Survey of hospital admissions related to diabetic foot disease - Survey

Diabetic Foot, The,  Spring, 2004  by D.R. Coles,  D.V. Coppini

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We did not utilise a standard wound classification system (Jeffcoate et al, 1993), although management strategies for use of antibiotics and wound care were based on standard published protocols (Mason et al, 1999). ICD codes were not used because the inclusion and exclusion criteria are directly related to diabetic foot disease or complications associated with neuropathy. It would have been difficult, if not impossible, to define these complications accurately based on ICD codes alone.

Amputation rates

An overall amputation rate of 24% in admitted patients compares well with our own previous admission records for diabetic foot clinic amputation rates (23% in 1997, unpublished data) and with other published series (Apelqvist and Agardh, 1992). Further analysis showed that 36% (9/25) of patients admitted with infected foot ulceration or gangrene had an amputation (below ankle level in 55%). The overall major amputation (BKA or AKA) rate was 12.5% (4/32). A 2 year retrospective audit in Gwent similarly showed an amputation prevalence rate of 7% (De P et al, 2000).

Our estimated amputation rates may also be influenced by off-site location of the vascular services (Royal Bournemouth Hospital), and our analysis does not include patients who may have been referred directly to the surgical vascular teams. The estimated length of patients' hospital stay did not include their stay on the vascular ward, although patients were generally transferred back to our care before home discharge.

Based on average hospital bed occupancy costs alone ([pounds sterling]250 daily in Poole Hospital), the overall annual cost for admissions for patients with diabetic foot complications during our survey was [pounds sterling]177 750. Projected costs for vascular or surgical intervention, amputation and rehabilitation are, however, not included and are likely to produce a hefty underestimate of the real figure! Krentz et al estimated an annual hospital cost of [pounds sterling]400 000 in a prospective survey conducted in 1997 (Krentz AM et al, 1997). In the US, lower extremity amputations are estimated to cost about $25 000 per case (Reiber et al, 1992).

Conclusions

The recently published National Service Framework for Diabetes (Department of Health, 2002) highlights that the core team should have 'unhindered access to urgent inpatient facilities.' Generally increasing trends of 'acute medical bed' occupancy in NHS hospitals may hinder easy access to such patients. Besides, as shown in our survey, patients at diabetic foot clinics tend to have longer than average hospital stays as a result of the complication itself or commonly associated co-morbidities or social problems, further aggravating 'bed pressures.' Proper implementation of these guidelines will require substantial investments related to 'speciality bed' availability and a regular inpatient podiatric service. It is now time for service providers to invest adequately into this speciality as any projected costs to improve services would be trivial in comparison with the socioeconomic implications related to diabetic foot disease. As an example, we estimate that an inpatient specialist podiatric session (ie, a 4h session each week) would cost about [pounds sterling]5000 per annum. We believe that an extra session in our hospital would reduce length of stay by at least 10%, an immediate saving of [pounds sterling]17000 per annum based on bed occupancy alone.