A Diabetic Emergency One Million Feet Long: Disparities and Burdens of Illness among Diabetic Foot Ulcer Cases within Emergency Departments in the United States, 2006–2010

Grant H Skrepnek,David G Armstrong,Joseph L Mills,Shahrad Taheri

doi:10.1371/journal.pone.0134914

Grant H Skrepnek, David G Armstrong + Show 2 more

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https://doi.org/10.1371/journal.pone.0134914

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Journal: PloS one	Publication Date: Aug 6, 2015
Citations: 119	License type: CC BY 4.0

Affiliation: University of Arizona

Abstract

ObjectivesTo evaluate the magnitude and impact of diabetic foot ulcers (DFUs) in emergency department (ED) settings from 2006–2010 in the United States (US).MethodsThis cross-sectional study utilized Agency for Healthcare Research and Quality (AHRQ) Healthcare Cost and Utilization Project (HCUP) National Emergency Department Sample (NEDS) discharge records of ED cases among persons ≥18 years with any-listed diagnosis of DFUs. Multivariable analyses were conducted for clinical outcomes of patient disposition from the ED and economic outcomes of charges and lengths of stay based upon patient demographic and socioeconomic factors, hospital characteristics, and comorbid disease states.ResultsOverall, 1,019,861 cases of diabetic foot complications presented to EDs in the US from 2006–2010, comprising 1.9% of the 54.2 million total diabetes cases. The mean patient age was 62.5 years and 59.4% were men. The national bill was $1.9 billion per year in the ED and $8.78 billion per year (US$ 2014) including inpatient charges among the 81.2% of cases that were admitted. Clinical outcomes included mortality in 2.0%, sepsis in 9.6% of cases and amputation in 10.5% (major-minor amputation ratio of 0.46). Multivariable analyses found that those residing in non-urban locations were associated with +51.3%, +14.9%, and +41.4% higher odds of major amputation, minor amputation, and inpatient death, respectively (p<0.05). Medicaid beneficiaries incurred +21.1% and +25.1% higher odds for major or minor amputations, respectively, than Medicare patients (p<0.05). Persons within the lowest income quartile regions were associated with a +38.5% higher odds of major amputation (p<0.05) versus the highest income regions.ConclusionDiabetic foot complications exact a substantial clinical and economic toll in acute care settings, particularly among the rural and working poor. Clear opportunities exist to reduce costs and improve outcomes for this systematically-neglected condition by establishing effective practice paradigms for screening, prevention, and coordinated care.

Highlights

1,019,861 cases of diabetic foot complications presented to emergency department (ED) in the United States (US) from 2006–2010, comprising 1.9% of the 54.2 million total diabetes cases
Multivariable analyses found that those residing in non-urban locations were associated with +51.3%, +14.9%, PLOS ONE | DOI:10.1371/journal.pone
While often initially silent because of attendant neuropathy, lower extremity complications of diabetes constitute a major public health burden in both the developed and developing world. [1,2,3] Overall, these complications frequently develop into diabetic foot ulcers (DFUs) which pose substantial risks of infection and amputation irrespective of critical limb ischemia

Summary

Introduction

While often initially silent because of attendant neuropathy, lower extremity complications of diabetes constitute a major public health burden in both the developed and developing world. [1,2,3] Overall, these complications frequently develop into diabetic foot ulcers (DFUs) which pose substantial risks of infection and amputation irrespective of critical limb ischemia. While often initially silent because of attendant neuropathy, lower extremity complications of diabetes constitute a major public health burden in both the developed and developing world. [1,2,3] Overall, these complications frequently develop into diabetic foot ulcers (DFUs) which pose substantial risks of infection and amputation irrespective of critical limb ischemia. [1,3,5,6] The major risk factors associated with the development of DFUs and subsequent amputation include neuropathy, nephropathy, ischemia (peripheral artery disease or PAD), hypertriglyceridemia, tobacco use, and poor glycemic control.[2,4,7,8]. Across numerous disease states, including diabetes, disparities in both the utilization of ED facilities and in health outcomes emanating from these settings have been observed and discussed including age, race or ethnicity, sex, geographic region, socioeconomic status, and insurance coverage.[9,10,11,12,13,14,15]

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