Foot Care in Diabetes: The Economic Case for Change Marion ......Step 2: Quality of current care...
Transcript of Foot Care in Diabetes: The Economic Case for Change Marion ......Step 2: Quality of current care...
Foot Care in Diabetes:
The Economic Case for Change
Marion Kerr
6th March 2012
© Insight Health Economics
The Economic Case for Change:
Key steps
Step 1: Scale of the Problem
Step 2: Quality of current care
Step 3: Estimates of how much foot care in
diabetes currently costs the NHS
Step 4: Clinical evidence on potential for better outcomes
Step 5: Estimates of the impact of improved care on quality
of life and NHS costs
The Economic Case for Change:
Key steps
Step 1: Scale of the Problem
Step 2: Quality of current care
Step 3: Estimates of how much foot care in
diabetes currently costs the NHS
Step 4: Clinical evidence on potential for better outcomes
Step 5: Estimates of the impact of improved care on quality
of life and NHS costs
Scale of the problem
• We estimate that at least 61,000 people with
diabetes in England have foot ulcers at any
given time
• Only ⅔ heal without surgery
• There are around 6,000 lower extremity
amputations a year in people with diabetes
• The risk of a lower extremity amputation in a
person with diabetes is 23 x that of a person
without diabetes
© Insight Health Economics
Scale of the problem
• As diabetes prevalence increases, the number of
amputations in diabetes is rising too. Source: Vamos et al. 2010
Impact of foot ulcers on quality of life
Health related quality of life (SF-6D) scores for people with diabetic foot ulcers and
other long-term conditions, and for healthy people aged 75+ (Source: Jeffcoate et al.
(2009), Brazier et al. (2004), Davison et al.(2009))
• Diabetic foot ulcer QOL rated lower than osteoarthritis, COPD, dialysis
• SF-6D or EQ-5D are building blocks for QALY estimation
Quality of life comparison:
ulcers and amputations
EQ-5D scores for patients with foot ulcers and amputation (Source:
Ragnarson Tennvall et al. (2000))
• Important in health economic analysis to compare scores obtained using a
single measurement instrument
• To convert any of these scores into QALYs also need to take into account life
expectancy effects
Survival after diabetic foot ulcers
• Liverpool foot clinic study suggests 5 year survival rate of 56%
• Illustrative relative survival estimate produced by adjusting Liverpool survival figure for expected survival in the general population aged 70-74
• However, important to note that foot ulcers are associated with high mortality, but deaths are not necessarily attributable to ulceration.
Five year relative survival rates for the four most common cancers (Source: ONS) and estimated five year relative survival rate for diabetic foot ulcer (Estimate derived from: Moulik et al. (2003))
0
10
20
30
40
50
60
70
80
90
Breast
Cancer
Prostate
Cancer
Colon
Cancer
Lung
Cancer
Diabetic
Foot
Ulcer
Rela
tive
5 ye
ar s
urvi
val (
%)
The Economic Case for Change:
Key steps
Step 1: Scale of the Problem
Step 2: Quality of current care
Step 3: Estimates of how much foot care in
diabetes currently costs the NHS
Step 4: Clinical evidence on potential for better outcomes
Step 5: Estimates of the impact of improved care on quality
of life and NHS costs
Quality of Current Care
QOF data indicate that around 85% of people with diabetes receive a foot check every 15 months
However, there is no correlation between foot review and amputation incidence at PCT level
It is not known what percentage of patients receive appropriate follow-on care
Quality of Current Care
• The total lower extremity amputation rate varies 8-fold
across PCTs, from 6.4 to 52.5 per 10,000 person
years Amputations per 10,000 people with diabetes, 2008-2011, by
PCT (Source: YHPHO)
Quality of Current Care
• There are no national data on service provision, quality of care or outcomes for most of the foot care pathway
• In the 2009 Diabetes UK patient survey – 26% of patients said they would like more access to a
foot specialist
– 14% identified faster access to foot screening as the thing that would most improve the quality of their care
Quality of Current Care
The Diabetes Inpatient Audit 2010 provides a fuller picture of acute care:
– Almost ¾ of inpatients with diabetes had no foot exam during their hospital stay
– 9.4% had a foot complication when admitted
– 2.2% developed a foot complication during their stay
– One fifth of sites did not have a multi-disciplinary foot team
The Economic Case for Change:
Key steps
Step 1: Scale of the Problem
Step 2: Quality of current care
Step 3: Estimates of how much foot care in
diabetes currently costs the NHS
Step 4: Clinical evidence on potential for better outcomes
Step 5: Estimates of the impact of improved care on quality
of life and NHS costs
NHS Expenditure – Ulceration and Amputation in Diabetes
• In 2010-11 the NHS spent an estimated £639 million to
£662 million a year on diabetic foot care
• Equivalent to £1 in in every £150 of total NHS spending
Primary, Community,
Outpatient Care and A & E £307m. - £324m.
Inpatient Care - Ulceration
£213m.
Amputation £119m. - £125m.
NHS Expenditure –
Ulceration and Amputation in Diabetes
Lower
estimate
Upper
estimate
Primary, community and outpatient
care £306,508,970 £323,062,601
Accident and emergency £849,278
Inpatient care – ulceration £213,151,916 £213,151,916
Inpatient care – amputation £43,546,901 £48,896,735
Post-amputation care £75,807,423 £75,807,423
Total £639,015,210 £661,767,953
NHS Expenditure – Primary, Community and
Outpatient Care
• Activity estimated using RCT for less severe ulcers, local
data for more severe ulcers
• Less severe ulcers estimated at 60%, more severe at
40%
• Second approach using NHS Diabetes/Diabetes UK
patient survey on resource use
• Weekly costs estimated from BNF, PSSRU, PbR tariffs,
studies, local data
• Scottish data show 2.5% of diabetes population had
ulceration in December 2010
• This multiple applied to diabetes population of England =
61,000
NHS Expenditure – Inpatient Care and
Post-Amputation Care
• Inpatient admissions identified in HES 2010-11 using
ICD 10 and OPCS 4 codes for diabetes, foot ulceration,
non-traumatic lower limb amputation
• For all amputation admissions and ulcer admissions in
foot care HRGs, entire cost of admission attributed,
using PbR tariffs
• For admissions in non-footcare HRGs, regression
analysis to estimate impact of ulceration on LOS (12.7
days) – excess bed days attributed
• Post-Amputation costs estimated using study and local
data
The Economic Case for Change:
Key steps
Step 1: Scale of the Problem
Step 2: Quality of current care
Step 3: Estimates of how much foot care in
diabetes currently costs the NHS
Step 4: Clinical evidence on potential for better outcomes
Step 5: Estimates of the impact of improved care on quality
of life and NHS costs
Clinical evidence on potential for better outcomes
• Clinical evidence suggests that:
– Diagnostic tests and risk stratification can predict the
risk of diabetic foot ulceration and amputation
– Early referral to specialist care reduces amputation rates and times to healing
– Multidisciplinary teams (inpatient and community-based/outpatient) can reduce amputation rates
– Cardiovascular screening and interventions for patients with ulcers can reduce mortality
The Economic Case for Change:
Key steps
Step 1: Scale of the Problem
Step 2: Quality of current care
Step 3: Estimates of how much foot care in
diabetes currently costs the NHS
Step 4: Clinical evidence on potential for better outcomes
Step 5: Estimates of the impact of improved care on quality
of life and NHS costs
Southampton University
Hospitals NHS Trust
• MDT - primary and secondary care
– Telephone advice and emergency access line
for patients and clinical staff
– weekly podiatry clinics at eight primary care
locations
– outpatient clinics in secondary care
– multi-disciplinary inpatient care
Estimates of the impact of
improved care on quality of life
and NHS costs
James Cook Hospital,
Middlesbrough
• MDT - secondary care with strong links to
community podiatry services
– Weekly 4-hour consultant-led clinic with a
DSN and 2 podiatrists
– Care pathways and protocols for
management of ulcers established
– Educational events organised
The potential for net savings and benefits will vary according to local
costs and baseline standards of care
Conclusions
• £1 in every £150 the NHS spends is for diabetic foot
problems
• MDTs with strong community links can deliver improved
patient outcomes and savings which exceed the cost of
the team
• No savings were estimated for reductions in ulcer
duration as data were not available
• The potential for net savings and benefits will vary
according to local costs and baseline standards of care
• Unless there is a significant increase in the quality and
efficiency of diabetes foot care, the cost of diabetic foot
care is likely to rise substantially in the coming years