Economic aspects of the diabetic foot

The prevalence of known diabetes in the UK is 1% of the population.’ This is probably a conservative estimate as American literature has shown a known prevalence of 2% and estimated the actual prevalence as high as 5%.’ If we assume the true prevalence in the UK to be 1.5%, there are close to 1 000 000 diabetics in this country. Diabetes is known to make a substantial contribution to the use of hospital inpatient facilities. In a single year, in a population of 1 900 000 in East Anglia, Williams3 found 50 14 diabetics were admitted to hospital. On average this diabetic population used 5.1 hospital bed days per person year compared with 1.1 days for the non-diabetic population. Because of the twin problems of peripheral neuropathy and peripheral vascular disease, foot problems contribute significantly to these numbers and substantially to the cost. It has been estimated that 20% of all hospital diabetic admissions result from foot problems.4 In this country Connor,’ in Hereford, found that 12% of the admissions to the diabetic unit were for foot problems. However, these patients occupied 47% of the bed days on the unit. Edmonds’j has stated that for the UK as a whole, more hospital bed days are accounted for by diabetic foot problems than all the other complications of diabetes combined. Williams’ figures can be extrapolated to the UK as a whole. Based on a population of 56 000 000, this would give 147 781 diabetic admissions annually, of which 29 556 would be due to foot problems. This is reinforced by studies from the USA which show 14% of diabetics are hospitalised for an average of 6 weeks per annum.7 Assuming this length of admission gives almost 1 250 000 bed days per annum for diabetic foot problems which, at the daily bed cost in Liverpool of & 180 per day, means an annual inpatient cost of &223 400 000 per annum. This is a conservative estimate as diabetic foot problems occupy more bed days on average than other diabetic complications. The hospital costs are not limited to bed occupancy as diabetic foot problems may lead to amputation. Diabetics account for over 75% of major non-traumatic amputations,8 and those requiring lower limb prostheses over 20% of the total referrals for artificial limbs.’ The cost of major amputations in diabetics in the UK, plus the fitting of an artificial limb, was estimated in 1985 to be &13 440 000.5 Allowing for only single digit inflation, this figure could now be nearer &23 000 000. Moreover, 10% of amputees die before leaving hospital, 50% develop contralateral foot problems within 3 years and within 5 years 50-75% are dead.” Costs in the community are more difficult to estimate but a study in Nottingham found nearly 7 times as many patients with diabetic foot problems in the community as in hospital during one single week. The median duration of lesions found was 4 months and nearly 10% had been present for over 1 year. District nurses made an average of 3 visits each week to each patient.” Many of these foot problems occur because the patient is unaware of the dangers and complications of peripheral neuropathy, and potentially could be avoided. The cost benefits of even a small reduction in the number of patients admitted to hospital would be considerable. Programmes aimed at prevention and education have shown a halving of annual amputation rates and hospital admissions. However, despite the enormous economic and social impact there is a paucity of well controlled, comparative clinical trials to aid in the prevention or treatment of the problem, either in this country or in the USA. Where such studies have taken place they have been successful in dramatically reducing the numbers of patients hospitalised or undergoing amputation. The introduction of a comprehensive foot care programme of education and foot inspection, at the Grady Memorial Hospital in Atlanta, reduced the amputation rate from 13.3 to 6.6 per 1000 diabetics. Hospital admissions for foot ulcers, infection and gangrene were reduced by 60% and an annual saving of > $10 000 000 was estimated.” Similar figures were achieved by King’s College Hospital in London. The introduction of a specialised foot clinic for diabetics halved the annual amputation rate and produced healing in the majority of both neuropathic and