Prevention of diabetes-related foot ulcers and amputations: a cost-utility analysis based on Markov model simulations

Abstract

Interventions directed towards preventing the development or deterioration of foot ulcers in patients with diabetes mellitus have been shown to reduce the frequency of lower extremity amputations (LEA) by approximately 50 % to 85 % [1,2]. Recently published international guidelines and consensus documents emphasize the importance of educating patients and health care providers, providing foot care, appropriate footwear and employing multidisciplinary foot care teams [3±6]. The need for prevention for the individual patient depends on the presence of risk factors such as peripheral neuropathy, foot deformities, peripheral vascular disease (PVD), and previous history of foot ulcer and amputation.Despite convincing figures that foot ulcer prevention and management reduces the incidence of foot ulcers and the probability of LEA, many diabetic patients in Sweden [7,8] as well as in other countries [3, 9±12] do not receive optimal prevention. Possible reasons include an insufficient knowledge among health care providers and decision-makers as well as Diabetologia (2001) Abstract Aims/hypothesis. We analysed the cost-effectiveness of intensified prevention in diabetic patients with different risks for foot ulcers and lower extremity amputations. Specifically, we examined whether the additional prevention costs associated with present recommendations would be offset by reduced costs of future foot ulcers and amputations. Methods. Markov-based 5-year cost-utility simulations of current versus optimal prevention were done for hypothetical cohorts of diabetic patients older than 24 years. The model included eight possible health states for four risk groups. A population of 1677 diabetes patients provided data on present foot ulcer prevention and general mortality. Optimal prevention was defined according to the International Consensus on the Diabetic Foot. Model assumptions, transition probabilities and other data included in the model were based on published literature. The main outcome measures were cumulative incidences of foot ulcers, amputations and deaths, costs, cost-effectiveness, and quality-adjusted life years.Results. An intensified prevention strategy including patient education, foot care and footwear is cost-effective if the risk for foot ulcers and lower extremity amputations can be reduced by 25 %. This is valid for all patients with diabetes except those with no specific risk factors. Conclusion/interpretation. Providing all diabetic patients at risk or high risk for foot ulcers and amputations with adequate prevention would be a cost-effective or even cost-saving strategy. [Diabetologia (2001

Evaluation of the effectiveness and cost-effectiveness of lightweight fibreglass heel casts in the management of ulcers of the heel in diabetes: a randomised controlled trial

“…With the consequences of unhealed and/or recurrent ulcers leading to further health interventions (including amputation), establishing the cost-effectiveness and clinical effectiveness of new interventions is warranted. Although other health economic analyses have assessed the cost-effectiveness of a range of orthotic devices within the context of patient management strategies, 28,29 the orthotic devices assessed have largely been intended for use as preventative strategies across the spectrum of risk categories for developing an ulcer of the foot, as opposed to being specifically intended for use in the management of an established ulcer of the heel.…”

Diabetic Foot Care - A Public Health Problem

“…Risk factors for amputation include being older, male, or a member of certain racial/ethnic groups, having poor glycemic control, having diabetes for a longer period, and practicing or receiving poor preventive health care. 6 Diabetologists started recognizing diabetic foot problems in UK in 1980 and in other European countries including Holland in 1990. Realizing the importance of diabetic foot problems, International Diabetic Federation also chose the theme of "Put Feet First, Prevent Amputations" of World Diabetes Day in 2005.…”

Economic aspects of diabetic foot care in a multidisciplinary setting: a review

“…Ragnarson-Tennvall and Apelqvist [53] analyzed the cost-effectiveness of 'intensified prevention' among patients with diabetes with different risk for foot ulcers and lower-extremity amputations using Markov model simulations. They specifically addressed whether the additional cost associated with present recommendations for prevention (as defined according to the International Consensus on the Diabetic Foot) would be offset by reduced costs of future foot ulcers and amputations.…”