Comorbidity and Health Care Resource Use Among Commercially Insured Non-Elderly Patients With Diabetic Macular Edema

BACKGROUND AND OBJECTIVE

Diabetic macular edema (DME) is a leading cause of blindness for non-elderly adults; however, health care-associated burden data from this population is lacking. The authors describe health care-associated burden in non-elderly patients with DME compared to those with diabetes and no DME.

PATIENTS AND METHODS

In this retrospective, large-cohort study examines enrollment and health care claims (2007 to 2011) from a national database of insured patients aged 18 to 63 years (mean: 51). Comorbidity and health care utilization differences between patients with DME (n = 24,326) and matched controls with diabetes but no DME (n = 122,710) were analyzed over 1 and 3 years.

RESULTS

DME patients had significantly more baseline comorbidities, and generally developed them at a higher rate over the study. Health care resource utilization rates were significantly higher in DME patients for every category analyzed. Patients with DME averaged more than 10 health care visits more than those with diabetes but no DME (25.5 vs 14.9; P < .001).

CONCLUSION

Working-age patients with DME exhibit a complicated comorbidity profile and high associated burden of health care consumption. Considering this burden is critical for managing this complex population.

Crural or Pedal Artery Revascularisation for Limb Salvage: is it Justified ?

With the ageing of population, the incidence of limb-threatening ischemia increases. In chronic critical limb ischemia, peripheral arterial occlusive disease almost always involves infrainguinal and infragenicular vessels. Fortunately, recent advances in vascular surgery made arterial reconstruction of crural and pedal vessels possible. Should crural or pedal bypass surgery be offered to these frail, polyvascular patients, or is primary amputation a preferable treatment option in case of advanced limb-threatening ischemia? In order to answer this controversial question, the author analysed recent literature data on the feasibility and durability of infrapopliteal bypasses. The quality of life was also considered as an outcome measure. Finally, the cost-effectiveness of both treatment modalities (limb-saving distal bypass versus primary amputation) was assessed.

Cost and mortality data of a regional limb salvage and hyperbaric medicine program for Wagner Grade 3 or 4 diabetic foot ulcers

We obtained costs and mortality data in two retrospective cohorts totaling 159 patients who have diabetes mellitus and onset of a diabetic foot ulcer (DFU). Data were collected from 2005 to 2013, with a follow-up period through September 30, 2014. A total of 106 patients entered an evidence-based limb salvage protocol (LSP) for Wagner Grade 3 or 4 (WG3/4) DFU and intention-to-treat adjunctive hyperbaric oxygen (HBO₂) therapy. A second cohort of 53 patients had a primary lower extremity amputation (LEA), either below the knee (BKA) or above the knee (AKA) and were not part of the LSP. Ninety-six of 106 patients completed the LSP/HBO₂with an average cost of USD $33,100. Eighty-eight of 96 patients (91.7%) who completed the LSP/HBO₂had intact lower extremities at one year. Thirty-four of the 96 patients (35.4%) died during the follow-up period. Costs for a historical cohort of 53 patients having a primary major LEA range from USD $66,300 to USD $73,000. Twenty-five of the 53 patients (47.2%) died. The difference in cost of care and mortality between an LSP with adjunctive HBO₂therapy vs. primary LEA is staggering. We conclude that an aggressive limb salvage program that includes HBO₂ therapy is cost-effective.

Policy evaluation in diabetes prevention and treatment using a population-based macro simulation model: the MICADO model

AIMS

To test a simulation model, the MICADO model, for estimating the long-term effects of interventions in people with and without diabetes.

METHODS

The MICADO model includes micro- and macrovascular diseases in relation to their risk factors. The strengths of this model are its population scope and the possibility to assess parameter uncertainty using probabilistic sensitivity analyses. Outcomes include incidence and prevalence of complications, quality of life, costs and cost-effectiveness. We externally validated MICADO's estimates of micro- and macrovascular complications in a Dutch cohort with diabetes (n = 498,400) by comparing these estimates with national and international empirical data.

RESULTS

For the annual number of people undergoing amputations, MICADO's estimate was 592 (95% interquantile range 291-842), which compared well with the registered number of people with diabetes-related amputations in the Netherlands (728). The incidence of end-stage renal disease estimated using the MICADO model was 247 people (95% interquartile range 120-363), which was also similar to the registered incidence in the Netherlands (277 people). MICADO performed well in the validation of macrovascular outcomes of population-based cohorts, while it had more difficulty in reflecting a highly selected trial population.

CONCLUSIONS

Validation by comparison with independent empirical data showed that the MICADO model simulates the natural course of diabetes and its micro- and macrovascular complications well. As a population-based model, MICADO can be applied for projections as well as scenario analyses to evaluate the long-term (cost-)effectiveness of population-level interventions targeting diabetes and its complications in the Netherlands or similar countries.

Outcomes and cost minimisation associated with outpatient parenteral antimicrobial therapy (OPAT) for foot infections in people with diabetes

OBJECTIVE

To determine clinical outcomes in patients with diabetic foot infections receiving outpatient parenteral antimicrobial therapy (OPAT), to evaluate cost savings from the use of OPAT and to analyse demographic, clinical and laboratory data that may predict OPAT failure.

RESEARCH DESIGN AND METHODOLOGY

A retrospective cohort analysis was conducted between 1 January 2007 and 7 July 2012 at a tertiary referral hospital in metropolitan Sydney. Patients with diabetic foot infection were identified from the outpatient parenteral antimicrobial therapy database. Demographic, clinical, laboratory and operative report data were obtained from patient charts and electronic medical records. Potential cost savings were calculated on the estimated cost of expenditure versus the expected savings. Linear regression was used to explore outcomes associated with outpatient parenteral antimicrobial therapy failure.

RESULTS

Fifty-nine patients were identified over the 5-year study period. The outpatient parenteral antimicrobial therapy success rate for diabetic foot infections was 88%. Following the resolution of the primary episode of infection, new infective episodes within the study period were high (n = 26, 44%). Regression analysis of variables for OPAT failure failed to indicate any factors reaching statistical significance. A total of 1569 days were saved by using outpatient parenteral antimicrobial therapy for an estimated total cost saving of $983,645 or $16,672 per patient.

CONCLUSION

Outpatient intravenous therapy for diabetic foot infections is an effective mode of treatment that can contribute to significant healthcare savings. High re-infection rates associated with diabetes foot ulceration in this population underline the need for close monitoring and management of these patients in multidisciplinary high-risk foot setting.

Elevated costs and high one-year mortality in patients with diabetic foot ulcers after surgery

INTRODUCTION

In Denmark, approximately 300,000 patients have a diabetes mellitus diagnosis. Recently published guidelines emphasise that health-care professionals who are in direct contact with citizens should be aware of the importance of prevention and early detection of diabetic foot ulcers. The objective of this study was to evaluate the mortality, length of hospital stay and economic impact on health care in patients with acute diabetic foot ulcers who were hospitalised in the Department of Orthopaedic Surgery, Aalborg University Hospital, Denmark.

METHODS

This was a prospective cohort study including all patients admitted with a diagnosis of acute foot ulcer to the Department of Orthopaedic Surgery, Aalborg, Denmark, from September 2011 to February 2012.

RESULTS

A total of 48 patients were referred for surgical treatment of a diabetic foot ulcer. The average age on admission was 64 years (35-87 years). The median length of hospital stay was 17 days (3-150 days), and 14 patients were readmitted within the first year. Within the first year of enrolment, 13 patients died, corresponding to a 36% mortality rate. Based on the Danish Diagnosis-Related Groups rates, the median cost associated with a case in the study population was 133,867 DKK.

CONCLUSION

Patients referred for surgical revision of diabetic foot ulcers are often severely ill, and the condition is associated with a high one-year mortality rate. Furthermore, the cost of these cases is considerable. Preventive interventions, early diagnosis and treatment and multidisciplinary interventions – before and during hospitalisation – should be implemented.

FUNDING

not relevant.

TRIAL REGISTRATION

The Danish Data Protection Agency (J. No. 2008-58-0028) approved the study.

Economic outcomes among Medicare patients receiving bioengineered cellular technologies for treatment of diabetic foot ulcers

OBJECTIVE

To assess the real-world medical services utilization and associated costs of Medicare patients with diabetic foot ulcers (DFUs) treated with Apligraf (bioengineered living cellular construct (BLCC)) or Dermagraft (human fibroblast-derived dermal substitute (HFDS)) compared with those receiving conventional care (CC).

METHODS

DFU patients were selected from Medicare de-identified administrative claims using ICD-9-CM codes. The analysis followed an 'intent-to-treat' design, with cohorts assigned based on use of (1) BLCC, (2) HFDS, or (3) CC (i.e., ≥1 claim for a DFU-related treatment procedure or podiatrist visit and no evidence of skin substitute use) for treatment of DFU in 2006-2012. Propensity score models were used to separately match BLCC and HFDS patients to CC patients with similar baseline demographics, wound severity, and physician experience measures. Medical resource use, lower-limb amputation rates, and total healthcare costs (2012 USD; from payer perspective) during the 18 months following treatment initiation were compared among the resulting matched samples.

RESULTS

Data for 502 matched BLCC-CC patient pairs and 222 matched HFDS-CC patient pairs were analyzed. Increased costs associated with outpatient service utilization relative to matched CC patients were offset by lower amputation rates (-27.6% BLCC, -22.2% HFDS), fewer days hospitalized (-33.3% BLCC, -42.4% HFDS), and fewer emergency department visits (-32.3% BLCC, -25.7% HFDS) among BLCC/HFDS patients. Consequently, BLCC and HFDS patients had per-patient average healthcare costs during the 18-month follow-up period that were lower than their respective matched CC counterparts (-$5253 BLCC, -$6991 HFDS).

LIMITATIONS

Findings relied on accuracy of diagnosis and procedure codes contained in the claims data, and did not account for outcomes and costs beyond 18 months after treatment initiation.

CONCLUSION

These findings suggest that use of BLCC and HFDS for treatment of DFU may lower overall medical costs through reduced utilization of costly healthcare services.

Cost of diabetic foot disease to the National Health Service in England

AIM

To estimate the annual cost of diabetic foot care in a universal healthcare system.

METHODS

National datasets and economic modelling were used to estimate the cost of diabetic foot disease to the National Health Service in England in 2010-2011. The cost of hospital admissions specific to foot disease or amputation was estimated from Hospital Episode Statistics and national tariffs. Multivariate regression analysis was used to estimate the impact of foot disease on length of stay in admissions that were not specific to foot disease or amputation. Costs in other areas were estimated from published studies and data from individual hospitals.

RESULTS

The cost of diabetic foot care in 2010-2011 is estimated at £580 m, almost 0.6% of National Health Service expenditure in England. We estimate that more than half this sum (£307 m) was spent on care for ulceration in primary and community settings. Of hospital admissions with recorded diabetes, 8.8% included ulcer care or amputation. Regression analysis suggests that foot disease was associated with a 2.51-fold (95% CI 2.43-2.59) increase in length of stay.The cost of inpatient ulcer care is estimated at £219 m, and that of amputation care at £55 m.

CONCLUSIONS

The cost of diabetic foot disease is substantial. Ignorance of the cost of current care may hinder commissioning of effective services for prevention and management in both community and secondary care.

Gender differences in the impact of poverty on health: disparities in risk of diabetes-related amputation

AIMS

To assess the combined impact of socio-economic status and gender on the risk of diabetes-related lower extremity amputation within a universal healthcare system.

METHODS

We conducted a population-based cohort study using administrative health databases from Ontario, Canada. Adults with pre-existing or newly diagnosed diabetes (N = 606 494) were included and the incidence of lower extremity amputation was assessed for the period 1 April 2002 to 31 March 2009. Socio-economic status was based on neighbourhood-level income groups, assigned to individuals using the Canadian Census and their postal code of residence.

RESULTS

Low socio-economic status was associated with a significantly higher incidence of lower extremity amputation (27.0 vs 19.3 per 10,000 person-years in the lowest (Q1) vs the highest (Q5) socio-economic status quintile. This relationship persisted after adjusting for primary care use, region of residence and comorbidity, and was greater among men (adjusted Q1:Q5 hazard ratio 1.41, 95% CI 1.30-1.54; P < 0.0001 for all male gender-socio-economic status interactions) than women (hazard ratio 1.20, 95% CI 1.06-1.36). Overall, the incidence of lower extremity amputation was higher among men than women (hazard ratio for men vs women: 1.87, 95% CI 1.79-1.96), with the greatest disparity between men in the lowest socio-economic status category and women in the highest (hazard ratio 2.39, 95% CI 2.06-2.77 and hazard ratio 2.30, 95% CI 1.97-2.68, for major and minor amputation, respectively).

CONCLUSIONS

Despite universal access to hospital and physician care, we found marked socio-economic status and gender disparities in the risk of lower extremity amputation among patients with diabetes. Men living in low-income neighbourhoods were at greatest risk.

Diabetic foot infections: state-of-the-art

Foot infections are frequent and potentially devastating complications of diabetes. Unchecked, infection can progress contiguously to involve the deeper soft tissues and ultimately the bone. Foot ulcers in people with diabetes are most often the consequence of one or more of the following: peripheral sensory neuropathy, motor neuropathy and gait disorders, peripheral arterial insufficiency or immunological impairments. Infection develops in over half of foot ulcers and is the factor that most often leads to lower extremity amputation. These amputations are associated with substantial morbidity, reduced quality of life and major financial costs. Most infections can be successfully treated with optimal wound care, antibiotic therapy and surgical procedures. Employing evidence-based guidelines, multidisciplinary teams and institution-specific clinical pathways provides the best approach to guide clinicians through this multifaceted problem. All clinicians regularly seeing people with diabetes should have an understanding of how to prevent, diagnose and treat foot infections, which requires familiarity with the pathophysiology of the problem and the literature supporting currently recommended care.

Does the diabetic foot have a significant impact on selected psychological or social characteristics of patients with diabetes mellitus?

The aim of our case-control study was to compare selected psychological and social characteristics between diabetic patients with and without the DF (controls).

METHODS

104 patients with and 48 without DF were included into our study. Both study groups were compared in terms of selected psychosocial characteristics.

RESULTS

Compared to controls, patients with DF had a significantly worse quality of life in the area of health and standard of living as shown by lower physical health domain (12.7 ± 2.8 versus 14.7 ± 2.5; P < 0.001) and environment domain (14.1 ± 2.2 versus 15 ± 1.8; P < 0.01) that negatively correlated with diabetes duration (r = -0.061; P = 0.003). Patients with DF subjectively felt more depressed in contrast to controls (24.5 versus 7.3%; P < 0.05); however, the depressive tuning was objectively proven in higher percentage in both study groups (83.2 versus 89.6; NS). We observed a significantly lower level of achieved education (P < 0.01), more patients with disability pensions (P < 0.01), and low self-support (P < 0.001) in patients with the DF compared to controls. In the subgroup of patients with a previous major amputation and DF (n = 6), there were significantly worse outcomes as in the environment domain (P < 0.01), employment status, and stress readaptation (P < 0.01) in contrast to the main study groups.

CONCLUSIONS

Patients with DF had a predominantly worse standard of living. In contrast to our expectations, patients with DF appeared to have good stress tolerability and mental health (with the exception of patients with previous major amputation) and did not reveal severe forms of depression or any associated consequences.

Impact of diabetes on costs before and after major lower extremity amputations in Germany

AIMS

To compare direct medical costs 1 year before up to 3 years after first major lower extremity amputation (LEA) between patients with and without diabetes.

METHODS

We used health insurance claims data and included patients with a first major LEA between 2005 and 2009. Costs for hospitalization, rehabilitation, outpatient care, outpatient drug prescriptions, non-physician services, durable medical equipment and long-term care were assessed. We estimated cost ratios (CR) for diabetes status using generalized linear models adjusted for age, sex, amputation level, care dependency as well as observation time and mortality within the corresponding period and costs before LEA.

RESULTS

We included 444 patients with first major LEA (58.3% had diabetes), 71.8% were male and the average age was 69.1 years. Total mean costs for 1 year before LEA were higher in patients with diabetes (24,504 vs. 18,961 Euros), which was also confirmed by the multivariate analysis (CR: 1.27; 95% CI: 1.06-1.52). Costs up to 24 weeks after LEA were virtually the same in both groups (36,686 vs. 35,858 Euros), but thereafter differences increase again with higher costs for diabetics. Costs for 3 years after LEA were 115,676 vs. 92,862 Euros, respectively (CR: 1.26; 95% CI: 1.12-1.42). Hospitalizations accounted for more than 50% of total costs irrespective of diabetes status and period.

CONCLUSIONS

Costs up to 24 weeks after first major LEA are mainly driven by the amputation itself irrespective of diabetes. Thereafter, costs for diabetic patients were higher again, which underlines the importance of studying long-term costs.

Geographic variation in Medicare spending and mortality for diabetic patients with foot ulcers and amputations

AIMS

The purpose of this study was to identify the presence or absence of geographic variation in Medicare spending and mortality rates for diabetic patients with foot ulcers (DFU) and lower extremity amputations (LEA).

METHODS

Diabetic beneficiaries with foot ulcers (n=682,887) and lower extremity amputations (n=151,752) were enrolled in Medicare Parts A and B during the calendar year 2007. We used ordinary least squares (OLS) regression to explain geographic variation in per capita Medicare spending and one-year mortality rates.

RESULTS

Health care spending and mortality rates varied considerably across the nation for our two patient cohorts. However, higher spending was not associated with a statistically significant reduction in one-year patient mortality (P=.12 for DFU, P=.20 for LEA). Macrovascular complications for amputees were more common in parts of the country with higher mortality rates (P<.001), but this association was not observed for our foot ulcer cohort (P=.12). In contrast, macrovascular complications were associated with increased per capita spending for beneficiaries with foot ulcers (P=.01). Rates of hospital admission were also associated with higher per capita spending and increased mortality rates for individuals with foot ulcers (P<.001 for health spending and mortality) and lower extremity amputations (P<.001 for health spending, P=.01 for mortality).

CONCLUSIONS

Geographic variation in Medicare spending and mortality rates for diabetic patients with foot ulcers and amputations is associated with regional differences in the utilization of inpatient services and the prevalence of macrovascular complications.

Predicting work-related disability and medical cost outcomes: estimating injury severity scores from workers' compensation data

PURPOSE

Acute work-related trauma is a leading cause of death and disability among US workers. The research objectives were to assess: (1) the feasibility of estimating Abbreviated Injury Scale-based injury severity scores (ISS) from ICD-9-CM codes available in workers' compensation (WC) medical billing data, (2) whether ISS predicts work-related disability and medical cost outcomes, (3) whether ISS adds value over other injury severity proxies, and (4) whether the utility of ISS differs for an all-injury sample compared with three specific injury samples (amputations, extremity fractures, traumatic brain injury).

METHODS

ISS was estimated from ICD-9-CM codes using Stata's user-written -icdpic- program for 208,522 compensable nonfatal WC claims for workers injured in Washington State from 1998 to 2008. The Akaike Information Criterion and R(2) were used to compare severity measures. Competing risks survival analysis was used to evaluate work disability outcomes. Adjusted total medical costs were modeled using linear regression.

RESULTS

Work disability and medical costs increased monotonically with injury severity. For a subset of 4,301 claims linked to the Washington State Trauma Registry (WTR), there was moderate agreement between WC-based ISS and WTR-based ISS. Including ISS together with an early hospitalization indicator resulted in the most informative models; however, early hospitalization is a more downstream measure.

CONCLUSIONS

ISS was significantly associated with work disability and medical cost outcomes for work-related injuries. Injury severity should be considered as a potential confounder for occupational injury intervention, program evaluation, or outcome studies, and can be estimated using existing software when ICD-9-CM codes are available.

A study of regional variation in the inpatient cost of lower extremity amputation among patients with diabetes in the United States

OBJECTIVE

Understanding of the effects of providers' cost on regional variation in healthcare spending is still very limited. The objective of this study is to assess cross-state and cross-region variations in inpatient cost of lower extremity amputation among diabetic patients (DLEA) in relation to patient, hospital, and state factors.

METHODS

Patient and hospital level data were obtained from the 2007 US Agency for Healthcare Research and Quality Healthcare Cost and Utilization Project (HCUP). State level data were obtained from the US Census Bureau and the Kaiser Family Foundation websites. Regression models were implemented to analyze the association between in-patient cost and variables at patient, hospital, and state levels.

RESULTS

This study analyzed data on 9066 DLEA hospitalizations from 39 states. The mean cost per in-patient stay was $17,103. Four out of the five most costly states were located on the East and West coasts (NY and NJ, CA and OR). Age, race, length of stay, level of amputation, in-patient mortality, primary payer, co-morbidities, and type of hospital were significantly correlated with in-patient costs and explained 55.3% of the cost variance. Based on the means of costs unexplained by those factors, the three West coast states had the highest costs, followed by five Midwestern states, and four Southern states, and Kansas were the least costly.

CONCLUSIONS

Over 40% of the variations in DLEA hospital costs could not be explained by major patient-, hospital-, and state-level variables. Further research is needed to examine whether similar patterns exist for other costly surgical procedures among diabetic patients.

Reducing lower leg amputations in diabetes: a challenge for patients, healthcare providers and the healthcare system

Amputation of the lower limb is one of the most feared diabetic complications. It is associated with loss of mobility and a poor quality of life. Amputations result in high economic burden for the healthcare system. The financial cost is also high for patients and their families, particularly in countries that lack a comprehensive health service and/or have a low income. Losing a leg frequently implies financial ruin for a whole family in these countries; therefore, a reduction in diabetes-related amputations is a major global priority. Marked geographical variation in amputation rates has been reported within specific regions of an individual country and between countries. A coordinated healthcare system with a multidisciplinary approach is essential if the number of amputations is to be reduced. This commentary discusses how studies on the variation in amputation rates can help to identify barriers in the access or delivery of care with the aim of reducing the burden of diabetic foot disease.

[Clinical characteristics and medical costs of diabetics with amputation at central urban hospitals in China]

OBJECTIVE

To explore the clinical characteristics, medical costs and its influencing factors in diabetics with amputation.

METHODS

The data of diabetic amputation for the whole year of 2010 at 39 central municipal Class 3A hospitals all across China were retrospectively analyzed according to a unified protocol, including demographic characteristics, diabetic complications, classification of diabetic foot disease, level and prognosis of amputation and medical costs at hospitals.

RESULTS

Among them, 28.2% of all amputated patients or 39.5% of non-traumatic patients were diabetics. There were 313 males and 162 females. The average age and duration of diabetes were (66 ± 12) years and (130 ± 94) months. The level of HbA1c was 8.9% ± 2.4%. Among all amputated diabetics, the concurrent conditions included neuropathy (50.1%), peripheral artery disease (74.8%), nephropathy (28.4%) and retinopathy (25.9%). The patients with foot ulcer at Wagner 4 (50.3%) were more common. Among them, 67.5% had minor amputation with a median hospitalization stay of 33.0 (24.0 - 45.0) days and a medical cost of 26 138 (16 155 - 46 021) yuan RMB. The duration of diabetes, diabetic complications, severity and location of ulcers and amputation level influenced their hospitalization durations and medical costs.

CONCLUSION

The patients with diabetes and amputation are elder with more chronic diabetic complications and uncontrolled hyperglycemia. Most of them have complications of local gangrene and require minor amputation at admission. Their hospital stays are longer and medical costs higher significantly correlated with diabetic complications, severity and location of foot ulcers and level of amputations.

[Pharmacoeconomics aspects of therapy for obliterating diseases of lower-limb peripheral arteries]

The study was aimed at assessing feasibility of treatment of patients suffering from critical ischaemia of lower extremities with iloprost as compared to the basic therapy by means of pharmacoeconomic analysis. The findings of clinical studies and meta-analyses demonstrated that therapy with iloprost results in a pronounced clinical effect as compared with the basic therapy: significantly (p<0.005) decreasing the number of amputations above the knee joint (23% versus 39%) and more frequently decreasing the size of trophic ulcers (in 49% of cases versus 26%). This provides maintenance of the ability to work in part of patients and a decrease in the frequency of hospitalization, which in its turn results in decreased costs of treatment and indirect expenses.. The results of the carried out study show that with due regard for only direct costs economy from treatment with iloprost would amount to 1,544,556 Roubles per 100 patients. With additionally taking into account of indirect costs economy from using iloprost as compared with basic therapy increases to 25,689,11 Roubles per 100 patients.

Lower extremity amputation prevention in Singapore: economic analysis of results

INTRODUCTION

The aim of the study was to determine the cost-effectiveness of the Lower Extremity Amputation Prevention (LEAP) strategy in comparison to standard clinical practice for treating patients with critical limb ischaemia (CLI).

METHODS

A retrospective cost-effectiveness analysis of the LEAP programme relative to pre-LEAP practice was performed from the perspective of Singapore hospitals. The cost incorporated in the analysis included direct medical costs incurred during the admission. Outcomes included the number of amputations, number of deaths and length of hospital stay after the initial treatment.

RESULTS

During the study period, the LEAP group had a lower amputation rate (29 percent versus 76 percent, p-value is 0.00001), lower related death rate (one percent versus 19 percent, p-value is 0.00001) and fewer in-hospital days per patient (17.8 days versus 23.16 days, p-value is 0.048) as compared to the standard clinical practice group. The implementation of the LEAP strategy generated cost savings of S$2,566 per patient during admission when compared with the pre-LEAP approach. The results were robust to variations in input parameters.

CONCLUSION

The LEAP strategy dominated standard practice in the management of patients with diabetes mellitus and CLI. The implementation of the LEAP strategy significantly improved patient outcomes and reduced hospital costs.