qinglu; Derhy, Patrick H; Kinnear, Ewan M; McPhail, Steven

doi:10.1111/dme.14961

Cited by 16 publications

(41 citation statements)

References 31 publications

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“…Considering that the estimated global disease burden caused by DFD is comparatively very large as well as increasing, 12,13 it would seem that existing DFD care is either not reducing this burden alone or not being widely implemented. 25,26 Next generation of treatments is therefore needed to help reduce this burden in the near future. There are various next generation treatments being tested in the field of DFD, 1,27 however, to cover all of them is beyond the scope of this paper.…”

Section: F I G U R Ementioning

confidence: 99%

A new declaration for feet's sake: Halving the global diabetic foot disease burden from 2% to 1% with next generation care

Lazzarini,

Raspovic,

Meloni

et al. 2023

Diabetes Metabolism Res

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The 1989 Saint Vincent Declaration established a goal of halving global diabetes‐related amputation rates. A generation later, this goal has been achieved for major but not minor amputations. However, diabetic foot disease (DFD) is not only a leading cause of global amputation but also of hospitalisation, poor quality of life (QoL) and disability burdens. In this paper, we review latest estimates on the global disease burden of DFD and the next generation care of DFD that could reduce this burden. We found DFD causes 2% of the global disease burden. This makes DFD the 13th largest of 350+ leading conditions causing the global disease burden, and much larger than dementia, breast cancer and type 1 diabetes. Neuropathy without ulcers and amputations makes up the largest portion of the global DFD burden yet receives the least DFD focus. Future care focussed on improving safe physical activity in people with DFD could considerably reduce the DFD burden, as this incorporates increasing physical fitness and QoL, while simultaneously decreasing ulceration and other risks. Charcot neuro‐osteoarthropathy is more prevalent than previously thought. Most cases respond well to non‐removable offloading devices, but surgical intervention may further reduce the considerable burden of these neuropathic fracture dislocations. Ischaemia is becoming more common and complex. Most cases respond well to revascularisation interventions, but novel revascularisation techniques, medical management and autologous cell therapies may hold the key to more cases responding in the future. We conclude that DFD causes a global disease burden larger than most conditions and existing guideline‐based care and next generation treatments can reduce this burden. We suggest the World Health Organization and International Diabetes Federation declare a new goal: halving the global DFD burden from 2% to 1% within the next generation.

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Section: F I G U R Ementioning

confidence: 99%

A new declaration for feet's sake: Halving the global diabetic foot disease burden from 2% to 1% with next generation care

Lazzarini,

Raspovic,

Meloni

et al. 2023

Diabetes Metabolism Res

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“…Diabetes-related foot ulcers (DFU) are a leading global cause of hospitalisation, amputation, disability and healthcare cost burdens. [1][2][3][4][5][6][7][8][9] Each year worldwide, around 20 million people with diabetes have a DFU. [1][2][3] The most common pathway to developing a DFU is via high plantar tissue stress on the insensate foot of a person with diabetesrelated peripheral neuropathy.…”

Section: Introductionmentioning

confidence: 99%

Effectiveness of offloading interventions for people with diabetes‐related foot ulcers: A systematic review and meta‐analysis

Lazzarini

Armstrong

Crews

et al. 2023

Diabetes Metabolism Res

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BackgroundOffloading treatment is crucial to heal diabetes‐related foot ulcers (DFU). This systematic review aimed to assess the effectiveness of offloading interventions for people with DFU.MethodsWe searched PubMed, EMBASE, Cochrane databases, and trials registries for all studies relating to offloading interventions in people with DFU to address 14 clinical question comparisons. Outcomes included ulcers healed, plantar pressure, weight‐bearing activity, adherence, new lesions, falls, infections, amputations, quality of life, costs, cost‐effectiveness, balance, and sustained healing. Included controlled studies were independently assessed for risk of bias and had key data extracted. Meta‐analyses were performed when outcome data from studies could be pooled. Evidence statements were developed using the GRADE approach when outcome data existed.ResultsFrom 19,923 studies screened, 194 eligible studies were identified (47 controlled, 147 non‐controlled), 35 meta‐analyses performed, and 128 evidence statements developed. We found non‐removable offloading devices likely increase ulcers healed compared to removable offloading devices (risk ratio [RR] 1.24, 95% CI 1.09–1.41; N = 14, n = 1083), and may increase adherence, cost‐effectiveness and decrease infections, but may increase new lesions. Removable knee‐high offloading devices may make little difference to ulcers healed compared to removable ankle‐high offloading devices (RR 1.00, 0.86–1.16; N = 6, n = 439), but may decrease plantar pressure and adherence. Any offloading device may increase ulcers healed (RR 1.39, 0.89–2.18; N = 5, n = 235) and cost‐effectiveness compared to therapeutic footwear and may decrease plantar pressure and infections. Digital flexor tenotomies with offloading devices likely increase ulcers healed (RR 2.43, 1.05–5.59; N = 1, n = 16) and sustained healing compared to devices alone, and may decrease plantar pressure and infections, but may increase new transfer lesions. Achilles tendon lengthening with offloading devices likely increase ulcers healed (RR 1.10, 0.97–1.27; N = 1, n = 64) and sustained healing compared to devices alone, but likely increase new heel ulcers.ConclusionsNon‐removable offloading devices are likely superior to all other offloading interventions to heal most plantar DFU. Digital flexor tenotomies and Achilles tendon lengthening in combination with offloading devices are likely superior for some specific plantar DFU locations. Otherwise, any offloading device is probably superior to therapeutic footwear and other non‐surgical offloading interventions to heal most plantar DFU. However, all these interventions have low‐to‐moderate certainty of evidence supporting their outcomes and more high‐quality trials are needed to improve our certainty for the effectiveness of most offloading interventions.

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“…[1][2][3][4]7 Despite the large national DFD burden, Australian regions implementing guideline-based care have demonstrated large reductions in their regional DFD burdens and costs. 4,[8][9][10][11] However, the most recent Australian guideline on DFD was published in 2011, 12 many of its recommendations are now outdated, 1,13 and the body of research on DFD has since expanded considerably. 14 Therefore, the recent Australian DFD Strategy recommended an urgent update of Australian DFD guideline to inform contemporary evidence-based practice and help reduce the large burden of DFD.…”

mentioning

confidence: 99%

“…Despite the large national DFD burden, Australian regions implementing guideline‐based care have demonstrated large reductions in their regional DFD burdens and costs 4,8‐11 . However, the most recent Australian guideline on DFD was published in 2011, 12 many of its recommendations are now outdated, 1,13 and the body of research on DFD has since expanded considerably 14 .…”

mentioning

confidence: 99%

Australian evidence‐based guidelines for the prevention and management of diabetes‐related foot disease: a guideline summary

Lazzarini,

Raspovic,

Prentice

et al. 2023

Medical Journal of Australia

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IntroductionDiabetes‐related foot disease (DFD) — foot ulcers, infection, ischaemia — is a leading cause of hospitalisation, disability, and health care costs in Australia. The previous 2011 Australian guideline for DFD was outdated. We developed new Australian evidence‐based guidelines for DFD by systematically adapting suitable international guidelines to the Australian context using the ADAPTE and GRADE approaches recommended by the NHMRC.Main recommendationsThis article summarises the most relevant of the 98 recommendations made across six new guidelines for the general medical audience, including: prevention — screening, education, self‐care, footwear, and treatments to prevent DFD; classification — classifications systems for ulcers, infection, ischaemia and auditing; peripheral artery disease (PAD) — examinations and imaging for diagnosis, severity classification, and treatments; infection — examinations, cultures, imaging and inflammatory markers for diagnosis, severity classification, and treatments; offloading — pressure offloading treatments for different ulcer types and locations; and wound healing — debridement, wound dressing selection principles and wound treatments for non‐healing ulcers. Changes in management as a result of the guidelineFor people without DFD, key changes include using a new risk stratification system for screening, categorising risk and managing people at increased risk of DFD. For those categorised at increased risk of DFD, more specific self‐monitoring, footwear prescription, surgical treatments, and activity management practices to prevent DFD have been recommended. For people with DFD, key changes include using new ulcer, infection and PAD classification systems for assessing, documenting and communicating DFD severity. These systems also inform more specific PAD, infection, pressure offloading, and wound healing management recommendations to resolve DFD.

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Cost‐effectiveness of guideline‐based care provision for patients with diabetes‐related foot ulcers: A modelled analysis using discrete event simulation

Cited by 16 publications

References 31 publications

A new declaration for feet's sake: Halving the global diabetic foot disease burden from 2% to 1% with next generation care

A new declaration for feet's sake: Halving the global diabetic foot disease burden from 2% to 1% with next generation care

Effectiveness of offloading interventions for people with diabetes‐related foot ulcers: A systematic review and meta‐analysis

Australian evidence‐based guidelines for the prevention and management of diabetes‐related foot disease: a guideline summary

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