Taking A Proactive, Long-Term View To Preventive Medicine

   In a recent position statement, “Third-Party Reimbursement For Diabetes Care, Self-Management Education and Supplies,” the American Diabetes Association (ADA) doesn’t exactly mince words. “To reach diabetes treatment goals, practitioners should have access to all classes of antidiabetic medications, equipment and supplies without undue controls. Without appropriate safeguards, these controls could constitute an obstruction of effective care.”    What about patients who do not have pain or cannot feel pain due to neuropathy? One of the often-cited statistics from researchers is that 85 percent of lower-limb amputations in patients with diabetes are preceded by foot ulcers. In a 2004 article in The New England Journal Of Medicine, Andrew Boulton, MD, and colleagues cited a study in which neuropathy accounted for the majority of foot ulcers and resulted in the greatest incidence of microvascular complications, which increased the annual costs of care by 70 percent.    It cost a total of $92 billion to manage diagnosed cases of diabetes in the United States in 2003, according to the aforementioned position statement by the ADA. Specifically, when it comes to foot ulcers, Dr. Boulton and his co-authors in the aforementioned article cite an estimated cost of $28,000 to treat one foot ulcer over a two-year period. In an introduction to a study published in Diabetes Care earlier this year, Vickie Driver, DPM, noted direct costs in 2001 ranging from $22,700 for toe amputations to over $50,000 for an above-knee amputation in patients with diabetes.    However, there is some very encouraging news in this regard. Recently at the American Diabetes Association’s Annual Scientific Sessions, the Centers For Disease Control reported findings from a study that revealed a 35 percent reduction in “diabetes-related, potentially preventable hospitalizations” from 1994 to 2002. The study evaluated four diabetes-related conditions, including lower-extremity amputations, a frequent complication of neuropathic foot ulcers in patients with diabetes.    In the aforementioned and extremely compelling Diabetes Care study, “Reducing Amputation Rates In Patients With Diabetes at a Military Medical Center,” Dr. Driver and her co-authors found that while there was a 48 percent increase in diagnosed diabetes cases over a five-year period at their center, there was a significant decrease in the incidence of lower-extremity amputation (LEA) in this high-risk population. According to the study, the incidence of LEA went from 9.9 out of every 1,000 patients in 1999 to 1.8 out of every 1,000 patients in 2003.    What were some keys to their success in managing these patients? All diabetic patients at the center are required by the Veterans Administration to undergo a comprehensive foot exam once a year. According to the authors, treatment priorities for lower-extremity wounds included “aggressive treatment of infections, diagnosis of ischemia and evaluation for possible revascularization,” offloading and enhancing the wound environment via “debridement, dressings and advanced wound care treatments when appropriate.”    In the article, Dr. Driver also emphasizes the “close collaboration” between multidisciplinary providers at her clinic whereas one may encounter more barriers to specialist referrals in a private practice environment.    Wound care specialists also recently testified before the Medicare Coverage Advisory Committee on the standard of care for chronic wounds (see page 8, “News And Trends,” June issue). One podiatrist who testified calls this “a major step” in working toward appropriate reimbursement and improved outcomes within a disease management model.    Hopefully, we will get to a point where everyone understands that preventive care and appropriate coverage for that care pay off in longer lives for high-risk patients.