foot care in diabetes: the economic case for change marion ......step 2: quality of current care...

Foot Care in Diabetes:

The Economic Case for Change

Marion Kerr

6th March 2012

© Insight Health Economics

The Economic Case for Change:

Key steps

Step 1: Scale of the Problem

Step 2: Quality of current care

Step 3: Estimates of how much foot care in

diabetes currently costs the NHS

Step 4: Clinical evidence on potential for better outcomes

Step 5: Estimates of the impact of improved care on quality

of life and NHS costs

Scale of the problem

• We estimate that at least 61,000 people with

diabetes in England have foot ulcers at any

given time

• Only ⅔ heal without surgery

• There are around 6,000 lower extremity

amputations a year in people with diabetes

• The risk of a lower extremity amputation in a

person with diabetes is 23 x that of a person

without diabetes

© Insight Health Economics

Scale of the problem

• As diabetes prevalence increases, the number of

amputations in diabetes is rising too. Source: Vamos et al. 2010

Impact of foot ulcers on quality of life

Health related quality of life (SF-6D) scores for people with diabetic foot ulcers and

other long-term conditions, and for healthy people aged 75+ (Source: Jeffcoate et al.

(2009), Brazier et al. (2004), Davison et al.(2009))

• Diabetic foot ulcer QOL rated lower than osteoarthritis, COPD, dialysis

• SF-6D or EQ-5D are building blocks for QALY estimation

Quality of life comparison:

ulcers and amputations

EQ-5D scores for patients with foot ulcers and amputation (Source:

Ragnarson Tennvall et al. (2000))

• Important in health economic analysis to compare scores obtained using a

single measurement instrument

• To convert any of these scores into QALYs also need to take into account life

expectancy effects

Survival after diabetic foot ulcers

• Liverpool foot clinic study suggests 5 year survival rate of 56%

• Illustrative relative survival estimate produced by adjusting Liverpool survival figure for expected survival in the general population aged 70-74

• However, important to note that foot ulcers are associated with high mortality, but deaths are not necessarily attributable to ulceration.

Five year relative survival rates for the four most common cancers (Source: ONS) and estimated five year relative survival rate for diabetic foot ulcer (Estimate derived from: Moulik et al. (2003))

0

10

20

30

40

50

60

70

80

90

Breast

Cancer

Prostate

Cancer

Colon

Cancer

Lung

Cancer

Diabetic

Foot

Ulcer

Rela

tive

5 ye

ar s

urvi

val (

%)


Key steps








Quality of Current Care

QOF data indicate that around 85% of people with diabetes receive a foot check every 15 months

However, there is no correlation between foot review and amputation incidence at PCT level

It is not known what percentage of patients receive appropriate follow-on care


• The total lower extremity amputation rate varies 8-fold

across PCTs, from 6.4 to 52.5 per 10,000 person

years Amputations per 10,000 people with diabetes, 2008-2011, by

PCT (Source: YHPHO)


• There are no national data on service provision, quality of care or outcomes for most of the foot care pathway

• In the 2009 Diabetes UK patient survey – 26% of patients said they would like more access to a

foot specialist

– 14% identified faster access to foot screening as the thing that would most improve the quality of their care


The Diabetes Inpatient Audit 2010 provides a fuller picture of acute care:

– Almost ¾ of inpatients with diabetes had no foot exam during their hospital stay

– 9.4% had a foot complication when admitted

– 2.2% developed a foot complication during their stay

– One fifth of sites did not have a multi-disciplinary foot team


Key steps








NHS Expenditure – Ulceration and Amputation in Diabetes

• In 2010-11 the NHS spent an estimated £639 million to

£662 million a year on diabetic foot care

• Equivalent to £1 in in every £150 of total NHS spending

Primary, Community,

Outpatient Care and A & E £307m. - £324m.

Inpatient Care - Ulceration

£213m.

Amputation £119m. - £125m.

NHS Expenditure –

Ulceration and Amputation in Diabetes

Lower

estimate

Upper

estimate

Primary, community and outpatient

care £306,508,970 £323,062,601

Accident and emergency £849,278

Inpatient care – ulceration £213,151,916 £213,151,916

Inpatient care – amputation £43,546,901 £48,896,735

Post-amputation care £75,807,423 £75,807,423

Total £639,015,210 £661,767,953

NHS Expenditure – Primary, Community and

Outpatient Care

• Activity estimated using RCT for less severe ulcers, local

data for more severe ulcers

• Less severe ulcers estimated at 60%, more severe at

40%

• Second approach using NHS Diabetes/Diabetes UK

patient survey on resource use

• Weekly costs estimated from BNF, PSSRU, PbR tariffs,

studies, local data

• Scottish data show 2.5% of diabetes population had

ulceration in December 2010

• This multiple applied to diabetes population of England =

61,000

NHS Expenditure – Inpatient Care and

Post-Amputation Care

• Inpatient admissions identified in HES 2010-11 using

ICD 10 and OPCS 4 codes for diabetes, foot ulceration,

non-traumatic lower limb amputation

• For all amputation admissions and ulcer admissions in

foot care HRGs, entire cost of admission attributed,

using PbR tariffs

• For admissions in non-footcare HRGs, regression

analysis to estimate impact of ulceration on LOS (12.7

days) – excess bed days attributed

• Post-Amputation costs estimated using study and local

data


Key steps








Clinical evidence on potential for better outcomes

• Clinical evidence suggests that:

– Diagnostic tests and risk stratification can predict the

risk of diabetic foot ulceration and amputation

– Early referral to specialist care reduces amputation rates and times to healing

– Multidisciplinary teams (inpatient and community-based/outpatient) can reduce amputation rates

– Cardiovascular screening and interventions for patients with ulcers can reduce mortality


Key steps








Southampton University

Hospitals NHS Trust

• MDT - primary and secondary care

– Telephone advice and emergency access line

for patients and clinical staff

– weekly podiatry clinics at eight primary care

locations

– outpatient clinics in secondary care

– multi-disciplinary inpatient care

Estimates of the impact of

improved care on quality of life

and NHS costs

James Cook Hospital,

Middlesbrough

• MDT - secondary care with strong links to

community podiatry services

– Weekly 4-hour consultant-led clinic with a

DSN and 2 podiatrists

– Care pathways and protocols for

management of ulcers established

– Educational events organised

The potential for net savings and benefits will vary according to local

costs and baseline standards of care

Conclusions

• £1 in every £150 the NHS spends is for diabetic foot

problems

• MDTs with strong community links can deliver improved

patient outcomes and savings which exceed the cost of

the team

• No savings were estimated for reductions in ulcer

duration as data were not available

• The potential for net savings and benefits will vary

according to local costs and baseline standards of care

• Unless there is a significant increase in the quality and

efficiency of diabetes foot care, the cost of diabetic foot

care is likely to rise substantially in the coming years

foot care in diabetes: the economic case for change marion ......step 2: quality of current care...

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