Does Perspective Pay In Treating High-Risk Patients?

Perspective. They say it comes with age and is the result of an ongoing culmination of life experiences. It is the hope that as we develop this sense of wisdom, we’ll be better equipped to make smarter choices and decisions that may have a lasting impact. However, no matter how much perspective we have, the gravity of economic realities has a way of derailing our long-term view. Certainly, bottom-line decisions are more prevalent given the current downturn in the economy. More than ever, though, it is clearly critical to maintain perspective when it comes to cost concerns in wound care for high-risk patients. It’s hard to ignore the statistical trends on hospitalization and how diabetes cases factor into the equation. A recent study from Solucient.com suggested that the overall demand for hospital beds in the United States may see a 46 percent increase within the next 25 years. A recent Philadelphia Inquirer report noted that one out of every six hospital stays in Pennsylvania in 2001 involved diabetes, costing more than $6 billion. More specifically, David Armstrong, DPM, has noted that diabetes-related lower extremity amputations cost nearly $2 billion and result in an “estimated 2,600 patient-years of hospital stay per year” in the U.S. (See “Diabetes Watch,” pg. 15, July 2001 issue.) In that column, Dr. Armstrong emphasized that five to 10 percent of amputees die during hospitalization and as much as 50 percent of these patients die within five years after undergoing an amputation. There are emerging modalities that may make a dent in some of these numbers, but does concern over cost get in the way of more widespread use? For example, Dr. Armstrong concedes that VAC (vacuum-assisted closure) therapy is an expensive modality that costs about $100 a day, but he says this modality more than pays for itself if it can lead to one less day in the hospital for the patient. “If we can get the patient out of the hospital just one day sooner (we often save several days actually), then the modality pays for itself at least nine-fold,” notes Dr. Armstrong, who points out that the average hospital day costs $1,000. Another intriguing treatment approach is using absorbable antibiotic-impregnated calcium sulfate pellets adjunctively in diabetic infected wounds and osteomyelitis cases. Not only may this modality facilitate highly concentrated antibiotic delivery to a specific site, Ritchard Rosen, DPM, adds that “hopefully, this will decrease hospitalization time as well as the need for costly intravenous antibiotics for a lengthy course.” (See “Technology In Practice,” pg. 70, December 2002 issue.) While antibiotics may be viewed as expensive, it’s important to keep the proverbial big picture in mind. In the supplement, “Managing Diabetic Foot Infections,” that accompanies this month’s issue, Dr. Armstrong cites a study by Apelqvist, et. al., in which the researchers “implied that the overall cost of antibiotics in treating a diabetic foot infection is less than 5 percent of the total direct cost associated with hospitalization.” That said, appropriate patient selection is a must, especially with the rise of resistant bacteria strains such as MRSA. As Benjamin Lipsky, MD, points out in the supplement, “The total ‘tonnage’ of antibiotics used is directly proportional to the rise of resistance.” Certainly, more studies on emerging modalities are needed in order to reach a common ground on safety and successful, long-term outcomes. I just hope that when cost-effectiveness comes into play, we have enough perspective to emphasize the “effectiveness” part of the equation.