Economic Burden of Diabetic Foot

Dr Sanjeev KelkarHead, Project Management GroupSecretary DFSI October 2007MSD Training Program

Information of this presentation courtesy Dr Anil Kapur of WDF Denmark

Economic Burden of Diabetic Foot

Even those patients with diabetes having ready access to health care and are provided with education on foot care, 9% develop foot infections in a two year follow up,

(Lavery LA, et al, Risk factors for foot infections in persons with diabetes mellitus, Diabetes Care, 2006,; 29:1288-93)

This is an English study

Temporal Prevalence in Urban South India

5.0

8.2

11.6

14.2

R2 = 0.9971

0

2

4

6

8

10

12

14

16

18

20

1988 1992 1996 2000

Kudremukh

Chennai

Chennai

ChennaiBangaloreHyderabad

Ramachandran A et al

Diabetes Mellitus- Genetics

Risk of Diabetes

- F/H/O Diabetes- One parent diabetic- One parent diabetic and

other from a diabetic family

Family History

20 %40 %

70 %

V Mohan & KGMM AlbertiV Mohan & KGMM AlbertiInternational Textbook of Diabetes Mellitus,1992,178.International Textbook of Diabetes Mellitus,1992,178.

• Family history significant predictor of Diabetes

Presenting SymptomsSymptoms All Type 1 Type 2Tiredness / Fatigue 50.7% 46.5% 51.0% Excess Urination 43.3% 59.2% 42.4% Excess Thirst/Hunger 38.2 % 52.1% 37.4% Weight Loss 19.7% 34.4% 18.9% Nausea/ Abdom. Pain 18.0% 17.8% 16.5% Non Healing Wound 7.4% 7.4% 7.4% Others 2.1% 2.1% 2.1%

Skin Infection 1.9% 3.2% 1.8% Heart Problems 1.3% 0.7% 1.3% Loss of Sensation 0.4% 0.4% 0.4%

CODI Study

Test All Type 1 Type 2Urine 93.8% 97.9% 93.6%FBS 91.8% 94.7% 91.6%PPBS 93.2% 96.1% 93.0%OGTT 17.9% 19.1% 17.8%GHb 7.6% 18.4% 7.0%Serum Lipids 7.4% 9.9% 7.3%Kidney Function 11.1% 17.4% 10.8%X-rays 16.8% 24.5% 16.4%ECG 25.5% 38.3% 24.8%Others 3.3% 4.3% 3.3%BP Measurement 54.3% 51.8% 54.4%Foot Examination 7.5% 11.7% 7.2%Eye Examination 35.1% 37.6% 35.0%

Lab Tests / Clinical Examination Since Diagnosis

CODI Study

Late Complications

39%31%

7% 3% 1%

Types of Complications

Foot Eye MI Stroke ESRD

Number of Complications

46%

30%

10%

14%

Nil One Two Three+

Does Not Include •Hypertension (27%)•Proteinuria (8%)•Elevated Creatinine (4%) •Lipid Abnormalities (54%)

CODE 2: Effect of complications on per patient costs

0

1

2

3

4C

ost i

mpa

ct fa

ctor

None Microvascular Macrovascular Both

Without complications With complications

1.7 X 2.0 X

3.5 X

Lucioni C et al. PharmacoEconomics- Italian Research Articles, 2000 2(1):1-21

None Microvascular Macrovascular Both

Effect Of Patient Education On Amputation Rates

Knee & Above

12%

15%

5%

46%

35%

60%

Toe & Metatarsal

Below KneeNo Education

Education

University Hospital of Geneva 1979-1989. All comparisons p<0.001. Assal JP et al. Diabete Metab 1993.

CODI Study / AKap/ NNEF ORG Centre for Social Research

Hospitalization Rate Complication Specific

34.5%

3.1%10.1%

22.6%17.6%

5.8% 4.1%

27.1% 26.7%

Hear

t

Neur

o

Eye

NHW

Kidn

ey

HBP

Skin TB

Para

lysi

s

CODI Study / AKap/ NNEF ORG Centre for Social Research

Total Mean Duration of HospitalizationCause Specific

14.78.2

14.5

13.9

32.5

9.411.1

21.525.7

6.7

16.013.2

0102030405060

Hear

t

Neur

o

Eye

NHW

Kidn

ey

HBP

Skin TB

Para

lysi

s

Hype

r

Hypo

Oth

er

Days

CODI Study / AKap/ NNEF ORG Centre for Social Research

Total Mean Hospitalization Cost Cause Specific

11.2

7.7

19.6

7.65.9

11.27.1

13.9

27.5

0

20

40

60

80

100

Hear

t

Neur

o

Eye

NHW

HBP

Skin

Hype

r

Hypo

Oth

er

Mea

n Co

st in

INR

('000

)

CODI Study / AKap/ NNEF ORG Centre for Social Research

Productivity LossProblems at Work

Working 3059 55.5%Problems at Work 1008 33.0%

Income Loss due to leave 1008 100.0%Gave up Business 4 0.1%

Reduced Working Hours 820 81.3%Voluntary Retirement 14 1.7%

Leave in Last Month 354 11.6%Feeling Uneasy 211 59.6%

Tiredness 12 3.4%Visit Doctor 70 19.8%Hospitalized 13 3.7%

No Reason Given 8 2.3%Missing Information 50 14.1%

Classification of Diabetic foot Wounds

Several available – none universally acceptable

Wagner – Meggitt six grade classification by depth of the ulcer and extent of

gangrene The University of Texas Classification

grades wounds by the ulcer depth and then stages by presence of infection and ischemia

Classification of Diabetic foot Wounds

S(AD) grades wound in five categories depending upon the size which includes area and depth, in addition to the presence of sepsis, arteriopathy, and denervation

PEDIS by the International working group on the Diabetic Foot – grading on

Perfusion, Extent, Depth, Infection and Sensation

Classification of Diabetic foot Wounds

The Infectious Diseases Society of America Subdivides infected diabetic foot wounds

in mild ie restricted involvement of skin and subcutaneous tissue

moderate ie, more extensive or affecting deeper tissues

severe ie,accompanied by systemic signs of infection or metabolic instability

Classification of Diabetic foot Wounds

Mike Edmonds – Ali Foster Normal Foot High risk foot Ulcerated foot Infected foot Ischemic foot Gangrenous foot

Classification of Diabetic foot Wounds

The purpose is as for all classifications To be able to describe as closely as

possible, to analyse such hopefully accurate descriptions of wounds in comparing results

Overlaps notwithstanding comparisons across studies may be difficult