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Discussion: The Economics of Limb Salvage in Diabetes

I their report, “The Economics of Limb Salvage in Diabetes,” Hunt et al. review the economic impact of prevention therapies, advanced wound care, and peripheral vascular interventions in preventing major lower extremity amputations. Limb preservation team services, including diagnostics, advanced treatments, and procedures, have been shown to positively impact limb loss, but the associated costs are not well understood or reported. Perhaps this is true because the burden of preventing amputations is often realized at a critical health care event, such as a limb-threatening infection or an acute critical limb ischemia. In 2007, the treatment of diabetes and its complications in the United States generated at least $116 billion in direct costs; at least 33 percent of these costs were linked to the treatment of foot ulcers.1 The vast majority of increased costs for diabetic foot problems are accounted for by hospital admissions. Patients with diabetic foot ulcers have a longer hospital stay on average and require more emergency department visits than those without diabetic foot ulcers.2 Another important but unmeasured cost is the indirect cost of diabetic foot pathologies, which include patient sick leave, lower productivity, disability, premature death, early retirement, and so on. It would have significant economic impact on welfare and Social Security. Therefore, the current economic burden and costs are underestimated, if we take into consideration indirect costs. Hunt et al. comprehensively review current economics of limb salvage in diabetes and conclude that primary or secondary prevention and early detection of diabetic foot ulcers are unsurprisingly the most cost-effective way to reduce cost and improve quality of life. They also mentioned that contact casts yield higher healing rates than bioengineered tissues or growth factors. We practice in a “high-tech” era, and “high-tech” products often attract both patients and providers. However, these products do not always yield better outcomes. We believe the critical component of utilizing advanced, “high-tech” therapies is knowing when to start, how long to continue, and when to stop. The problem lies in the fact that we have sophisticated, expensive treatment options, yet we have very few diagnostics that will allow us to understand appropriate responders or timing. As clinicians, we should not ignore the cost effectiveness of “low-tech/low-cost” products, such as the total-contact cast. A similar concept is known from general diabetes management. This is the “lowtech/low-cost” approach of diet and lifestyle modification and is the treatment of choice for prediabetes and early-stage diabetes. Prevention, early detection, and expedient intervention in diabetics who are at high risk for limb loss are the most cost-effective ways to reduce amputations. However, we would not be surprised if comparative effectiveness studies showed that low-tech/lowcost products reveal equal or even better clinical outcomes than more sophisticated high-tech products that accelerate early healing. Most clinicians believe that “low-tech/low-cost” practices and therapies should be employed in the clinical management of the high-risk diabetic foot as a standard practice. When patients fail to heal in a timely fashion, “high-tech” products should be considered quickly, to prevent infections, hospitalizations, and amputations. Focusing specifically on prevention practices, Hunt et al. point out that prevention is relatively inexpensive compared with the cost of treating an ulcer or a single hospital admission for an amputation. They go on to correctly state that preventive therapy needs to be provided as a continuum of care; thus, even relatively inexpensive therapies that are poorly selected burden the health care system.