Hospitalisation Cost of Diabetic Patients with Foot Ulcers: A Retrospective Descriptive Analysis from Turkey
←
→
Page content transcription
If your browser does not render page correctly, please read the page content below
Original Article
Turk J Endocrinol Metab
Hospitalisation Cost of Diabetic Patients with
Foot Ulcers: A Retrospective Descriptive
Analysis from Turkey
Diyabetik Ayak Ülserli Hastaların Hastane Maliyeti:
Türkiye'den Retrospektif Bir Analiz
İbrahim Halil AÇAR, Nuray Gül AÇAR*, Zeynel Abidin SAYİNER**, Mustafa ARAZ**,
Ersin AKARSU**
Department of Hematology, Çukurova University Faculty of Medicine, Adana, TURKEY
*Clinic of Internal Medicine, Seyhan Adana State Hospital, Adana, TURKEY
**Division of Endocrinology and Metabolism, Gaziantep University Faculty of Medicine, Gaziantep, TURKEY
Objective: With the increase in the prevalence of diabetes and Amaç: Diyabet ile birlikte diyabete bağlı komplikasyonların da
associated complications, most of the healthcare expenditure is artmasıyla sağlık harcamalarının çoğu diyabet komplikasyonla-
due to treatments of diabetes complications. This study evalua- rının tedavi harcamalarından kaynaklanmaktadır. Bu çalışmada,
ted the determinants affecting the total treatment cost in hos- diyabetin önemli bir komplikasyonu olan diyabetik ayak ülseri
pitalized patients with diabetic foot ulcers (DFU), an important ile hastanede yatan hastalarda, toplam tedavi maliyetini etkile-
complication of diabetes. Material and Methods: Factors af- yen faktörler değerlendirildi. Gereç ve Yöntemler: Diyabetik
fecting cost in 300 cases of hospitalization due to DFU were ayak ülseri nedeniyle hastaneye yatırılan 300 olguda, maliyeti
analyzed retrospectively. Hospital invoices were examined, and etkileyen faktörler geriye dönük olarak incelendi. Hastane fatu-
incurred cost of each patient was calculated in Turkish lira and raları incelendi ve her hastanın tahakkuk eden maliyeti Türk li-
then converted into US dollars at the exchange rate on the date rası olarak hesaplandı ve hastanede yattığı gün sayısı dikkate
of hospitalization, considering the number of days of hospitali- alınarak yatış tarihindeki döviz kuru üzerinden ABD dolarına çev-
zation. Results: Among the 300 included patients, the ratio of rildi. Bulgular: Üç yüz hasta arasında erkek/kadın katılımcı
male/female participants was 1.94. The mean age of the pati- oranı 1,94 idi. Hastaların ortalama yaşı 62,6±11 yıl idi. Hemog-
ents was 62.6±11 years. Hemoglobin A1c mean was determined lobin A1c ortalaması %9,5±2,4 olarak belirlendi. Ortalama has-
as 9.5±2.4%. The average hospitalization time was 17.8±12.9 tanede kalış süresi 17,8±12,9 gündü. Wagner evrelerine göre
days. When the average cost was analyzed according to Wagner ortalama maliyet incelendiğinde, hastalığın evresi arttıkça orta-
phases, the average cost increased as the stage of the disease. lama maliyet yükselmişti. Maliyeti en çok etkileyen faktör has-
The factor that most affected the cost was hospitalization cost tanede kalmak için ödenen maliyet olarak saptandı (p=0,001,
(p=0.001, r=3.24). Diagnostic imaging tests affected the total r=3,24). Toplam maliyeti hastaneye yatış maliyetinden sonra en
cost the most (p=0.001, r=2.52) after hospitalization. Conclu- fazla etkileyen değişken ise tanısal görüntüleme testleriydi
sion: The cost of hospitalization was the most important factor (p=0,001, r=2,52). Sonuç: Hastanede yatış maliyeti, toplam
affecting the total cost in the analysis of DFU. Therefore, taking maliyeti etkileyen en önemli faktördü. Bu nedenle ülser evresi
precautions before the advancement of ulcer stage and treat- ilerlemeden önlem alınması ve erken dönemde tedavi edilmesi-
ment at an early stage is expected to reduce the treatment cost. nin tedavi maliyetini düşürecektir. Ayrıca mümkün olan en kısa
In addition, reducing the duration of hospital stay will be effec- sürede hastanın, hastaneden taburcu edilmesi ve hastanede
tive in reducing the cost of DFU treatment. kalış süresinin azaltılması da diyabetik ayak ülseri tedavisin ma-
DOI: 10.25179/tjem.2021-82008
liyetinin düşürülmesinde etkili olacaktır.
Keywords: Diabetes mellitus; diabetic foot ulcers; Anahtar kelimeler: Diabetes mellitus;
cost of treatment diyabetik ayak ülseri; tedavi maliyeti
Address for Correspondence: Zeynel Abidin SAYİNER, Division of Endocrinology and Metabolism,
Gaziantep University Faculty of Medicine, Gaziantep, TURKEY
Phone: 90 507 944 87 80 E-mail: zeynelasayiner@hotmail.com
Peer review under responsibility of Turkish Journal of Endocrinology and Metabolism.
Received: 02 Feb 2021 Received in revised form: 07 Jun 2021 Accepted: 08 Jun 2021 Available online: 22 Jun 2021
1308-9846 / ® Copyright 2020 by Society of Endocrinology and Metabolism of Turkey.
Publication and hosting by Turkiye Klinikleri.
This is an open access article under the CC BY-NC-SA license (https://creativecommons.org/licenses/by-nc-sa/4.0/)Introduction DFU diagnosis who applied to outpatient
Diabetic foot ulcer (DFU) is one of the com- clinics or were hospitalized in other clinics
mon complications of both Type 1 and Type were not included in the study.
2 diabetes mellitus (DM). Patients with DFU Age, gender, hemoglobin A1c, Wagner
generally need long and intensive treat- grade, and length of hospital stay were ex-
ments. DFU is the primary cause of the ne- amined with a diagnosis of DFU in these 300
cessity of hospitalization in diabetes and the patients (ages of 18-90), with grades 1 to 5
reason for hospitalization of one in every according to the Wagner Classification.
five diabetic patients (1). DM is the cause of There are various methods of classification
50-70% of non-traumatic amputations. of DFU; nevertheless, Wagner classification is
Treatment of diabetic patients suffering from used more frequently than others. This clas-
DFU is more costly than the non-DFU dia- sification was made according to the ulcer
betic population (2). Healthcare costs for area, depth, and tissue damage. Wagner
people diagnosed with diabetes represent a classification is a potential guide for the treat-
significant proportion of the estimated na- ment approach in clinical practice (8, 9).
tional cost of $ 327 billion in the United Cost of negative-pressure wound treatment,
States (3). In Turkey, 16.4% of total health diagnostic imaging examinations, daily
expenditures was due to the treatment of di- dressing and wound care, antibiotic therapy,
abetes in 2008. However, this rate increased insulin treatment, amputation treatment,
to 23% in 2012 (4). and hospitalization were calculated. Total
In 2025, the number of people with diabetes cost was analyzed (Republic of Turkey Social
is expected to increase from 51 million to 72 Security Institution bills of our hospital were
million (41% increase) in developed coun- retrospectively examined) (10). All this in-
tries and from 84 million to 228 million formation was recorded in case report
(170%) in developing countries (5, 6). Un- forms. The impact of each factor on the total
fortunately, the number of DFU patients is cost was determined.
expected to increase with the increase in the The mean length of stay and the mean cost
number of patients with diabetes (7). The analysis of 300 patients with DFU complica-
cost of DFU treatment is quite high because tions were estimated. To calculating the cost
of amputation, long duration of wound care, of hospitalization of each patient, the data
the need for hospitalization, and loss of obtained from the day of hospitalization to
workforce. Although patients with DFU re- the day of discharge were analyzed. In this
quire substantial resource utilization, little is study, costs were calculated in Turkish lira
known about the burden of DFUs on the (₺) and converted to USD ($) at the ex-
healthcare system around the world. More- change rate at the time of the hospitaliza-
over, studies on the evaluation of costs for tion.
the treatment and diagnostic intervention This study was approved by the Ethics com-
are limited. In this study, we aimed to ret- mittee of the Gaziantep University Clinical
rospectively evaluate treatment cost in pa- Research Ethics Committee and conducted
tients followed up for DFU and determine in accordance with the Helsinki Declaration
the effect of each factor on the total cost. Principles. Decision number of 145 dated
12.09.2018.
Material and Methods The criteria of research participation for pa-
tients were: diagnosed with Type 2 diabetes,
A total of 300 male and female patients with
having DFU, more than eighteen years of
Type 2 DM over the age of eighteen who
age.
were hospitalized in Endocrinology and Me-
tabolism department for the treatment of Statistical Analysis
DFU were included in our study. Among
The compatibility of numerical data to nor-
them, there were 198 (66%) males and 102
mal distribution was tested with the
(34%) females. The number 300 was deter-
Shapiro-Wilk test. Student’s t-test was used
mined by a calculation of the sample’s
to compare variables with normal distribu-
power analysis. Patients whose diagnosis
tion in two groups. One-way analysis of vari-
and treatment were first made at our center
ance was used to compare variables that fit
were included in the study. Patients with
2normal distribution in three or more groups. Analysis of the average cost of the cases ac- The relationships between quantitative vari- cording to the Wagner grades revealed that ables thought to have an effect on the total the average cost increased as the grade in- cost were examined by Pearson’s correlation creased (Table 2). analysis, and then regression analysis was A statistically significant, moderately posi- applied to determine their effects on the tive correlation was observed between the total cost. SPSS 22. 0 (SPSS Inc. Chicago. Wagner Grade and the cost of amputation IL. USA) package program was used for the treatment (p
Table 2. The relationship between Wagner grades and creased the total cost (13). Similarly, in our
cost of hospitalization. study, we observed that after the hospital-
ization cost, the variable affecting the total
Cost (USD $)
cost the most was diagnostic imaging tests.
Number of mean standard Most cases in our study had the use of di-
Wagner grade cases deviation rect radiography, magnetic resonance (MR),
2 81 772.07±655.25 bone scintigraphy, and lower extremity ar-
3 117 1863.26±1292.23 terial doppler ultrasonography. Further as-
4 62 1927.48±1332.45 sessment of the available bills showed that
5 40 3556.05±2077.80 bone scintigraphy was the most costly per
shot among the imaging methods, consider-
ing the available bills. The patient with DFU
must undergo X-ray radiography imaging to
Thus, reducing the duration and number of detect bone deformities in the wound area,
hospitalizations will be effective in reducing foreign objects, or gas formations in soft tis-
the cost of treatment of DFU. Patients with sue. Therefore, the use of low-cost exami-
DFU may need to stay in the hospital for a nations is recommended first in the case of
longer duration due to uncontrolled hyper- DFU suspicion (14). Direct X-ray radiography
glycemia, long-term wound care, late-heal- may not be sufficient for patients who do not
ing wound infections, debridement, recover with antibiotherapy and are ob-
amputations, and emerging complications; served to have osteomyelitis or deep soft
(12) these factors contributed to increasing tissue abscess. In these cases, the sensitiv-
the cost. The average cost was also found to ity and specificity of MR imaging are higher
increase as the Wagner grade increased. (15). Bone scintigraphy and other radionu-
The highest average cost of treatment was clide bone scans can be performed in pa-
of Wagner grade five patients. As the Wag- tients where MR imaging is contraindicated
ner grade progressed, prolonging the length or cannot be performed (16). We think that
of hospitalization and increasing the fre- avoiding unnecessary use of imaging meth-
quency of amputation led to increasing ods such as MR and bone scintigraphy would
costs. In our study, the relationship between be cost-effective and hope that developing
the Wagner grade and the cost of amputa- radiological examination eligibility criteria
tion treatment was statistically significant. will be helpful in reducing unnecessary de-
It is expected that taking precautions before mands and building consensus among de-
the disease reaches the advanced grade and partments.
starting treatment from the early grade will The male/female ratio of participants in this
reduce the treatment cost. study was found to be 1.94. The reason for
A meta-analysis investigating the cost-ef- the higher rates of DFU in male patients
fectiveness of diagnostic imaging methods compared to female patients may be be-
revealed that some non-invasive diagnostic cause men work under physically severe
procedures performed on patients did not conditions, do not care enough about foot
contribute to the treatment; in fact, they in- hygiene, and due to neuropathy.
Table 3. Results of regression analysis between total cost and various variables.
Regression model Regression coefficient p value
Cost of negative-pressure wound therapy 0.827 0.001
Cost of diagnostic imaging examinations 2.522 0.001
Cost of daily wound care and dressing 1.027 0.110
Cost of antibiotic treatment 0.847 0.001
Cost of insulin medication 1.397 0.001
Cost of hospitalization 3.242 0.001
4Prolonged hospitalization is an important Authorship Contributions
factor that leads to high costs. In our study, Idea/Concept: Ersin Akarsu; Design: Ersin
patients with DFU had longer hospitalization Akarsu, İbrahim Halil Açar; Control/Super-
times. vision: Ersin Akarsu, Zeynel Abidin Sayiner,
This study, however, had some limitations. Mustafa Araz; Data Collection and/or Pro-
Wagner classification, despite very useful, is cessing: Nuray Gül Açar, İbrahim Halil Açar,
quite outdated and overcome by many other Zeynel Abidin Sayiner; Analysis and/or In-
methods, more recently introduced. We terpretation: Ersin Akarsu; Literature Re-
should have chosen one of these more up- view: Zeynel Abidin Sayiner, Nuray Gül Açar,
dated classification methods. Second, our İbrahim Halil Açar; Writing the Article:
study did not include patients with reperfu- İbrahim Halil Açar, Zeynel Abidin Sayiner,
sion procedures or bypass surgery. Besides, Ersin Akarsu; Critical Review: Zeynel Abidin
off-loading footwear cost was also not taken Sayiner, Ersin Akarsu, Mustafa Araz; Refer-
into account. However, we thought that the ences and Fundings: İbrahim Halil Açar,
study addresses a very important issue, Nuray Gül Açar; Materials: İbrahim Halil
which is often undervalued. Evaluation of Açar, Ersin Akarsu.
the costs of DF, different components of
health system expenditure, and differences References
between costs in patients with different 1. Apelqvist J. Diagnostics and treatment of the dia-
complexities will be very useful for the econ- betic foot. Endocrine. 2012;41:384-397. PMID:
omy of the countries. Thus we hope that the 22367583.
aim of this study is not only inspirational but 2. Gershater MA, Löndahl M, Nyberg P, Larsson J,
will provide guidance for future studies. Thörne J, Eneroth M, Apelqvist J. Complexity of fac-
tors related to outcome of neuropathic and neuroisc-
Conclusion haemic/ischaemic diabetic foot ulcers: a cohort
The most important factor affecting the total study. Diabetologia. 2009;52:398-407. PMID: 190
cost in the cost analysis of DFU was found 37626.
to be the cost of hospitalization. Reducing 3. Johnson EP, Dunn M, Cooper M, Bhakta N. Diabetes
the rate of hospitalizations will be effective Prevention Program Sites Compared With Diabetes
in reducing the treatment cost of DFU. Prevalence and Ratio of Primary Care Physicians in
Texas. Prev Chronic Dis. 2019;16:E165. PMID:
Therefore, taking precautions before the dis-
31878987; PMCID: PMC6936669.
ease reaches an advanced stage and start-
4. Turkey Diabetes Program 2015-2020. T. C. Ministry
ing treatment at an early stage will shorten
of Health Public Health Agency of Turkey: Ankara.
the length of hospital stay and reduce the
2014;23-38. https://extranet.who.int/ncdccs/ Data/
total cost of treatment.
TUR_D1_T%C3%BCrkiye%20Diyabet%20Prog-
ram%C4%B1%202015-2020.pdf
Source of Finance
5. Satman İ, İmamoğlu Ş, Yılmaz C, Akalın S, Salman
During this study, no financial or spiritual S. Glisemik bozukluklarda tanı, sınıflama ve tedavi.
support was received neither from any phar- Diabetes Mellitus ve Komplikasyonlarının Tanı, Te-
maceutical company that has a direct con- davi ve İzleme Kılavuzu. 6. Baskı. Ankara: Türkiye
nection with the research subject, nor from Endokrinoloji ve Metabolizma Derneği Yayınları;
a company that provides or produces med- 2013:15-30. https://www.ktu.edu.tr/dosyalar/17_
ical instruments and materials which may 02_15_2b178.pdf
negatively affect the evaluation process of 6. Apelqvist J, Larsson J. What is the most effective
this study. way to reduce incidence of amputation in the dia-
betic foot? Diabetes Metab Res Rev. 2000;16 Suppl
Conflict of Interest 1:S75-83. PMID: 11054894.
No conflicts of interest between the authors 7. Tang UH, Zügner R, Lisovskaja V, Karlsson J, Hag-
and / or family members of the scientific and berg K, Tranberg R. Foot deformities, function in the
medical committee members or members of lower extremities, and plantar pressure in patients
the potential conflicts of interest, counsel- with diabetes at high risk to develop foot ulcers.
ing, expertise, working conditions, share Diabet Foot Ankle. 2015;6:27593. PMID: 2608
holding and similar situations in any firm. 7865; PMCID: PMC4472554.
58. Schaper NC, van Netten JJ, Apelqvist J, Bus SA, lation-based cohort study. CMAJ Open. 2020;8:E48-
Hinchliffe RJ, Lipsky BA; IWGDF Editorial Board. E55. PMID: 31992559; PMCID: PMC6996034.
Practical Guidelines on the prevention and manage- 13. Krishnan S, Nash F, Baker N, Fowler D, Rayman G.
ment of diabetic foot disease (IWGDF 2019 update). Reduction in diabetic amputations over 11 years in
Diabetes Metab Res Rev. 2020;36 Suppl 1:e3266. a defined U.K. population: benefits of multidiscipli-
PMID: 32176447. nary team work and continuous prospective audit.
9. Satman I, Imamoglu S, Yilmaz C; ADMIRE Study Diabetes Care. 2008;31:99-101. PMID: 17934
Group. A patient-based study on the adherence of 144.
physicians to guidelines for the management of type 14. Nelson EA, O'Meara S, Craig D, Iglesias C, Golder
2 diabetes in Turkey. Diabetes Res Clin Pract. S, Dalton J, Claxton K, Bell-Syer SE, Jude E, Dow-
2012;98:75-82. PMID: 22652276. son C, Gadsby R, O'Hare P, Powell J. A series of
10. Sosyal Güvenlik Kurumu [Internet]. Turkey Medula systematic reviews to inform a decision analysis for
Data SCI. Erişim linki: http://www.sgk.gov.tr/wps/ sampling and treating infected diabetic foot ulcers.
portal/sgk/tr/kurumsal/e-fatura 05.05.2018. Health Technol Assess. 2006;10:iii-iv, ix-x, 1-221.
11. Keskek SO, Kirim S, Yanmaz N. Estimated costs of PMID: 16595081.
the treatment of diabetic foot ulcers in a tertiary 15. Russell JM, Peterson JJ, Bancroft LW. MR imaging of
hospital in Turkey. Pak J Med Sci. 2014;30:968-971. the diabetic foot. Magn Reson Imaging Clin N Am.
PMID: 25225508; PMCID: PMC4163214. 2008;16:59-70, vi. PMID: 18440478.
12. Shulman R, Slater M, Khan S, Jones C, Walker JD, 16. Dinh T, Snyder G, Veves A. Current techniques to
Jacklin K, Green ME, Frymire E, Shah BR. Preva- detect foot infection in the diabetic patient. Int J
lence, incidence and outcomes of diabetes in Onta- Low Extrem Wounds. 2010;9:24-30. PMID: 2020
rio First Nations children: a longitudinal popu 7620.
6You can also read
