Slide 1

Diabetic Neuropathy
in the workforce
and cost
Panagiotis V. Tsaklis, PhD
Associate Professor
School of Health Professions
“Alexander” TEI Thessaloniki
Sen. Researcher
Dept Public Health Sciences
Occupational & Environmental Medicine
Karolinska Institutet

mellitus…


The global prevalence of diabetes is
predicted to double by the year 2030 from
2.8% to 4.4%.



…Of individuals with diabetes, a substantial
number will develop lower extremity disease
including peripheral neuropathy, foot ulcers
and peripheral arterial disease…

Does it cost much??


In 2007, the estimated national cost in US of diabetes
exceeded $174 billion…


This estimate included $116 billion in diabetesrelated medical costs and $58 billion in reduced
productivity ….due to increased work absenteeism,
reduced work and daily productivity, unemployment
from disease-related disability, and early death..



Polyneuropathy is one of the commonest complications of the
diabetes and the commonest form of neuropathy in the
developed World. Diabetic polyneuropathy encompasses
several neuropathic syndromes the commonest of which is
distal symmetrical neuropathy, the main initiating factor for foot
ulceration. The epidemiology of diabetic neuropathy has
recently been reviewed in reasonable detail

…from the 1999-2000 population-based US Health and Nutrition
Survey (NHANES), The prevalence (history) of peripheral
neuropathy (> 1 insensate area) in people with diabetes was
28.5%...


The EURODIAB Prospective Complications Study which
involved the examination of 3250 type 1 patients, from 16
European countries, found a prevalence rate of 28% for distal
symmetrical neuropathy

…painful diabetic
peripheral neuropathy (pDPN) is associated with
worse health outcomes…
…however, among pDPN patients, few studies have
examined the relationship between the severity of
pain and health outcomes……

Lost Productive Time (LPT) and diabetes neuropathy…
…studies suggest that individuals
40 to 65 years old in the US workforce, with diabetes and neuropathic
symptoms experience excess health-related LPT compared with that of
others with and without diabetes

…The mean hours of LPT per week was substantially higher in the
diabetes patients with neuropathic symptoms
compared with in the others 4.21 hrs vs 1.90 hrs…(diabetic &
controls)
…more individuals who had diabetes with neuropathic symptoms
reported moderate to severe impact on work ability (ie, score 5 on a
scale from 0–10 compared with those without neuropathic
symptoms
(where 0 means “it has no effect on my ability to work” and 10 means “I am no longer able
to work”)

Cost of Lost Productive Time…$ $ $ $ $...:
In the US Workforce gives a equivalent of $3.65 billion
per year in health-related LPT, a cost per worker that is more
than 2.5 times higher than workers with diabetes without neuropathic
Symptoms…

In conclusion,…The severity might
lead to decreased health status,

•It is observed a prevalence of moderate-to-severe pain among pDPN
patients
•also indicate that health outcomes are significantly worse as pain severity
increases.
•Specifically, work impairment, health care resource use, and the associated
indirect and direct costs increase significantly as the level of pain severity
increases.
•These data emphasize the need
for effectively managing pain in patients with pDPN.

Peripheral (symmetrical) Neuropathy
(Sensory-Motor Neuropathy) which leads to……
Complications
Intrinsic muscles atrophy
→ foot deformities
Reflex reduction
→ Gait alteration…
Calluses & Ulcers occurrence
Amputations…

Aggravating Factors…
Peripheral Vascular Disease

Joint Mobility Reduction
Foot Structural deformities

Foot soft tissues lesions
Autonomous Neuropathy ???
Vassel-Kinetic Neuropathy (VASOMOTOR)
Sweat -Kinetic Neuropathy (SUDOMOTOR)

“autosympathectomy.”

Diabetic foot……The majority of lower extremity disease in people with diabetes is
treated in outpatient, clinic or office settings

Focus on Foot Ulcers

Foot ulcers are defined as a cutaneous erosion
extending through the dermis to deeper tissue, result
from various etiologic factors and are characterized
by an inability to self-repair in a timely and orderly
manner

Frequency of Lower Extremity Conditions in the U.S. Population with
Diabetes per 1,000.
Hospital Discharge Data for Ulcer/inflammation/infection (Ulcer),
Peripheral Neuropathy, and Peripheral Arterial Disease (PAD), 19932002

Age-adjusted Hospital Discharge Rates for Lower Extremity Disease
in the U.S. Population with Diabetes per 1,000.
Ulcer/inflammation/infection (Ulcer), Peripheral Neuropathy, and
Peripheral Arterial Disease (PAD), 1993-2002

R
a
t
e
/
1
,
0
0
0

Population-Based Diabetic Foot Ulcer Incidence and Prevalence
from Selected Studies…
First Author/
Reference

Foot Ulcer
Foot Ulcer

Population Studied

Annual
Prevalence /100
Incidence /100

Abbott (16)

Borssen (32)

Kumar (12)
Lavery (33)

Malgrane (34)
MMWR (35)
Moss (23)

Ramsey (28)
Walters (14)

Cohort of 6,613 patients in six district
clinics in NW England followed for 2
yrs, Type 1, 2 diabetes
375 patients Umea County Sweden, Age
15-50,
Type 1 = 298, Type 2 = 77
Cross-sectional study of 811 Type 2
patients from three UK cities
Cohort of 1,666 patients, San Antonio,
Texas, 51% Mexican Americans,
followed for 2 yrs
664 patients from 16 French diabetes
centers
2000-2002 BRFSS US survey of adults
> 18 yrs
Cohort of 2,990 patients with late and
early-onset diabetes
Nested case-control study in HMO,
8,905 Type 1, Type 2
Cross-sectional study of 1,077 Type 1, 2
patients in 10 UK general medicine
practices

2.2

4.7

2.0

10.0 IDDM
9.0 NIDDM

1.0

5.3

3.4

—

—

15.8%

—

11.8%

2.4 younger

9.5 younger

2.6 older

10.5 older

1.9
4.1

7.4

Frequency of U.S. Hospitalization for Ulcer-Related Conditions
in Individuals with Diabetes by Diagnosis, 2001-2002
Type of ulcer

ICD-CM
Codes

Estimated
Frequency
2001

Estimated
Frequency
2002

Cellulitis, abscess, or infected ulcer
Other cellulitis and abscess, foot except toes

681.1
682.7

26,685
81,367

29,347
83,954

Ulcer of lower limbs, except decubitus
Osteomyelitis

707.1
730.07

209,088
60,989

216,785
66,591

129,466

134,274

83,546

78,983

730.17
730.27
730.37
730.87
730.97

Chronic nonhealing ulcers

707.0
707.9

Atherosclerosis of lower limb with ulcer

440.23

Or gangrene

440.24

Ulcers Health Care Costs…



Optimally, the estimation of diabetic foot ulcer costs
spans an entire ulcer episode from lesion onset to
final resolution.



Two studies provided direct costs associated with the
entire diabetic foot ulcer history. This methodology
captures the many inpatient and outpatient
costs/charges associated with foot ulcers and is
preferable to reporting only charge for a single
hospitalization or limited time interval

Direct Cost for Foot Ulcers in Persons with Diabetes From Two
Studies
Author

# Patients/

Outcome

Average
Episode Cost
(US $)

Inpatient
Cost %

Outpatient
Cost %

Primary healing =
63%

$6,664

61

39

18

82

Study Type

Apelqvist Prospective
(27)
314 General
Internal
Medicine
Patients
Ramsey
(28)

Healed after
amputation = 24%

Nested casePrimary healing =
control study
84%
in HMO of
Amputation =
8,905 Type 1,2
16%

$44,790

$27,987

Total
Attributable
cost

Ulcer Reimbursement to Hospitals for Patients with and
without Diabetes, 2002
Medstat (Private)1
Source:

Length of Stay

Average $
Reimbursement

Length of Stay

Average $
Reimbursement

18

Peripheral Neuropathy with
complications

5.6

9,036

5.5

4,782

19

Peripheral Neuropathy
without complications

4.8

6,061

3.6

3,034

277

Cellulitis > age 17 with
complications

4.8

6,823

5.7

4,000

278

Cellulitis > age 17 without
complications

3.4

4,426

4.2

2,192

271

Skin Ulcers

11.0

11,638

7.3

5,227

238

Osteomyelitis

5.9

9,913

8.7

7,376

130

Peripheral Arterial Disease
with complications

5.1

7,743

5.6

4,554

131

Peripheral Arterial Disease
without complications

4.3

5,768

4.1

2,375

1Medstat

Group,
Thompson
DRG
Corporati
on, 2005
2Centers

for
Medicare
and
Medicaid
Services,
2005

Key:
DRG =
Diagnostic
Related
Group

Medicare2

Condition

In conclusion….


The average private hospital reimbursement for a
foot ulcer for 11 days is about $11,638 while
Medicare reimbursement for foot ulcer conditions is
usually for 7.3 days and $5,227.



The direct economic cost attributable to foot ulcers
from onset for two years approaches $28,000.



Guideline-based care is needed to improve outcomes
and provide cost savings compared with standard
care

Final conclusions and suggestions!!!










Diabetes has pervasive emotional and physical effects on patients lives.
Additionally, physical and psychological barriers, time and monetary
limitations, and a lack of social support complicates disease management
People, especially those with little education, may not understand the
progressive nature of diabetes. However, using diabetes complications as
a scare tactic may only exacerbate feelings of helplessness if patients view
future complications as inevitable
Documented workplace discrimination allegations indicate that people with
diabetes are more likely to experience prejudice, which can affect job
retention. This in turn may affect access to health insurance and health
maintenance
balancing familial and work responsibilities may complicate diabetes
management because of feelings of obligation. Working patients need
flexible supports that facilitate program participation such as longer clinic
hours, child care services, time management training, and flexible work
schedules that accommodate doctor visits and exercise
Finally, diabetes supports should address the whole person — physically,
psychologically, and socially. Future interventions for working people with
diabetes should include coordinated programs that involve social,
emotional, and lifestyle supports to help keep people healthy so that they
can work well

Thank U
4 your
@Ntion !!

Pts


Slide 2

Diabetic Neuropathy
in the workforce
and cost
Panagiotis V. Tsaklis, PhD
Associate Professor
School of Health Professions
“Alexander” TEI Thessaloniki
Sen. Researcher
Dept Public Health Sciences
Occupational & Environmental Medicine
Karolinska Institutet

mellitus…


The global prevalence of diabetes is
predicted to double by the year 2030 from
2.8% to 4.4%.



…Of individuals with diabetes, a substantial
number will develop lower extremity disease
including peripheral neuropathy, foot ulcers
and peripheral arterial disease…

Does it cost much??


In 2007, the estimated national cost in US of diabetes
exceeded $174 billion…


This estimate included $116 billion in diabetesrelated medical costs and $58 billion in reduced
productivity ….due to increased work absenteeism,
reduced work and daily productivity, unemployment
from disease-related disability, and early death..



Polyneuropathy is one of the commonest complications of the
diabetes and the commonest form of neuropathy in the
developed World. Diabetic polyneuropathy encompasses
several neuropathic syndromes the commonest of which is
distal symmetrical neuropathy, the main initiating factor for foot
ulceration. The epidemiology of diabetic neuropathy has
recently been reviewed in reasonable detail

…from the 1999-2000 population-based US Health and Nutrition
Survey (NHANES), The prevalence (history) of peripheral
neuropathy (> 1 insensate area) in people with diabetes was
28.5%...


The EURODIAB Prospective Complications Study which
involved the examination of 3250 type 1 patients, from 16
European countries, found a prevalence rate of 28% for distal
symmetrical neuropathy

…painful diabetic
peripheral neuropathy (pDPN) is associated with
worse health outcomes…
…however, among pDPN patients, few studies have
examined the relationship between the severity of
pain and health outcomes……

Lost Productive Time (LPT) and diabetes neuropathy…
…studies suggest that individuals
40 to 65 years old in the US workforce, with diabetes and neuropathic
symptoms experience excess health-related LPT compared with that of
others with and without diabetes

…The mean hours of LPT per week was substantially higher in the
diabetes patients with neuropathic symptoms
compared with in the others 4.21 hrs vs 1.90 hrs…(diabetic &
controls)
…more individuals who had diabetes with neuropathic symptoms
reported moderate to severe impact on work ability (ie, score 5 on a
scale from 0–10 compared with those without neuropathic
symptoms
(where 0 means “it has no effect on my ability to work” and 10 means “I am no longer able
to work”)

Cost of Lost Productive Time…$ $ $ $ $...:
In the US Workforce gives a equivalent of $3.65 billion
per year in health-related LPT, a cost per worker that is more
than 2.5 times higher than workers with diabetes without neuropathic
Symptoms…

In conclusion,…The severity might
lead to decreased health status,

•It is observed a prevalence of moderate-to-severe pain among pDPN
patients
•also indicate that health outcomes are significantly worse as pain severity
increases.
•Specifically, work impairment, health care resource use, and the associated
indirect and direct costs increase significantly as the level of pain severity
increases.
•These data emphasize the need
for effectively managing pain in patients with pDPN.

Peripheral (symmetrical) Neuropathy
(Sensory-Motor Neuropathy) which leads to……
Complications
Intrinsic muscles atrophy
→ foot deformities
Reflex reduction
→ Gait alteration…
Calluses & Ulcers occurrence
Amputations…

Aggravating Factors…
Peripheral Vascular Disease

Joint Mobility Reduction
Foot Structural deformities

Foot soft tissues lesions
Autonomous Neuropathy ???
Vassel-Kinetic Neuropathy (VASOMOTOR)
Sweat -Kinetic Neuropathy (SUDOMOTOR)

“autosympathectomy.”

Diabetic foot……The majority of lower extremity disease in people with diabetes is
treated in outpatient, clinic or office settings

Focus on Foot Ulcers

Foot ulcers are defined as a cutaneous erosion
extending through the dermis to deeper tissue, result
from various etiologic factors and are characterized
by an inability to self-repair in a timely and orderly
manner

Frequency of Lower Extremity Conditions in the U.S. Population with
Diabetes per 1,000.
Hospital Discharge Data for Ulcer/inflammation/infection (Ulcer),
Peripheral Neuropathy, and Peripheral Arterial Disease (PAD), 19932002

Age-adjusted Hospital Discharge Rates for Lower Extremity Disease
in the U.S. Population with Diabetes per 1,000.
Ulcer/inflammation/infection (Ulcer), Peripheral Neuropathy, and
Peripheral Arterial Disease (PAD), 1993-2002

R
a
t
e
/
1
,
0
0
0

Population-Based Diabetic Foot Ulcer Incidence and Prevalence
from Selected Studies…
First Author/
Reference

Foot Ulcer
Foot Ulcer

Population Studied

Annual
Prevalence /100
Incidence /100

Abbott (16)

Borssen (32)

Kumar (12)
Lavery (33)

Malgrane (34)
MMWR (35)
Moss (23)

Ramsey (28)
Walters (14)

Cohort of 6,613 patients in six district
clinics in NW England followed for 2
yrs, Type 1, 2 diabetes
375 patients Umea County Sweden, Age
15-50,
Type 1 = 298, Type 2 = 77
Cross-sectional study of 811 Type 2
patients from three UK cities
Cohort of 1,666 patients, San Antonio,
Texas, 51% Mexican Americans,
followed for 2 yrs
664 patients from 16 French diabetes
centers
2000-2002 BRFSS US survey of adults
> 18 yrs
Cohort of 2,990 patients with late and
early-onset diabetes
Nested case-control study in HMO,
8,905 Type 1, Type 2
Cross-sectional study of 1,077 Type 1, 2
patients in 10 UK general medicine
practices

2.2

4.7

2.0

10.0 IDDM
9.0 NIDDM

1.0

5.3

3.4

—

—

15.8%

—

11.8%

2.4 younger

9.5 younger

2.6 older

10.5 older

1.9
4.1

7.4

Frequency of U.S. Hospitalization for Ulcer-Related Conditions
in Individuals with Diabetes by Diagnosis, 2001-2002
Type of ulcer

ICD-CM
Codes

Estimated
Frequency
2001

Estimated
Frequency
2002

Cellulitis, abscess, or infected ulcer
Other cellulitis and abscess, foot except toes

681.1
682.7

26,685
81,367

29,347
83,954

Ulcer of lower limbs, except decubitus
Osteomyelitis

707.1
730.07

209,088
60,989

216,785
66,591

129,466

134,274

83,546

78,983

730.17
730.27
730.37
730.87
730.97

Chronic nonhealing ulcers

707.0
707.9

Atherosclerosis of lower limb with ulcer

440.23

Or gangrene

440.24

Ulcers Health Care Costs…



Optimally, the estimation of diabetic foot ulcer costs
spans an entire ulcer episode from lesion onset to
final resolution.



Two studies provided direct costs associated with the
entire diabetic foot ulcer history. This methodology
captures the many inpatient and outpatient
costs/charges associated with foot ulcers and is
preferable to reporting only charge for a single
hospitalization or limited time interval

Direct Cost for Foot Ulcers in Persons with Diabetes From Two
Studies
Author

# Patients/

Outcome

Average
Episode Cost
(US $)

Inpatient
Cost %

Outpatient
Cost %

Primary healing =
63%

$6,664

61

39

18

82

Study Type

Apelqvist Prospective
(27)
314 General
Internal
Medicine
Patients
Ramsey
(28)

Healed after
amputation = 24%

Nested casePrimary healing =
control study
84%
in HMO of
Amputation =
8,905 Type 1,2
16%

$44,790

$27,987

Total
Attributable
cost

Ulcer Reimbursement to Hospitals for Patients with and
without Diabetes, 2002
Medstat (Private)1
Source:

Length of Stay

Average $
Reimbursement

Length of Stay

Average $
Reimbursement

18

Peripheral Neuropathy with
complications

5.6

9,036

5.5

4,782

19

Peripheral Neuropathy
without complications

4.8

6,061

3.6

3,034

277

Cellulitis > age 17 with
complications

4.8

6,823

5.7

4,000

278

Cellulitis > age 17 without
complications

3.4

4,426

4.2

2,192

271

Skin Ulcers

11.0

11,638

7.3

5,227

238

Osteomyelitis

5.9

9,913

8.7

7,376

130

Peripheral Arterial Disease
with complications

5.1

7,743

5.6

4,554

131

Peripheral Arterial Disease
without complications

4.3

5,768

4.1

2,375

1Medstat

Group,
Thompson
DRG
Corporati
on, 2005
2Centers

for
Medicare
and
Medicaid
Services,
2005

Key:
DRG =
Diagnostic
Related
Group

Medicare2

Condition

In conclusion….


The average private hospital reimbursement for a
foot ulcer for 11 days is about $11,638 while
Medicare reimbursement for foot ulcer conditions is
usually for 7.3 days and $5,227.



The direct economic cost attributable to foot ulcers
from onset for two years approaches $28,000.



Guideline-based care is needed to improve outcomes
and provide cost savings compared with standard
care

Final conclusions and suggestions!!!










Diabetes has pervasive emotional and physical effects on patients lives.
Additionally, physical and psychological barriers, time and monetary
limitations, and a lack of social support complicates disease management
People, especially those with little education, may not understand the
progressive nature of diabetes. However, using diabetes complications as
a scare tactic may only exacerbate feelings of helplessness if patients view
future complications as inevitable
Documented workplace discrimination allegations indicate that people with
diabetes are more likely to experience prejudice, which can affect job
retention. This in turn may affect access to health insurance and health
maintenance
balancing familial and work responsibilities may complicate diabetes
management because of feelings of obligation. Working patients need
flexible supports that facilitate program participation such as longer clinic
hours, child care services, time management training, and flexible work
schedules that accommodate doctor visits and exercise
Finally, diabetes supports should address the whole person — physically,
psychologically, and socially. Future interventions for working people with
diabetes should include coordinated programs that involve social,
emotional, and lifestyle supports to help keep people healthy so that they
can work well

Thank U
4 your
@Ntion !!

Pts


Slide 3

Diabetic Neuropathy
in the workforce
and cost
Panagiotis V. Tsaklis, PhD
Associate Professor
School of Health Professions
“Alexander” TEI Thessaloniki
Sen. Researcher
Dept Public Health Sciences
Occupational & Environmental Medicine
Karolinska Institutet

mellitus…


The global prevalence of diabetes is
predicted to double by the year 2030 from
2.8% to 4.4%.



…Of individuals with diabetes, a substantial
number will develop lower extremity disease
including peripheral neuropathy, foot ulcers
and peripheral arterial disease…

Does it cost much??


In 2007, the estimated national cost in US of diabetes
exceeded $174 billion…


This estimate included $116 billion in diabetesrelated medical costs and $58 billion in reduced
productivity ….due to increased work absenteeism,
reduced work and daily productivity, unemployment
from disease-related disability, and early death..



Polyneuropathy is one of the commonest complications of the
diabetes and the commonest form of neuropathy in the
developed World. Diabetic polyneuropathy encompasses
several neuropathic syndromes the commonest of which is
distal symmetrical neuropathy, the main initiating factor for foot
ulceration. The epidemiology of diabetic neuropathy has
recently been reviewed in reasonable detail

…from the 1999-2000 population-based US Health and Nutrition
Survey (NHANES), The prevalence (history) of peripheral
neuropathy (> 1 insensate area) in people with diabetes was
28.5%...


The EURODIAB Prospective Complications Study which
involved the examination of 3250 type 1 patients, from 16
European countries, found a prevalence rate of 28% for distal
symmetrical neuropathy

…painful diabetic
peripheral neuropathy (pDPN) is associated with
worse health outcomes…
…however, among pDPN patients, few studies have
examined the relationship between the severity of
pain and health outcomes……

Lost Productive Time (LPT) and diabetes neuropathy…
…studies suggest that individuals
40 to 65 years old in the US workforce, with diabetes and neuropathic
symptoms experience excess health-related LPT compared with that of
others with and without diabetes

…The mean hours of LPT per week was substantially higher in the
diabetes patients with neuropathic symptoms
compared with in the others 4.21 hrs vs 1.90 hrs…(diabetic &
controls)
…more individuals who had diabetes with neuropathic symptoms
reported moderate to severe impact on work ability (ie, score 5 on a
scale from 0–10 compared with those without neuropathic
symptoms
(where 0 means “it has no effect on my ability to work” and 10 means “I am no longer able
to work”)

Cost of Lost Productive Time…$ $ $ $ $...:
In the US Workforce gives a equivalent of $3.65 billion
per year in health-related LPT, a cost per worker that is more
than 2.5 times higher than workers with diabetes without neuropathic
Symptoms…

In conclusion,…The severity might
lead to decreased health status,

•It is observed a prevalence of moderate-to-severe pain among pDPN
patients
•also indicate that health outcomes are significantly worse as pain severity
increases.
•Specifically, work impairment, health care resource use, and the associated
indirect and direct costs increase significantly as the level of pain severity
increases.
•These data emphasize the need
for effectively managing pain in patients with pDPN.

Peripheral (symmetrical) Neuropathy
(Sensory-Motor Neuropathy) which leads to……
Complications
Intrinsic muscles atrophy
→ foot deformities
Reflex reduction
→ Gait alteration…
Calluses & Ulcers occurrence
Amputations…

Aggravating Factors…
Peripheral Vascular Disease

Joint Mobility Reduction
Foot Structural deformities

Foot soft tissues lesions
Autonomous Neuropathy ???
Vassel-Kinetic Neuropathy (VASOMOTOR)
Sweat -Kinetic Neuropathy (SUDOMOTOR)

“autosympathectomy.”

Diabetic foot……The majority of lower extremity disease in people with diabetes is
treated in outpatient, clinic or office settings

Focus on Foot Ulcers

Foot ulcers are defined as a cutaneous erosion
extending through the dermis to deeper tissue, result
from various etiologic factors and are characterized
by an inability to self-repair in a timely and orderly
manner

Frequency of Lower Extremity Conditions in the U.S. Population with
Diabetes per 1,000.
Hospital Discharge Data for Ulcer/inflammation/infection (Ulcer),
Peripheral Neuropathy, and Peripheral Arterial Disease (PAD), 19932002

Age-adjusted Hospital Discharge Rates for Lower Extremity Disease
in the U.S. Population with Diabetes per 1,000.
Ulcer/inflammation/infection (Ulcer), Peripheral Neuropathy, and
Peripheral Arterial Disease (PAD), 1993-2002

R
a
t
e
/
1
,
0
0
0

Population-Based Diabetic Foot Ulcer Incidence and Prevalence
from Selected Studies…
First Author/
Reference

Foot Ulcer
Foot Ulcer

Population Studied

Annual
Prevalence /100
Incidence /100

Abbott (16)

Borssen (32)

Kumar (12)
Lavery (33)

Malgrane (34)
MMWR (35)
Moss (23)

Ramsey (28)
Walters (14)

Cohort of 6,613 patients in six district
clinics in NW England followed for 2
yrs, Type 1, 2 diabetes
375 patients Umea County Sweden, Age
15-50,
Type 1 = 298, Type 2 = 77
Cross-sectional study of 811 Type 2
patients from three UK cities
Cohort of 1,666 patients, San Antonio,
Texas, 51% Mexican Americans,
followed for 2 yrs
664 patients from 16 French diabetes
centers
2000-2002 BRFSS US survey of adults
> 18 yrs
Cohort of 2,990 patients with late and
early-onset diabetes
Nested case-control study in HMO,
8,905 Type 1, Type 2
Cross-sectional study of 1,077 Type 1, 2
patients in 10 UK general medicine
practices

2.2

4.7

2.0

10.0 IDDM
9.0 NIDDM

1.0

5.3

3.4

—

—

15.8%

—

11.8%

2.4 younger

9.5 younger

2.6 older

10.5 older

1.9
4.1

7.4

Frequency of U.S. Hospitalization for Ulcer-Related Conditions
in Individuals with Diabetes by Diagnosis, 2001-2002
Type of ulcer

ICD-CM
Codes

Estimated
Frequency
2001

Estimated
Frequency
2002

Cellulitis, abscess, or infected ulcer
Other cellulitis and abscess, foot except toes

681.1
682.7

26,685
81,367

29,347
83,954

Ulcer of lower limbs, except decubitus
Osteomyelitis

707.1
730.07

209,088
60,989

216,785
66,591

129,466

134,274

83,546

78,983

730.17
730.27
730.37
730.87
730.97

Chronic nonhealing ulcers

707.0
707.9

Atherosclerosis of lower limb with ulcer

440.23

Or gangrene

440.24

Ulcers Health Care Costs…



Optimally, the estimation of diabetic foot ulcer costs
spans an entire ulcer episode from lesion onset to
final resolution.



Two studies provided direct costs associated with the
entire diabetic foot ulcer history. This methodology
captures the many inpatient and outpatient
costs/charges associated with foot ulcers and is
preferable to reporting only charge for a single
hospitalization or limited time interval

Direct Cost for Foot Ulcers in Persons with Diabetes From Two
Studies
Author

# Patients/

Outcome

Average
Episode Cost
(US $)

Inpatient
Cost %

Outpatient
Cost %

Primary healing =
63%

$6,664

61

39

18

82

Study Type

Apelqvist Prospective
(27)
314 General
Internal
Medicine
Patients
Ramsey
(28)

Healed after
amputation = 24%

Nested casePrimary healing =
control study
84%
in HMO of
Amputation =
8,905 Type 1,2
16%

$44,790

$27,987

Total
Attributable
cost

Ulcer Reimbursement to Hospitals for Patients with and
without Diabetes, 2002
Medstat (Private)1
Source:

Length of Stay

Average $
Reimbursement

Length of Stay

Average $
Reimbursement

18

Peripheral Neuropathy with
complications

5.6

9,036

5.5

4,782

19

Peripheral Neuropathy
without complications

4.8

6,061

3.6

3,034

277

Cellulitis > age 17 with
complications

4.8

6,823

5.7

4,000

278

Cellulitis > age 17 without
complications

3.4

4,426

4.2

2,192

271

Skin Ulcers

11.0

11,638

7.3

5,227

238

Osteomyelitis

5.9

9,913

8.7

7,376

130

Peripheral Arterial Disease
with complications

5.1

7,743

5.6

4,554

131

Peripheral Arterial Disease
without complications

4.3

5,768

4.1

2,375

1Medstat

Group,
Thompson
DRG
Corporati
on, 2005
2Centers

for
Medicare
and
Medicaid
Services,
2005

Key:
DRG =
Diagnostic
Related
Group

Medicare2

Condition

In conclusion….


The average private hospital reimbursement for a
foot ulcer for 11 days is about $11,638 while
Medicare reimbursement for foot ulcer conditions is
usually for 7.3 days and $5,227.



The direct economic cost attributable to foot ulcers
from onset for two years approaches $28,000.



Guideline-based care is needed to improve outcomes
and provide cost savings compared with standard
care

Final conclusions and suggestions!!!










Diabetes has pervasive emotional and physical effects on patients lives.
Additionally, physical and psychological barriers, time and monetary
limitations, and a lack of social support complicates disease management
People, especially those with little education, may not understand the
progressive nature of diabetes. However, using diabetes complications as
a scare tactic may only exacerbate feelings of helplessness if patients view
future complications as inevitable
Documented workplace discrimination allegations indicate that people with
diabetes are more likely to experience prejudice, which can affect job
retention. This in turn may affect access to health insurance and health
maintenance
balancing familial and work responsibilities may complicate diabetes
management because of feelings of obligation. Working patients need
flexible supports that facilitate program participation such as longer clinic
hours, child care services, time management training, and flexible work
schedules that accommodate doctor visits and exercise
Finally, diabetes supports should address the whole person — physically,
psychologically, and socially. Future interventions for working people with
diabetes should include coordinated programs that involve social,
emotional, and lifestyle supports to help keep people healthy so that they
can work well

Thank U
4 your
@Ntion !!

Pts


Slide 4

Diabetic Neuropathy
in the workforce
and cost
Panagiotis V. Tsaklis, PhD
Associate Professor
School of Health Professions
“Alexander” TEI Thessaloniki
Sen. Researcher
Dept Public Health Sciences
Occupational & Environmental Medicine
Karolinska Institutet

mellitus…


The global prevalence of diabetes is
predicted to double by the year 2030 from
2.8% to 4.4%.



…Of individuals with diabetes, a substantial
number will develop lower extremity disease
including peripheral neuropathy, foot ulcers
and peripheral arterial disease…

Does it cost much??


In 2007, the estimated national cost in US of diabetes
exceeded $174 billion…


This estimate included $116 billion in diabetesrelated medical costs and $58 billion in reduced
productivity ….due to increased work absenteeism,
reduced work and daily productivity, unemployment
from disease-related disability, and early death..



Polyneuropathy is one of the commonest complications of the
diabetes and the commonest form of neuropathy in the
developed World. Diabetic polyneuropathy encompasses
several neuropathic syndromes the commonest of which is
distal symmetrical neuropathy, the main initiating factor for foot
ulceration. The epidemiology of diabetic neuropathy has
recently been reviewed in reasonable detail

…from the 1999-2000 population-based US Health and Nutrition
Survey (NHANES), The prevalence (history) of peripheral
neuropathy (> 1 insensate area) in people with diabetes was
28.5%...


The EURODIAB Prospective Complications Study which
involved the examination of 3250 type 1 patients, from 16
European countries, found a prevalence rate of 28% for distal
symmetrical neuropathy

…painful diabetic
peripheral neuropathy (pDPN) is associated with
worse health outcomes…
…however, among pDPN patients, few studies have
examined the relationship between the severity of
pain and health outcomes……

Lost Productive Time (LPT) and diabetes neuropathy…
…studies suggest that individuals
40 to 65 years old in the US workforce, with diabetes and neuropathic
symptoms experience excess health-related LPT compared with that of
others with and without diabetes

…The mean hours of LPT per week was substantially higher in the
diabetes patients with neuropathic symptoms
compared with in the others 4.21 hrs vs 1.90 hrs…(diabetic &
controls)
…more individuals who had diabetes with neuropathic symptoms
reported moderate to severe impact on work ability (ie, score 5 on a
scale from 0–10 compared with those without neuropathic
symptoms
(where 0 means “it has no effect on my ability to work” and 10 means “I am no longer able
to work”)

Cost of Lost Productive Time…$ $ $ $ $...:
In the US Workforce gives a equivalent of $3.65 billion
per year in health-related LPT, a cost per worker that is more
than 2.5 times higher than workers with diabetes without neuropathic
Symptoms…

In conclusion,…The severity might
lead to decreased health status,

•It is observed a prevalence of moderate-to-severe pain among pDPN
patients
•also indicate that health outcomes are significantly worse as pain severity
increases.
•Specifically, work impairment, health care resource use, and the associated
indirect and direct costs increase significantly as the level of pain severity
increases.
•These data emphasize the need
for effectively managing pain in patients with pDPN.

Peripheral (symmetrical) Neuropathy
(Sensory-Motor Neuropathy) which leads to……
Complications
Intrinsic muscles atrophy
→ foot deformities
Reflex reduction
→ Gait alteration…
Calluses & Ulcers occurrence
Amputations…

Aggravating Factors…
Peripheral Vascular Disease

Joint Mobility Reduction
Foot Structural deformities

Foot soft tissues lesions
Autonomous Neuropathy ???
Vassel-Kinetic Neuropathy (VASOMOTOR)
Sweat -Kinetic Neuropathy (SUDOMOTOR)

“autosympathectomy.”

Diabetic foot……The majority of lower extremity disease in people with diabetes is
treated in outpatient, clinic or office settings

Focus on Foot Ulcers

Foot ulcers are defined as a cutaneous erosion
extending through the dermis to deeper tissue, result
from various etiologic factors and are characterized
by an inability to self-repair in a timely and orderly
manner

Frequency of Lower Extremity Conditions in the U.S. Population with
Diabetes per 1,000.
Hospital Discharge Data for Ulcer/inflammation/infection (Ulcer),
Peripheral Neuropathy, and Peripheral Arterial Disease (PAD), 19932002

Age-adjusted Hospital Discharge Rates for Lower Extremity Disease
in the U.S. Population with Diabetes per 1,000.
Ulcer/inflammation/infection (Ulcer), Peripheral Neuropathy, and
Peripheral Arterial Disease (PAD), 1993-2002

R
a
t
e
/
1
,
0
0
0

Population-Based Diabetic Foot Ulcer Incidence and Prevalence
from Selected Studies…
First Author/
Reference

Foot Ulcer
Foot Ulcer

Population Studied

Annual
Prevalence /100
Incidence /100

Abbott (16)

Borssen (32)

Kumar (12)
Lavery (33)

Malgrane (34)
MMWR (35)
Moss (23)

Ramsey (28)
Walters (14)

Cohort of 6,613 patients in six district
clinics in NW England followed for 2
yrs, Type 1, 2 diabetes
375 patients Umea County Sweden, Age
15-50,
Type 1 = 298, Type 2 = 77
Cross-sectional study of 811 Type 2
patients from three UK cities
Cohort of 1,666 patients, San Antonio,
Texas, 51% Mexican Americans,
followed for 2 yrs
664 patients from 16 French diabetes
centers
2000-2002 BRFSS US survey of adults
> 18 yrs
Cohort of 2,990 patients with late and
early-onset diabetes
Nested case-control study in HMO,
8,905 Type 1, Type 2
Cross-sectional study of 1,077 Type 1, 2
patients in 10 UK general medicine
practices

2.2

4.7

2.0

10.0 IDDM
9.0 NIDDM

1.0

5.3

3.4

—

—

15.8%

—

11.8%

2.4 younger

9.5 younger

2.6 older

10.5 older

1.9
4.1

7.4

Frequency of U.S. Hospitalization for Ulcer-Related Conditions
in Individuals with Diabetes by Diagnosis, 2001-2002
Type of ulcer

ICD-CM
Codes

Estimated
Frequency
2001

Estimated
Frequency
2002

Cellulitis, abscess, or infected ulcer
Other cellulitis and abscess, foot except toes

681.1
682.7

26,685
81,367

29,347
83,954

Ulcer of lower limbs, except decubitus
Osteomyelitis

707.1
730.07

209,088
60,989

216,785
66,591

129,466

134,274

83,546

78,983

730.17
730.27
730.37
730.87
730.97

Chronic nonhealing ulcers

707.0
707.9

Atherosclerosis of lower limb with ulcer

440.23

Or gangrene

440.24

Ulcers Health Care Costs…



Optimally, the estimation of diabetic foot ulcer costs
spans an entire ulcer episode from lesion onset to
final resolution.



Two studies provided direct costs associated with the
entire diabetic foot ulcer history. This methodology
captures the many inpatient and outpatient
costs/charges associated with foot ulcers and is
preferable to reporting only charge for a single
hospitalization or limited time interval

Direct Cost for Foot Ulcers in Persons with Diabetes From Two
Studies
Author

# Patients/

Outcome

Average
Episode Cost
(US $)

Inpatient
Cost %

Outpatient
Cost %

Primary healing =
63%

$6,664

61

39

18

82

Study Type

Apelqvist Prospective
(27)
314 General
Internal
Medicine
Patients
Ramsey
(28)

Healed after
amputation = 24%

Nested casePrimary healing =
control study
84%
in HMO of
Amputation =
8,905 Type 1,2
16%

$44,790

$27,987

Total
Attributable
cost

Ulcer Reimbursement to Hospitals for Patients with and
without Diabetes, 2002
Medstat (Private)1
Source:

Length of Stay

Average $
Reimbursement

Length of Stay

Average $
Reimbursement

18

Peripheral Neuropathy with
complications

5.6

9,036

5.5

4,782

19

Peripheral Neuropathy
without complications

4.8

6,061

3.6

3,034

277

Cellulitis > age 17 with
complications

4.8

6,823

5.7

4,000

278

Cellulitis > age 17 without
complications

3.4

4,426

4.2

2,192

271

Skin Ulcers

11.0

11,638

7.3

5,227

238

Osteomyelitis

5.9

9,913

8.7

7,376

130

Peripheral Arterial Disease
with complications

5.1

7,743

5.6

4,554

131

Peripheral Arterial Disease
without complications

4.3

5,768

4.1

2,375

1Medstat

Group,
Thompson
DRG
Corporati
on, 2005
2Centers

for
Medicare
and
Medicaid
Services,
2005

Key:
DRG =
Diagnostic
Related
Group

Medicare2

Condition

In conclusion….


The average private hospital reimbursement for a
foot ulcer for 11 days is about $11,638 while
Medicare reimbursement for foot ulcer conditions is
usually for 7.3 days and $5,227.



The direct economic cost attributable to foot ulcers
from onset for two years approaches $28,000.



Guideline-based care is needed to improve outcomes
and provide cost savings compared with standard
care

Final conclusions and suggestions!!!










Diabetes has pervasive emotional and physical effects on patients lives.
Additionally, physical and psychological barriers, time and monetary
limitations, and a lack of social support complicates disease management
People, especially those with little education, may not understand the
progressive nature of diabetes. However, using diabetes complications as
a scare tactic may only exacerbate feelings of helplessness if patients view
future complications as inevitable
Documented workplace discrimination allegations indicate that people with
diabetes are more likely to experience prejudice, which can affect job
retention. This in turn may affect access to health insurance and health
maintenance
balancing familial and work responsibilities may complicate diabetes
management because of feelings of obligation. Working patients need
flexible supports that facilitate program participation such as longer clinic
hours, child care services, time management training, and flexible work
schedules that accommodate doctor visits and exercise
Finally, diabetes supports should address the whole person — physically,
psychologically, and socially. Future interventions for working people with
diabetes should include coordinated programs that involve social,
emotional, and lifestyle supports to help keep people healthy so that they
can work well

Thank U
4 your
@Ntion !!

Pts


Slide 5

Diabetic Neuropathy
in the workforce
and cost
Panagiotis V. Tsaklis, PhD
Associate Professor
School of Health Professions
“Alexander” TEI Thessaloniki
Sen. Researcher
Dept Public Health Sciences
Occupational & Environmental Medicine
Karolinska Institutet

mellitus…


The global prevalence of diabetes is
predicted to double by the year 2030 from
2.8% to 4.4%.



…Of individuals with diabetes, a substantial
number will develop lower extremity disease
including peripheral neuropathy, foot ulcers
and peripheral arterial disease…

Does it cost much??


In 2007, the estimated national cost in US of diabetes
exceeded $174 billion…


This estimate included $116 billion in diabetesrelated medical costs and $58 billion in reduced
productivity ….due to increased work absenteeism,
reduced work and daily productivity, unemployment
from disease-related disability, and early death..



Polyneuropathy is one of the commonest complications of the
diabetes and the commonest form of neuropathy in the
developed World. Diabetic polyneuropathy encompasses
several neuropathic syndromes the commonest of which is
distal symmetrical neuropathy, the main initiating factor for foot
ulceration. The epidemiology of diabetic neuropathy has
recently been reviewed in reasonable detail

…from the 1999-2000 population-based US Health and Nutrition
Survey (NHANES), The prevalence (history) of peripheral
neuropathy (> 1 insensate area) in people with diabetes was
28.5%...


The EURODIAB Prospective Complications Study which
involved the examination of 3250 type 1 patients, from 16
European countries, found a prevalence rate of 28% for distal
symmetrical neuropathy

…painful diabetic
peripheral neuropathy (pDPN) is associated with
worse health outcomes…
…however, among pDPN patients, few studies have
examined the relationship between the severity of
pain and health outcomes……

Lost Productive Time (LPT) and diabetes neuropathy…
…studies suggest that individuals
40 to 65 years old in the US workforce, with diabetes and neuropathic
symptoms experience excess health-related LPT compared with that of
others with and without diabetes

…The mean hours of LPT per week was substantially higher in the
diabetes patients with neuropathic symptoms
compared with in the others 4.21 hrs vs 1.90 hrs…(diabetic &
controls)
…more individuals who had diabetes with neuropathic symptoms
reported moderate to severe impact on work ability (ie, score 5 on a
scale from 0–10 compared with those without neuropathic
symptoms
(where 0 means “it has no effect on my ability to work” and 10 means “I am no longer able
to work”)

Cost of Lost Productive Time…$ $ $ $ $...:
In the US Workforce gives a equivalent of $3.65 billion
per year in health-related LPT, a cost per worker that is more
than 2.5 times higher than workers with diabetes without neuropathic
Symptoms…

In conclusion,…The severity might
lead to decreased health status,

•It is observed a prevalence of moderate-to-severe pain among pDPN
patients
•also indicate that health outcomes are significantly worse as pain severity
increases.
•Specifically, work impairment, health care resource use, and the associated
indirect and direct costs increase significantly as the level of pain severity
increases.
•These data emphasize the need
for effectively managing pain in patients with pDPN.

Peripheral (symmetrical) Neuropathy
(Sensory-Motor Neuropathy) which leads to……
Complications
Intrinsic muscles atrophy
→ foot deformities
Reflex reduction
→ Gait alteration…
Calluses & Ulcers occurrence
Amputations…

Aggravating Factors…
Peripheral Vascular Disease

Joint Mobility Reduction
Foot Structural deformities

Foot soft tissues lesions
Autonomous Neuropathy ???
Vassel-Kinetic Neuropathy (VASOMOTOR)
Sweat -Kinetic Neuropathy (SUDOMOTOR)

“autosympathectomy.”

Diabetic foot……The majority of lower extremity disease in people with diabetes is
treated in outpatient, clinic or office settings

Focus on Foot Ulcers

Foot ulcers are defined as a cutaneous erosion
extending through the dermis to deeper tissue, result
from various etiologic factors and are characterized
by an inability to self-repair in a timely and orderly
manner

Frequency of Lower Extremity Conditions in the U.S. Population with
Diabetes per 1,000.
Hospital Discharge Data for Ulcer/inflammation/infection (Ulcer),
Peripheral Neuropathy, and Peripheral Arterial Disease (PAD), 19932002

Age-adjusted Hospital Discharge Rates for Lower Extremity Disease
in the U.S. Population with Diabetes per 1,000.
Ulcer/inflammation/infection (Ulcer), Peripheral Neuropathy, and
Peripheral Arterial Disease (PAD), 1993-2002

R
a
t
e
/
1
,
0
0
0

Population-Based Diabetic Foot Ulcer Incidence and Prevalence
from Selected Studies…
First Author/
Reference

Foot Ulcer
Foot Ulcer

Population Studied

Annual
Prevalence /100
Incidence /100

Abbott (16)

Borssen (32)

Kumar (12)
Lavery (33)

Malgrane (34)
MMWR (35)
Moss (23)

Ramsey (28)
Walters (14)

Cohort of 6,613 patients in six district
clinics in NW England followed for 2
yrs, Type 1, 2 diabetes
375 patients Umea County Sweden, Age
15-50,
Type 1 = 298, Type 2 = 77
Cross-sectional study of 811 Type 2
patients from three UK cities
Cohort of 1,666 patients, San Antonio,
Texas, 51% Mexican Americans,
followed for 2 yrs
664 patients from 16 French diabetes
centers
2000-2002 BRFSS US survey of adults
> 18 yrs
Cohort of 2,990 patients with late and
early-onset diabetes
Nested case-control study in HMO,
8,905 Type 1, Type 2
Cross-sectional study of 1,077 Type 1, 2
patients in 10 UK general medicine
practices

2.2

4.7

2.0

10.0 IDDM
9.0 NIDDM

1.0

5.3

3.4

—

—

15.8%

—

11.8%

2.4 younger

9.5 younger

2.6 older

10.5 older

1.9
4.1

7.4

Frequency of U.S. Hospitalization for Ulcer-Related Conditions
in Individuals with Diabetes by Diagnosis, 2001-2002
Type of ulcer

ICD-CM
Codes

Estimated
Frequency
2001

Estimated
Frequency
2002

Cellulitis, abscess, or infected ulcer
Other cellulitis and abscess, foot except toes

681.1
682.7

26,685
81,367

29,347
83,954

Ulcer of lower limbs, except decubitus
Osteomyelitis

707.1
730.07

209,088
60,989

216,785
66,591

129,466

134,274

83,546

78,983

730.17
730.27
730.37
730.87
730.97

Chronic nonhealing ulcers

707.0
707.9

Atherosclerosis of lower limb with ulcer

440.23

Or gangrene

440.24

Ulcers Health Care Costs…



Optimally, the estimation of diabetic foot ulcer costs
spans an entire ulcer episode from lesion onset to
final resolution.



Two studies provided direct costs associated with the
entire diabetic foot ulcer history. This methodology
captures the many inpatient and outpatient
costs/charges associated with foot ulcers and is
preferable to reporting only charge for a single
hospitalization or limited time interval

Direct Cost for Foot Ulcers in Persons with Diabetes From Two
Studies
Author

# Patients/

Outcome

Average
Episode Cost
(US $)

Inpatient
Cost %

Outpatient
Cost %

Primary healing =
63%

$6,664

61

39

18

82

Study Type

Apelqvist Prospective
(27)
314 General
Internal
Medicine
Patients
Ramsey
(28)

Healed after
amputation = 24%

Nested casePrimary healing =
control study
84%
in HMO of
Amputation =
8,905 Type 1,2
16%

$44,790

$27,987

Total
Attributable
cost

Ulcer Reimbursement to Hospitals for Patients with and
without Diabetes, 2002
Medstat (Private)1
Source:

Length of Stay

Average $
Reimbursement

Length of Stay

Average $
Reimbursement

18

Peripheral Neuropathy with
complications

5.6

9,036

5.5

4,782

19

Peripheral Neuropathy
without complications

4.8

6,061

3.6

3,034

277

Cellulitis > age 17 with
complications

4.8

6,823

5.7

4,000

278

Cellulitis > age 17 without
complications

3.4

4,426

4.2

2,192

271

Skin Ulcers

11.0

11,638

7.3

5,227

238

Osteomyelitis

5.9

9,913

8.7

7,376

130

Peripheral Arterial Disease
with complications

5.1

7,743

5.6

4,554

131

Peripheral Arterial Disease
without complications

4.3

5,768

4.1

2,375

1Medstat

Group,
Thompson
DRG
Corporati
on, 2005
2Centers

for
Medicare
and
Medicaid
Services,
2005

Key:
DRG =
Diagnostic
Related
Group

Medicare2

Condition

In conclusion….


The average private hospital reimbursement for a
foot ulcer for 11 days is about $11,638 while
Medicare reimbursement for foot ulcer conditions is
usually for 7.3 days and $5,227.



The direct economic cost attributable to foot ulcers
from onset for two years approaches $28,000.



Guideline-based care is needed to improve outcomes
and provide cost savings compared with standard
care

Final conclusions and suggestions!!!










Diabetes has pervasive emotional and physical effects on patients lives.
Additionally, physical and psychological barriers, time and monetary
limitations, and a lack of social support complicates disease management
People, especially those with little education, may not understand the
progressive nature of diabetes. However, using diabetes complications as
a scare tactic may only exacerbate feelings of helplessness if patients view
future complications as inevitable
Documented workplace discrimination allegations indicate that people with
diabetes are more likely to experience prejudice, which can affect job
retention. This in turn may affect access to health insurance and health
maintenance
balancing familial and work responsibilities may complicate diabetes
management because of feelings of obligation. Working patients need
flexible supports that facilitate program participation such as longer clinic
hours, child care services, time management training, and flexible work
schedules that accommodate doctor visits and exercise
Finally, diabetes supports should address the whole person — physically,
psychologically, and socially. Future interventions for working people with
diabetes should include coordinated programs that involve social,
emotional, and lifestyle supports to help keep people healthy so that they
can work well

Thank U
4 your
@Ntion !!

Pts


Slide 6

Diabetic Neuropathy
in the workforce
and cost
Panagiotis V. Tsaklis, PhD
Associate Professor
School of Health Professions
“Alexander” TEI Thessaloniki
Sen. Researcher
Dept Public Health Sciences
Occupational & Environmental Medicine
Karolinska Institutet

mellitus…


The global prevalence of diabetes is
predicted to double by the year 2030 from
2.8% to 4.4%.



…Of individuals with diabetes, a substantial
number will develop lower extremity disease
including peripheral neuropathy, foot ulcers
and peripheral arterial disease…

Does it cost much??


In 2007, the estimated national cost in US of diabetes
exceeded $174 billion…


This estimate included $116 billion in diabetesrelated medical costs and $58 billion in reduced
productivity ….due to increased work absenteeism,
reduced work and daily productivity, unemployment
from disease-related disability, and early death..



Polyneuropathy is one of the commonest complications of the
diabetes and the commonest form of neuropathy in the
developed World. Diabetic polyneuropathy encompasses
several neuropathic syndromes the commonest of which is
distal symmetrical neuropathy, the main initiating factor for foot
ulceration. The epidemiology of diabetic neuropathy has
recently been reviewed in reasonable detail

…from the 1999-2000 population-based US Health and Nutrition
Survey (NHANES), The prevalence (history) of peripheral
neuropathy (> 1 insensate area) in people with diabetes was
28.5%...


The EURODIAB Prospective Complications Study which
involved the examination of 3250 type 1 patients, from 16
European countries, found a prevalence rate of 28% for distal
symmetrical neuropathy

…painful diabetic
peripheral neuropathy (pDPN) is associated with
worse health outcomes…
…however, among pDPN patients, few studies have
examined the relationship between the severity of
pain and health outcomes……

Lost Productive Time (LPT) and diabetes neuropathy…
…studies suggest that individuals
40 to 65 years old in the US workforce, with diabetes and neuropathic
symptoms experience excess health-related LPT compared with that of
others with and without diabetes

…The mean hours of LPT per week was substantially higher in the
diabetes patients with neuropathic symptoms
compared with in the others 4.21 hrs vs 1.90 hrs…(diabetic &
controls)
…more individuals who had diabetes with neuropathic symptoms
reported moderate to severe impact on work ability (ie, score 5 on a
scale from 0–10 compared with those without neuropathic
symptoms
(where 0 means “it has no effect on my ability to work” and 10 means “I am no longer able
to work”)

Cost of Lost Productive Time…$ $ $ $ $...:
In the US Workforce gives a equivalent of $3.65 billion
per year in health-related LPT, a cost per worker that is more
than 2.5 times higher than workers with diabetes without neuropathic
Symptoms…

In conclusion,…The severity might
lead to decreased health status,

•It is observed a prevalence of moderate-to-severe pain among pDPN
patients
•also indicate that health outcomes are significantly worse as pain severity
increases.
•Specifically, work impairment, health care resource use, and the associated
indirect and direct costs increase significantly as the level of pain severity
increases.
•These data emphasize the need
for effectively managing pain in patients with pDPN.

Peripheral (symmetrical) Neuropathy
(Sensory-Motor Neuropathy) which leads to……
Complications
Intrinsic muscles atrophy
→ foot deformities
Reflex reduction
→ Gait alteration…
Calluses & Ulcers occurrence
Amputations…

Aggravating Factors…
Peripheral Vascular Disease

Joint Mobility Reduction
Foot Structural deformities

Foot soft tissues lesions
Autonomous Neuropathy ???
Vassel-Kinetic Neuropathy (VASOMOTOR)
Sweat -Kinetic Neuropathy (SUDOMOTOR)

“autosympathectomy.”

Diabetic foot……The majority of lower extremity disease in people with diabetes is
treated in outpatient, clinic or office settings

Focus on Foot Ulcers

Foot ulcers are defined as a cutaneous erosion
extending through the dermis to deeper tissue, result
from various etiologic factors and are characterized
by an inability to self-repair in a timely and orderly
manner

Frequency of Lower Extremity Conditions in the U.S. Population with
Diabetes per 1,000.
Hospital Discharge Data for Ulcer/inflammation/infection (Ulcer),
Peripheral Neuropathy, and Peripheral Arterial Disease (PAD), 19932002

Age-adjusted Hospital Discharge Rates for Lower Extremity Disease
in the U.S. Population with Diabetes per 1,000.
Ulcer/inflammation/infection (Ulcer), Peripheral Neuropathy, and
Peripheral Arterial Disease (PAD), 1993-2002

R
a
t
e
/
1
,
0
0
0

Population-Based Diabetic Foot Ulcer Incidence and Prevalence
from Selected Studies…
First Author/
Reference

Foot Ulcer
Foot Ulcer

Population Studied

Annual
Prevalence /100
Incidence /100

Abbott (16)

Borssen (32)

Kumar (12)
Lavery (33)

Malgrane (34)
MMWR (35)
Moss (23)

Ramsey (28)
Walters (14)

Cohort of 6,613 patients in six district
clinics in NW England followed for 2
yrs, Type 1, 2 diabetes
375 patients Umea County Sweden, Age
15-50,
Type 1 = 298, Type 2 = 77
Cross-sectional study of 811 Type 2
patients from three UK cities
Cohort of 1,666 patients, San Antonio,
Texas, 51% Mexican Americans,
followed for 2 yrs
664 patients from 16 French diabetes
centers
2000-2002 BRFSS US survey of adults
> 18 yrs
Cohort of 2,990 patients with late and
early-onset diabetes
Nested case-control study in HMO,
8,905 Type 1, Type 2
Cross-sectional study of 1,077 Type 1, 2
patients in 10 UK general medicine
practices

2.2

4.7

2.0

10.0 IDDM
9.0 NIDDM

1.0

5.3

3.4

—

—

15.8%

—

11.8%

2.4 younger

9.5 younger

2.6 older

10.5 older

1.9
4.1

7.4

Frequency of U.S. Hospitalization for Ulcer-Related Conditions
in Individuals with Diabetes by Diagnosis, 2001-2002
Type of ulcer

ICD-CM
Codes

Estimated
Frequency
2001

Estimated
Frequency
2002

Cellulitis, abscess, or infected ulcer
Other cellulitis and abscess, foot except toes

681.1
682.7

26,685
81,367

29,347
83,954

Ulcer of lower limbs, except decubitus
Osteomyelitis

707.1
730.07

209,088
60,989

216,785
66,591

129,466

134,274

83,546

78,983

730.17
730.27
730.37
730.87
730.97

Chronic nonhealing ulcers

707.0
707.9

Atherosclerosis of lower limb with ulcer

440.23

Or gangrene

440.24

Ulcers Health Care Costs…



Optimally, the estimation of diabetic foot ulcer costs
spans an entire ulcer episode from lesion onset to
final resolution.



Two studies provided direct costs associated with the
entire diabetic foot ulcer history. This methodology
captures the many inpatient and outpatient
costs/charges associated with foot ulcers and is
preferable to reporting only charge for a single
hospitalization or limited time interval

Direct Cost for Foot Ulcers in Persons with Diabetes From Two
Studies
Author

# Patients/

Outcome

Average
Episode Cost
(US $)

Inpatient
Cost %

Outpatient
Cost %

Primary healing =
63%

$6,664

61

39

18

82

Study Type

Apelqvist Prospective
(27)
314 General
Internal
Medicine
Patients
Ramsey
(28)

Healed after
amputation = 24%

Nested casePrimary healing =
control study
84%
in HMO of
Amputation =
8,905 Type 1,2
16%

$44,790

$27,987

Total
Attributable
cost

Ulcer Reimbursement to Hospitals for Patients with and
without Diabetes, 2002
Medstat (Private)1
Source:

Length of Stay

Average $
Reimbursement

Length of Stay

Average $
Reimbursement

18

Peripheral Neuropathy with
complications

5.6

9,036

5.5

4,782

19

Peripheral Neuropathy
without complications

4.8

6,061

3.6

3,034

277

Cellulitis > age 17 with
complications

4.8

6,823

5.7

4,000

278

Cellulitis > age 17 without
complications

3.4

4,426

4.2

2,192

271

Skin Ulcers

11.0

11,638

7.3

5,227

238

Osteomyelitis

5.9

9,913

8.7

7,376

130

Peripheral Arterial Disease
with complications

5.1

7,743

5.6

4,554

131

Peripheral Arterial Disease
without complications

4.3

5,768

4.1

2,375

1Medstat

Group,
Thompson
DRG
Corporati
on, 2005
2Centers

for
Medicare
and
Medicaid
Services,
2005

Key:
DRG =
Diagnostic
Related
Group

Medicare2

Condition

In conclusion….


The average private hospital reimbursement for a
foot ulcer for 11 days is about $11,638 while
Medicare reimbursement for foot ulcer conditions is
usually for 7.3 days and $5,227.



The direct economic cost attributable to foot ulcers
from onset for two years approaches $28,000.



Guideline-based care is needed to improve outcomes
and provide cost savings compared with standard
care

Final conclusions and suggestions!!!










Diabetes has pervasive emotional and physical effects on patients lives.
Additionally, physical and psychological barriers, time and monetary
limitations, and a lack of social support complicates disease management
People, especially those with little education, may not understand the
progressive nature of diabetes. However, using diabetes complications as
a scare tactic may only exacerbate feelings of helplessness if patients view
future complications as inevitable
Documented workplace discrimination allegations indicate that people with
diabetes are more likely to experience prejudice, which can affect job
retention. This in turn may affect access to health insurance and health
maintenance
balancing familial and work responsibilities may complicate diabetes
management because of feelings of obligation. Working patients need
flexible supports that facilitate program participation such as longer clinic
hours, child care services, time management training, and flexible work
schedules that accommodate doctor visits and exercise
Finally, diabetes supports should address the whole person — physically,
psychologically, and socially. Future interventions for working people with
diabetes should include coordinated programs that involve social,
emotional, and lifestyle supports to help keep people healthy so that they
can work well

Thank U
4 your
@Ntion !!

Pts


Slide 7

Diabetic Neuropathy
in the workforce
and cost
Panagiotis V. Tsaklis, PhD
Associate Professor
School of Health Professions
“Alexander” TEI Thessaloniki
Sen. Researcher
Dept Public Health Sciences
Occupational & Environmental Medicine
Karolinska Institutet

mellitus…


The global prevalence of diabetes is
predicted to double by the year 2030 from
2.8% to 4.4%.



…Of individuals with diabetes, a substantial
number will develop lower extremity disease
including peripheral neuropathy, foot ulcers
and peripheral arterial disease…

Does it cost much??


In 2007, the estimated national cost in US of diabetes
exceeded $174 billion…


This estimate included $116 billion in diabetesrelated medical costs and $58 billion in reduced
productivity ….due to increased work absenteeism,
reduced work and daily productivity, unemployment
from disease-related disability, and early death..



Polyneuropathy is one of the commonest complications of the
diabetes and the commonest form of neuropathy in the
developed World. Diabetic polyneuropathy encompasses
several neuropathic syndromes the commonest of which is
distal symmetrical neuropathy, the main initiating factor for foot
ulceration. The epidemiology of diabetic neuropathy has
recently been reviewed in reasonable detail

…from the 1999-2000 population-based US Health and Nutrition
Survey (NHANES), The prevalence (history) of peripheral
neuropathy (> 1 insensate area) in people with diabetes was
28.5%...


The EURODIAB Prospective Complications Study which
involved the examination of 3250 type 1 patients, from 16
European countries, found a prevalence rate of 28% for distal
symmetrical neuropathy

…painful diabetic
peripheral neuropathy (pDPN) is associated with
worse health outcomes…
…however, among pDPN patients, few studies have
examined the relationship between the severity of
pain and health outcomes……

Lost Productive Time (LPT) and diabetes neuropathy…
…studies suggest that individuals
40 to 65 years old in the US workforce, with diabetes and neuropathic
symptoms experience excess health-related LPT compared with that of
others with and without diabetes

…The mean hours of LPT per week was substantially higher in the
diabetes patients with neuropathic symptoms
compared with in the others 4.21 hrs vs 1.90 hrs…(diabetic &
controls)
…more individuals who had diabetes with neuropathic symptoms
reported moderate to severe impact on work ability (ie, score 5 on a
scale from 0–10 compared with those without neuropathic
symptoms
(where 0 means “it has no effect on my ability to work” and 10 means “I am no longer able
to work”)

Cost of Lost Productive Time…$ $ $ $ $...:
In the US Workforce gives a equivalent of $3.65 billion
per year in health-related LPT, a cost per worker that is more
than 2.5 times higher than workers with diabetes without neuropathic
Symptoms…

In conclusion,…The severity might
lead to decreased health status,

•It is observed a prevalence of moderate-to-severe pain among pDPN
patients
•also indicate that health outcomes are significantly worse as pain severity
increases.
•Specifically, work impairment, health care resource use, and the associated
indirect and direct costs increase significantly as the level of pain severity
increases.
•These data emphasize the need
for effectively managing pain in patients with pDPN.

Peripheral (symmetrical) Neuropathy
(Sensory-Motor Neuropathy) which leads to……
Complications
Intrinsic muscles atrophy
→ foot deformities
Reflex reduction
→ Gait alteration…
Calluses & Ulcers occurrence
Amputations…

Aggravating Factors…
Peripheral Vascular Disease

Joint Mobility Reduction
Foot Structural deformities

Foot soft tissues lesions
Autonomous Neuropathy ???
Vassel-Kinetic Neuropathy (VASOMOTOR)
Sweat -Kinetic Neuropathy (SUDOMOTOR)

“autosympathectomy.”

Diabetic foot……The majority of lower extremity disease in people with diabetes is
treated in outpatient, clinic or office settings

Focus on Foot Ulcers

Foot ulcers are defined as a cutaneous erosion
extending through the dermis to deeper tissue, result
from various etiologic factors and are characterized
by an inability to self-repair in a timely and orderly
manner

Frequency of Lower Extremity Conditions in the U.S. Population with
Diabetes per 1,000.
Hospital Discharge Data for Ulcer/inflammation/infection (Ulcer),
Peripheral Neuropathy, and Peripheral Arterial Disease (PAD), 19932002

Age-adjusted Hospital Discharge Rates for Lower Extremity Disease
in the U.S. Population with Diabetes per 1,000.
Ulcer/inflammation/infection (Ulcer), Peripheral Neuropathy, and
Peripheral Arterial Disease (PAD), 1993-2002

R
a
t
e
/
1
,
0
0
0

Population-Based Diabetic Foot Ulcer Incidence and Prevalence
from Selected Studies…
First Author/
Reference

Foot Ulcer
Foot Ulcer

Population Studied

Annual
Prevalence /100
Incidence /100

Abbott (16)

Borssen (32)

Kumar (12)
Lavery (33)

Malgrane (34)
MMWR (35)
Moss (23)

Ramsey (28)
Walters (14)

Cohort of 6,613 patients in six district
clinics in NW England followed for 2
yrs, Type 1, 2 diabetes
375 patients Umea County Sweden, Age
15-50,
Type 1 = 298, Type 2 = 77
Cross-sectional study of 811 Type 2
patients from three UK cities
Cohort of 1,666 patients, San Antonio,
Texas, 51% Mexican Americans,
followed for 2 yrs
664 patients from 16 French diabetes
centers
2000-2002 BRFSS US survey of adults
> 18 yrs
Cohort of 2,990 patients with late and
early-onset diabetes
Nested case-control study in HMO,
8,905 Type 1, Type 2
Cross-sectional study of 1,077 Type 1, 2
patients in 10 UK general medicine
practices

2.2

4.7

2.0

10.0 IDDM
9.0 NIDDM

1.0

5.3

3.4

—

—

15.8%

—

11.8%

2.4 younger

9.5 younger

2.6 older

10.5 older

1.9
4.1

7.4

Frequency of U.S. Hospitalization for Ulcer-Related Conditions
in Individuals with Diabetes by Diagnosis, 2001-2002
Type of ulcer

ICD-CM
Codes

Estimated
Frequency
2001

Estimated
Frequency
2002

Cellulitis, abscess, or infected ulcer
Other cellulitis and abscess, foot except toes

681.1
682.7

26,685
81,367

29,347
83,954

Ulcer of lower limbs, except decubitus
Osteomyelitis

707.1
730.07

209,088
60,989

216,785
66,591

129,466

134,274

83,546

78,983

730.17
730.27
730.37
730.87
730.97

Chronic nonhealing ulcers

707.0
707.9

Atherosclerosis of lower limb with ulcer

440.23

Or gangrene

440.24

Ulcers Health Care Costs…



Optimally, the estimation of diabetic foot ulcer costs
spans an entire ulcer episode from lesion onset to
final resolution.



Two studies provided direct costs associated with the
entire diabetic foot ulcer history. This methodology
captures the many inpatient and outpatient
costs/charges associated with foot ulcers and is
preferable to reporting only charge for a single
hospitalization or limited time interval

Direct Cost for Foot Ulcers in Persons with Diabetes From Two
Studies
Author

# Patients/

Outcome

Average
Episode Cost
(US $)

Inpatient
Cost %

Outpatient
Cost %

Primary healing =
63%

$6,664

61

39

18

82

Study Type

Apelqvist Prospective
(27)
314 General
Internal
Medicine
Patients
Ramsey
(28)

Healed after
amputation = 24%

Nested casePrimary healing =
control study
84%
in HMO of
Amputation =
8,905 Type 1,2
16%

$44,790

$27,987

Total
Attributable
cost

Ulcer Reimbursement to Hospitals for Patients with and
without Diabetes, 2002
Medstat (Private)1
Source:

Length of Stay

Average $
Reimbursement

Length of Stay

Average $
Reimbursement

18

Peripheral Neuropathy with
complications

5.6

9,036

5.5

4,782

19

Peripheral Neuropathy
without complications

4.8

6,061

3.6

3,034

277

Cellulitis > age 17 with
complications

4.8

6,823

5.7

4,000

278

Cellulitis > age 17 without
complications

3.4

4,426

4.2

2,192

271

Skin Ulcers

11.0

11,638

7.3

5,227

238

Osteomyelitis

5.9

9,913

8.7

7,376

130

Peripheral Arterial Disease
with complications

5.1

7,743

5.6

4,554

131

Peripheral Arterial Disease
without complications

4.3

5,768

4.1

2,375

1Medstat

Group,
Thompson
DRG
Corporati
on, 2005
2Centers

for
Medicare
and
Medicaid
Services,
2005

Key:
DRG =
Diagnostic
Related
Group

Medicare2

Condition

In conclusion….


The average private hospital reimbursement for a
foot ulcer for 11 days is about $11,638 while
Medicare reimbursement for foot ulcer conditions is
usually for 7.3 days and $5,227.



The direct economic cost attributable to foot ulcers
from onset for two years approaches $28,000.



Guideline-based care is needed to improve outcomes
and provide cost savings compared with standard
care

Final conclusions and suggestions!!!










Diabetes has pervasive emotional and physical effects on patients lives.
Additionally, physical and psychological barriers, time and monetary
limitations, and a lack of social support complicates disease management
People, especially those with little education, may not understand the
progressive nature of diabetes. However, using diabetes complications as
a scare tactic may only exacerbate feelings of helplessness if patients view
future complications as inevitable
Documented workplace discrimination allegations indicate that people with
diabetes are more likely to experience prejudice, which can affect job
retention. This in turn may affect access to health insurance and health
maintenance
balancing familial and work responsibilities may complicate diabetes
management because of feelings of obligation. Working patients need
flexible supports that facilitate program participation such as longer clinic
hours, child care services, time management training, and flexible work
schedules that accommodate doctor visits and exercise
Finally, diabetes supports should address the whole person — physically,
psychologically, and socially. Future interventions for working people with
diabetes should include coordinated programs that involve social,
emotional, and lifestyle supports to help keep people healthy so that they
can work well

Thank U
4 your
@Ntion !!

Pts


Slide 8

Diabetic Neuropathy
in the workforce
and cost
Panagiotis V. Tsaklis, PhD
Associate Professor
School of Health Professions
“Alexander” TEI Thessaloniki
Sen. Researcher
Dept Public Health Sciences
Occupational & Environmental Medicine
Karolinska Institutet

mellitus…


The global prevalence of diabetes is
predicted to double by the year 2030 from
2.8% to 4.4%.



…Of individuals with diabetes, a substantial
number will develop lower extremity disease
including peripheral neuropathy, foot ulcers
and peripheral arterial disease…

Does it cost much??


In 2007, the estimated national cost in US of diabetes
exceeded $174 billion…


This estimate included $116 billion in diabetesrelated medical costs and $58 billion in reduced
productivity ….due to increased work absenteeism,
reduced work and daily productivity, unemployment
from disease-related disability, and early death..



Polyneuropathy is one of the commonest complications of the
diabetes and the commonest form of neuropathy in the
developed World. Diabetic polyneuropathy encompasses
several neuropathic syndromes the commonest of which is
distal symmetrical neuropathy, the main initiating factor for foot
ulceration. The epidemiology of diabetic neuropathy has
recently been reviewed in reasonable detail

…from the 1999-2000 population-based US Health and Nutrition
Survey (NHANES), The prevalence (history) of peripheral
neuropathy (> 1 insensate area) in people with diabetes was
28.5%...


The EURODIAB Prospective Complications Study which
involved the examination of 3250 type 1 patients, from 16
European countries, found a prevalence rate of 28% for distal
symmetrical neuropathy

…painful diabetic
peripheral neuropathy (pDPN) is associated with
worse health outcomes…
…however, among pDPN patients, few studies have
examined the relationship between the severity of
pain and health outcomes……

Lost Productive Time (LPT) and diabetes neuropathy…
…studies suggest that individuals
40 to 65 years old in the US workforce, with diabetes and neuropathic
symptoms experience excess health-related LPT compared with that of
others with and without diabetes

…The mean hours of LPT per week was substantially higher in the
diabetes patients with neuropathic symptoms
compared with in the others 4.21 hrs vs 1.90 hrs…(diabetic &
controls)
…more individuals who had diabetes with neuropathic symptoms
reported moderate to severe impact on work ability (ie, score 5 on a
scale from 0–10 compared with those without neuropathic
symptoms
(where 0 means “it has no effect on my ability to work” and 10 means “I am no longer able
to work”)

Cost of Lost Productive Time…$ $ $ $ $...:
In the US Workforce gives a equivalent of $3.65 billion
per year in health-related LPT, a cost per worker that is more
than 2.5 times higher than workers with diabetes without neuropathic
Symptoms…

In conclusion,…The severity might
lead to decreased health status,

•It is observed a prevalence of moderate-to-severe pain among pDPN
patients
•also indicate that health outcomes are significantly worse as pain severity
increases.
•Specifically, work impairment, health care resource use, and the associated
indirect and direct costs increase significantly as the level of pain severity
increases.
•These data emphasize the need
for effectively managing pain in patients with pDPN.

Peripheral (symmetrical) Neuropathy
(Sensory-Motor Neuropathy) which leads to……
Complications
Intrinsic muscles atrophy
→ foot deformities
Reflex reduction
→ Gait alteration…
Calluses & Ulcers occurrence
Amputations…

Aggravating Factors…
Peripheral Vascular Disease

Joint Mobility Reduction
Foot Structural deformities

Foot soft tissues lesions
Autonomous Neuropathy ???
Vassel-Kinetic Neuropathy (VASOMOTOR)
Sweat -Kinetic Neuropathy (SUDOMOTOR)

“autosympathectomy.”

Diabetic foot……The majority of lower extremity disease in people with diabetes is
treated in outpatient, clinic or office settings

Focus on Foot Ulcers

Foot ulcers are defined as a cutaneous erosion
extending through the dermis to deeper tissue, result
from various etiologic factors and are characterized
by an inability to self-repair in a timely and orderly
manner

Frequency of Lower Extremity Conditions in the U.S. Population with
Diabetes per 1,000.
Hospital Discharge Data for Ulcer/inflammation/infection (Ulcer),
Peripheral Neuropathy, and Peripheral Arterial Disease (PAD), 19932002

Age-adjusted Hospital Discharge Rates for Lower Extremity Disease
in the U.S. Population with Diabetes per 1,000.
Ulcer/inflammation/infection (Ulcer), Peripheral Neuropathy, and
Peripheral Arterial Disease (PAD), 1993-2002

R
a
t
e
/
1
,
0
0
0

Population-Based Diabetic Foot Ulcer Incidence and Prevalence
from Selected Studies…
First Author/
Reference

Foot Ulcer
Foot Ulcer

Population Studied

Annual
Prevalence /100
Incidence /100

Abbott (16)

Borssen (32)

Kumar (12)
Lavery (33)

Malgrane (34)
MMWR (35)
Moss (23)

Ramsey (28)
Walters (14)

Cohort of 6,613 patients in six district
clinics in NW England followed for 2
yrs, Type 1, 2 diabetes
375 patients Umea County Sweden, Age
15-50,
Type 1 = 298, Type 2 = 77
Cross-sectional study of 811 Type 2
patients from three UK cities
Cohort of 1,666 patients, San Antonio,
Texas, 51% Mexican Americans,
followed for 2 yrs
664 patients from 16 French diabetes
centers
2000-2002 BRFSS US survey of adults
> 18 yrs
Cohort of 2,990 patients with late and
early-onset diabetes
Nested case-control study in HMO,
8,905 Type 1, Type 2
Cross-sectional study of 1,077 Type 1, 2
patients in 10 UK general medicine
practices

2.2

4.7

2.0

10.0 IDDM
9.0 NIDDM

1.0

5.3

3.4

—

—

15.8%

—

11.8%

2.4 younger

9.5 younger

2.6 older

10.5 older

1.9
4.1

7.4

Frequency of U.S. Hospitalization for Ulcer-Related Conditions
in Individuals with Diabetes by Diagnosis, 2001-2002
Type of ulcer

ICD-CM
Codes

Estimated
Frequency
2001

Estimated
Frequency
2002

Cellulitis, abscess, or infected ulcer
Other cellulitis and abscess, foot except toes

681.1
682.7

26,685
81,367

29,347
83,954

Ulcer of lower limbs, except decubitus
Osteomyelitis

707.1
730.07

209,088
60,989

216,785
66,591

129,466

134,274

83,546

78,983

730.17
730.27
730.37
730.87
730.97

Chronic nonhealing ulcers

707.0
707.9

Atherosclerosis of lower limb with ulcer

440.23

Or gangrene

440.24

Ulcers Health Care Costs…



Optimally, the estimation of diabetic foot ulcer costs
spans an entire ulcer episode from lesion onset to
final resolution.



Two studies provided direct costs associated with the
entire diabetic foot ulcer history. This methodology
captures the many inpatient and outpatient
costs/charges associated with foot ulcers and is
preferable to reporting only charge for a single
hospitalization or limited time interval

Direct Cost for Foot Ulcers in Persons with Diabetes From Two
Studies
Author

# Patients/

Outcome

Average
Episode Cost
(US $)

Inpatient
Cost %

Outpatient
Cost %

Primary healing =
63%

$6,664

61

39

18

82

Study Type

Apelqvist Prospective
(27)
314 General
Internal
Medicine
Patients
Ramsey
(28)

Healed after
amputation = 24%

Nested casePrimary healing =
control study
84%
in HMO of
Amputation =
8,905 Type 1,2
16%

$44,790

$27,987

Total
Attributable
cost

Ulcer Reimbursement to Hospitals for Patients with and
without Diabetes, 2002
Medstat (Private)1
Source:

Length of Stay

Average $
Reimbursement

Length of Stay

Average $
Reimbursement

18

Peripheral Neuropathy with
complications

5.6

9,036

5.5

4,782

19

Peripheral Neuropathy
without complications

4.8

6,061

3.6

3,034

277

Cellulitis > age 17 with
complications

4.8

6,823

5.7

4,000

278

Cellulitis > age 17 without
complications

3.4

4,426

4.2

2,192

271

Skin Ulcers

11.0

11,638

7.3

5,227

238

Osteomyelitis

5.9

9,913

8.7

7,376

130

Peripheral Arterial Disease
with complications

5.1

7,743

5.6

4,554

131

Peripheral Arterial Disease
without complications

4.3

5,768

4.1

2,375

1Medstat

Group,
Thompson
DRG
Corporati
on, 2005
2Centers

for
Medicare
and
Medicaid
Services,
2005

Key:
DRG =
Diagnostic
Related
Group

Medicare2

Condition

In conclusion….


The average private hospital reimbursement for a
foot ulcer for 11 days is about $11,638 while
Medicare reimbursement for foot ulcer conditions is
usually for 7.3 days and $5,227.



The direct economic cost attributable to foot ulcers
from onset for two years approaches $28,000.



Guideline-based care is needed to improve outcomes
and provide cost savings compared with standard
care

Final conclusions and suggestions!!!










Diabetes has pervasive emotional and physical effects on patients lives.
Additionally, physical and psychological barriers, time and monetary
limitations, and a lack of social support complicates disease management
People, especially those with little education, may not understand the
progressive nature of diabetes. However, using diabetes complications as
a scare tactic may only exacerbate feelings of helplessness if patients view
future complications as inevitable
Documented workplace discrimination allegations indicate that people with
diabetes are more likely to experience prejudice, which can affect job
retention. This in turn may affect access to health insurance and health
maintenance
balancing familial and work responsibilities may complicate diabetes
management because of feelings of obligation. Working patients need
flexible supports that facilitate program participation such as longer clinic
hours, child care services, time management training, and flexible work
schedules that accommodate doctor visits and exercise
Finally, diabetes supports should address the whole person — physically,
psychologically, and socially. Future interventions for working people with
diabetes should include coordinated programs that involve social,
emotional, and lifestyle supports to help keep people healthy so that they
can work well

Thank U
4 your
@Ntion !!

Pts


Slide 9

Diabetic Neuropathy
in the workforce
and cost
Panagiotis V. Tsaklis, PhD
Associate Professor
School of Health Professions
“Alexander” TEI Thessaloniki
Sen. Researcher
Dept Public Health Sciences
Occupational & Environmental Medicine
Karolinska Institutet

mellitus…


The global prevalence of diabetes is
predicted to double by the year 2030 from
2.8% to 4.4%.



…Of individuals with diabetes, a substantial
number will develop lower extremity disease
including peripheral neuropathy, foot ulcers
and peripheral arterial disease…

Does it cost much??


In 2007, the estimated national cost in US of diabetes
exceeded $174 billion…


This estimate included $116 billion in diabetesrelated medical costs and $58 billion in reduced
productivity ….due to increased work absenteeism,
reduced work and daily productivity, unemployment
from disease-related disability, and early death..



Polyneuropathy is one of the commonest complications of the
diabetes and the commonest form of neuropathy in the
developed World. Diabetic polyneuropathy encompasses
several neuropathic syndromes the commonest of which is
distal symmetrical neuropathy, the main initiating factor for foot
ulceration. The epidemiology of diabetic neuropathy has
recently been reviewed in reasonable detail

…from the 1999-2000 population-based US Health and Nutrition
Survey (NHANES), The prevalence (history) of peripheral
neuropathy (> 1 insensate area) in people with diabetes was
28.5%...


The EURODIAB Prospective Complications Study which
involved the examination of 3250 type 1 patients, from 16
European countries, found a prevalence rate of 28% for distal
symmetrical neuropathy

…painful diabetic
peripheral neuropathy (pDPN) is associated with
worse health outcomes…
…however, among pDPN patients, few studies have
examined the relationship between the severity of
pain and health outcomes……

Lost Productive Time (LPT) and diabetes neuropathy…
…studies suggest that individuals
40 to 65 years old in the US workforce, with diabetes and neuropathic
symptoms experience excess health-related LPT compared with that of
others with and without diabetes

…The mean hours of LPT per week was substantially higher in the
diabetes patients with neuropathic symptoms
compared with in the others 4.21 hrs vs 1.90 hrs…(diabetic &
controls)
…more individuals who had diabetes with neuropathic symptoms
reported moderate to severe impact on work ability (ie, score 5 on a
scale from 0–10 compared with those without neuropathic
symptoms
(where 0 means “it has no effect on my ability to work” and 10 means “I am no longer able
to work”)

Cost of Lost Productive Time…$ $ $ $ $...:
In the US Workforce gives a equivalent of $3.65 billion
per year in health-related LPT, a cost per worker that is more
than 2.5 times higher than workers with diabetes without neuropathic
Symptoms…

In conclusion,…The severity might
lead to decreased health status,

•It is observed a prevalence of moderate-to-severe pain among pDPN
patients
•also indicate that health outcomes are significantly worse as pain severity
increases.
•Specifically, work impairment, health care resource use, and the associated
indirect and direct costs increase significantly as the level of pain severity
increases.
•These data emphasize the need
for effectively managing pain in patients with pDPN.

Peripheral (symmetrical) Neuropathy
(Sensory-Motor Neuropathy) which leads to……
Complications
Intrinsic muscles atrophy
→ foot deformities
Reflex reduction
→ Gait alteration…
Calluses & Ulcers occurrence
Amputations…

Aggravating Factors…
Peripheral Vascular Disease

Joint Mobility Reduction
Foot Structural deformities

Foot soft tissues lesions
Autonomous Neuropathy ???
Vassel-Kinetic Neuropathy (VASOMOTOR)
Sweat -Kinetic Neuropathy (SUDOMOTOR)

“autosympathectomy.”

Diabetic foot……The majority of lower extremity disease in people with diabetes is
treated in outpatient, clinic or office settings

Focus on Foot Ulcers

Foot ulcers are defined as a cutaneous erosion
extending through the dermis to deeper tissue, result
from various etiologic factors and are characterized
by an inability to self-repair in a timely and orderly
manner

Frequency of Lower Extremity Conditions in the U.S. Population with
Diabetes per 1,000.
Hospital Discharge Data for Ulcer/inflammation/infection (Ulcer),
Peripheral Neuropathy, and Peripheral Arterial Disease (PAD), 19932002

Age-adjusted Hospital Discharge Rates for Lower Extremity Disease
in the U.S. Population with Diabetes per 1,000.
Ulcer/inflammation/infection (Ulcer), Peripheral Neuropathy, and
Peripheral Arterial Disease (PAD), 1993-2002

R
a
t
e
/
1
,
0
0
0

Population-Based Diabetic Foot Ulcer Incidence and Prevalence
from Selected Studies…
First Author/
Reference

Foot Ulcer
Foot Ulcer

Population Studied

Annual
Prevalence /100
Incidence /100

Abbott (16)

Borssen (32)

Kumar (12)
Lavery (33)

Malgrane (34)
MMWR (35)
Moss (23)

Ramsey (28)
Walters (14)

Cohort of 6,613 patients in six district
clinics in NW England followed for 2
yrs, Type 1, 2 diabetes
375 patients Umea County Sweden, Age
15-50,
Type 1 = 298, Type 2 = 77
Cross-sectional study of 811 Type 2
patients from three UK cities
Cohort of 1,666 patients, San Antonio,
Texas, 51% Mexican Americans,
followed for 2 yrs
664 patients from 16 French diabetes
centers
2000-2002 BRFSS US survey of adults
> 18 yrs
Cohort of 2,990 patients with late and
early-onset diabetes
Nested case-control study in HMO,
8,905 Type 1, Type 2
Cross-sectional study of 1,077 Type 1, 2
patients in 10 UK general medicine
practices

2.2

4.7

2.0

10.0 IDDM
9.0 NIDDM

1.0

5.3

3.4

—

—

15.8%

—

11.8%

2.4 younger

9.5 younger

2.6 older

10.5 older

1.9
4.1

7.4

Frequency of U.S. Hospitalization for Ulcer-Related Conditions
in Individuals with Diabetes by Diagnosis, 2001-2002
Type of ulcer

ICD-CM
Codes

Estimated
Frequency
2001

Estimated
Frequency
2002

Cellulitis, abscess, or infected ulcer
Other cellulitis and abscess, foot except toes

681.1
682.7

26,685
81,367

29,347
83,954

Ulcer of lower limbs, except decubitus
Osteomyelitis

707.1
730.07

209,088
60,989

216,785
66,591

129,466

134,274

83,546

78,983

730.17
730.27
730.37
730.87
730.97

Chronic nonhealing ulcers

707.0
707.9

Atherosclerosis of lower limb with ulcer

440.23

Or gangrene

440.24

Ulcers Health Care Costs…



Optimally, the estimation of diabetic foot ulcer costs
spans an entire ulcer episode from lesion onset to
final resolution.



Two studies provided direct costs associated with the
entire diabetic foot ulcer history. This methodology
captures the many inpatient and outpatient
costs/charges associated with foot ulcers and is
preferable to reporting only charge for a single
hospitalization or limited time interval

Direct Cost for Foot Ulcers in Persons with Diabetes From Two
Studies
Author

# Patients/

Outcome

Average
Episode Cost
(US $)

Inpatient
Cost %

Outpatient
Cost %

Primary healing =
63%

$6,664

61

39

18

82

Study Type

Apelqvist Prospective
(27)
314 General
Internal
Medicine
Patients
Ramsey
(28)

Healed after
amputation = 24%

Nested casePrimary healing =
control study
84%
in HMO of
Amputation =
8,905 Type 1,2
16%

$44,790

$27,987

Total
Attributable
cost

Ulcer Reimbursement to Hospitals for Patients with and
without Diabetes, 2002
Medstat (Private)1
Source:

Length of Stay

Average $
Reimbursement

Length of Stay

Average $
Reimbursement

18

Peripheral Neuropathy with
complications

5.6

9,036

5.5

4,782

19

Peripheral Neuropathy
without complications

4.8

6,061

3.6

3,034

277

Cellulitis > age 17 with
complications

4.8

6,823

5.7

4,000

278

Cellulitis > age 17 without
complications

3.4

4,426

4.2

2,192

271

Skin Ulcers

11.0

11,638

7.3

5,227

238

Osteomyelitis

5.9

9,913

8.7

7,376

130

Peripheral Arterial Disease
with complications

5.1

7,743

5.6

4,554

131

Peripheral Arterial Disease
without complications

4.3

5,768

4.1

2,375

1Medstat

Group,
Thompson
DRG
Corporati
on, 2005
2Centers

for
Medicare
and
Medicaid
Services,
2005

Key:
DRG =
Diagnostic
Related
Group

Medicare2

Condition

In conclusion….


The average private hospital reimbursement for a
foot ulcer for 11 days is about $11,638 while
Medicare reimbursement for foot ulcer conditions is
usually for 7.3 days and $5,227.



The direct economic cost attributable to foot ulcers
from onset for two years approaches $28,000.



Guideline-based care is needed to improve outcomes
and provide cost savings compared with standard
care

Final conclusions and suggestions!!!










Diabetes has pervasive emotional and physical effects on patients lives.
Additionally, physical and psychological barriers, time and monetary
limitations, and a lack of social support complicates disease management
People, especially those with little education, may not understand the
progressive nature of diabetes. However, using diabetes complications as
a scare tactic may only exacerbate feelings of helplessness if patients view
future complications as inevitable
Documented workplace discrimination allegations indicate that people with
diabetes are more likely to experience prejudice, which can affect job
retention. This in turn may affect access to health insurance and health
maintenance
balancing familial and work responsibilities may complicate diabetes
management because of feelings of obligation. Working patients need
flexible supports that facilitate program participation such as longer clinic
hours, child care services, time management training, and flexible work
schedules that accommodate doctor visits and exercise
Finally, diabetes supports should address the whole person — physically,
psychologically, and socially. Future interventions for working people with
diabetes should include coordinated programs that involve social,
emotional, and lifestyle supports to help keep people healthy so that they
can work well

Thank U
4 your
@Ntion !!

Pts


Slide 10

Diabetic Neuropathy
in the workforce
and cost
Panagiotis V. Tsaklis, PhD
Associate Professor
School of Health Professions
“Alexander” TEI Thessaloniki
Sen. Researcher
Dept Public Health Sciences
Occupational & Environmental Medicine
Karolinska Institutet

mellitus…


The global prevalence of diabetes is
predicted to double by the year 2030 from
2.8% to 4.4%.



…Of individuals with diabetes, a substantial
number will develop lower extremity disease
including peripheral neuropathy, foot ulcers
and peripheral arterial disease…

Does it cost much??


In 2007, the estimated national cost in US of diabetes
exceeded $174 billion…


This estimate included $116 billion in diabetesrelated medical costs and $58 billion in reduced
productivity ….due to increased work absenteeism,
reduced work and daily productivity, unemployment
from disease-related disability, and early death..



Polyneuropathy is one of the commonest complications of the
diabetes and the commonest form of neuropathy in the
developed World. Diabetic polyneuropathy encompasses
several neuropathic syndromes the commonest of which is
distal symmetrical neuropathy, the main initiating factor for foot
ulceration. The epidemiology of diabetic neuropathy has
recently been reviewed in reasonable detail

…from the 1999-2000 population-based US Health and Nutrition
Survey (NHANES), The prevalence (history) of peripheral
neuropathy (> 1 insensate area) in people with diabetes was
28.5%...


The EURODIAB Prospective Complications Study which
involved the examination of 3250 type 1 patients, from 16
European countries, found a prevalence rate of 28% for distal
symmetrical neuropathy

…painful diabetic
peripheral neuropathy (pDPN) is associated with
worse health outcomes…
…however, among pDPN patients, few studies have
examined the relationship between the severity of
pain and health outcomes……

Lost Productive Time (LPT) and diabetes neuropathy…
…studies suggest that individuals
40 to 65 years old in the US workforce, with diabetes and neuropathic
symptoms experience excess health-related LPT compared with that of
others with and without diabetes

…The mean hours of LPT per week was substantially higher in the
diabetes patients with neuropathic symptoms
compared with in the others 4.21 hrs vs 1.90 hrs…(diabetic &
controls)
…more individuals who had diabetes with neuropathic symptoms
reported moderate to severe impact on work ability (ie, score 5 on a
scale from 0–10 compared with those without neuropathic
symptoms
(where 0 means “it has no effect on my ability to work” and 10 means “I am no longer able
to work”)

Cost of Lost Productive Time…$ $ $ $ $...:
In the US Workforce gives a equivalent of $3.65 billion
per year in health-related LPT, a cost per worker that is more
than 2.5 times higher than workers with diabetes without neuropathic
Symptoms…

In conclusion,…The severity might
lead to decreased health status,

•It is observed a prevalence of moderate-to-severe pain among pDPN
patients
•also indicate that health outcomes are significantly worse as pain severity
increases.
•Specifically, work impairment, health care resource use, and the associated
indirect and direct costs increase significantly as the level of pain severity
increases.
•These data emphasize the need
for effectively managing pain in patients with pDPN.

Peripheral (symmetrical) Neuropathy
(Sensory-Motor Neuropathy) which leads to……
Complications
Intrinsic muscles atrophy
→ foot deformities
Reflex reduction
→ Gait alteration…
Calluses & Ulcers occurrence
Amputations…

Aggravating Factors…
Peripheral Vascular Disease

Joint Mobility Reduction
Foot Structural deformities

Foot soft tissues lesions
Autonomous Neuropathy ???
Vassel-Kinetic Neuropathy (VASOMOTOR)
Sweat -Kinetic Neuropathy (SUDOMOTOR)

“autosympathectomy.”

Diabetic foot……The majority of lower extremity disease in people with diabetes is
treated in outpatient, clinic or office settings

Focus on Foot Ulcers

Foot ulcers are defined as a cutaneous erosion
extending through the dermis to deeper tissue, result
from various etiologic factors and are characterized
by an inability to self-repair in a timely and orderly
manner

Frequency of Lower Extremity Conditions in the U.S. Population with
Diabetes per 1,000.
Hospital Discharge Data for Ulcer/inflammation/infection (Ulcer),
Peripheral Neuropathy, and Peripheral Arterial Disease (PAD), 19932002

Age-adjusted Hospital Discharge Rates for Lower Extremity Disease
in the U.S. Population with Diabetes per 1,000.
Ulcer/inflammation/infection (Ulcer), Peripheral Neuropathy, and
Peripheral Arterial Disease (PAD), 1993-2002

R
a
t
e
/
1
,
0
0
0

Population-Based Diabetic Foot Ulcer Incidence and Prevalence
from Selected Studies…
First Author/
Reference

Foot Ulcer
Foot Ulcer

Population Studied

Annual
Prevalence /100
Incidence /100

Abbott (16)

Borssen (32)

Kumar (12)
Lavery (33)

Malgrane (34)
MMWR (35)
Moss (23)

Ramsey (28)
Walters (14)

Cohort of 6,613 patients in six district
clinics in NW England followed for 2
yrs, Type 1, 2 diabetes
375 patients Umea County Sweden, Age
15-50,
Type 1 = 298, Type 2 = 77
Cross-sectional study of 811 Type 2
patients from three UK cities
Cohort of 1,666 patients, San Antonio,
Texas, 51% Mexican Americans,
followed for 2 yrs
664 patients from 16 French diabetes
centers
2000-2002 BRFSS US survey of adults
> 18 yrs
Cohort of 2,990 patients with late and
early-onset diabetes
Nested case-control study in HMO,
8,905 Type 1, Type 2
Cross-sectional study of 1,077 Type 1, 2
patients in 10 UK general medicine
practices

2.2

4.7

2.0

10.0 IDDM
9.0 NIDDM

1.0

5.3

3.4

—

—

15.8%

—

11.8%

2.4 younger

9.5 younger

2.6 older

10.5 older

1.9
4.1

7.4

Frequency of U.S. Hospitalization for Ulcer-Related Conditions
in Individuals with Diabetes by Diagnosis, 2001-2002
Type of ulcer

ICD-CM
Codes

Estimated
Frequency
2001

Estimated
Frequency
2002

Cellulitis, abscess, or infected ulcer
Other cellulitis and abscess, foot except toes

681.1
682.7

26,685
81,367

29,347
83,954

Ulcer of lower limbs, except decubitus
Osteomyelitis

707.1
730.07

209,088
60,989

216,785
66,591

129,466

134,274

83,546

78,983

730.17
730.27
730.37
730.87
730.97

Chronic nonhealing ulcers

707.0
707.9

Atherosclerosis of lower limb with ulcer

440.23

Or gangrene

440.24

Ulcers Health Care Costs…



Optimally, the estimation of diabetic foot ulcer costs
spans an entire ulcer episode from lesion onset to
final resolution.



Two studies provided direct costs associated with the
entire diabetic foot ulcer history. This methodology
captures the many inpatient and outpatient
costs/charges associated with foot ulcers and is
preferable to reporting only charge for a single
hospitalization or limited time interval

Direct Cost for Foot Ulcers in Persons with Diabetes From Two
Studies
Author

# Patients/

Outcome

Average
Episode Cost
(US $)

Inpatient
Cost %

Outpatient
Cost %

Primary healing =
63%

$6,664

61

39

18

82

Study Type

Apelqvist Prospective
(27)
314 General
Internal
Medicine
Patients
Ramsey
(28)

Healed after
amputation = 24%

Nested casePrimary healing =
control study
84%
in HMO of
Amputation =
8,905 Type 1,2
16%

$44,790

$27,987

Total
Attributable
cost

Ulcer Reimbursement to Hospitals for Patients with and
without Diabetes, 2002
Medstat (Private)1
Source:

Length of Stay

Average $
Reimbursement

Length of Stay

Average $
Reimbursement

18

Peripheral Neuropathy with
complications

5.6

9,036

5.5

4,782

19

Peripheral Neuropathy
without complications

4.8

6,061

3.6

3,034

277

Cellulitis > age 17 with
complications

4.8

6,823

5.7

4,000

278

Cellulitis > age 17 without
complications

3.4

4,426

4.2

2,192

271

Skin Ulcers

11.0

11,638

7.3

5,227

238

Osteomyelitis

5.9

9,913

8.7

7,376

130

Peripheral Arterial Disease
with complications

5.1

7,743

5.6

4,554

131

Peripheral Arterial Disease
without complications

4.3

5,768

4.1

2,375

1Medstat

Group,
Thompson
DRG
Corporati
on, 2005
2Centers

for
Medicare
and
Medicaid
Services,
2005

Key:
DRG =
Diagnostic
Related
Group

Medicare2

Condition

In conclusion….


The average private hospital reimbursement for a
foot ulcer for 11 days is about $11,638 while
Medicare reimbursement for foot ulcer conditions is
usually for 7.3 days and $5,227.



The direct economic cost attributable to foot ulcers
from onset for two years approaches $28,000.



Guideline-based care is needed to improve outcomes
and provide cost savings compared with standard
care

Final conclusions and suggestions!!!










Diabetes has pervasive emotional and physical effects on patients lives.
Additionally, physical and psychological barriers, time and monetary
limitations, and a lack of social support complicates disease management
People, especially those with little education, may not understand the
progressive nature of diabetes. However, using diabetes complications as
a scare tactic may only exacerbate feelings of helplessness if patients view
future complications as inevitable
Documented workplace discrimination allegations indicate that people with
diabetes are more likely to experience prejudice, which can affect job
retention. This in turn may affect access to health insurance and health
maintenance
balancing familial and work responsibilities may complicate diabetes
management because of feelings of obligation. Working patients need
flexible supports that facilitate program participation such as longer clinic
hours, child care services, time management training, and flexible work
schedules that accommodate doctor visits and exercise
Finally, diabetes supports should address the whole person — physically,
psychologically, and socially. Future interventions for working people with
diabetes should include coordinated programs that involve social,
emotional, and lifestyle supports to help keep people healthy so that they
can work well

Thank U
4 your
@Ntion !!

Pts


Slide 11

Diabetic Neuropathy
in the workforce
and cost
Panagiotis V. Tsaklis, PhD
Associate Professor
School of Health Professions
“Alexander” TEI Thessaloniki
Sen. Researcher
Dept Public Health Sciences
Occupational & Environmental Medicine
Karolinska Institutet

mellitus…


The global prevalence of diabetes is
predicted to double by the year 2030 from
2.8% to 4.4%.



…Of individuals with diabetes, a substantial
number will develop lower extremity disease
including peripheral neuropathy, foot ulcers
and peripheral arterial disease…

Does it cost much??


In 2007, the estimated national cost in US of diabetes
exceeded $174 billion…


This estimate included $116 billion in diabetesrelated medical costs and $58 billion in reduced
productivity ….due to increased work absenteeism,
reduced work and daily productivity, unemployment
from disease-related disability, and early death..



Polyneuropathy is one of the commonest complications of the
diabetes and the commonest form of neuropathy in the
developed World. Diabetic polyneuropathy encompasses
several neuropathic syndromes the commonest of which is
distal symmetrical neuropathy, the main initiating factor for foot
ulceration. The epidemiology of diabetic neuropathy has
recently been reviewed in reasonable detail

…from the 1999-2000 population-based US Health and Nutrition
Survey (NHANES), The prevalence (history) of peripheral
neuropathy (> 1 insensate area) in people with diabetes was
28.5%...


The EURODIAB Prospective Complications Study which
involved the examination of 3250 type 1 patients, from 16
European countries, found a prevalence rate of 28% for distal
symmetrical neuropathy

…painful diabetic
peripheral neuropathy (pDPN) is associated with
worse health outcomes…
…however, among pDPN patients, few studies have
examined the relationship between the severity of
pain and health outcomes……

Lost Productive Time (LPT) and diabetes neuropathy…
…studies suggest that individuals
40 to 65 years old in the US workforce, with diabetes and neuropathic
symptoms experience excess health-related LPT compared with that of
others with and without diabetes

…The mean hours of LPT per week was substantially higher in the
diabetes patients with neuropathic symptoms
compared with in the others 4.21 hrs vs 1.90 hrs…(diabetic &
controls)
…more individuals who had diabetes with neuropathic symptoms
reported moderate to severe impact on work ability (ie, score 5 on a
scale from 0–10 compared with those without neuropathic
symptoms
(where 0 means “it has no effect on my ability to work” and 10 means “I am no longer able
to work”)

Cost of Lost Productive Time…$ $ $ $ $...:
In the US Workforce gives a equivalent of $3.65 billion
per year in health-related LPT, a cost per worker that is more
than 2.5 times higher than workers with diabetes without neuropathic
Symptoms…

In conclusion,…The severity might
lead to decreased health status,

•It is observed a prevalence of moderate-to-severe pain among pDPN
patients
•also indicate that health outcomes are significantly worse as pain severity
increases.
•Specifically, work impairment, health care resource use, and the associated
indirect and direct costs increase significantly as the level of pain severity
increases.
•These data emphasize the need
for effectively managing pain in patients with pDPN.

Peripheral (symmetrical) Neuropathy
(Sensory-Motor Neuropathy) which leads to……
Complications
Intrinsic muscles atrophy
→ foot deformities
Reflex reduction
→ Gait alteration…
Calluses & Ulcers occurrence
Amputations…

Aggravating Factors…
Peripheral Vascular Disease

Joint Mobility Reduction
Foot Structural deformities

Foot soft tissues lesions
Autonomous Neuropathy ???
Vassel-Kinetic Neuropathy (VASOMOTOR)
Sweat -Kinetic Neuropathy (SUDOMOTOR)

“autosympathectomy.”

Diabetic foot……The majority of lower extremity disease in people with diabetes is
treated in outpatient, clinic or office settings

Focus on Foot Ulcers

Foot ulcers are defined as a cutaneous erosion
extending through the dermis to deeper tissue, result
from various etiologic factors and are characterized
by an inability to self-repair in a timely and orderly
manner

Frequency of Lower Extremity Conditions in the U.S. Population with
Diabetes per 1,000.
Hospital Discharge Data for Ulcer/inflammation/infection (Ulcer),
Peripheral Neuropathy, and Peripheral Arterial Disease (PAD), 19932002

Age-adjusted Hospital Discharge Rates for Lower Extremity Disease
in the U.S. Population with Diabetes per 1,000.
Ulcer/inflammation/infection (Ulcer), Peripheral Neuropathy, and
Peripheral Arterial Disease (PAD), 1993-2002

R
a
t
e
/
1
,
0
0
0

Population-Based Diabetic Foot Ulcer Incidence and Prevalence
from Selected Studies…
First Author/
Reference

Foot Ulcer
Foot Ulcer

Population Studied

Annual
Prevalence /100
Incidence /100

Abbott (16)

Borssen (32)

Kumar (12)
Lavery (33)

Malgrane (34)
MMWR (35)
Moss (23)

Ramsey (28)
Walters (14)

Cohort of 6,613 patients in six district
clinics in NW England followed for 2
yrs, Type 1, 2 diabetes
375 patients Umea County Sweden, Age
15-50,
Type 1 = 298, Type 2 = 77
Cross-sectional study of 811 Type 2
patients from three UK cities
Cohort of 1,666 patients, San Antonio,
Texas, 51% Mexican Americans,
followed for 2 yrs
664 patients from 16 French diabetes
centers
2000-2002 BRFSS US survey of adults
> 18 yrs
Cohort of 2,990 patients with late and
early-onset diabetes
Nested case-control study in HMO,
8,905 Type 1, Type 2
Cross-sectional study of 1,077 Type 1, 2
patients in 10 UK general medicine
practices

2.2

4.7

2.0

10.0 IDDM
9.0 NIDDM

1.0

5.3

3.4

—

—

15.8%

—

11.8%

2.4 younger

9.5 younger

2.6 older

10.5 older

1.9
4.1

7.4

Frequency of U.S. Hospitalization for Ulcer-Related Conditions
in Individuals with Diabetes by Diagnosis, 2001-2002
Type of ulcer

ICD-CM
Codes

Estimated
Frequency
2001

Estimated
Frequency
2002

Cellulitis, abscess, or infected ulcer
Other cellulitis and abscess, foot except toes

681.1
682.7

26,685
81,367

29,347
83,954

Ulcer of lower limbs, except decubitus
Osteomyelitis

707.1
730.07

209,088
60,989

216,785
66,591

129,466

134,274

83,546

78,983

730.17
730.27
730.37
730.87
730.97

Chronic nonhealing ulcers

707.0
707.9

Atherosclerosis of lower limb with ulcer

440.23

Or gangrene

440.24

Ulcers Health Care Costs…



Optimally, the estimation of diabetic foot ulcer costs
spans an entire ulcer episode from lesion onset to
final resolution.



Two studies provided direct costs associated with the
entire diabetic foot ulcer history. This methodology
captures the many inpatient and outpatient
costs/charges associated with foot ulcers and is
preferable to reporting only charge for a single
hospitalization or limited time interval

Direct Cost for Foot Ulcers in Persons with Diabetes From Two
Studies
Author

# Patients/

Outcome

Average
Episode Cost
(US $)

Inpatient
Cost %

Outpatient
Cost %

Primary healing =
63%

$6,664

61

39

18

82

Study Type

Apelqvist Prospective
(27)
314 General
Internal
Medicine
Patients
Ramsey
(28)

Healed after
amputation = 24%

Nested casePrimary healing =
control study
84%
in HMO of
Amputation =
8,905 Type 1,2
16%

$44,790

$27,987

Total
Attributable
cost

Ulcer Reimbursement to Hospitals for Patients with and
without Diabetes, 2002
Medstat (Private)1
Source:

Length of Stay

Average $
Reimbursement

Length of Stay

Average $
Reimbursement

18

Peripheral Neuropathy with
complications

5.6

9,036

5.5

4,782

19

Peripheral Neuropathy
without complications

4.8

6,061

3.6

3,034

277

Cellulitis > age 17 with
complications

4.8

6,823

5.7

4,000

278

Cellulitis > age 17 without
complications

3.4

4,426

4.2

2,192

271

Skin Ulcers

11.0

11,638

7.3

5,227

238

Osteomyelitis

5.9

9,913

8.7

7,376

130

Peripheral Arterial Disease
with complications

5.1

7,743

5.6

4,554

131

Peripheral Arterial Disease
without complications

4.3

5,768

4.1

2,375

1Medstat

Group,
Thompson
DRG
Corporati
on, 2005
2Centers

for
Medicare
and
Medicaid
Services,
2005

Key:
DRG =
Diagnostic
Related
Group

Medicare2

Condition

In conclusion….


The average private hospital reimbursement for a
foot ulcer for 11 days is about $11,638 while
Medicare reimbursement for foot ulcer conditions is
usually for 7.3 days and $5,227.



The direct economic cost attributable to foot ulcers
from onset for two years approaches $28,000.



Guideline-based care is needed to improve outcomes
and provide cost savings compared with standard
care

Final conclusions and suggestions!!!










Diabetes has pervasive emotional and physical effects on patients lives.
Additionally, physical and psychological barriers, time and monetary
limitations, and a lack of social support complicates disease management
People, especially those with little education, may not understand the
progressive nature of diabetes. However, using diabetes complications as
a scare tactic may only exacerbate feelings of helplessness if patients view
future complications as inevitable
Documented workplace discrimination allegations indicate that people with
diabetes are more likely to experience prejudice, which can affect job
retention. This in turn may affect access to health insurance and health
maintenance
balancing familial and work responsibilities may complicate diabetes
management because of feelings of obligation. Working patients need
flexible supports that facilitate program participation such as longer clinic
hours, child care services, time management training, and flexible work
schedules that accommodate doctor visits and exercise
Finally, diabetes supports should address the whole person — physically,
psychologically, and socially. Future interventions for working people with
diabetes should include coordinated programs that involve social,
emotional, and lifestyle supports to help keep people healthy so that they
can work well

Thank U
4 your
@Ntion !!

Pts


Slide 12

Diabetic Neuropathy
in the workforce
and cost
Panagiotis V. Tsaklis, PhD
Associate Professor
School of Health Professions
“Alexander” TEI Thessaloniki
Sen. Researcher
Dept Public Health Sciences
Occupational & Environmental Medicine
Karolinska Institutet

mellitus…


The global prevalence of diabetes is
predicted to double by the year 2030 from
2.8% to 4.4%.



…Of individuals with diabetes, a substantial
number will develop lower extremity disease
including peripheral neuropathy, foot ulcers
and peripheral arterial disease…

Does it cost much??


In 2007, the estimated national cost in US of diabetes
exceeded $174 billion…


This estimate included $116 billion in diabetesrelated medical costs and $58 billion in reduced
productivity ….due to increased work absenteeism,
reduced work and daily productivity, unemployment
from disease-related disability, and early death..



Polyneuropathy is one of the commonest complications of the
diabetes and the commonest form of neuropathy in the
developed World. Diabetic polyneuropathy encompasses
several neuropathic syndromes the commonest of which is
distal symmetrical neuropathy, the main initiating factor for foot
ulceration. The epidemiology of diabetic neuropathy has
recently been reviewed in reasonable detail

…from the 1999-2000 population-based US Health and Nutrition
Survey (NHANES), The prevalence (history) of peripheral
neuropathy (> 1 insensate area) in people with diabetes was
28.5%...


The EURODIAB Prospective Complications Study which
involved the examination of 3250 type 1 patients, from 16
European countries, found a prevalence rate of 28% for distal
symmetrical neuropathy

…painful diabetic
peripheral neuropathy (pDPN) is associated with
worse health outcomes…
…however, among pDPN patients, few studies have
examined the relationship between the severity of
pain and health outcomes……

Lost Productive Time (LPT) and diabetes neuropathy…
…studies suggest that individuals
40 to 65 years old in the US workforce, with diabetes and neuropathic
symptoms experience excess health-related LPT compared with that of
others with and without diabetes

…The mean hours of LPT per week was substantially higher in the
diabetes patients with neuropathic symptoms
compared with in the others 4.21 hrs vs 1.90 hrs…(diabetic &
controls)
…more individuals who had diabetes with neuropathic symptoms
reported moderate to severe impact on work ability (ie, score 5 on a
scale from 0–10 compared with those without neuropathic
symptoms
(where 0 means “it has no effect on my ability to work” and 10 means “I am no longer able
to work”)

Cost of Lost Productive Time…$ $ $ $ $...:
In the US Workforce gives a equivalent of $3.65 billion
per year in health-related LPT, a cost per worker that is more
than 2.5 times higher than workers with diabetes without neuropathic
Symptoms…

In conclusion,…The severity might
lead to decreased health status,

•It is observed a prevalence of moderate-to-severe pain among pDPN
patients
•also indicate that health outcomes are significantly worse as pain severity
increases.
•Specifically, work impairment, health care resource use, and the associated
indirect and direct costs increase significantly as the level of pain severity
increases.
•These data emphasize the need
for effectively managing pain in patients with pDPN.

Peripheral (symmetrical) Neuropathy
(Sensory-Motor Neuropathy) which leads to……
Complications
Intrinsic muscles atrophy
→ foot deformities
Reflex reduction
→ Gait alteration…
Calluses & Ulcers occurrence
Amputations…

Aggravating Factors…
Peripheral Vascular Disease

Joint Mobility Reduction
Foot Structural deformities

Foot soft tissues lesions
Autonomous Neuropathy ???
Vassel-Kinetic Neuropathy (VASOMOTOR)
Sweat -Kinetic Neuropathy (SUDOMOTOR)

“autosympathectomy.”

Diabetic foot……The majority of lower extremity disease in people with diabetes is
treated in outpatient, clinic or office settings

Focus on Foot Ulcers

Foot ulcers are defined as a cutaneous erosion
extending through the dermis to deeper tissue, result
from various etiologic factors and are characterized
by an inability to self-repair in a timely and orderly
manner

Frequency of Lower Extremity Conditions in the U.S. Population with
Diabetes per 1,000.
Hospital Discharge Data for Ulcer/inflammation/infection (Ulcer),
Peripheral Neuropathy, and Peripheral Arterial Disease (PAD), 19932002

Age-adjusted Hospital Discharge Rates for Lower Extremity Disease
in the U.S. Population with Diabetes per 1,000.
Ulcer/inflammation/infection (Ulcer), Peripheral Neuropathy, and
Peripheral Arterial Disease (PAD), 1993-2002

R
a
t
e
/
1
,
0
0
0

Population-Based Diabetic Foot Ulcer Incidence and Prevalence
from Selected Studies…
First Author/
Reference

Foot Ulcer
Foot Ulcer

Population Studied

Annual
Prevalence /100
Incidence /100

Abbott (16)

Borssen (32)

Kumar (12)
Lavery (33)

Malgrane (34)
MMWR (35)
Moss (23)

Ramsey (28)
Walters (14)

Cohort of 6,613 patients in six district
clinics in NW England followed for 2
yrs, Type 1, 2 diabetes
375 patients Umea County Sweden, Age
15-50,
Type 1 = 298, Type 2 = 77
Cross-sectional study of 811 Type 2
patients from three UK cities
Cohort of 1,666 patients, San Antonio,
Texas, 51% Mexican Americans,
followed for 2 yrs
664 patients from 16 French diabetes
centers
2000-2002 BRFSS US survey of adults
> 18 yrs
Cohort of 2,990 patients with late and
early-onset diabetes
Nested case-control study in HMO,
8,905 Type 1, Type 2
Cross-sectional study of 1,077 Type 1, 2
patients in 10 UK general medicine
practices

2.2

4.7

2.0

10.0 IDDM
9.0 NIDDM

1.0

5.3

3.4

—

—

15.8%

—

11.8%

2.4 younger

9.5 younger

2.6 older

10.5 older

1.9
4.1

7.4

Frequency of U.S. Hospitalization for Ulcer-Related Conditions
in Individuals with Diabetes by Diagnosis, 2001-2002
Type of ulcer

ICD-CM
Codes

Estimated
Frequency
2001

Estimated
Frequency
2002

Cellulitis, abscess, or infected ulcer
Other cellulitis and abscess, foot except toes

681.1
682.7

26,685
81,367

29,347
83,954

Ulcer of lower limbs, except decubitus
Osteomyelitis

707.1
730.07

209,088
60,989

216,785
66,591

129,466

134,274

83,546

78,983

730.17
730.27
730.37
730.87
730.97

Chronic nonhealing ulcers

707.0
707.9

Atherosclerosis of lower limb with ulcer

440.23

Or gangrene

440.24

Ulcers Health Care Costs…



Optimally, the estimation of diabetic foot ulcer costs
spans an entire ulcer episode from lesion onset to
final resolution.



Two studies provided direct costs associated with the
entire diabetic foot ulcer history. This methodology
captures the many inpatient and outpatient
costs/charges associated with foot ulcers and is
preferable to reporting only charge for a single
hospitalization or limited time interval

Direct Cost for Foot Ulcers in Persons with Diabetes From Two
Studies
Author

# Patients/

Outcome

Average
Episode Cost
(US $)

Inpatient
Cost %

Outpatient
Cost %

Primary healing =
63%

$6,664

61

39

18

82

Study Type

Apelqvist Prospective
(27)
314 General
Internal
Medicine
Patients
Ramsey
(28)

Healed after
amputation = 24%

Nested casePrimary healing =
control study
84%
in HMO of
Amputation =
8,905 Type 1,2
16%

$44,790

$27,987

Total
Attributable
cost

Ulcer Reimbursement to Hospitals for Patients with and
without Diabetes, 2002
Medstat (Private)1
Source:

Length of Stay

Average $
Reimbursement

Length of Stay

Average $
Reimbursement

18

Peripheral Neuropathy with
complications

5.6

9,036

5.5

4,782

19

Peripheral Neuropathy
without complications

4.8

6,061

3.6

3,034

277

Cellulitis > age 17 with
complications

4.8

6,823

5.7

4,000

278

Cellulitis > age 17 without
complications

3.4

4,426

4.2

2,192

271

Skin Ulcers

11.0

11,638

7.3

5,227

238

Osteomyelitis

5.9

9,913

8.7

7,376

130

Peripheral Arterial Disease
with complications

5.1

7,743

5.6

4,554

131

Peripheral Arterial Disease
without complications

4.3

5,768

4.1

2,375

1Medstat

Group,
Thompson
DRG
Corporati
on, 2005
2Centers

for
Medicare
and
Medicaid
Services,
2005

Key:
DRG =
Diagnostic
Related
Group

Medicare2

Condition

In conclusion….


The average private hospital reimbursement for a
foot ulcer for 11 days is about $11,638 while
Medicare reimbursement for foot ulcer conditions is
usually for 7.3 days and $5,227.



The direct economic cost attributable to foot ulcers
from onset for two years approaches $28,000.



Guideline-based care is needed to improve outcomes
and provide cost savings compared with standard
care

Final conclusions and suggestions!!!










Diabetes has pervasive emotional and physical effects on patients lives.
Additionally, physical and psychological barriers, time and monetary
limitations, and a lack of social support complicates disease management
People, especially those with little education, may not understand the
progressive nature of diabetes. However, using diabetes complications as
a scare tactic may only exacerbate feelings of helplessness if patients view
future complications as inevitable
Documented workplace discrimination allegations indicate that people with
diabetes are more likely to experience prejudice, which can affect job
retention. This in turn may affect access to health insurance and health
maintenance
balancing familial and work responsibilities may complicate diabetes
management because of feelings of obligation. Working patients need
flexible supports that facilitate program participation such as longer clinic
hours, child care services, time management training, and flexible work
schedules that accommodate doctor visits and exercise
Finally, diabetes supports should address the whole person — physically,
psychologically, and socially. Future interventions for working people with
diabetes should include coordinated programs that involve social,
emotional, and lifestyle supports to help keep people healthy so that they
can work well

Thank U
4 your
@Ntion !!

Pts


Slide 13

Diabetic Neuropathy
in the workforce
and cost
Panagiotis V. Tsaklis, PhD
Associate Professor
School of Health Professions
“Alexander” TEI Thessaloniki
Sen. Researcher
Dept Public Health Sciences
Occupational & Environmental Medicine
Karolinska Institutet

mellitus…


The global prevalence of diabetes is
predicted to double by the year 2030 from
2.8% to 4.4%.



…Of individuals with diabetes, a substantial
number will develop lower extremity disease
including peripheral neuropathy, foot ulcers
and peripheral arterial disease…

Does it cost much??


In 2007, the estimated national cost in US of diabetes
exceeded $174 billion…


This estimate included $116 billion in diabetesrelated medical costs and $58 billion in reduced
productivity ….due to increased work absenteeism,
reduced work and daily productivity, unemployment
from disease-related disability, and early death..



Polyneuropathy is one of the commonest complications of the
diabetes and the commonest form of neuropathy in the
developed World. Diabetic polyneuropathy encompasses
several neuropathic syndromes the commonest of which is
distal symmetrical neuropathy, the main initiating factor for foot
ulceration. The epidemiology of diabetic neuropathy has
recently been reviewed in reasonable detail

…from the 1999-2000 population-based US Health and Nutrition
Survey (NHANES), The prevalence (history) of peripheral
neuropathy (> 1 insensate area) in people with diabetes was
28.5%...


The EURODIAB Prospective Complications Study which
involved the examination of 3250 type 1 patients, from 16
European countries, found a prevalence rate of 28% for distal
symmetrical neuropathy

…painful diabetic
peripheral neuropathy (pDPN) is associated with
worse health outcomes…
…however, among pDPN patients, few studies have
examined the relationship between the severity of
pain and health outcomes……

Lost Productive Time (LPT) and diabetes neuropathy…
…studies suggest that individuals
40 to 65 years old in the US workforce, with diabetes and neuropathic
symptoms experience excess health-related LPT compared with that of
others with and without diabetes

…The mean hours of LPT per week was substantially higher in the
diabetes patients with neuropathic symptoms
compared with in the others 4.21 hrs vs 1.90 hrs…(diabetic &
controls)
…more individuals who had diabetes with neuropathic symptoms
reported moderate to severe impact on work ability (ie, score 5 on a
scale from 0–10 compared with those without neuropathic
symptoms
(where 0 means “it has no effect on my ability to work” and 10 means “I am no longer able
to work”)

Cost of Lost Productive Time…$ $ $ $ $...:
In the US Workforce gives a equivalent of $3.65 billion
per year in health-related LPT, a cost per worker that is more
than 2.5 times higher than workers with diabetes without neuropathic
Symptoms…

In conclusion,…The severity might
lead to decreased health status,

•It is observed a prevalence of moderate-to-severe pain among pDPN
patients
•also indicate that health outcomes are significantly worse as pain severity
increases.
•Specifically, work impairment, health care resource use, and the associated
indirect and direct costs increase significantly as the level of pain severity
increases.
•These data emphasize the need
for effectively managing pain in patients with pDPN.

Peripheral (symmetrical) Neuropathy
(Sensory-Motor Neuropathy) which leads to……
Complications
Intrinsic muscles atrophy
→ foot deformities
Reflex reduction
→ Gait alteration…
Calluses & Ulcers occurrence
Amputations…

Aggravating Factors…
Peripheral Vascular Disease

Joint Mobility Reduction
Foot Structural deformities

Foot soft tissues lesions
Autonomous Neuropathy ???
Vassel-Kinetic Neuropathy (VASOMOTOR)
Sweat -Kinetic Neuropathy (SUDOMOTOR)

“autosympathectomy.”

Diabetic foot……The majority of lower extremity disease in people with diabetes is
treated in outpatient, clinic or office settings

Focus on Foot Ulcers

Foot ulcers are defined as a cutaneous erosion
extending through the dermis to deeper tissue, result
from various etiologic factors and are characterized
by an inability to self-repair in a timely and orderly
manner

Frequency of Lower Extremity Conditions in the U.S. Population with
Diabetes per 1,000.
Hospital Discharge Data for Ulcer/inflammation/infection (Ulcer),
Peripheral Neuropathy, and Peripheral Arterial Disease (PAD), 19932002

Age-adjusted Hospital Discharge Rates for Lower Extremity Disease
in the U.S. Population with Diabetes per 1,000.
Ulcer/inflammation/infection (Ulcer), Peripheral Neuropathy, and
Peripheral Arterial Disease (PAD), 1993-2002

R
a
t
e
/
1
,
0
0
0

Population-Based Diabetic Foot Ulcer Incidence and Prevalence
from Selected Studies…
First Author/
Reference

Foot Ulcer
Foot Ulcer

Population Studied

Annual
Prevalence /100
Incidence /100

Abbott (16)

Borssen (32)

Kumar (12)
Lavery (33)

Malgrane (34)
MMWR (35)
Moss (23)

Ramsey (28)
Walters (14)

Cohort of 6,613 patients in six district
clinics in NW England followed for 2
yrs, Type 1, 2 diabetes
375 patients Umea County Sweden, Age
15-50,
Type 1 = 298, Type 2 = 77
Cross-sectional study of 811 Type 2
patients from three UK cities
Cohort of 1,666 patients, San Antonio,
Texas, 51% Mexican Americans,
followed for 2 yrs
664 patients from 16 French diabetes
centers
2000-2002 BRFSS US survey of adults
> 18 yrs
Cohort of 2,990 patients with late and
early-onset diabetes
Nested case-control study in HMO,
8,905 Type 1, Type 2
Cross-sectional study of 1,077 Type 1, 2
patients in 10 UK general medicine
practices

2.2

4.7

2.0

10.0 IDDM
9.0 NIDDM

1.0

5.3

3.4

—

—

15.8%

—

11.8%

2.4 younger

9.5 younger

2.6 older

10.5 older

1.9
4.1

7.4

Frequency of U.S. Hospitalization for Ulcer-Related Conditions
in Individuals with Diabetes by Diagnosis, 2001-2002
Type of ulcer

ICD-CM
Codes

Estimated
Frequency
2001

Estimated
Frequency
2002

Cellulitis, abscess, or infected ulcer
Other cellulitis and abscess, foot except toes

681.1
682.7

26,685
81,367

29,347
83,954

Ulcer of lower limbs, except decubitus
Osteomyelitis

707.1
730.07

209,088
60,989

216,785
66,591

129,466

134,274

83,546

78,983

730.17
730.27
730.37
730.87
730.97

Chronic nonhealing ulcers

707.0
707.9

Atherosclerosis of lower limb with ulcer

440.23

Or gangrene

440.24

Ulcers Health Care Costs…



Optimally, the estimation of diabetic foot ulcer costs
spans an entire ulcer episode from lesion onset to
final resolution.



Two studies provided direct costs associated with the
entire diabetic foot ulcer history. This methodology
captures the many inpatient and outpatient
costs/charges associated with foot ulcers and is
preferable to reporting only charge for a single
hospitalization or limited time interval

Direct Cost for Foot Ulcers in Persons with Diabetes From Two
Studies
Author

# Patients/

Outcome

Average
Episode Cost
(US $)

Inpatient
Cost %

Outpatient
Cost %

Primary healing =
63%

$6,664

61

39

18

82

Study Type

Apelqvist Prospective
(27)
314 General
Internal
Medicine
Patients
Ramsey
(28)

Healed after
amputation = 24%

Nested casePrimary healing =
control study
84%
in HMO of
Amputation =
8,905 Type 1,2
16%

$44,790

$27,987

Total
Attributable
cost

Ulcer Reimbursement to Hospitals for Patients with and
without Diabetes, 2002
Medstat (Private)1
Source:

Length of Stay

Average $
Reimbursement

Length of Stay

Average $
Reimbursement

18

Peripheral Neuropathy with
complications

5.6

9,036

5.5

4,782

19

Peripheral Neuropathy
without complications

4.8

6,061

3.6

3,034

277

Cellulitis > age 17 with
complications

4.8

6,823

5.7

4,000

278

Cellulitis > age 17 without
complications

3.4

4,426

4.2

2,192

271

Skin Ulcers

11.0

11,638

7.3

5,227

238

Osteomyelitis

5.9

9,913

8.7

7,376

130

Peripheral Arterial Disease
with complications

5.1

7,743

5.6

4,554

131

Peripheral Arterial Disease
without complications

4.3

5,768

4.1

2,375

1Medstat

Group,
Thompson
DRG
Corporati
on, 2005
2Centers

for
Medicare
and
Medicaid
Services,
2005

Key:
DRG =
Diagnostic
Related
Group

Medicare2

Condition

In conclusion….


The average private hospital reimbursement for a
foot ulcer for 11 days is about $11,638 while
Medicare reimbursement for foot ulcer conditions is
usually for 7.3 days and $5,227.



The direct economic cost attributable to foot ulcers
from onset for two years approaches $28,000.



Guideline-based care is needed to improve outcomes
and provide cost savings compared with standard
care

Final conclusions and suggestions!!!










Diabetes has pervasive emotional and physical effects on patients lives.
Additionally, physical and psychological barriers, time and monetary
limitations, and a lack of social support complicates disease management
People, especially those with little education, may not understand the
progressive nature of diabetes. However, using diabetes complications as
a scare tactic may only exacerbate feelings of helplessness if patients view
future complications as inevitable
Documented workplace discrimination allegations indicate that people with
diabetes are more likely to experience prejudice, which can affect job
retention. This in turn may affect access to health insurance and health
maintenance
balancing familial and work responsibilities may complicate diabetes
management because of feelings of obligation. Working patients need
flexible supports that facilitate program participation such as longer clinic
hours, child care services, time management training, and flexible work
schedules that accommodate doctor visits and exercise
Finally, diabetes supports should address the whole person — physically,
psychologically, and socially. Future interventions for working people with
diabetes should include coordinated programs that involve social,
emotional, and lifestyle supports to help keep people healthy so that they
can work well

Thank U
4 your
@Ntion !!

Pts


Slide 14

Diabetic Neuropathy
in the workforce
and cost
Panagiotis V. Tsaklis, PhD
Associate Professor
School of Health Professions
“Alexander” TEI Thessaloniki
Sen. Researcher
Dept Public Health Sciences
Occupational & Environmental Medicine
Karolinska Institutet

mellitus…


The global prevalence of diabetes is
predicted to double by the year 2030 from
2.8% to 4.4%.



…Of individuals with diabetes, a substantial
number will develop lower extremity disease
including peripheral neuropathy, foot ulcers
and peripheral arterial disease…

Does it cost much??


In 2007, the estimated national cost in US of diabetes
exceeded $174 billion…


This estimate included $116 billion in diabetesrelated medical costs and $58 billion in reduced
productivity ….due to increased work absenteeism,
reduced work and daily productivity, unemployment
from disease-related disability, and early death..



Polyneuropathy is one of the commonest complications of the
diabetes and the commonest form of neuropathy in the
developed World. Diabetic polyneuropathy encompasses
several neuropathic syndromes the commonest of which is
distal symmetrical neuropathy, the main initiating factor for foot
ulceration. The epidemiology of diabetic neuropathy has
recently been reviewed in reasonable detail

…from the 1999-2000 population-based US Health and Nutrition
Survey (NHANES), The prevalence (history) of peripheral
neuropathy (> 1 insensate area) in people with diabetes was
28.5%...


The EURODIAB Prospective Complications Study which
involved the examination of 3250 type 1 patients, from 16
European countries, found a prevalence rate of 28% for distal
symmetrical neuropathy

…painful diabetic
peripheral neuropathy (pDPN) is associated with
worse health outcomes…
…however, among pDPN patients, few studies have
examined the relationship between the severity of
pain and health outcomes……

Lost Productive Time (LPT) and diabetes neuropathy…
…studies suggest that individuals
40 to 65 years old in the US workforce, with diabetes and neuropathic
symptoms experience excess health-related LPT compared with that of
others with and without diabetes

…The mean hours of LPT per week was substantially higher in the
diabetes patients with neuropathic symptoms
compared with in the others 4.21 hrs vs 1.90 hrs…(diabetic &
controls)
…more individuals who had diabetes with neuropathic symptoms
reported moderate to severe impact on work ability (ie, score 5 on a
scale from 0–10 compared with those without neuropathic
symptoms
(where 0 means “it has no effect on my ability to work” and 10 means “I am no longer able
to work”)

Cost of Lost Productive Time…$ $ $ $ $...:
In the US Workforce gives a equivalent of $3.65 billion
per year in health-related LPT, a cost per worker that is more
than 2.5 times higher than workers with diabetes without neuropathic
Symptoms…

In conclusion,…The severity might
lead to decreased health status,

•It is observed a prevalence of moderate-to-severe pain among pDPN
patients
•also indicate that health outcomes are significantly worse as pain severity
increases.
•Specifically, work impairment, health care resource use, and the associated
indirect and direct costs increase significantly as the level of pain severity
increases.
•These data emphasize the need
for effectively managing pain in patients with pDPN.

Peripheral (symmetrical) Neuropathy
(Sensory-Motor Neuropathy) which leads to……
Complications
Intrinsic muscles atrophy
→ foot deformities
Reflex reduction
→ Gait alteration…
Calluses & Ulcers occurrence
Amputations…

Aggravating Factors…
Peripheral Vascular Disease

Joint Mobility Reduction
Foot Structural deformities

Foot soft tissues lesions
Autonomous Neuropathy ???
Vassel-Kinetic Neuropathy (VASOMOTOR)
Sweat -Kinetic Neuropathy (SUDOMOTOR)

“autosympathectomy.”

Diabetic foot……The majority of lower extremity disease in people with diabetes is
treated in outpatient, clinic or office settings

Focus on Foot Ulcers

Foot ulcers are defined as a cutaneous erosion
extending through the dermis to deeper tissue, result
from various etiologic factors and are characterized
by an inability to self-repair in a timely and orderly
manner

Frequency of Lower Extremity Conditions in the U.S. Population with
Diabetes per 1,000.
Hospital Discharge Data for Ulcer/inflammation/infection (Ulcer),
Peripheral Neuropathy, and Peripheral Arterial Disease (PAD), 19932002

Age-adjusted Hospital Discharge Rates for Lower Extremity Disease
in the U.S. Population with Diabetes per 1,000.
Ulcer/inflammation/infection (Ulcer), Peripheral Neuropathy, and
Peripheral Arterial Disease (PAD), 1993-2002

R
a
t
e
/
1
,
0
0
0

Population-Based Diabetic Foot Ulcer Incidence and Prevalence
from Selected Studies…
First Author/
Reference

Foot Ulcer
Foot Ulcer

Population Studied

Annual
Prevalence /100
Incidence /100

Abbott (16)

Borssen (32)

Kumar (12)
Lavery (33)

Malgrane (34)
MMWR (35)
Moss (23)

Ramsey (28)
Walters (14)

Cohort of 6,613 patients in six district
clinics in NW England followed for 2
yrs, Type 1, 2 diabetes
375 patients Umea County Sweden, Age
15-50,
Type 1 = 298, Type 2 = 77
Cross-sectional study of 811 Type 2
patients from three UK cities
Cohort of 1,666 patients, San Antonio,
Texas, 51% Mexican Americans,
followed for 2 yrs
664 patients from 16 French diabetes
centers
2000-2002 BRFSS US survey of adults
> 18 yrs
Cohort of 2,990 patients with late and
early-onset diabetes
Nested case-control study in HMO,
8,905 Type 1, Type 2
Cross-sectional study of 1,077 Type 1, 2
patients in 10 UK general medicine
practices

2.2

4.7

2.0

10.0 IDDM
9.0 NIDDM

1.0

5.3

3.4

—

—

15.8%

—

11.8%

2.4 younger

9.5 younger

2.6 older

10.5 older

1.9
4.1

7.4

Frequency of U.S. Hospitalization for Ulcer-Related Conditions
in Individuals with Diabetes by Diagnosis, 2001-2002
Type of ulcer

ICD-CM
Codes

Estimated
Frequency
2001

Estimated
Frequency
2002

Cellulitis, abscess, or infected ulcer
Other cellulitis and abscess, foot except toes

681.1
682.7

26,685
81,367

29,347
83,954

Ulcer of lower limbs, except decubitus
Osteomyelitis

707.1
730.07

209,088
60,989

216,785
66,591

129,466

134,274

83,546

78,983

730.17
730.27
730.37
730.87
730.97

Chronic nonhealing ulcers

707.0
707.9

Atherosclerosis of lower limb with ulcer

440.23

Or gangrene

440.24

Ulcers Health Care Costs…



Optimally, the estimation of diabetic foot ulcer costs
spans an entire ulcer episode from lesion onset to
final resolution.



Two studies provided direct costs associated with the
entire diabetic foot ulcer history. This methodology
captures the many inpatient and outpatient
costs/charges associated with foot ulcers and is
preferable to reporting only charge for a single
hospitalization or limited time interval

Direct Cost for Foot Ulcers in Persons with Diabetes From Two
Studies
Author

# Patients/

Outcome

Average
Episode Cost
(US $)

Inpatient
Cost %

Outpatient
Cost %

Primary healing =
63%

$6,664

61

39

18

82

Study Type

Apelqvist Prospective
(27)
314 General
Internal
Medicine
Patients
Ramsey
(28)

Healed after
amputation = 24%

Nested casePrimary healing =
control study
84%
in HMO of
Amputation =
8,905 Type 1,2
16%

$44,790

$27,987

Total
Attributable
cost

Ulcer Reimbursement to Hospitals for Patients with and
without Diabetes, 2002
Medstat (Private)1
Source:

Length of Stay

Average $
Reimbursement

Length of Stay

Average $
Reimbursement

18

Peripheral Neuropathy with
complications

5.6

9,036

5.5

4,782

19

Peripheral Neuropathy
without complications

4.8

6,061

3.6

3,034

277

Cellulitis > age 17 with
complications

4.8

6,823

5.7

4,000

278

Cellulitis > age 17 without
complications

3.4

4,426

4.2

2,192

271

Skin Ulcers

11.0

11,638

7.3

5,227

238

Osteomyelitis

5.9

9,913

8.7

7,376

130

Peripheral Arterial Disease
with complications

5.1

7,743

5.6

4,554

131

Peripheral Arterial Disease
without complications

4.3

5,768

4.1

2,375

1Medstat

Group,
Thompson
DRG
Corporati
on, 2005
2Centers

for
Medicare
and
Medicaid
Services,
2005

Key:
DRG =
Diagnostic
Related
Group

Medicare2

Condition

In conclusion….


The average private hospital reimbursement for a
foot ulcer for 11 days is about $11,638 while
Medicare reimbursement for foot ulcer conditions is
usually for 7.3 days and $5,227.



The direct economic cost attributable to foot ulcers
from onset for two years approaches $28,000.



Guideline-based care is needed to improve outcomes
and provide cost savings compared with standard
care

Final conclusions and suggestions!!!










Diabetes has pervasive emotional and physical effects on patients lives.
Additionally, physical and psychological barriers, time and monetary
limitations, and a lack of social support complicates disease management
People, especially those with little education, may not understand the
progressive nature of diabetes. However, using diabetes complications as
a scare tactic may only exacerbate feelings of helplessness if patients view
future complications as inevitable
Documented workplace discrimination allegations indicate that people with
diabetes are more likely to experience prejudice, which can affect job
retention. This in turn may affect access to health insurance and health
maintenance
balancing familial and work responsibilities may complicate diabetes
management because of feelings of obligation. Working patients need
flexible supports that facilitate program participation such as longer clinic
hours, child care services, time management training, and flexible work
schedules that accommodate doctor visits and exercise
Finally, diabetes supports should address the whole person — physically,
psychologically, and socially. Future interventions for working people with
diabetes should include coordinated programs that involve social,
emotional, and lifestyle supports to help keep people healthy so that they
can work well

Thank U
4 your
@Ntion !!

Pts


Slide 15

Diabetic Neuropathy
in the workforce
and cost
Panagiotis V. Tsaklis, PhD
Associate Professor
School of Health Professions
“Alexander” TEI Thessaloniki
Sen. Researcher
Dept Public Health Sciences
Occupational & Environmental Medicine
Karolinska Institutet

mellitus…


The global prevalence of diabetes is
predicted to double by the year 2030 from
2.8% to 4.4%.



…Of individuals with diabetes, a substantial
number will develop lower extremity disease
including peripheral neuropathy, foot ulcers
and peripheral arterial disease…

Does it cost much??


In 2007, the estimated national cost in US of diabetes
exceeded $174 billion…


This estimate included $116 billion in diabetesrelated medical costs and $58 billion in reduced
productivity ….due to increased work absenteeism,
reduced work and daily productivity, unemployment
from disease-related disability, and early death..



Polyneuropathy is one of the commonest complications of the
diabetes and the commonest form of neuropathy in the
developed World. Diabetic polyneuropathy encompasses
several neuropathic syndromes the commonest of which is
distal symmetrical neuropathy, the main initiating factor for foot
ulceration. The epidemiology of diabetic neuropathy has
recently been reviewed in reasonable detail

…from the 1999-2000 population-based US Health and Nutrition
Survey (NHANES), The prevalence (history) of peripheral
neuropathy (> 1 insensate area) in people with diabetes was
28.5%...


The EURODIAB Prospective Complications Study which
involved the examination of 3250 type 1 patients, from 16
European countries, found a prevalence rate of 28% for distal
symmetrical neuropathy

…painful diabetic
peripheral neuropathy (pDPN) is associated with
worse health outcomes…
…however, among pDPN patients, few studies have
examined the relationship between the severity of
pain and health outcomes……

Lost Productive Time (LPT) and diabetes neuropathy…
…studies suggest that individuals
40 to 65 years old in the US workforce, with diabetes and neuropathic
symptoms experience excess health-related LPT compared with that of
others with and without diabetes

…The mean hours of LPT per week was substantially higher in the
diabetes patients with neuropathic symptoms
compared with in the others 4.21 hrs vs 1.90 hrs…(diabetic &
controls)
…more individuals who had diabetes with neuropathic symptoms
reported moderate to severe impact on work ability (ie, score 5 on a
scale from 0–10 compared with those without neuropathic
symptoms
(where 0 means “it has no effect on my ability to work” and 10 means “I am no longer able
to work”)

Cost of Lost Productive Time…$ $ $ $ $...:
In the US Workforce gives a equivalent of $3.65 billion
per year in health-related LPT, a cost per worker that is more
than 2.5 times higher than workers with diabetes without neuropathic
Symptoms…

In conclusion,…The severity might
lead to decreased health status,

•It is observed a prevalence of moderate-to-severe pain among pDPN
patients
•also indicate that health outcomes are significantly worse as pain severity
increases.
•Specifically, work impairment, health care resource use, and the associated
indirect and direct costs increase significantly as the level of pain severity
increases.
•These data emphasize the need
for effectively managing pain in patients with pDPN.

Peripheral (symmetrical) Neuropathy
(Sensory-Motor Neuropathy) which leads to……
Complications
Intrinsic muscles atrophy
→ foot deformities
Reflex reduction
→ Gait alteration…
Calluses & Ulcers occurrence
Amputations…

Aggravating Factors…
Peripheral Vascular Disease

Joint Mobility Reduction
Foot Structural deformities

Foot soft tissues lesions
Autonomous Neuropathy ???
Vassel-Kinetic Neuropathy (VASOMOTOR)
Sweat -Kinetic Neuropathy (SUDOMOTOR)

“autosympathectomy.”

Diabetic foot……The majority of lower extremity disease in people with diabetes is
treated in outpatient, clinic or office settings

Focus on Foot Ulcers

Foot ulcers are defined as a cutaneous erosion
extending through the dermis to deeper tissue, result
from various etiologic factors and are characterized
by an inability to self-repair in a timely and orderly
manner

Frequency of Lower Extremity Conditions in the U.S. Population with
Diabetes per 1,000.
Hospital Discharge Data for Ulcer/inflammation/infection (Ulcer),
Peripheral Neuropathy, and Peripheral Arterial Disease (PAD), 19932002

Age-adjusted Hospital Discharge Rates for Lower Extremity Disease
in the U.S. Population with Diabetes per 1,000.
Ulcer/inflammation/infection (Ulcer), Peripheral Neuropathy, and
Peripheral Arterial Disease (PAD), 1993-2002

R
a
t
e
/
1
,
0
0
0

Population-Based Diabetic Foot Ulcer Incidence and Prevalence
from Selected Studies…
First Author/
Reference

Foot Ulcer
Foot Ulcer

Population Studied

Annual
Prevalence /100
Incidence /100

Abbott (16)

Borssen (32)

Kumar (12)
Lavery (33)

Malgrane (34)
MMWR (35)
Moss (23)

Ramsey (28)
Walters (14)

Cohort of 6,613 patients in six district
clinics in NW England followed for 2
yrs, Type 1, 2 diabetes
375 patients Umea County Sweden, Age
15-50,
Type 1 = 298, Type 2 = 77
Cross-sectional study of 811 Type 2
patients from three UK cities
Cohort of 1,666 patients, San Antonio,
Texas, 51% Mexican Americans,
followed for 2 yrs
664 patients from 16 French diabetes
centers
2000-2002 BRFSS US survey of adults
> 18 yrs
Cohort of 2,990 patients with late and
early-onset diabetes
Nested case-control study in HMO,
8,905 Type 1, Type 2
Cross-sectional study of 1,077 Type 1, 2
patients in 10 UK general medicine
practices

2.2

4.7

2.0

10.0 IDDM
9.0 NIDDM

1.0

5.3

3.4

—

—

15.8%

—

11.8%

2.4 younger

9.5 younger

2.6 older

10.5 older

1.9
4.1

7.4

Frequency of U.S. Hospitalization for Ulcer-Related Conditions
in Individuals with Diabetes by Diagnosis, 2001-2002
Type of ulcer

ICD-CM
Codes

Estimated
Frequency
2001

Estimated
Frequency
2002

Cellulitis, abscess, or infected ulcer
Other cellulitis and abscess, foot except toes

681.1
682.7

26,685
81,367

29,347
83,954

Ulcer of lower limbs, except decubitus
Osteomyelitis

707.1
730.07

209,088
60,989

216,785
66,591

129,466

134,274

83,546

78,983

730.17
730.27
730.37
730.87
730.97

Chronic nonhealing ulcers

707.0
707.9

Atherosclerosis of lower limb with ulcer

440.23

Or gangrene

440.24

Ulcers Health Care Costs…



Optimally, the estimation of diabetic foot ulcer costs
spans an entire ulcer episode from lesion onset to
final resolution.



Two studies provided direct costs associated with the
entire diabetic foot ulcer history. This methodology
captures the many inpatient and outpatient
costs/charges associated with foot ulcers and is
preferable to reporting only charge for a single
hospitalization or limited time interval

Direct Cost for Foot Ulcers in Persons with Diabetes From Two
Studies
Author

# Patients/

Outcome

Average
Episode Cost
(US $)

Inpatient
Cost %

Outpatient
Cost %

Primary healing =
63%

$6,664

61

39

18

82

Study Type

Apelqvist Prospective
(27)
314 General
Internal
Medicine
Patients
Ramsey
(28)

Healed after
amputation = 24%

Nested casePrimary healing =
control study
84%
in HMO of
Amputation =
8,905 Type 1,2
16%

$44,790

$27,987

Total
Attributable
cost

Ulcer Reimbursement to Hospitals for Patients with and
without Diabetes, 2002
Medstat (Private)1
Source:

Length of Stay

Average $
Reimbursement

Length of Stay

Average $
Reimbursement

18

Peripheral Neuropathy with
complications

5.6

9,036

5.5

4,782

19

Peripheral Neuropathy
without complications

4.8

6,061

3.6

3,034

277

Cellulitis > age 17 with
complications

4.8

6,823

5.7

4,000

278

Cellulitis > age 17 without
complications

3.4

4,426

4.2

2,192

271

Skin Ulcers

11.0

11,638

7.3

5,227

238

Osteomyelitis

5.9

9,913

8.7

7,376

130

Peripheral Arterial Disease
with complications

5.1

7,743

5.6

4,554

131

Peripheral Arterial Disease
without complications

4.3

5,768

4.1

2,375

1Medstat

Group,
Thompson
DRG
Corporati
on, 2005
2Centers

for
Medicare
and
Medicaid
Services,
2005

Key:
DRG =
Diagnostic
Related
Group

Medicare2

Condition

In conclusion….


The average private hospital reimbursement for a
foot ulcer for 11 days is about $11,638 while
Medicare reimbursement for foot ulcer conditions is
usually for 7.3 days and $5,227.



The direct economic cost attributable to foot ulcers
from onset for two years approaches $28,000.



Guideline-based care is needed to improve outcomes
and provide cost savings compared with standard
care

Final conclusions and suggestions!!!










Diabetes has pervasive emotional and physical effects on patients lives.
Additionally, physical and psychological barriers, time and monetary
limitations, and a lack of social support complicates disease management
People, especially those with little education, may not understand the
progressive nature of diabetes. However, using diabetes complications as
a scare tactic may only exacerbate feelings of helplessness if patients view
future complications as inevitable
Documented workplace discrimination allegations indicate that people with
diabetes are more likely to experience prejudice, which can affect job
retention. This in turn may affect access to health insurance and health
maintenance
balancing familial and work responsibilities may complicate diabetes
management because of feelings of obligation. Working patients need
flexible supports that facilitate program participation such as longer clinic
hours, child care services, time management training, and flexible work
schedules that accommodate doctor visits and exercise
Finally, diabetes supports should address the whole person — physically,
psychologically, and socially. Future interventions for working people with
diabetes should include coordinated programs that involve social,
emotional, and lifestyle supports to help keep people healthy so that they
can work well

Thank U
4 your
@Ntion !!

Pts


Slide 16

Diabetic Neuropathy
in the workforce
and cost
Panagiotis V. Tsaklis, PhD
Associate Professor
School of Health Professions
“Alexander” TEI Thessaloniki
Sen. Researcher
Dept Public Health Sciences
Occupational & Environmental Medicine
Karolinska Institutet

mellitus…


The global prevalence of diabetes is
predicted to double by the year 2030 from
2.8% to 4.4%.



…Of individuals with diabetes, a substantial
number will develop lower extremity disease
including peripheral neuropathy, foot ulcers
and peripheral arterial disease…

Does it cost much??


In 2007, the estimated national cost in US of diabetes
exceeded $174 billion…


This estimate included $116 billion in diabetesrelated medical costs and $58 billion in reduced
productivity ….due to increased work absenteeism,
reduced work and daily productivity, unemployment
from disease-related disability, and early death..



Polyneuropathy is one of the commonest complications of the
diabetes and the commonest form of neuropathy in the
developed World. Diabetic polyneuropathy encompasses
several neuropathic syndromes the commonest of which is
distal symmetrical neuropathy, the main initiating factor for foot
ulceration. The epidemiology of diabetic neuropathy has
recently been reviewed in reasonable detail

…from the 1999-2000 population-based US Health and Nutrition
Survey (NHANES), The prevalence (history) of peripheral
neuropathy (> 1 insensate area) in people with diabetes was
28.5%...


The EURODIAB Prospective Complications Study which
involved the examination of 3250 type 1 patients, from 16
European countries, found a prevalence rate of 28% for distal
symmetrical neuropathy

…painful diabetic
peripheral neuropathy (pDPN) is associated with
worse health outcomes…
…however, among pDPN patients, few studies have
examined the relationship between the severity of
pain and health outcomes……

Lost Productive Time (LPT) and diabetes neuropathy…
…studies suggest that individuals
40 to 65 years old in the US workforce, with diabetes and neuropathic
symptoms experience excess health-related LPT compared with that of
others with and without diabetes

…The mean hours of LPT per week was substantially higher in the
diabetes patients with neuropathic symptoms
compared with in the others 4.21 hrs vs 1.90 hrs…(diabetic &
controls)
…more individuals who had diabetes with neuropathic symptoms
reported moderate to severe impact on work ability (ie, score 5 on a
scale from 0–10 compared with those without neuropathic
symptoms
(where 0 means “it has no effect on my ability to work” and 10 means “I am no longer able
to work”)

Cost of Lost Productive Time…$ $ $ $ $...:
In the US Workforce gives a equivalent of $3.65 billion
per year in health-related LPT, a cost per worker that is more
than 2.5 times higher than workers with diabetes without neuropathic
Symptoms…

In conclusion,…The severity might
lead to decreased health status,

•It is observed a prevalence of moderate-to-severe pain among pDPN
patients
•also indicate that health outcomes are significantly worse as pain severity
increases.
•Specifically, work impairment, health care resource use, and the associated
indirect and direct costs increase significantly as the level of pain severity
increases.
•These data emphasize the need
for effectively managing pain in patients with pDPN.

Peripheral (symmetrical) Neuropathy
(Sensory-Motor Neuropathy) which leads to……
Complications
Intrinsic muscles atrophy
→ foot deformities
Reflex reduction
→ Gait alteration…
Calluses & Ulcers occurrence
Amputations…

Aggravating Factors…
Peripheral Vascular Disease

Joint Mobility Reduction
Foot Structural deformities

Foot soft tissues lesions
Autonomous Neuropathy ???
Vassel-Kinetic Neuropathy (VASOMOTOR)
Sweat -Kinetic Neuropathy (SUDOMOTOR)

“autosympathectomy.”

Diabetic foot……The majority of lower extremity disease in people with diabetes is
treated in outpatient, clinic or office settings

Focus on Foot Ulcers

Foot ulcers are defined as a cutaneous erosion
extending through the dermis to deeper tissue, result
from various etiologic factors and are characterized
by an inability to self-repair in a timely and orderly
manner

Frequency of Lower Extremity Conditions in the U.S. Population with
Diabetes per 1,000.
Hospital Discharge Data for Ulcer/inflammation/infection (Ulcer),
Peripheral Neuropathy, and Peripheral Arterial Disease (PAD), 19932002

Age-adjusted Hospital Discharge Rates for Lower Extremity Disease
in the U.S. Population with Diabetes per 1,000.
Ulcer/inflammation/infection (Ulcer), Peripheral Neuropathy, and
Peripheral Arterial Disease (PAD), 1993-2002

R
a
t
e
/
1
,
0
0
0

Population-Based Diabetic Foot Ulcer Incidence and Prevalence
from Selected Studies…
First Author/
Reference

Foot Ulcer
Foot Ulcer

Population Studied

Annual
Prevalence /100
Incidence /100

Abbott (16)

Borssen (32)

Kumar (12)
Lavery (33)

Malgrane (34)
MMWR (35)
Moss (23)

Ramsey (28)
Walters (14)

Cohort of 6,613 patients in six district
clinics in NW England followed for 2
yrs, Type 1, 2 diabetes
375 patients Umea County Sweden, Age
15-50,
Type 1 = 298, Type 2 = 77
Cross-sectional study of 811 Type 2
patients from three UK cities
Cohort of 1,666 patients, San Antonio,
Texas, 51% Mexican Americans,
followed for 2 yrs
664 patients from 16 French diabetes
centers
2000-2002 BRFSS US survey of adults
> 18 yrs
Cohort of 2,990 patients with late and
early-onset diabetes
Nested case-control study in HMO,
8,905 Type 1, Type 2
Cross-sectional study of 1,077 Type 1, 2
patients in 10 UK general medicine
practices

2.2

4.7

2.0

10.0 IDDM
9.0 NIDDM

1.0

5.3

3.4

—

—

15.8%

—

11.8%

2.4 younger

9.5 younger

2.6 older

10.5 older

1.9
4.1

7.4

Frequency of U.S. Hospitalization for Ulcer-Related Conditions
in Individuals with Diabetes by Diagnosis, 2001-2002
Type of ulcer

ICD-CM
Codes

Estimated
Frequency
2001

Estimated
Frequency
2002

Cellulitis, abscess, or infected ulcer
Other cellulitis and abscess, foot except toes

681.1
682.7

26,685
81,367

29,347
83,954

Ulcer of lower limbs, except decubitus
Osteomyelitis

707.1
730.07

209,088
60,989

216,785
66,591

129,466

134,274

83,546

78,983

730.17
730.27
730.37
730.87
730.97

Chronic nonhealing ulcers

707.0
707.9

Atherosclerosis of lower limb with ulcer

440.23

Or gangrene

440.24

Ulcers Health Care Costs…



Optimally, the estimation of diabetic foot ulcer costs
spans an entire ulcer episode from lesion onset to
final resolution.



Two studies provided direct costs associated with the
entire diabetic foot ulcer history. This methodology
captures the many inpatient and outpatient
costs/charges associated with foot ulcers and is
preferable to reporting only charge for a single
hospitalization or limited time interval

Direct Cost for Foot Ulcers in Persons with Diabetes From Two
Studies
Author

# Patients/

Outcome

Average
Episode Cost
(US $)

Inpatient
Cost %

Outpatient
Cost %

Primary healing =
63%

$6,664

61

39

18

82

Study Type

Apelqvist Prospective
(27)
314 General
Internal
Medicine
Patients
Ramsey
(28)

Healed after
amputation = 24%

Nested casePrimary healing =
control study
84%
in HMO of
Amputation =
8,905 Type 1,2
16%

$44,790

$27,987

Total
Attributable
cost

Ulcer Reimbursement to Hospitals for Patients with and
without Diabetes, 2002
Medstat (Private)1
Source:

Length of Stay

Average $
Reimbursement

Length of Stay

Average $
Reimbursement

18

Peripheral Neuropathy with
complications

5.6

9,036

5.5

4,782

19

Peripheral Neuropathy
without complications

4.8

6,061

3.6

3,034

277

Cellulitis > age 17 with
complications

4.8

6,823

5.7

4,000

278

Cellulitis > age 17 without
complications

3.4

4,426

4.2

2,192

271

Skin Ulcers

11.0

11,638

7.3

5,227

238

Osteomyelitis

5.9

9,913

8.7

7,376

130

Peripheral Arterial Disease
with complications

5.1

7,743

5.6

4,554

131

Peripheral Arterial Disease
without complications

4.3

5,768

4.1

2,375

1Medstat

Group,
Thompson
DRG
Corporati
on, 2005
2Centers

for
Medicare
and
Medicaid
Services,
2005

Key:
DRG =
Diagnostic
Related
Group

Medicare2

Condition

In conclusion….


The average private hospital reimbursement for a
foot ulcer for 11 days is about $11,638 while
Medicare reimbursement for foot ulcer conditions is
usually for 7.3 days and $5,227.



The direct economic cost attributable to foot ulcers
from onset for two years approaches $28,000.



Guideline-based care is needed to improve outcomes
and provide cost savings compared with standard
care

Final conclusions and suggestions!!!










Diabetes has pervasive emotional and physical effects on patients lives.
Additionally, physical and psychological barriers, time and monetary
limitations, and a lack of social support complicates disease management
People, especially those with little education, may not understand the
progressive nature of diabetes. However, using diabetes complications as
a scare tactic may only exacerbate feelings of helplessness if patients view
future complications as inevitable
Documented workplace discrimination allegations indicate that people with
diabetes are more likely to experience prejudice, which can affect job
retention. This in turn may affect access to health insurance and health
maintenance
balancing familial and work responsibilities may complicate diabetes
management because of feelings of obligation. Working patients need
flexible supports that facilitate program participation such as longer clinic
hours, child care services, time management training, and flexible work
schedules that accommodate doctor visits and exercise
Finally, diabetes supports should address the whole person — physically,
psychologically, and socially. Future interventions for working people with
diabetes should include coordinated programs that involve social,
emotional, and lifestyle supports to help keep people healthy so that they
can work well

Thank U
4 your
@Ntion !!

Pts


Slide 17

Diabetic Neuropathy
in the workforce
and cost
Panagiotis V. Tsaklis, PhD
Associate Professor
School of Health Professions
“Alexander” TEI Thessaloniki
Sen. Researcher
Dept Public Health Sciences
Occupational & Environmental Medicine
Karolinska Institutet

mellitus…


The global prevalence of diabetes is
predicted to double by the year 2030 from
2.8% to 4.4%.



…Of individuals with diabetes, a substantial
number will develop lower extremity disease
including peripheral neuropathy, foot ulcers
and peripheral arterial disease…

Does it cost much??


In 2007, the estimated national cost in US of diabetes
exceeded $174 billion…


This estimate included $116 billion in diabetesrelated medical costs and $58 billion in reduced
productivity ….due to increased work absenteeism,
reduced work and daily productivity, unemployment
from disease-related disability, and early death..



Polyneuropathy is one of the commonest complications of the
diabetes and the commonest form of neuropathy in the
developed World. Diabetic polyneuropathy encompasses
several neuropathic syndromes the commonest of which is
distal symmetrical neuropathy, the main initiating factor for foot
ulceration. The epidemiology of diabetic neuropathy has
recently been reviewed in reasonable detail

…from the 1999-2000 population-based US Health and Nutrition
Survey (NHANES), The prevalence (history) of peripheral
neuropathy (> 1 insensate area) in people with diabetes was
28.5%...


The EURODIAB Prospective Complications Study which
involved the examination of 3250 type 1 patients, from 16
European countries, found a prevalence rate of 28% for distal
symmetrical neuropathy

…painful diabetic
peripheral neuropathy (pDPN) is associated with
worse health outcomes…
…however, among pDPN patients, few studies have
examined the relationship between the severity of
pain and health outcomes……

Lost Productive Time (LPT) and diabetes neuropathy…
…studies suggest that individuals
40 to 65 years old in the US workforce, with diabetes and neuropathic
symptoms experience excess health-related LPT compared with that of
others with and without diabetes

…The mean hours of LPT per week was substantially higher in the
diabetes patients with neuropathic symptoms
compared with in the others 4.21 hrs vs 1.90 hrs…(diabetic &
controls)
…more individuals who had diabetes with neuropathic symptoms
reported moderate to severe impact on work ability (ie, score 5 on a
scale from 0–10 compared with those without neuropathic
symptoms
(where 0 means “it has no effect on my ability to work” and 10 means “I am no longer able
to work”)

Cost of Lost Productive Time…$ $ $ $ $...:
In the US Workforce gives a equivalent of $3.65 billion
per year in health-related LPT, a cost per worker that is more
than 2.5 times higher than workers with diabetes without neuropathic
Symptoms…

In conclusion,…The severity might
lead to decreased health status,

•It is observed a prevalence of moderate-to-severe pain among pDPN
patients
•also indicate that health outcomes are significantly worse as pain severity
increases.
•Specifically, work impairment, health care resource use, and the associated
indirect and direct costs increase significantly as the level of pain severity
increases.
•These data emphasize the need
for effectively managing pain in patients with pDPN.

Peripheral (symmetrical) Neuropathy
(Sensory-Motor Neuropathy) which leads to……
Complications
Intrinsic muscles atrophy
→ foot deformities
Reflex reduction
→ Gait alteration…
Calluses & Ulcers occurrence
Amputations…

Aggravating Factors…
Peripheral Vascular Disease

Joint Mobility Reduction
Foot Structural deformities

Foot soft tissues lesions
Autonomous Neuropathy ???
Vassel-Kinetic Neuropathy (VASOMOTOR)
Sweat -Kinetic Neuropathy (SUDOMOTOR)

“autosympathectomy.”

Diabetic foot……The majority of lower extremity disease in people with diabetes is
treated in outpatient, clinic or office settings

Focus on Foot Ulcers

Foot ulcers are defined as a cutaneous erosion
extending through the dermis to deeper tissue, result
from various etiologic factors and are characterized
by an inability to self-repair in a timely and orderly
manner

Frequency of Lower Extremity Conditions in the U.S. Population with
Diabetes per 1,000.
Hospital Discharge Data for Ulcer/inflammation/infection (Ulcer),
Peripheral Neuropathy, and Peripheral Arterial Disease (PAD), 19932002

Age-adjusted Hospital Discharge Rates for Lower Extremity Disease
in the U.S. Population with Diabetes per 1,000.
Ulcer/inflammation/infection (Ulcer), Peripheral Neuropathy, and
Peripheral Arterial Disease (PAD), 1993-2002

R
a
t
e
/
1
,
0
0
0

Population-Based Diabetic Foot Ulcer Incidence and Prevalence
from Selected Studies…
First Author/
Reference

Foot Ulcer
Foot Ulcer

Population Studied

Annual
Prevalence /100
Incidence /100

Abbott (16)

Borssen (32)

Kumar (12)
Lavery (33)

Malgrane (34)
MMWR (35)
Moss (23)

Ramsey (28)
Walters (14)

Cohort of 6,613 patients in six district
clinics in NW England followed for 2
yrs, Type 1, 2 diabetes
375 patients Umea County Sweden, Age
15-50,
Type 1 = 298, Type 2 = 77
Cross-sectional study of 811 Type 2
patients from three UK cities
Cohort of 1,666 patients, San Antonio,
Texas, 51% Mexican Americans,
followed for 2 yrs
664 patients from 16 French diabetes
centers
2000-2002 BRFSS US survey of adults
> 18 yrs
Cohort of 2,990 patients with late and
early-onset diabetes
Nested case-control study in HMO,
8,905 Type 1, Type 2
Cross-sectional study of 1,077 Type 1, 2
patients in 10 UK general medicine
practices

2.2

4.7

2.0

10.0 IDDM
9.0 NIDDM

1.0

5.3

3.4

—

—

15.8%

—

11.8%

2.4 younger

9.5 younger

2.6 older

10.5 older

1.9
4.1

7.4

Frequency of U.S. Hospitalization for Ulcer-Related Conditions
in Individuals with Diabetes by Diagnosis, 2001-2002
Type of ulcer

ICD-CM
Codes

Estimated
Frequency
2001

Estimated
Frequency
2002

Cellulitis, abscess, or infected ulcer
Other cellulitis and abscess, foot except toes

681.1
682.7

26,685
81,367

29,347
83,954

Ulcer of lower limbs, except decubitus
Osteomyelitis

707.1
730.07

209,088
60,989

216,785
66,591

129,466

134,274

83,546

78,983

730.17
730.27
730.37
730.87
730.97

Chronic nonhealing ulcers

707.0
707.9

Atherosclerosis of lower limb with ulcer

440.23

Or gangrene

440.24

Ulcers Health Care Costs…



Optimally, the estimation of diabetic foot ulcer costs
spans an entire ulcer episode from lesion onset to
final resolution.



Two studies provided direct costs associated with the
entire diabetic foot ulcer history. This methodology
captures the many inpatient and outpatient
costs/charges associated with foot ulcers and is
preferable to reporting only charge for a single
hospitalization or limited time interval

Direct Cost for Foot Ulcers in Persons with Diabetes From Two
Studies
Author

# Patients/

Outcome

Average
Episode Cost
(US $)

Inpatient
Cost %

Outpatient
Cost %

Primary healing =
63%

$6,664

61

39

18

82

Study Type

Apelqvist Prospective
(27)
314 General
Internal
Medicine
Patients
Ramsey
(28)

Healed after
amputation = 24%

Nested casePrimary healing =
control study
84%
in HMO of
Amputation =
8,905 Type 1,2
16%

$44,790

$27,987

Total
Attributable
cost

Ulcer Reimbursement to Hospitals for Patients with and
without Diabetes, 2002
Medstat (Private)1
Source:

Length of Stay

Average $
Reimbursement

Length of Stay

Average $
Reimbursement

18

Peripheral Neuropathy with
complications

5.6

9,036

5.5

4,782

19

Peripheral Neuropathy
without complications

4.8

6,061

3.6

3,034

277

Cellulitis > age 17 with
complications

4.8

6,823

5.7

4,000

278

Cellulitis > age 17 without
complications

3.4

4,426

4.2

2,192

271

Skin Ulcers

11.0

11,638

7.3

5,227

238

Osteomyelitis

5.9

9,913

8.7

7,376

130

Peripheral Arterial Disease
with complications

5.1

7,743

5.6

4,554

131

Peripheral Arterial Disease
without complications

4.3

5,768

4.1

2,375

1Medstat

Group,
Thompson
DRG
Corporati
on, 2005
2Centers

for
Medicare
and
Medicaid
Services,
2005

Key:
DRG =
Diagnostic
Related
Group

Medicare2

Condition

In conclusion….


The average private hospital reimbursement for a
foot ulcer for 11 days is about $11,638 while
Medicare reimbursement for foot ulcer conditions is
usually for 7.3 days and $5,227.



The direct economic cost attributable to foot ulcers
from onset for two years approaches $28,000.



Guideline-based care is needed to improve outcomes
and provide cost savings compared with standard
care

Final conclusions and suggestions!!!










Diabetes has pervasive emotional and physical effects on patients lives.
Additionally, physical and psychological barriers, time and monetary
limitations, and a lack of social support complicates disease management
People, especially those with little education, may not understand the
progressive nature of diabetes. However, using diabetes complications as
a scare tactic may only exacerbate feelings of helplessness if patients view
future complications as inevitable
Documented workplace discrimination allegations indicate that people with
diabetes are more likely to experience prejudice, which can affect job
retention. This in turn may affect access to health insurance and health
maintenance
balancing familial and work responsibilities may complicate diabetes
management because of feelings of obligation. Working patients need
flexible supports that facilitate program participation such as longer clinic
hours, child care services, time management training, and flexible work
schedules that accommodate doctor visits and exercise
Finally, diabetes supports should address the whole person — physically,
psychologically, and socially. Future interventions for working people with
diabetes should include coordinated programs that involve social,
emotional, and lifestyle supports to help keep people healthy so that they
can work well

Thank U
4 your
@Ntion !!

Pts


Slide 18

Diabetic Neuropathy
in the workforce
and cost
Panagiotis V. Tsaklis, PhD
Associate Professor
School of Health Professions
“Alexander” TEI Thessaloniki
Sen. Researcher
Dept Public Health Sciences
Occupational & Environmental Medicine
Karolinska Institutet

mellitus…


The global prevalence of diabetes is
predicted to double by the year 2030 from
2.8% to 4.4%.



…Of individuals with diabetes, a substantial
number will develop lower extremity disease
including peripheral neuropathy, foot ulcers
and peripheral arterial disease…

Does it cost much??


In 2007, the estimated national cost in US of diabetes
exceeded $174 billion…


This estimate included $116 billion in diabetesrelated medical costs and $58 billion in reduced
productivity ….due to increased work absenteeism,
reduced work and daily productivity, unemployment
from disease-related disability, and early death..



Polyneuropathy is one of the commonest complications of the
diabetes and the commonest form of neuropathy in the
developed World. Diabetic polyneuropathy encompasses
several neuropathic syndromes the commonest of which is
distal symmetrical neuropathy, the main initiating factor for foot
ulceration. The epidemiology of diabetic neuropathy has
recently been reviewed in reasonable detail

…from the 1999-2000 population-based US Health and Nutrition
Survey (NHANES), The prevalence (history) of peripheral
neuropathy (> 1 insensate area) in people with diabetes was
28.5%...


The EURODIAB Prospective Complications Study which
involved the examination of 3250 type 1 patients, from 16
European countries, found a prevalence rate of 28% for distal
symmetrical neuropathy

…painful diabetic
peripheral neuropathy (pDPN) is associated with
worse health outcomes…
…however, among pDPN patients, few studies have
examined the relationship between the severity of
pain and health outcomes……

Lost Productive Time (LPT) and diabetes neuropathy…
…studies suggest that individuals
40 to 65 years old in the US workforce, with diabetes and neuropathic
symptoms experience excess health-related LPT compared with that of
others with and without diabetes

…The mean hours of LPT per week was substantially higher in the
diabetes patients with neuropathic symptoms
compared with in the others 4.21 hrs vs 1.90 hrs…(diabetic &
controls)
…more individuals who had diabetes with neuropathic symptoms
reported moderate to severe impact on work ability (ie, score 5 on a
scale from 0–10 compared with those without neuropathic
symptoms
(where 0 means “it has no effect on my ability to work” and 10 means “I am no longer able
to work”)

Cost of Lost Productive Time…$ $ $ $ $...:
In the US Workforce gives a equivalent of $3.65 billion
per year in health-related LPT, a cost per worker that is more
than 2.5 times higher than workers with diabetes without neuropathic
Symptoms…

In conclusion,…The severity might
lead to decreased health status,

•It is observed a prevalence of moderate-to-severe pain among pDPN
patients
•also indicate that health outcomes are significantly worse as pain severity
increases.
•Specifically, work impairment, health care resource use, and the associated
indirect and direct costs increase significantly as the level of pain severity
increases.
•These data emphasize the need
for effectively managing pain in patients with pDPN.

Peripheral (symmetrical) Neuropathy
(Sensory-Motor Neuropathy) which leads to……
Complications
Intrinsic muscles atrophy
→ foot deformities
Reflex reduction
→ Gait alteration…
Calluses & Ulcers occurrence
Amputations…

Aggravating Factors…
Peripheral Vascular Disease

Joint Mobility Reduction
Foot Structural deformities

Foot soft tissues lesions
Autonomous Neuropathy ???
Vassel-Kinetic Neuropathy (VASOMOTOR)
Sweat -Kinetic Neuropathy (SUDOMOTOR)

“autosympathectomy.”

Diabetic foot……The majority of lower extremity disease in people with diabetes is
treated in outpatient, clinic or office settings

Focus on Foot Ulcers

Foot ulcers are defined as a cutaneous erosion
extending through the dermis to deeper tissue, result
from various etiologic factors and are characterized
by an inability to self-repair in a timely and orderly
manner

Frequency of Lower Extremity Conditions in the U.S. Population with
Diabetes per 1,000.
Hospital Discharge Data for Ulcer/inflammation/infection (Ulcer),
Peripheral Neuropathy, and Peripheral Arterial Disease (PAD), 19932002

Age-adjusted Hospital Discharge Rates for Lower Extremity Disease
in the U.S. Population with Diabetes per 1,000.
Ulcer/inflammation/infection (Ulcer), Peripheral Neuropathy, and
Peripheral Arterial Disease (PAD), 1993-2002

R
a
t
e
/
1
,
0
0
0

Population-Based Diabetic Foot Ulcer Incidence and Prevalence
from Selected Studies…
First Author/
Reference

Foot Ulcer
Foot Ulcer

Population Studied

Annual
Prevalence /100
Incidence /100

Abbott (16)

Borssen (32)

Kumar (12)
Lavery (33)

Malgrane (34)
MMWR (35)
Moss (23)

Ramsey (28)
Walters (14)

Cohort of 6,613 patients in six district
clinics in NW England followed for 2
yrs, Type 1, 2 diabetes
375 patients Umea County Sweden, Age
15-50,
Type 1 = 298, Type 2 = 77
Cross-sectional study of 811 Type 2
patients from three UK cities
Cohort of 1,666 patients, San Antonio,
Texas, 51% Mexican Americans,
followed for 2 yrs
664 patients from 16 French diabetes
centers
2000-2002 BRFSS US survey of adults
> 18 yrs
Cohort of 2,990 patients with late and
early-onset diabetes
Nested case-control study in HMO,
8,905 Type 1, Type 2
Cross-sectional study of 1,077 Type 1, 2
patients in 10 UK general medicine
practices

2.2

4.7

2.0

10.0 IDDM
9.0 NIDDM

1.0

5.3

3.4

—

—

15.8%

—

11.8%

2.4 younger

9.5 younger

2.6 older

10.5 older

1.9
4.1

7.4

Frequency of U.S. Hospitalization for Ulcer-Related Conditions
in Individuals with Diabetes by Diagnosis, 2001-2002
Type of ulcer

ICD-CM
Codes

Estimated
Frequency
2001

Estimated
Frequency
2002

Cellulitis, abscess, or infected ulcer
Other cellulitis and abscess, foot except toes

681.1
682.7

26,685
81,367

29,347
83,954

Ulcer of lower limbs, except decubitus
Osteomyelitis

707.1
730.07

209,088
60,989

216,785
66,591

129,466

134,274

83,546

78,983

730.17
730.27
730.37
730.87
730.97

Chronic nonhealing ulcers

707.0
707.9

Atherosclerosis of lower limb with ulcer

440.23

Or gangrene

440.24

Ulcers Health Care Costs…



Optimally, the estimation of diabetic foot ulcer costs
spans an entire ulcer episode from lesion onset to
final resolution.



Two studies provided direct costs associated with the
entire diabetic foot ulcer history. This methodology
captures the many inpatient and outpatient
costs/charges associated with foot ulcers and is
preferable to reporting only charge for a single
hospitalization or limited time interval

Direct Cost for Foot Ulcers in Persons with Diabetes From Two
Studies
Author

# Patients/

Outcome

Average
Episode Cost
(US $)

Inpatient
Cost %

Outpatient
Cost %

Primary healing =
63%

$6,664

61

39

18

82

Study Type

Apelqvist Prospective
(27)
314 General
Internal
Medicine
Patients
Ramsey
(28)

Healed after
amputation = 24%

Nested casePrimary healing =
control study
84%
in HMO of
Amputation =
8,905 Type 1,2
16%

$44,790

$27,987

Total
Attributable
cost

Ulcer Reimbursement to Hospitals for Patients with and
without Diabetes, 2002
Medstat (Private)1
Source:

Length of Stay

Average $
Reimbursement

Length of Stay

Average $
Reimbursement

18

Peripheral Neuropathy with
complications

5.6

9,036

5.5

4,782

19

Peripheral Neuropathy
without complications

4.8

6,061

3.6

3,034

277

Cellulitis > age 17 with
complications

4.8

6,823

5.7

4,000

278

Cellulitis > age 17 without
complications

3.4

4,426

4.2

2,192

271

Skin Ulcers

11.0

11,638

7.3

5,227

238

Osteomyelitis

5.9

9,913

8.7

7,376

130

Peripheral Arterial Disease
with complications

5.1

7,743

5.6

4,554

131

Peripheral Arterial Disease
without complications

4.3

5,768

4.1

2,375

1Medstat

Group,
Thompson
DRG
Corporati
on, 2005
2Centers

for
Medicare
and
Medicaid
Services,
2005

Key:
DRG =
Diagnostic
Related
Group

Medicare2

Condition

In conclusion….


The average private hospital reimbursement for a
foot ulcer for 11 days is about $11,638 while
Medicare reimbursement for foot ulcer conditions is
usually for 7.3 days and $5,227.



The direct economic cost attributable to foot ulcers
from onset for two years approaches $28,000.



Guideline-based care is needed to improve outcomes
and provide cost savings compared with standard
care

Final conclusions and suggestions!!!










Diabetes has pervasive emotional and physical effects on patients lives.
Additionally, physical and psychological barriers, time and monetary
limitations, and a lack of social support complicates disease management
People, especially those with little education, may not understand the
progressive nature of diabetes. However, using diabetes complications as
a scare tactic may only exacerbate feelings of helplessness if patients view
future complications as inevitable
Documented workplace discrimination allegations indicate that people with
diabetes are more likely to experience prejudice, which can affect job
retention. This in turn may affect access to health insurance and health
maintenance
balancing familial and work responsibilities may complicate diabetes
management because of feelings of obligation. Working patients need
flexible supports that facilitate program participation such as longer clinic
hours, child care services, time management training, and flexible work
schedules that accommodate doctor visits and exercise
Finally, diabetes supports should address the whole person — physically,
psychologically, and socially. Future interventions for working people with
diabetes should include coordinated programs that involve social,
emotional, and lifestyle supports to help keep people healthy so that they
can work well

Thank U
4 your
@Ntion !!

Pts


Slide 19

Diabetic Neuropathy
in the workforce
and cost
Panagiotis V. Tsaklis, PhD
Associate Professor
School of Health Professions
“Alexander” TEI Thessaloniki
Sen. Researcher
Dept Public Health Sciences
Occupational & Environmental Medicine
Karolinska Institutet

mellitus…


The global prevalence of diabetes is
predicted to double by the year 2030 from
2.8% to 4.4%.



…Of individuals with diabetes, a substantial
number will develop lower extremity disease
including peripheral neuropathy, foot ulcers
and peripheral arterial disease…

Does it cost much??


In 2007, the estimated national cost in US of diabetes
exceeded $174 billion…


This estimate included $116 billion in diabetesrelated medical costs and $58 billion in reduced
productivity ….due to increased work absenteeism,
reduced work and daily productivity, unemployment
from disease-related disability, and early death..



Polyneuropathy is one of the commonest complications of the
diabetes and the commonest form of neuropathy in the
developed World. Diabetic polyneuropathy encompasses
several neuropathic syndromes the commonest of which is
distal symmetrical neuropathy, the main initiating factor for foot
ulceration. The epidemiology of diabetic neuropathy has
recently been reviewed in reasonable detail

…from the 1999-2000 population-based US Health and Nutrition
Survey (NHANES), The prevalence (history) of peripheral
neuropathy (> 1 insensate area) in people with diabetes was
28.5%...


The EURODIAB Prospective Complications Study which
involved the examination of 3250 type 1 patients, from 16
European countries, found a prevalence rate of 28% for distal
symmetrical neuropathy

…painful diabetic
peripheral neuropathy (pDPN) is associated with
worse health outcomes…
…however, among pDPN patients, few studies have
examined the relationship between the severity of
pain and health outcomes……

Lost Productive Time (LPT) and diabetes neuropathy…
…studies suggest that individuals
40 to 65 years old in the US workforce, with diabetes and neuropathic
symptoms experience excess health-related LPT compared with that of
others with and without diabetes

…The mean hours of LPT per week was substantially higher in the
diabetes patients with neuropathic symptoms
compared with in the others 4.21 hrs vs 1.90 hrs…(diabetic &
controls)
…more individuals who had diabetes with neuropathic symptoms
reported moderate to severe impact on work ability (ie, score 5 on a
scale from 0–10 compared with those without neuropathic
symptoms
(where 0 means “it has no effect on my ability to work” and 10 means “I am no longer able
to work”)

Cost of Lost Productive Time…$ $ $ $ $...:
In the US Workforce gives a equivalent of $3.65 billion
per year in health-related LPT, a cost per worker that is more
than 2.5 times higher than workers with diabetes without neuropathic
Symptoms…

In conclusion,…The severity might
lead to decreased health status,

•It is observed a prevalence of moderate-to-severe pain among pDPN
patients
•also indicate that health outcomes are significantly worse as pain severity
increases.
•Specifically, work impairment, health care resource use, and the associated
indirect and direct costs increase significantly as the level of pain severity
increases.
•These data emphasize the need
for effectively managing pain in patients with pDPN.

Peripheral (symmetrical) Neuropathy
(Sensory-Motor Neuropathy) which leads to……
Complications
Intrinsic muscles atrophy
→ foot deformities
Reflex reduction
→ Gait alteration…
Calluses & Ulcers occurrence
Amputations…

Aggravating Factors…
Peripheral Vascular Disease

Joint Mobility Reduction
Foot Structural deformities

Foot soft tissues lesions
Autonomous Neuropathy ???
Vassel-Kinetic Neuropathy (VASOMOTOR)
Sweat -Kinetic Neuropathy (SUDOMOTOR)

“autosympathectomy.”

Diabetic foot……The majority of lower extremity disease in people with diabetes is
treated in outpatient, clinic or office settings

Focus on Foot Ulcers

Foot ulcers are defined as a cutaneous erosion
extending through the dermis to deeper tissue, result
from various etiologic factors and are characterized
by an inability to self-repair in a timely and orderly
manner

Frequency of Lower Extremity Conditions in the U.S. Population with
Diabetes per 1,000.
Hospital Discharge Data for Ulcer/inflammation/infection (Ulcer),
Peripheral Neuropathy, and Peripheral Arterial Disease (PAD), 19932002

Age-adjusted Hospital Discharge Rates for Lower Extremity Disease
in the U.S. Population with Diabetes per 1,000.
Ulcer/inflammation/infection (Ulcer), Peripheral Neuropathy, and
Peripheral Arterial Disease (PAD), 1993-2002

R
a
t
e
/
1
,
0
0
0

Population-Based Diabetic Foot Ulcer Incidence and Prevalence
from Selected Studies…
First Author/
Reference

Foot Ulcer
Foot Ulcer

Population Studied

Annual
Prevalence /100
Incidence /100

Abbott (16)

Borssen (32)

Kumar (12)
Lavery (33)

Malgrane (34)
MMWR (35)
Moss (23)

Ramsey (28)
Walters (14)

Cohort of 6,613 patients in six district
clinics in NW England followed for 2
yrs, Type 1, 2 diabetes
375 patients Umea County Sweden, Age
15-50,
Type 1 = 298, Type 2 = 77
Cross-sectional study of 811 Type 2
patients from three UK cities
Cohort of 1,666 patients, San Antonio,
Texas, 51% Mexican Americans,
followed for 2 yrs
664 patients from 16 French diabetes
centers
2000-2002 BRFSS US survey of adults
> 18 yrs
Cohort of 2,990 patients with late and
early-onset diabetes
Nested case-control study in HMO,
8,905 Type 1, Type 2
Cross-sectional study of 1,077 Type 1, 2
patients in 10 UK general medicine
practices

2.2

4.7

2.0

10.0 IDDM
9.0 NIDDM

1.0

5.3

3.4

—

—

15.8%

—

11.8%

2.4 younger

9.5 younger

2.6 older

10.5 older

1.9
4.1

7.4

Frequency of U.S. Hospitalization for Ulcer-Related Conditions
in Individuals with Diabetes by Diagnosis, 2001-2002
Type of ulcer

ICD-CM
Codes

Estimated
Frequency
2001

Estimated
Frequency
2002

Cellulitis, abscess, or infected ulcer
Other cellulitis and abscess, foot except toes

681.1
682.7

26,685
81,367

29,347
83,954

Ulcer of lower limbs, except decubitus
Osteomyelitis

707.1
730.07

209,088
60,989

216,785
66,591

129,466

134,274

83,546

78,983

730.17
730.27
730.37
730.87
730.97

Chronic nonhealing ulcers

707.0
707.9

Atherosclerosis of lower limb with ulcer

440.23

Or gangrene

440.24

Ulcers Health Care Costs…



Optimally, the estimation of diabetic foot ulcer costs
spans an entire ulcer episode from lesion onset to
final resolution.



Two studies provided direct costs associated with the
entire diabetic foot ulcer history. This methodology
captures the many inpatient and outpatient
costs/charges associated with foot ulcers and is
preferable to reporting only charge for a single
hospitalization or limited time interval

Direct Cost for Foot Ulcers in Persons with Diabetes From Two
Studies
Author

# Patients/

Outcome

Average
Episode Cost
(US $)

Inpatient
Cost %

Outpatient
Cost %

Primary healing =
63%

$6,664

61

39

18

82

Study Type

Apelqvist Prospective
(27)
314 General
Internal
Medicine
Patients
Ramsey
(28)

Healed after
amputation = 24%

Nested casePrimary healing =
control study
84%
in HMO of
Amputation =
8,905 Type 1,2
16%

$44,790

$27,987

Total
Attributable
cost

Ulcer Reimbursement to Hospitals for Patients with and
without Diabetes, 2002
Medstat (Private)1
Source:

Length of Stay

Average $
Reimbursement

Length of Stay

Average $
Reimbursement

18

Peripheral Neuropathy with
complications

5.6

9,036

5.5

4,782

19

Peripheral Neuropathy
without complications

4.8

6,061

3.6

3,034

277

Cellulitis > age 17 with
complications

4.8

6,823

5.7

4,000

278

Cellulitis > age 17 without
complications

3.4

4,426

4.2

2,192

271

Skin Ulcers

11.0

11,638

7.3

5,227

238

Osteomyelitis

5.9

9,913

8.7

7,376

130

Peripheral Arterial Disease
with complications

5.1

7,743

5.6

4,554

131

Peripheral Arterial Disease
without complications

4.3

5,768

4.1

2,375

1Medstat

Group,
Thompson
DRG
Corporati
on, 2005
2Centers

for
Medicare
and
Medicaid
Services,
2005

Key:
DRG =
Diagnostic
Related
Group

Medicare2

Condition

In conclusion….


The average private hospital reimbursement for a
foot ulcer for 11 days is about $11,638 while
Medicare reimbursement for foot ulcer conditions is
usually for 7.3 days and $5,227.



The direct economic cost attributable to foot ulcers
from onset for two years approaches $28,000.



Guideline-based care is needed to improve outcomes
and provide cost savings compared with standard
care

Final conclusions and suggestions!!!










Diabetes has pervasive emotional and physical effects on patients lives.
Additionally, physical and psychological barriers, time and monetary
limitations, and a lack of social support complicates disease management
People, especially those with little education, may not understand the
progressive nature of diabetes. However, using diabetes complications as
a scare tactic may only exacerbate feelings of helplessness if patients view
future complications as inevitable
Documented workplace discrimination allegations indicate that people with
diabetes are more likely to experience prejudice, which can affect job
retention. This in turn may affect access to health insurance and health
maintenance
balancing familial and work responsibilities may complicate diabetes
management because of feelings of obligation. Working patients need
flexible supports that facilitate program participation such as longer clinic
hours, child care services, time management training, and flexible work
schedules that accommodate doctor visits and exercise
Finally, diabetes supports should address the whole person — physically,
psychologically, and socially. Future interventions for working people with
diabetes should include coordinated programs that involve social,
emotional, and lifestyle supports to help keep people healthy so that they
can work well

Thank U
4 your
@Ntion !!

Pts


Slide 20

Diabetic Neuropathy
in the workforce
and cost
Panagiotis V. Tsaklis, PhD
Associate Professor
School of Health Professions
“Alexander” TEI Thessaloniki
Sen. Researcher
Dept Public Health Sciences
Occupational & Environmental Medicine
Karolinska Institutet

mellitus…


The global prevalence of diabetes is
predicted to double by the year 2030 from
2.8% to 4.4%.



…Of individuals with diabetes, a substantial
number will develop lower extremity disease
including peripheral neuropathy, foot ulcers
and peripheral arterial disease…

Does it cost much??


In 2007, the estimated national cost in US of diabetes
exceeded $174 billion…


This estimate included $116 billion in diabetesrelated medical costs and $58 billion in reduced
productivity ….due to increased work absenteeism,
reduced work and daily productivity, unemployment
from disease-related disability, and early death..



Polyneuropathy is one of the commonest complications of the
diabetes and the commonest form of neuropathy in the
developed World. Diabetic polyneuropathy encompasses
several neuropathic syndromes the commonest of which is
distal symmetrical neuropathy, the main initiating factor for foot
ulceration. The epidemiology of diabetic neuropathy has
recently been reviewed in reasonable detail

…from the 1999-2000 population-based US Health and Nutrition
Survey (NHANES), The prevalence (history) of peripheral
neuropathy (> 1 insensate area) in people with diabetes was
28.5%...


The EURODIAB Prospective Complications Study which
involved the examination of 3250 type 1 patients, from 16
European countries, found a prevalence rate of 28% for distal
symmetrical neuropathy

…painful diabetic
peripheral neuropathy (pDPN) is associated with
worse health outcomes…
…however, among pDPN patients, few studies have
examined the relationship between the severity of
pain and health outcomes……

Lost Productive Time (LPT) and diabetes neuropathy…
…studies suggest that individuals
40 to 65 years old in the US workforce, with diabetes and neuropathic
symptoms experience excess health-related LPT compared with that of
others with and without diabetes

…The mean hours of LPT per week was substantially higher in the
diabetes patients with neuropathic symptoms
compared with in the others 4.21 hrs vs 1.90 hrs…(diabetic &
controls)
…more individuals who had diabetes with neuropathic symptoms
reported moderate to severe impact on work ability (ie, score 5 on a
scale from 0–10 compared with those without neuropathic
symptoms
(where 0 means “it has no effect on my ability to work” and 10 means “I am no longer able
to work”)

Cost of Lost Productive Time…$ $ $ $ $...:
In the US Workforce gives a equivalent of $3.65 billion
per year in health-related LPT, a cost per worker that is more
than 2.5 times higher than workers with diabetes without neuropathic
Symptoms…

In conclusion,…The severity might
lead to decreased health status,

•It is observed a prevalence of moderate-to-severe pain among pDPN
patients
•also indicate that health outcomes are significantly worse as pain severity
increases.
•Specifically, work impairment, health care resource use, and the associated
indirect and direct costs increase significantly as the level of pain severity
increases.
•These data emphasize the need
for effectively managing pain in patients with pDPN.

Peripheral (symmetrical) Neuropathy
(Sensory-Motor Neuropathy) which leads to……
Complications
Intrinsic muscles atrophy
→ foot deformities
Reflex reduction
→ Gait alteration…
Calluses & Ulcers occurrence
Amputations…

Aggravating Factors…
Peripheral Vascular Disease

Joint Mobility Reduction
Foot Structural deformities

Foot soft tissues lesions
Autonomous Neuropathy ???
Vassel-Kinetic Neuropathy (VASOMOTOR)
Sweat -Kinetic Neuropathy (SUDOMOTOR)

“autosympathectomy.”

Diabetic foot……The majority of lower extremity disease in people with diabetes is
treated in outpatient, clinic or office settings

Focus on Foot Ulcers

Foot ulcers are defined as a cutaneous erosion
extending through the dermis to deeper tissue, result
from various etiologic factors and are characterized
by an inability to self-repair in a timely and orderly
manner

Frequency of Lower Extremity Conditions in the U.S. Population with
Diabetes per 1,000.
Hospital Discharge Data for Ulcer/inflammation/infection (Ulcer),
Peripheral Neuropathy, and Peripheral Arterial Disease (PAD), 19932002

Age-adjusted Hospital Discharge Rates for Lower Extremity Disease
in the U.S. Population with Diabetes per 1,000.
Ulcer/inflammation/infection (Ulcer), Peripheral Neuropathy, and
Peripheral Arterial Disease (PAD), 1993-2002

R
a
t
e
/
1
,
0
0
0

Population-Based Diabetic Foot Ulcer Incidence and Prevalence
from Selected Studies…
First Author/
Reference

Foot Ulcer
Foot Ulcer

Population Studied

Annual
Prevalence /100
Incidence /100

Abbott (16)

Borssen (32)

Kumar (12)
Lavery (33)

Malgrane (34)
MMWR (35)
Moss (23)

Ramsey (28)
Walters (14)

Cohort of 6,613 patients in six district
clinics in NW England followed for 2
yrs, Type 1, 2 diabetes
375 patients Umea County Sweden, Age
15-50,
Type 1 = 298, Type 2 = 77
Cross-sectional study of 811 Type 2
patients from three UK cities
Cohort of 1,666 patients, San Antonio,
Texas, 51% Mexican Americans,
followed for 2 yrs
664 patients from 16 French diabetes
centers
2000-2002 BRFSS US survey of adults
> 18 yrs
Cohort of 2,990 patients with late and
early-onset diabetes
Nested case-control study in HMO,
8,905 Type 1, Type 2
Cross-sectional study of 1,077 Type 1, 2
patients in 10 UK general medicine
practices

2.2

4.7

2.0

10.0 IDDM
9.0 NIDDM

1.0

5.3

3.4

—

—

15.8%

—

11.8%

2.4 younger

9.5 younger

2.6 older

10.5 older

1.9
4.1

7.4

Frequency of U.S. Hospitalization for Ulcer-Related Conditions
in Individuals with Diabetes by Diagnosis, 2001-2002
Type of ulcer

ICD-CM
Codes

Estimated
Frequency
2001

Estimated
Frequency
2002

Cellulitis, abscess, or infected ulcer
Other cellulitis and abscess, foot except toes

681.1
682.7

26,685
81,367

29,347
83,954

Ulcer of lower limbs, except decubitus
Osteomyelitis

707.1
730.07

209,088
60,989

216,785
66,591

129,466

134,274

83,546

78,983

730.17
730.27
730.37
730.87
730.97

Chronic nonhealing ulcers

707.0
707.9

Atherosclerosis of lower limb with ulcer

440.23

Or gangrene

440.24

Ulcers Health Care Costs…



Optimally, the estimation of diabetic foot ulcer costs
spans an entire ulcer episode from lesion onset to
final resolution.



Two studies provided direct costs associated with the
entire diabetic foot ulcer history. This methodology
captures the many inpatient and outpatient
costs/charges associated with foot ulcers and is
preferable to reporting only charge for a single
hospitalization or limited time interval

Direct Cost for Foot Ulcers in Persons with Diabetes From Two
Studies
Author

# Patients/

Outcome

Average
Episode Cost
(US $)

Inpatient
Cost %

Outpatient
Cost %

Primary healing =
63%

$6,664

61

39

18

82

Study Type

Apelqvist Prospective
(27)
314 General
Internal
Medicine
Patients
Ramsey
(28)

Healed after
amputation = 24%

Nested casePrimary healing =
control study
84%
in HMO of
Amputation =
8,905 Type 1,2
16%

$44,790

$27,987

Total
Attributable
cost

Ulcer Reimbursement to Hospitals for Patients with and
without Diabetes, 2002
Medstat (Private)1
Source:

Length of Stay

Average $
Reimbursement

Length of Stay

Average $
Reimbursement

18

Peripheral Neuropathy with
complications

5.6

9,036

5.5

4,782

19

Peripheral Neuropathy
without complications

4.8

6,061

3.6

3,034

277

Cellulitis > age 17 with
complications

4.8

6,823

5.7

4,000

278

Cellulitis > age 17 without
complications

3.4

4,426

4.2

2,192

271

Skin Ulcers

11.0

11,638

7.3

5,227

238

Osteomyelitis

5.9

9,913

8.7

7,376

130

Peripheral Arterial Disease
with complications

5.1

7,743

5.6

4,554

131

Peripheral Arterial Disease
without complications

4.3

5,768

4.1

2,375

1Medstat

Group,
Thompson
DRG
Corporati
on, 2005
2Centers

for
Medicare
and
Medicaid
Services,
2005

Key:
DRG =
Diagnostic
Related
Group

Medicare2

Condition

In conclusion….


The average private hospital reimbursement for a
foot ulcer for 11 days is about $11,638 while
Medicare reimbursement for foot ulcer conditions is
usually for 7.3 days and $5,227.



The direct economic cost attributable to foot ulcers
from onset for two years approaches $28,000.



Guideline-based care is needed to improve outcomes
and provide cost savings compared with standard
care

Final conclusions and suggestions!!!










Diabetes has pervasive emotional and physical effects on patients lives.
Additionally, physical and psychological barriers, time and monetary
limitations, and a lack of social support complicates disease management
People, especially those with little education, may not understand the
progressive nature of diabetes. However, using diabetes complications as
a scare tactic may only exacerbate feelings of helplessness if patients view
future complications as inevitable
Documented workplace discrimination allegations indicate that people with
diabetes are more likely to experience prejudice, which can affect job
retention. This in turn may affect access to health insurance and health
maintenance
balancing familial and work responsibilities may complicate diabetes
management because of feelings of obligation. Working patients need
flexible supports that facilitate program participation such as longer clinic
hours, child care services, time management training, and flexible work
schedules that accommodate doctor visits and exercise
Finally, diabetes supports should address the whole person — physically,
psychologically, and socially. Future interventions for working people with
diabetes should include coordinated programs that involve social,
emotional, and lifestyle supports to help keep people healthy so that they
can work well

Thank U
4 your
@Ntion !!

Pts


Slide 21

Diabetic Neuropathy
in the workforce
and cost
Panagiotis V. Tsaklis, PhD
Associate Professor
School of Health Professions
“Alexander” TEI Thessaloniki
Sen. Researcher
Dept Public Health Sciences
Occupational & Environmental Medicine
Karolinska Institutet

mellitus…


The global prevalence of diabetes is
predicted to double by the year 2030 from
2.8% to 4.4%.



…Of individuals with diabetes, a substantial
number will develop lower extremity disease
including peripheral neuropathy, foot ulcers
and peripheral arterial disease…

Does it cost much??


In 2007, the estimated national cost in US of diabetes
exceeded $174 billion…


This estimate included $116 billion in diabetesrelated medical costs and $58 billion in reduced
productivity ….due to increased work absenteeism,
reduced work and daily productivity, unemployment
from disease-related disability, and early death..



Polyneuropathy is one of the commonest complications of the
diabetes and the commonest form of neuropathy in the
developed World. Diabetic polyneuropathy encompasses
several neuropathic syndromes the commonest of which is
distal symmetrical neuropathy, the main initiating factor for foot
ulceration. The epidemiology of diabetic neuropathy has
recently been reviewed in reasonable detail

…from the 1999-2000 population-based US Health and Nutrition
Survey (NHANES), The prevalence (history) of peripheral
neuropathy (> 1 insensate area) in people with diabetes was
28.5%...


The EURODIAB Prospective Complications Study which
involved the examination of 3250 type 1 patients, from 16
European countries, found a prevalence rate of 28% for distal
symmetrical neuropathy

…painful diabetic
peripheral neuropathy (pDPN) is associated with
worse health outcomes…
…however, among pDPN patients, few studies have
examined the relationship between the severity of
pain and health outcomes……

Lost Productive Time (LPT) and diabetes neuropathy…
…studies suggest that individuals
40 to 65 years old in the US workforce, with diabetes and neuropathic
symptoms experience excess health-related LPT compared with that of
others with and without diabetes

…The mean hours of LPT per week was substantially higher in the
diabetes patients with neuropathic symptoms
compared with in the others 4.21 hrs vs 1.90 hrs…(diabetic &
controls)
…more individuals who had diabetes with neuropathic symptoms
reported moderate to severe impact on work ability (ie, score 5 on a
scale from 0–10 compared with those without neuropathic
symptoms
(where 0 means “it has no effect on my ability to work” and 10 means “I am no longer able
to work”)

Cost of Lost Productive Time…$ $ $ $ $...:
In the US Workforce gives a equivalent of $3.65 billion
per year in health-related LPT, a cost per worker that is more
than 2.5 times higher than workers with diabetes without neuropathic
Symptoms…

In conclusion,…The severity might
lead to decreased health status,

•It is observed a prevalence of moderate-to-severe pain among pDPN
patients
•also indicate that health outcomes are significantly worse as pain severity
increases.
•Specifically, work impairment, health care resource use, and the associated
indirect and direct costs increase significantly as the level of pain severity
increases.
•These data emphasize the need
for effectively managing pain in patients with pDPN.

Peripheral (symmetrical) Neuropathy
(Sensory-Motor Neuropathy) which leads to……
Complications
Intrinsic muscles atrophy
→ foot deformities
Reflex reduction
→ Gait alteration…
Calluses & Ulcers occurrence
Amputations…

Aggravating Factors…
Peripheral Vascular Disease

Joint Mobility Reduction
Foot Structural deformities

Foot soft tissues lesions
Autonomous Neuropathy ???
Vassel-Kinetic Neuropathy (VASOMOTOR)
Sweat -Kinetic Neuropathy (SUDOMOTOR)

“autosympathectomy.”

Diabetic foot……The majority of lower extremity disease in people with diabetes is
treated in outpatient, clinic or office settings

Focus on Foot Ulcers

Foot ulcers are defined as a cutaneous erosion
extending through the dermis to deeper tissue, result
from various etiologic factors and are characterized
by an inability to self-repair in a timely and orderly
manner

Frequency of Lower Extremity Conditions in the U.S. Population with
Diabetes per 1,000.
Hospital Discharge Data for Ulcer/inflammation/infection (Ulcer),
Peripheral Neuropathy, and Peripheral Arterial Disease (PAD), 19932002

Age-adjusted Hospital Discharge Rates for Lower Extremity Disease
in the U.S. Population with Diabetes per 1,000.
Ulcer/inflammation/infection (Ulcer), Peripheral Neuropathy, and
Peripheral Arterial Disease (PAD), 1993-2002

R
a
t
e
/
1
,
0
0
0

Population-Based Diabetic Foot Ulcer Incidence and Prevalence
from Selected Studies…
First Author/
Reference

Foot Ulcer
Foot Ulcer

Population Studied

Annual
Prevalence /100
Incidence /100

Abbott (16)

Borssen (32)

Kumar (12)
Lavery (33)

Malgrane (34)
MMWR (35)
Moss (23)

Ramsey (28)
Walters (14)

Cohort of 6,613 patients in six district
clinics in NW England followed for 2
yrs, Type 1, 2 diabetes
375 patients Umea County Sweden, Age
15-50,
Type 1 = 298, Type 2 = 77
Cross-sectional study of 811 Type 2
patients from three UK cities
Cohort of 1,666 patients, San Antonio,
Texas, 51% Mexican Americans,
followed for 2 yrs
664 patients from 16 French diabetes
centers
2000-2002 BRFSS US survey of adults
> 18 yrs
Cohort of 2,990 patients with late and
early-onset diabetes
Nested case-control study in HMO,
8,905 Type 1, Type 2
Cross-sectional study of 1,077 Type 1, 2
patients in 10 UK general medicine
practices

2.2

4.7

2.0

10.0 IDDM
9.0 NIDDM

1.0

5.3

3.4

—

—

15.8%

—

11.8%

2.4 younger

9.5 younger

2.6 older

10.5 older

1.9
4.1

7.4

Frequency of U.S. Hospitalization for Ulcer-Related Conditions
in Individuals with Diabetes by Diagnosis, 2001-2002
Type of ulcer

ICD-CM
Codes

Estimated
Frequency
2001

Estimated
Frequency
2002

Cellulitis, abscess, or infected ulcer
Other cellulitis and abscess, foot except toes

681.1
682.7

26,685
81,367

29,347
83,954

Ulcer of lower limbs, except decubitus
Osteomyelitis

707.1
730.07

209,088
60,989

216,785
66,591

129,466

134,274

83,546

78,983

730.17
730.27
730.37
730.87
730.97

Chronic nonhealing ulcers

707.0
707.9

Atherosclerosis of lower limb with ulcer

440.23

Or gangrene

440.24

Ulcers Health Care Costs…



Optimally, the estimation of diabetic foot ulcer costs
spans an entire ulcer episode from lesion onset to
final resolution.



Two studies provided direct costs associated with the
entire diabetic foot ulcer history. This methodology
captures the many inpatient and outpatient
costs/charges associated with foot ulcers and is
preferable to reporting only charge for a single
hospitalization or limited time interval

Direct Cost for Foot Ulcers in Persons with Diabetes From Two
Studies
Author

# Patients/

Outcome

Average
Episode Cost
(US $)

Inpatient
Cost %

Outpatient
Cost %

Primary healing =
63%

$6,664

61

39

18

82

Study Type

Apelqvist Prospective
(27)
314 General
Internal
Medicine
Patients
Ramsey
(28)

Healed after
amputation = 24%

Nested casePrimary healing =
control study
84%
in HMO of
Amputation =
8,905 Type 1,2
16%

$44,790

$27,987

Total
Attributable
cost

Ulcer Reimbursement to Hospitals for Patients with and
without Diabetes, 2002
Medstat (Private)1
Source:

Length of Stay

Average $
Reimbursement

Length of Stay

Average $
Reimbursement

18

Peripheral Neuropathy with
complications

5.6

9,036

5.5

4,782

19

Peripheral Neuropathy
without complications

4.8

6,061

3.6

3,034

277

Cellulitis > age 17 with
complications

4.8

6,823

5.7

4,000

278

Cellulitis > age 17 without
complications

3.4

4,426

4.2

2,192

271

Skin Ulcers

11.0

11,638

7.3

5,227

238

Osteomyelitis

5.9

9,913

8.7

7,376

130

Peripheral Arterial Disease
with complications

5.1

7,743

5.6

4,554

131

Peripheral Arterial Disease
without complications

4.3

5,768

4.1

2,375

1Medstat

Group,
Thompson
DRG
Corporati
on, 2005
2Centers

for
Medicare
and
Medicaid
Services,
2005

Key:
DRG =
Diagnostic
Related
Group

Medicare2

Condition

In conclusion….


The average private hospital reimbursement for a
foot ulcer for 11 days is about $11,638 while
Medicare reimbursement for foot ulcer conditions is
usually for 7.3 days and $5,227.



The direct economic cost attributable to foot ulcers
from onset for two years approaches $28,000.



Guideline-based care is needed to improve outcomes
and provide cost savings compared with standard
care

Final conclusions and suggestions!!!










Diabetes has pervasive emotional and physical effects on patients lives.
Additionally, physical and psychological barriers, time and monetary
limitations, and a lack of social support complicates disease management
People, especially those with little education, may not understand the
progressive nature of diabetes. However, using diabetes complications as
a scare tactic may only exacerbate feelings of helplessness if patients view
future complications as inevitable
Documented workplace discrimination allegations indicate that people with
diabetes are more likely to experience prejudice, which can affect job
retention. This in turn may affect access to health insurance and health
maintenance
balancing familial and work responsibilities may complicate diabetes
management because of feelings of obligation. Working patients need
flexible supports that facilitate program participation such as longer clinic
hours, child care services, time management training, and flexible work
schedules that accommodate doctor visits and exercise
Finally, diabetes supports should address the whole person — physically,
psychologically, and socially. Future interventions for working people with
diabetes should include coordinated programs that involve social,
emotional, and lifestyle supports to help keep people healthy so that they
can work well

Thank U
4 your
@Ntion !!

Pts