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Management and Prevention of Diabetic Foot Ulcers and Infections

A Health Economic Review

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Abstract

Diabetic foot ulcers and infections are common and incur substantial economic burden for society, patients and families. We performed a comprehensive review, on a number of databases, of health economic evaluations of a variety of different prevention, diagnostic and treatment strategies in the area of diabetic foot ulcers and infections. We included English-language, peer-reviewed, cost-effectiveness, cost-minimization, cost-utility and cost-benefit studies that evaluated a treatment modality against placebo or comparator (i.e. drug, standard of care), regardless of year. Differences were settled through consensus.

The search resulted in 1885 potential citations, of which 20 studies were retained for analysis (3 cost minimization, 13 cost effectiveness and 4 cost utility). Quality scores of studies ranged from 70.8% (fair) to 87.5% (good); mean = 78.4% ± 5.33%.

In diagnosing osteomyelitis in patients with diabetic foot infection, magnetic resonance imaging (MRI) showed 82% sensitivity and 80% specificity. MRI cost less than 3-phase bone scanning + Indium (In)-111/Gallium (Ga)-67; however, when compared with prolonged antibacterials, MRI cost $US120 (year 1993 value) more without additional quality-adjusted life-expectancy. Prevention strategies improved life expectancy and QALYs and reduced foot ulcer rates and amputations.

Ampicillin/sulbactam and imipenem/cilastatin were both 80% successful in treating diabetic foot infections but the latter cost $US2924 more (year 1994 value). Linezolid cure rates were higher (97.7%) than vancomycin (86.0%) and cost $US873 less (year 2004 value). Ertapenem costs were significantly lower than piperacillin/tazobactam ($US356 vs $US503, respectively; year 2005 values). Becaplermin plus good wound care may be cost effective in specific populations. Bioengineered living-skin equivalents increased ulcer-free months and ulcers healed, but costs varied between countries. Promogran® produced more ulcer-free months than wound care alone (3.75 vs 3.41 months, respectively). Treatment with cadexomer iodine resulted in higher rates of healed ulcer (29% vs 11%) and lower weekly treatment costs (Swedish krona [SEK]903 vs SEK1421; year 1993 values) than standard care. Filgrastim decreased hospital stays, time to resolution and costs (36% lower) compared with usual care. Adjunctive hyperbaric oxygen produced an incremental cost per QALY at year 1 of $US27 310 and $US2255 at year 12 (year 2001 values).

Overall, preventive strategies were shown to be cost effective and potentially cost saving. Various antibacterial regimens are cost effective but empiric choices should be based on local resistance patterns. MRI was cost effective compared with three-phase bone scanning + In-111/Ga-67 but not against prolonged antibacterial therapy. Other innovations (becaplermin, bioengineered living-skin equivalents, filgrastim, cadexomer iodine ointment, hyperbaric oxygen, Promogran®) may be cost effective in this population but more studies are needed to confirm these findings.

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Notes

  1. The use of trade names is for product identification purposes only and does not imply endorsement.

References

  1. Bartus CL, Margolis DJ. Reducing the incidence of foot ulceration and amputation in diabetes. Curr Diab Rep 2004; 4: 413–8

    Article  PubMed  Google Scholar 

  2. Canadian Diabetes Association. The prevalence and costs of diabetes[online]. Available from URL: http://www.diabetes.ca/Section_About/prevalence.asp [Accessed 2007 Nov 9]

  3. Lipsky BA, Berendt AR, Deery HG, et al. Diagnosis and treatment of diabetic foot infections. Clin Infect Dis 2004; 39: 885–910

    Article  PubMed  Google Scholar 

  4. Armstrong DG, Lipsky BA. Advances in the treatment of diabetic foot infections. Diabetes Technol Ther 2004; 6: 167–77

    Article  PubMed  CAS  Google Scholar 

  5. Boulton AJM, Vileikyte L, Ragnarson-Tennvall G, et al. The global burden of diabetic foot infections. Lancet 2005; 366: 1719–24

    Article  PubMed  Google Scholar 

  6. Wu S, Armstrong DG. Risk assessment of the diabetic foot and wound. Int Wound J 2005; 2: 17–24

    Article  PubMed  Google Scholar 

  7. Kantor J, Margolis DJ. Treatment options for diabetic neuropathic foot ulcers: a cost-effectiveness analysis. Dermatol Surg 2001; 27: 347–51

    Article  PubMed  CAS  Google Scholar 

  8. Ragnarson-Tennvall G, Apelqvist J. Health-economic consequences of diabetic foot lesions. Clin Infect Dis 2004; 39: S132–9

    Article  Google Scholar 

  9. Ramsey SD, Newton K, Blough D, et al. Incidence, outcomes, and costs of foot ulcers in patients with diabetes. Diabetes Care 1999; 22: 382–7

    Article  PubMed  CAS  Google Scholar 

  10. Ulbrecht JS, Cavanagh PR, Caputo GM. Foot problems in diabetes: an overview. Clin Infect Dis 2004; 39: S73–82

    Article  Google Scholar 

  11. Apelqvist J, Larson J. What is the most effective way to reduce incidence of amputation in the diabetic foot? Diabetes Metab Res Rev 2000; 16: S75–83

    Article  Google Scholar 

  12. Canadian Diabetes Association. Clinical Practice Guidelines Expert Committee. Canadian Diabetes Association 2003 clinical practice guidelines for the prevention and management of diabetes in Canada. Can J Diabetes 2003; 27: S1–152

    Google Scholar 

  13. Ollendorf DA, Kotsanos JG, Wishner WJ, et al. Potential economic benefits of lower-extremity amputation prevention strategies in diabetes. Diabetes Care 1998; 21: 1240–5

    Article  PubMed  CAS  Google Scholar 

  14. Haynes RB. Of studies, summaries, synopses and systems: the ‘4S’ evolution of services for finding current best evidence. Evid Based Nurs 2005; 8: 4–6

    Article  PubMed  Google Scholar 

  15. Matricali GA, Dereymaeker G, Muls E, et al. Economic aspects of diabetic foot care in a multidisciplinary setting: a review. Diabetes Metabol Res Rev 2007; 23: 339–47

    Article  Google Scholar 

  16. Edmonds M, Gough A, Solovera J, et al. Filgrastim in the treatment of infected diabetic foot ulcers: retrospective cost analysis of a phase II randomised clinical trial. Clin Drug Invest 1999; 17: 275–86

    Article  Google Scholar 

  17. Tice AD, Turpin RS, Hoey C, et al. Comparative costs of ertapenem and piperacillin-tazobactam in the treatment of diabetic foot infections. Am J Health-Syst Pharm 2007; 64: 1080–6

    PubMed  Google Scholar 

  18. Apelqvist J, Ragnarson-Tennvall G. Cavity foot ulcers in diabetic patients: a comparative study of cadexomer iodine ointment and standard treatment. An economic analysis alongside a clinical trial. Acta Derm Venereol 1996; 76: 231–5

    PubMed  CAS  Google Scholar 

  19. Morrison WB, Schweitzer ME, Wapner KL, et al. Osteomyelitis in feet of diabetics: clinical accuracy, surgical utility, and cost-effectiveness of MR imaging. Radiology 1995; 196: 557–64

    PubMed  CAS  Google Scholar 

  20. McCabe CJ, Stevenson RC, Dolan AM. Evaluation of a diabetic foot screening and protection programme. Diabet Med 1998; 15: 80–4

    Article  PubMed  CAS  Google Scholar 

  21. McKinnon PS, Paladino JA, Grayson ML, et al. Cost-effectiveness of ampicillin/sulbactam versus imipenem/cilastatin in the treatment of limb-threatening foot infections in diabetic patients. Clin Infect Dis 1997; 24: 57–63

    Article  PubMed  CAS  Google Scholar 

  22. McKinnon PS, Sorensen SV, Liu LZ, et al. Impact of linezolid on economic outcomes and determinants of costs in a clinical trial evaluating patients with MRSA complicated skin and soft tissue infections. Ann Pharmacother 2006; 40: 1017–23

    Article  PubMed  Google Scholar 

  23. Ghatnekar O, Persson U, Willis M, et al. Cost effectiveness of becaplermin in the treatment of diabetic foot ulcers in four European Countries. Pharmacoeconomics 2001; 19: 767–78

    Article  PubMed  CAS  Google Scholar 

  24. Persson U, Willis M, Odegaard K, et al. The cost-effectiveness of treating diabetic lower extremity ulcers with becaplermin (Regranex): a core model with an application using Swedish cost data. Value Health 2000; 3: S39–46

    Article  PubMed  Google Scholar 

  25. Sibbald RG, Torrance G, Hux M, et al. Cost-effectiveness of becaplermin for non-healing neuropathic diabetic foot ulcer. Ostomy Wound Manage 2003; 49: 76–84

    PubMed  Google Scholar 

  26. Ghatnekar O, Persson U, Willis M, et al. The cost-effectiveness in the UK of treating diabetic lower extremity ulcers with becaplermin gel. J Drug Assess 2000; 3: 243–51

    Google Scholar 

  27. Steinberg J, Beusterien K, Plante K, et al. A cost analysis of a living skin equivalent in the treatment of diabetic foot ulcers. Wounds: A Compendium of Clinical Research and Practice 2002; 14: 142–9

    Google Scholar 

  28. Redekop WK, McDonnell J, Verboom P, et al. The cost effectiveness of Apligraf. Pharmacoeconomics 2003; 21 (16): 1171–83

    Article  PubMed  Google Scholar 

  29. Allenet B, Paree F, Lebrun T, et al. Cost-effectiveness modeling of Dermagraft® for the treatment of diabetic foot ulcers in the French context. Diabetes Metab 2000; 26: 125–32

    PubMed  CAS  Google Scholar 

  30. Ghatnekar O, Willis M, Persson U. Cost-effectiveness of treating deep diabetic foot ulcers with Promogran in four European countries. J Wound Care 2002; 11: 70–4

    PubMed  CAS  Google Scholar 

  31. Eckman MH, Greenfield S, Mackey WC, et al. Foot infections in diabetic patients: decision and cost-effectiveness analyses. JAMA 1995; 273: 712–20

    Article  PubMed  CAS  Google Scholar 

  32. Ortegon MM, Redekop WK, Niessen LW. Cost-effectiveness of prevention and treatment of the diabetic foot. Diabetes Care 2004; 27: 901–7

    Article  PubMed  Google Scholar 

  33. Ragnarson-Tennvall G, Apelqvist J. Prevention of diabetes-related foot ulcers and amputations: a cost-utility analysis based on Markov model simulations. Diabetologia 2001; 44: 2077–87

    Article  PubMed  CAS  Google Scholar 

  34. Guo S, Counte MA, Gillespie KN, et al. Cost-effectiveness of adjunctive hyperbaric oxygen in the treatment of diabetic ulcers. Intl J Technol Assess Health Care 2003; 19: 731–7

    Google Scholar 

  35. Iskedjian M, Trakas K, Bradley CA, et al. Quality assessment of economic evaluations published in PharmacoEconomics: the first four years (1992. Pharmacoeconomics 1997; 12 (6): 685–94

    Article  PubMed  CAS  Google Scholar 

  36. Redekop WK, Stolk EA, Kok E, et al. Diabetic foot ulcers and amputations: estimates of health utility for use in cost-effectiveness analyses of new treatments. Diabetes Metab 2004; 30: 549–56

    Article  PubMed  CAS  Google Scholar 

  37. Lipsky BA, Armstrong DG, Citron DM, et al. Ertapenem versus piperacillin/tazobactam for diabetic foot infections (SIDESTEP): prospective, randomised, controlled, double-blinded, multicentre trial. Lancet 2005; 366: 1695–703

    Article  PubMed  CAS  Google Scholar 

  38. Veves A, Falanga V, Armstrong DG, et al. Graftskin, a human skin equivalent, is effective in the management of noninfected neuropathic diabetic foot ulcers: a prospective randomized multicenter clinical trial. Diabetes Care 2001; 24: 290–5

    Article  PubMed  CAS  Google Scholar 

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Acknowledgements

T. Einarson has acted as a consultant for generic and brand name companies and Government agencies. The other authors have no conflicts of interest that are directly relevant to the content of this review.

No sources of funding were used to assist in the preparation of this review.

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Authors and Affiliations

  1. Leslie Dan Faculty of Pharmacy, University of Toronto, 144 College Street, Toronto, Ontario, M5S 3M2, Canada

    Ivy Chow &  Thomas R. Einarson

  2. Universidad Nacional de Colombia, Bogotá DC, Colombia

    Elkin V. Lemos

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  1. Ivy Chow
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Correspondence to Thomas R. Einarson.

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Chow, I., Lemos, E.V. & Einarson, T.R. Management and Prevention of Diabetic Foot Ulcers and Infections. Pharmacoeconomics 26, 1019–1035 (2008). https://doi.org/10.2165/0019053-200826120-00005

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