Economic Considerations of Amputation Prevention

Transcription

1 Economic Considerations of Amputation Prevention Adam Landsman, DPM, PhD Assistant Professor of Surgery Harvard Medical School Chief, Division of Podiatric Surgery Cambridge Health Alliance Cambridge, MA

2 Disclosures Speaker s Bureau: Soluble Systems Medline Valeant Anacor Stockholder: None Grant/Research Support: None Honorarium: None Medical/Scientific Boards: Lifenet Health Consultant: Soluble Systems

3 Obamacare... Doing more with less Universal coverage Accountable care medicine Cost matters Outcomes matter Medicine has to become insurance blind

4 Treating wounds is expensive. Pay more attention to... Progression of healing Earlier detection of problems Aggressive correction of shortcomings

5 Sheehan Study Results of the study, which included 203 patients: Message: If you are not seeing progress, you need to change your treatment plan! Sheehan et al. Diabetes Care. 2003;26:

6 Thinking about chronic diabetic wounds years ago, our first line of therapy for chronic diabetic foot ulcers was amputation Today, we use a Step-wise approach to healing

7 Wound Assessment Location Forefoot Dorsal/Plantar Hindfoot Circulation Infection Bacterial load Necrosis

8 Wound Assessment Moisture Balance Inflammation Mechanical pressure Collagen and Growth Factors Glycemic Control Nutritional Status Compliance

9 All of these things have to be optimal, in order to get a wound to heal.

10 This philosophy led us to advanced biologics When we don t know what to do to get a wound to heal, we throw everything at it INCLUDING the kitchen sink! More tools to get wounds closed.

11 What ARE the economic considerations? Lost work days Office visits Cost of materials Advanced biologics Wound dressings Psycologic/Emotional Surgical Expenses Travel Amputation Home Health & Rehab Hospitalization Prosthetics Preventive Medicine BS control Custom insoles Shoes Insurance Costs Out-of-Pocket Costs Medications Infections Emergency Room Visits Extended Care

12 Perspectives... Economic considerations for Insurance Carrier Government Physician Hospital PATIENT

13 Economic Facts US CDC (2007) 24Million Diabetics $174B for tx of DM and complications $116B direct costs $58.3B indirect costs PVD Complications = 31% ($53.9B) Neuro Complications = 24% ($41.8B)

14 Admission for Amputations 80,000 70,000 60,000 50,000 40,000 30,000 20,000 10, Hospitalizations 2005 Hospitalizations

15 Hospital Admission for Amputation 40 Series Days 2005 Days

16 Cost per Ulcer (2001) Stockl 2004 $45,000 $40,000 $35,000 $30,000 $25,000 $20,000 $15,000 No PVD With PVD $10,000 $5,000 $0 Wagner 1 Wagner 2 Wagner 3 Wagner 4/5

17 Cost of Amputations $50,000 $45,000 $40,000 $35,000 $30,000 $25,000 $20,000 Holzer, 1998 Apelqvist, 1994 $15,000 $10,000 $5,000 $0 Primary Wound Healing Amputation

18 How do we prevent Amputations? Markov Model Projects cost and effect of intervention Allows for recurrence of ulcerations Ollendorf, et al (1998) Prevention and management of DFU s reduce amputations by 50% overall Each component tied to reduction in amputations. Cost benefits of prevention... Save $2900-$4442 per patient, per year

19 Reduction in costs with prevention 80% Series 1 70% 60% 50% 40% 30% 20% 10% 0% Educational Intervention Multidisciplinary Team Therapeutic Footware

20 Clearly, amputations cost lots of $$$ But what about the cost of avoiding an amputation?? When do we say, enough is enough??

21 What is the cost of DFU tx? Rice, et al (2014) Diabetes Care Matched Diabetics w/ and w/o DFU s to compare cost of treatment This represents an added annual cost of treatment of approximately $8900 $18,000 $16,000 $14,000 $12,000 $10,000 $8,000 $6,000 $4,000 $2,000 $0 NO DFU W/ DFU

22 What costs so much?? Only 1.3% with ulcers received biologic skin substitutes 1.8% received HBO BUT % more days of hospitalization 85% more home health days 41% more ED visits 35% more outpatient physician visits 3.8% of these patients ended up with an amputation

23 Is BKA a cost effective option? Amputations cost approximately $45K including prosthesis and rehab. Management of a DFU costs $8900 annually. 5 years of DFU treatment = 1 BKA 3.8% of patients treated for DFU go on to have BKA

24 The most cost-effective treatment is PREVENTION Education Multi-disciplinary Team Approach Protective shoe gear

25 Quality of Life People with diabetic foot ulcer have tremendous limitations on their lives Bathing is problematic Traveling is problematic Chronic odor Chronic infection Biggest barrier to amputation for many patients is their doctor s hesitancy!

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28 Closing Remarks / Thank You alandsman@cha.harvard.edu