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Diabetic Neuropathy in the workforce and cost Panagiotis V. Tsaklis, PhD Associate Professor School of Health Professions “Alexander” TEI Thessaloniki.

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Presentation on theme: "Diabetic Neuropathy in the workforce and cost Panagiotis V. Tsaklis, PhD Associate Professor School of Health Professions “Alexander” TEI Thessaloniki."— Presentation transcript:

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

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

3 Does it cost much??  In 2007, the estimated national cost in US of diabetes exceeded $174 billion…  This estimate included $116 billion in diabetes- related 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..

4  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

5 …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

6 …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…

7 In conclusion,…The severity might lead to decreased health status, It is observed a prevalence of moderate-to-severe pain among pDPN It is observed a prevalence of moderate-to-severe pain among pDPNpatients also indicate that health outcomes are significantly worse as pain severity increases. also indicate that health outcomes are significantly worse as pain severity increases. Specifically, work impairment, health care resource use, and the associated 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 These data emphasize the need for effectively managing pain in patients with pDPN.

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

9 Aggravating Factors… Peripheral Vascular Disease Joint Mobility Reduction Joint Mobility Reduction Foot Structural deformities Foot Structural deformities Foot soft tissues lesions Foot soft tissues lesions Autonomous Neuropathy ??? Autonomous Neuropathy ???  Vassel-Kinetic Neuropathy (VASOMOTOR)  Sweat -Kinetic Neuropathy (SUDOMOTOR) “autosympathectomy.” “autosympathectomy.”

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

11 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

12 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), 1993- 2002

13 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 Rate / 1,000Rate / 1,000

14 Population-Based Diabetic Foot Ulcer Incidence and Prevalence from Selected Studies… First Author/ Reference Population Studied Foot Ulcer Annual Incidence /100 Foot Ulcer Prevalence /100 Abbott (16) Cohort of 6,613 patients in six district clinics in NW England followed for 2 yrs, Type 1, 2 diabetes 2.24.7 Borssen (32) 375 patients Umea County Sweden, Age 15-50, Type 1 = 298, Type 2 = 77 2.0 10.0 IDDM 9.0 NIDDM Kumar (12) Cross-sectional study of 811 Type 2 patients from three UK cities 1.05.3 Lavery (33) Cohort of 1,666 patients, San Antonio, Texas, 51% Mexican Americans, followed for 2 yrs 3.4— Malgrane (34) 664 patients from 16 French diabetes centers —15.8% MMWR (35) 2000-2002 BRFSS US survey of adults > 18 yrs —11.8% Moss (23) Cohort of 2,990 patients with late and early-onset diabetes 2.4 younger 2.6 older 9.5 younger 10.5 older Ramsey (28) Nested case-control study in HMO, 8,905 Type 1, Type 2 1.9 Walters (14) Cross-sectional study of 1,077 Type 1, 2 patients in 10 UK general medicine practices 4.17.4

15 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 681.126,68529,347 Other cellulitis and abscess, foot except toes 682.781,36783,954 Ulcer of lower limbs, except decubitus 707.1209,088216,785 Osteomyelitis730.07730.17730.27730.37730.87730.9760,98966,591 Chronic nonhealing ulcers 707.0707.9129,466134,274 Atherosclerosis of lower limb with ulcer Or gangrene 440.23440.2483,54678,983

16 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

17 Direct Cost for Foot Ulcers in Persons with Diabetes From Two StudiesAuthor # Patients/ Study Type Outcome Average Episode Cost (US $) Inpatient Cost % Outpatient Cost % Apelqvist (27) Prospective 314 General Internal Medicine Patients Primary healing = 63% Healed after amputation = 24% $6,664$44,7906139 Ramsey (28) Nested case- control study in HMO of 8,905 Type 1,2 Primary healing = 84% Amputation = 16% $27,987 Total Attributable cost 1882

18 Ulcer Reimbursement to Hospitals for Patients with and without Diabetes, 2002 Medstat (Private) 1 Medicare 2 Length of Stay Average $ Reimbursement Length of Stay Average $ Reimbursement DRGCondition 18 Peripheral Neuropathy with complications 5.69,0365.54,782 19 Peripheral Neuropathy without complications 4.86,0613.63,034 277 Cellulitis > age 17 with complications 4.86,8235.74,000 278 Cellulitis > age 17 without complications 3.44,4264.22,192 271 Skin Ulcers 11.011,6387.35,227 238 Osteomyelitis 5.99,9138.77,376 130 Peripheral Arterial Disease with complications 5.17,7435.64,554 131 Peripheral Arterial Disease without complications 4.35,7684.12,375 Source: 1 Medstat Group, Thompson Corporati on, 2005 2 Centers for Medicare and Medicaid Services, 2005 Key: DRG = Diagnostic Related Group

19 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

20 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

21 Pts Thank U 4 your @Ntion !!


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