JAMES R. CHRISTINA, DPM DIRECTOR SCIENTIFIC AFFAIRS AMERICAN PODIATRIC MEDICAL ASSOCIATION FOOTCARE AND DIABETES

Epidemiology of Diabetes 23.6 million in US  7.8% of population  ~ 10% in District of Columbia  8.7% of those > 20 yrs old  24% of Hispanic Americans  3,651 diagnosed daily  Leading cause of:  Blindness  Renal Failure  Amputation  5 th leading cause of death

Epidemiology of Amputation >60% of all amputations involve diabetes in US 9-20% of ulcerations end in amputation ~84% of lower extremity amputations are preceded by ulceration

Economic Impact of Diabetes ~ $174 BILLION Annual Cost Per Capita Medical Expenditure  $13,243 for diabetes  $2,560 for non-diabetic $4-28 Billion on Foot Ulceration 15 Million work days lost 59% longer duration of hospital stay for diabetic patients with foot ulcers

Following the First Lower Extremity Amputation: Contralateral amputation  68% within 5 years Mortality Rate  50% at 3 years Institutionalization  25% remain permanently Lavery, van Houtum, Armstrong, Am J Med, 1997

The Value of Care by a Podiatrist Results of the Thomson Reuters Healthcare (TRH) Study

DETAILS OF THE STUDY TRH using their MarketScan Data Base examined claims from 316,527 patients with commercial insurance and 157,529 patients with Medicare (and employer sponsored secondary insurance) Study focused on one specific aspect of diabetic foot care—those patients that developed a foot ulceration. A comparison was then made by looking at the year preceding the ulceration to see if any care from a podiatrist was provided to the patient.

RATES OF RISK FACTORS ARE HIGHER AMONG COMMERCIALLY INSURED PATIENTS WITH DIABETES WHO SEE PODIATRISTS Population Aged 18–64 Patients with Podiatrist visit Unmatched Comparison Matched Comparison Sample Size53,582316,52753,578 Cardiovascular53.3%46.8%*53.7% Nephropathy3.7%2.4%*3.7% Eye6.3%4.2%*6.2% PAD4.9%2.7%*4.7% Neuropathy4.2%2.4%*4.1% Deformity1.9%0.7%*1.7%* Callus0.3%0.1%*0.2% Nail Pathology3.7%1.3%*3.2%* 9 PAD = peripheral arterial disease Comparison group consists of patients with diabetes who do not see podiatrists, matching is based on propensity scores * Statistically significant difference at P < 0.05

RATES OF RISK FACTORS ARE HIGHER AMONG MEDICARE BENEFICIARIES WITH DIABETES WHO SEE PODIATRISTS Population Aged 65+ Patients with Podiatrist visit Unmatched Comparison Matched Comparison Sample Size43,050157,52943,042 Cardiovascular64.1%56.1%*63.7% Nephropathy8.5%5.1%*8.4% Eye7.8%5.7%*7.6% PAD10.4%6.2%*10.2% Neuropathy3.7%2.3%*3.6% Deformity2.9%1.3%*2.6%* Callus0.3%0.2%*0.3% Nail Pathology6.0%2.5%*5.4%* 10 PAD = peripheral arterial disease Comparison group consists of patients with diabetes who do not see podiatrists, matching is based on propensity scores * Statistically significant difference at P < 0.05

THE RESULTS Average savings over a three year time period (year before ulceration and two years after ulceration):  Commercial Insurance—Savings of $19,686 per patient if they had at least one visit to a podiatrist  Medicare: Savings of $4,271 per patient if they had at least one visit to a podiatrist

Comparison of healthcare costs during year before and two years after index foot ulcer diagnosis, podiatry and comparison groups

AMPUTATION REDUCTION: LIMBS SAVED

ODDS OF NEGATIVE OUTCOMES WERE LOWER AMONG PATIENTS WHO SEE PODIATRISTS 15 Commercial Ins: Aged 18–64 n=5,883 podiatry n=5,883 comparison Adjusted Odds Ratio (95% Confidence Interval) Percent Change in Odds of Outcome for Patients with Podiatry Amputation (0.573–0.886)28.8% lower odds Hospitalization (0.712–0.867)24.4% lower odds Medicare: Aged 65+ n=10,165 podiatry n=10,165 comparison Adjusted Odds Ratio (95% Confidence Interval) Percent Change in Odds of Outcome for Patients with Podiatry Amputation (0.652–0.921)22.5% lower odds Hospitalization (0.805–0.926)13.7% lower odds Logistic regression models estimated the odds of each outcome occurring within two years of the first foot ulcer diagnosis, controlling for demographic and clinical characteristics Podiatric care was defined as at least three visits prior to the first foot ulcer

WHAT IF EVERY AT RISK DIABETIC PATIENT SAW A PODIATRIST? Extrapolating the results from the study:  $1.97 billion could be saved in the commercial insurance group in one year  $1.53 billion could be saved in the Medicare group in one year  $3.5 billion total savings in one year

Objective To determine effectiveness of receipt of care from podiatrist and lower extremity clinician specialists (LEC specialists) on diabetes mellitus (DM)-related lower extremity amputation.

Data Sources Medicare 5 percent sample claims, 1991–2007.

Data Collection Individuals were stratified based on disease severity:  Stage 1——neuropathy, paresthesia, pain in feet, diabetic amyotrophy  Stage 2——cellutis, Charcot foot  Stage 3——ulcer  Stage 4——osteomyelitis, gangrene  After exclusions, there were 117,879 individuals in Stage 1, 31,582 in Stage 2, 31,199 in Stage 3, 55,068 in Stage 4 subsamples, and 189,598 in the combined analysis sample.

Principal Findings Persons visiting a podiatrist and an LEC specialist within a year before developing all stage complications were between 31 percent (ulceration) and 77 percent (cellulitis and Charcot foot) as likely to undergo amputation compared with individuals visiting other health professionals.

Conclusions Visiting both a podiatrist and an LEC specialist in the year before LEC diagnosis was protective of undergoing lower extremity amputation, suggesting a benefit from multidisciplinary care The results were most favorable to a pattern of care involving a combination of podiatrists and lower extremity specialists

VALUE Two independent large scale retrospective reviews demonstrated that care by podiatrists of persons with diabetes resulted in decreased lower extremity complications including amputations resulting in significant cost savings.

Moving Forward These studies involved retrospective reviews, how do we take this information and use it prospectively to improve the health of people with diabetes?

Podiatrists providing foot and ankle care for all persons with diabetes Every person with diabetes would be evaluated by a podiatrist completing a comprehensive lower extremity exam. Based on the findings of the examination, the patient would be assigned to a risk categorization and then care would be provided based on the risk classification.

Category Risk Profile Evaluation Frequency 0 Normal Annual 1 Peripheral Neuropathy (LOPS) Semi-annual 2 Neuropathy, deformity, and/or PAD Quarterly 3 Previous ulcer or amputation Monthly to quarterly Risk Categorization System: Recommendations from the American Diabetes Association Clinical Guidelines

GOALS Reduce complications including ulcerations, hospitalizations and ultimately amputations. Improve quality of life for people with diabetes. Significantly reduce health care costs associated with diabetes and lower extremity complications. Significantly reduce non-health care costs associated with lower extremity complications from diabetes.

Other Benefits Data from the Thomson Reuters Healthcare Study showed a decrease in hospitalizations from all causes, not just those related to lower extremity amputations Podiatrists become another member of the healthcare team providing care for the patient with diabetes which provides additional checks on:  Blood sugar control  Blood pressure control  Cholesterol regulation

BARRIERS Preventive care does have a cost associated with it:  There would be increased costs with more frequent visits based on the risk category of the patient, however, these increased costs would be minimal compared to the cost savings that would be realized by long term savings and improved quality of life.

QUESTIONS?

JAMES R. CHRISTINA, DPM THANK YOU