Diabetic Neuropathy in the workforce

and cost

Panagiotis V. Tsaklis, PhDPanagiotis V. Tsaklis, PhDAssociate ProfessorAssociate ProfessorSchool of Health ProfessionsSchool of Health Professions““Alexander” TEI ThessalonikiAlexander” TEI Thessaloniki

Sen. ResearcherSen. ResearcherDept Public Health SciencesDept Public Health SciencesOccupational & Environmental MedicineOccupational & Environmental MedicineKarolinska Institutet Karolinska Institutet

mellitus…mellitus…

The global prevalence of diabetes is The global prevalence of diabetes is predicted to double by the year 2030 from predicted to double by the year 2030 from 2.8% to 4.4%.2.8% to 4.4%.

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

Does it cost much??Does it cost much?? In 2007, the estimated national cost in US of diabetes In 2007, the estimated national cost in US of diabetes

exceeded exceeded $174 billion…$174 billion…

This estimate included This estimate included $116 billion$116 billion in diabetes-related in diabetes-related medical costs and medical costs and $58 billion$58 billion in in reduced productivityreduced productivity

….due to increased work absenteeism, reduced work ….due to increased work absenteeism, reduced work and daily productivity, unemployment from disease-and daily productivity, unemployment from disease-

related disability, and early death..related disability, and early death..

PolyneuropathyPolyneuropathy is one of the commonest complications of the diabetes is one of the commonest complications of the diabetes and the commonest form of neuropathy in the developed World. and the commonest form of neuropathy in the developed World. Diabetic polyneuropathy encompasses several neuropathic syndromes Diabetic polyneuropathy encompasses several neuropathic syndromes the commonest of which is the commonest of which is distal symmetrical neuropathydistal symmetrical neuropathy, the main , the main initiating factor for foot ulceration. The epidemiology of diabetic initiating factor for foot ulceration. The epidemiology of diabetic neuropathy has recently been reviewed in reasonable detailneuropathy has recently been reviewed in reasonable detail

……from the 1999-2000 population-based US Health and Nutrition Survey from the 1999-2000 population-based US Health and Nutrition Survey (NHANES), The prevalence (history) of peripheral neuropathy ((NHANES), The prevalence (history) of peripheral neuropathy (>> 1 1 insensate area) in people with diabetes was 28.5%...insensate area) in people with diabetes was 28.5%...

The EURODIAB Prospective Complications Study which involved the The EURODIAB Prospective Complications Study which involved the examination of 3250 type 1 patients, from 16 European countries, found examination of 3250 type 1 patients, from 16 European countries, found a prevalence rate of 28% for distal symmetrical neuropathya prevalence rate of 28% for distal symmetrical neuropathy

……painful diabeticpainful diabeticperipheral neuropathy (pDPN) is associated withperipheral neuropathy (pDPN) is associated withworse health outcomes…worse health outcomes…

……however, among pDPN patients, few studies have however, among pDPN patients, few studies have examined the relationship between the severity of examined the relationship between the severity of pain and health outcomes……pain and health outcomes……

Lost Productive Time (LPT) and diabetes neuropathyLost Productive Time (LPT) and diabetes neuropathy……

……studies suggest that individualsstudies suggest that individuals40 to 65 years old in the US workforce, with diabetes and neuropathic 40 to 65 years old in the US workforce, with diabetes and neuropathic symptoms experience excess health-related LPT compared with that of symptoms experience excess health-related LPT compared with that of others with and without diabetesothers with and without diabetes

……The mean hours of LPT per week was substantially higher in the The mean hours of LPT per week was substantially higher in the diabetes patients with neuropathic symptomsdiabetes patients with neuropathic symptomscompared with in the others compared with in the others 4.21 hrs vs 1.90 hrs…(diabetic & controls)4.21 hrs vs 1.90 hrs…(diabetic & controls)

……more individuals who had diabetes with neuropathic symptomsmore individuals who had diabetes with neuropathic symptomsreported moderate to severe impact on reported moderate to severe impact on work abilitywork ability (ie, score 5 on a (ie, score 5 on ascale from 0–10 compared with those without neuropathic symptoms 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 (where 0 means “it has no effect on my ability to work” and 10 means “I am no longer able to work”)to work”)

Cost of Lost Productive Time…Cost of Lost Productive Time…$$ $ $ $ $...:$ $ $ $...:In the US Workforce gives a equivalent of $3.65 billion In the US Workforce gives a equivalent of $3.65 billion per year in health-related LPT, a cost per worker that is moreper year in health-related LPT, a cost per worker that is morethan than 2.52.5 times higher than workers with diabetes without neuropathic times higher than workers with diabetes without neuropathicSymptoms…Symptoms…

In conclusion,…The severity mightIn conclusion,…The severity mightlead to decreased health status, lead to decreased health status,

•It is observed a prevalence of moderate-to-severe pain among pDPNIt is observed a prevalence of moderate-to-severe pain among pDPNpatientspatients•also indicate that health outcomes are significantly worse as pain severity also indicate that health outcomes are significantly worse as pain severity increases. increases. •Specifically, work impairment, health care resource use, and the associatedSpecifically, work impairment, health care resource use, and the associatedindirect and direct costs increase significantly as the level of pain severity indirect and direct costs increase significantly as the level of pain severity increases.increases.•These data emphasize the needThese data emphasize the needfor effectively managing pain in patients with pDPN.for effectively managing pain in patients with pDPN.

PeripheralPeripheral ( (symmetricalsymmetrical) ) NeuropathyNeuropathy

Intrinsic muscles atrophy → foot deformities

Reflex reductionReflex reduction →→ Gait alteration…Gait alteration…

Calluses Calluses & & Ulcers occurrence Ulcers occurrence

Amputations…Amputations…

Complications

(Sensory-Motor Neuropathy) which leads to……

Aggravating Factors…Aggravating Factors…

Peripheral Vascular Disease Peripheral Vascular Disease

Joint Mobility ReductionJoint Mobility Reduction

Foot Structural deformitiesFoot Structural deformities

Foot soft tissues lesionsFoot soft tissues lesions

Autonomous Neuropathy ???Autonomous Neuropathy ???

Vassel-Kinetic Neuropathy (VASOMOTOR)Sweat -Kinetic Neuropathy (SUDOMOTOR) ““autosympathectomy.” autosympathectomy.”

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

Focus on Foot UlcersFocus on Foot Ulcers

Foot ulcers are defined as a cutaneous erosion Foot ulcers are defined as a cutaneous erosion extending through the dermis to deeper tissue, result extending through the dermis to deeper tissue, result from various etiologic factors and are characterized from various etiologic factors and are characterized by an by an inability to self-repair in a timely and orderly inability to self-repair in a timely and orderly mannermanner

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

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 / 1,000

Population-Based Diabetic Foot Ulcer Incidence and Prevalencefrom Selected Studies…

First Author/First Author/

ReferenceReference Population StudiedPopulation Studied

Foot UlcerFoot Ulcer

Annual Annual

Incidence /100Incidence /100

Foot UlcerFoot Ulcer

Prevalence /100Prevalence /100

Abbott (16)Abbott (16) Cohort of 6,613 patients in six district Cohort of 6,613 patients in six district

clinics in NW England followed for 2 clinics in NW England followed for 2

yrs, Type 1, 2 diabetesyrs, Type 1, 2 diabetes

2.22.2 4.74.7

Borssen (32) Borssen (32) 375 patients Umea County Sweden, Age 375 patients Umea County Sweden, Age

15-50, 15-50,

Type 1 = 298, Type 2 = 77Type 1 = 298, Type 2 = 77

2.02.0 10.0 IDDM10.0 IDDM

9.0 NIDDM9.0 NIDDM

Kumar (12) Kumar (12) Cross-sectional study of 811 Type 2 Cross-sectional study of 811 Type 2

patients from three UK citiespatients from three UK cities1.01.0 5.35.3

Lavery (33) Lavery (33) Cohort of 1,666 patients, San Antonio, Cohort of 1,666 patients, San Antonio,

Texas, 51% Mexican Americans, Texas, 51% Mexican Americans,

followed for 2 yrsfollowed for 2 yrs

3.43.4 ——

Malgrane (34) Malgrane (34) 664 patients from 16 French diabetes 664 patients from 16 French diabetes

centerscenters—— 15.8%15.8%

MMWR (35)MMWR (35) 2000-2002 BRFSS US survey of adults 2000-2002 BRFSS US survey of adults

> 18 yrs> 18 yrs—— 11.8%11.8%

Moss (23) Moss (23) Cohort of 2,990 patients with late and Cohort of 2,990 patients with late and

early-onset diabetesearly-onset diabetes2.4 younger2.4 younger

2.6 older2.6 older

9.5 younger9.5 younger

10.5 older10.5 older

Ramsey (28) Ramsey (28) Nested case-control study in HMO, Nested case-control study in HMO,

8,905 Type 1, Type 28,905 Type 1, Type 21.91.9

Walters (14) Walters (14) Cross-sectional study of 1,077 Type 1, 2 Cross-sectional study of 1,077 Type 1, 2

patients in 10 UK general medicine patients in 10 UK general medicine

practicespractices

4.14.1 7.47.4

Frequency of U.S. Hospitalization for Ulcer-Related Conditionsin Individuals with Diabetes by Diagnosis, 2001-2002

Type of ulcerType of ulcer ICD-CM ICD-CM

CodesCodesEstimated Estimated

Frequency Frequency

20012001

Estimated Estimated

Frequency Frequency

20022002

Cellulitis, abscess, or infected ulcerCellulitis, abscess, or infected ulcer 681.1681.1 26,68526,685 29,34729,347

Other cellulitis and abscess, foot except toesOther cellulitis and abscess, foot except toes 682.7682.7 81,36781,367 83,95483,954

Ulcer of lower limbs, except decubitusUlcer of lower limbs, except decubitus 707.1707.1 209,088209,088 216,785216,785

OsteomyelitisOsteomyelitis 730.07730.07

730.17730.17

730.27730.27

730.37730.37

730.87730.87

730.97730.97

60,98960,989 66,59166,591

Chronic nonhealing ulcersChronic nonhealing ulcers 707.0707.0

707.9707.9

129,466129,466 134,274134,274

Atherosclerosis of lower limb with ulcer Atherosclerosis of lower limb with ulcer

OrOr gangrene gangrene

440.23440.23

440.24440.24

83,54683,546 78,98378,983

Ulcers Ulcers Health Care CostsHealth Care Costs……

Optimally, the estimation of diabetic foot ulcer costs Optimally, the estimation of diabetic foot ulcer costs spans an entire ulcer episode from lesion onset to spans an entire ulcer episode from lesion onset to final resolution. final resolution.

Two studies provided direct costs associated with the Two studies provided direct costs associated with the entire diabetic foot ulcer history. This methodology entire diabetic foot ulcer history. This methodology captures the many inpatient and outpatient captures the many inpatient and outpatient costs/charges associated with foot ulcers and is costs/charges associated with foot ulcers and is preferable to reporting only charge for a single preferable to reporting only charge for a single hospitalization or limited time intervalhospitalization or limited time interval

Direct Cost for Foot Ulcers in Persons with Diabetes From Two Studies

Author Author # Patients/# Patients/

Study TypeStudy Type

OutcomeOutcome Average Average

Episode Cost Episode Cost

(US $)(US $)

Inpatient Inpatient

Cost %Cost %Outpatient Outpatient

Cost %Cost %

Apelqvist Apelqvist

(27) (27) Prospective Prospective

314 General 314 General

Internal Internal

Medicine Medicine

PatientsPatients

Primary healing = Primary healing =

63%63%

Healed after Healed after

amputation = amputation =

24%24%

$6,664$6,664

$44,790$44,790

6161 3939

Ramsey Ramsey

(28) (28) Nested case-Nested case-

control study control study

in HMO of in HMO of

8,905 Type 8,905 Type

1,2 1,2

Primary healing = Primary healing =

84%84%

Amputation = Amputation =

16%16%

$27,987 $27,987

Total Total

Attributable Attributable

costcost

1818 8282

Ulcer Reimbursement to Hospitals for Patients with and without Diabetes, 2002

Medstat (Private)Medstat (Private)11 MedicareMedicare22

Length of StayLength of Stay Average $ Average $

ReimbursementReimbursementLength of StayLength of Stay Average $ Average $

ReimbursementReimbursement

DRGDRG ConditionCondition

1818Peripheral Neuropathy with Peripheral Neuropathy with

complicationscomplications 5.65.6 9,0369,036 5.55.5 4,7824,782

1919Peripheral Neuropathy Peripheral Neuropathy

without complicationswithout complications 4.84.8 6,0616,061 3.63.6 3,0343,034

277277Cellulitis > age 17 with Cellulitis > age 17 with

complicationscomplications 4.84.8 6,8236,823 5.75.7 4,0004,000

278278Cellulitis > age 17 without Cellulitis > age 17 without

complicationscomplications 3.43.4 4,4264,426 4.24.2 2,1922,192

271271 Skin UlcersSkin Ulcers 11.011.0 11,63811,638 7.37.3 5,2275,227

238238 OsteomyelitisOsteomyelitis 5.95.9 9,9139,913 8.78.7 7,3767,376

130130Peripheral Arterial Disease Peripheral Arterial Disease

with complicationswith complications 5.15.1 7,7437,743 5.65.6 4,5544,554

131131Peripheral Arterial Disease Peripheral Arterial Disease

without complicationswithout complications 4.34.3 5,7685,768 4.14.1 2,3752,375

Source:

1Medstat Group, Thompson Corporation, 2005

2Centers for Medicare and Medicaid Services, 2005

Key: DRG = Diagnostic Related Group

In conclusion….In conclusion….

The average private hospital reimbursement for a foot The average private hospital reimbursement for a foot ulcer for 11 days is about $11,638 while Medicare ulcer for 11 days is about $11,638 while Medicare reimbursement for foot ulcer conditions is usually for reimbursement for foot ulcer conditions is usually for 7.3 days and $5,227. 7.3 days and $5,227.

The direct economic cost attributable to foot ulcers from The direct economic cost attributable to foot ulcers from onset for two years approaches $28,000. onset for two years approaches $28,000.

Guideline-based care is needed to improve outcomes Guideline-based care is needed to improve outcomes and provide cost savings compared with standard careand provide cost savings compared with standard care

Final conclusions and suggestions!!!Final conclusions and suggestions!!! Diabetes has pervasive emotional and physical effects on patients lives. Diabetes has pervasive emotional and physical effects on patients lives.

Additionally, physical and psychological barriers, time and monetary Additionally, physical and psychological barriers, time and monetary limitations, and a lack of social support complicates disease managementlimitations, and a lack of social support complicates disease management

People, especially those with little education, may not understand the People, especially those with little education, may not understand the progressive nature of diabetes. However, using diabetes complications as progressive nature of diabetes. However, using diabetes complications as a scare tactic may only exacerbate feelings of helplessness if patients view a scare tactic may only exacerbate feelings of helplessness if patients view future complications as inevitablefuture complications as inevitable

Documented workplace discrimination allegations indicate that people with Documented workplace discrimination allegations indicate that people with diabetes are more likely to experience prejudice, which can affect job diabetes are more likely to experience prejudice, which can affect job retention. This in turn may affect access to health insurance and health retention. This in turn may affect access to health insurance and health maintenancemaintenance

balancing familial and work responsibilities may complicate diabetes balancing familial and work responsibilities may complicate diabetes management because of feelings of obligation. Working patients need management because of feelings of obligation. Working patients need flexible supports that facilitate program participation such as longer clinic flexible supports that facilitate program participation such as longer clinic hours, child care services, time management training, and flexible work hours, child care services, time management training, and flexible work schedules that accommodate doctor visits and exerciseschedules that accommodate doctor visits and exercise

Finally, diabetes supports should address the whole person — physically, Finally, diabetes supports should address the whole person — physically, psychologically, and socially. Future interventions for working people with psychologically, and socially. Future interventions for working people with diabetes should include coordinated programs that involve social, diabetes should include coordinated programs that involve social, emotional, and lifestyle supports to help keep people healthy so that they emotional, and lifestyle supports to help keep people healthy so that they can work wellcan work well

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