Financial burden of diabetic foot ulcers to world: a progressive topic to discuss always

Epidemiology of diabetic foot complication

It is evident that foot care service reduces the amputations in diabetic patients. ¹⁰ In the report published on amputations it has been shown that native Americans have higher rate of amputation compared to Madrid population suffering from diabetes. ¹¹ Another study conducted prevalence rate of DFUs between developed and developing countries along with European countries. ¹² A meta-analysis study published recently showed that the worldwide prevalence rate of DFU was 6.3%. ¹³ North America showed the highest prevalence rate of 13.0% ¹³ compared with Oceania with prevalence rate of 3.0%. ¹³ Africa showed a prevalence rate of 7.2% which is higher than Asia (5.5 %). ¹³ Europe showed a prevalence rate of 5.1%, ¹³ Australia has prevalence rate of 1.5% (130) and Belgium with 16.6% ¹³ followed by Canada (14.8%) and USA at 13.0%. ¹³ India showed a prevalence rate of 11.6%. ¹³

Economic Burden of diabetic foot complications

In addition to the mortality and morbidity associated with DM, foot lesions have adverse consequences on healthcare system and health economics. The cost of DFUs may vary with the interventions used to treat foot ulcers and management approaches. In 2001, the US healthcare system recorded a US$10.9 billion expenditure towards diabetic foot care management and treatment. ¹⁴ In parallel with this, the United Kingdom (UK) estimated expenditure at £3 billion. ¹⁴ Moreover, the total annual cost of DFUs was estimated to be £252 million. ¹⁵ It is evident that lower limb amputations are preceded by foot ulcers in around 75–85% of cases, commonly in association with chronic infection and severe gangrene. In addition to the direct expenditure towards foot ulcers, there is also indirect expenditure that possibly contributes to loss of productivity, family costs, family status, and loss of quality of life.

In a previously published study related to cost expenditure of DFUs between 1994 and 2000, it has been demonstrated that cost of DFUs devoid of lower limb amputations ranged from US$993 to US$17,519. ¹⁶ In another study, however, the expenditure of a DFU occurrence in the initial 2 years post diagnosis was US$30,724. ¹⁷ Only the lowest cost in these studies is only evident due to insurance premiums and younger aged patients compared with the highest cost among the deep foot ulcers patients. Moreover, the comparisons of data from different health economics studies are complex due to differences in study design (primary care versus secondary care data, prospective versus retrospective), patient selection, grade of DFU, healthcare machinery and operation, treatment approaches, analysis time, reimbursement strategies, perspective of the studies and countries involved. In a prospective study performed on Swedish patients with DFUs without amputations untill healing of ulcers completely, the most expenses incurred during patient care (37% of total health care costs) and treatment of topical wounds cost 45% of the total budget. ¹⁸

In a review related to the costs of lower limb amputations, the range lies between US$16,488 and US$66,215 (1998 currency). ¹⁸ The cost was found higher in the amputation procedure and its associated nursing and institutional care compared with costs included in the surgical procedure. It showed that for minor lower limb amputation (only at foot level), the cost was US$43,800, while the major lower limb amputations (above ankle) was US$66,215 . ¹⁸ In these studies it was observed that a substantial part of the expenditure was not incurred in the surgeries, but included rehabilitation medicine, nursing homes and internal medicine. ¹⁸ The conclusions derived from these studies clearly state that prevention of DFUs and lower limb amputations may be the most effective way to reduce the high cost.

Studies performed in European countries estimated that the direct and indirect expenditure in care for patients suffering from DFUs incurred US$13,561 annually. ¹⁹ Patients in France showed a monthly expenditure of US$1265 in the healthcare of DFUs. ²⁰ Moreover several other studies related to the expenditure system of DFUs held in UK estimated $7539/patient that results in a total expense of 514 million US dollars annually. ²¹ Belgium showed an indirect and direct expenditure of US$10,572 per ulcer. ²² In Sweden, the expenses incurred as a total cost for healing DFUs was estimated around US$24,965/patient without amputation while they were US$47,518 and US$42,858 with amputation with minor and major surgeries respectively. ²³ Recently in 2017, the economic burden of DFUs in India showed expenses of US$1960 for the treatment of DFUs. In the previously published literature of costs of DFU treatment and management, it was demonstrated that DFU patients spent four times (~US$296) to that of non-DFU patients with DM (~US$69.91). It is estimated that treatment expenses of neuropathic ulcers (ambulatory care), chronic infected neuropathic foot (ambulatory care), advanced DFUs (care, limb amputation) and neuroischemic foot (bypass) was around US$56, US$165, US$1080, US$960, US$2650 and US$1960, respectively. ²⁴