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JAMES R. CHRISTINA, DPM DIRECTOR SCIENTIFIC AFFAIRS AMERICAN PODIATRIC MEDICAL ASSOCIATION FOOTCARE AND DIABETES

JAMES R. CHRISTINA, DPM DIRECTOR SCIENTIFIC AFFAIRS AMERICAN PODIATRIC MEDICAL ASSOCIATION FOOTCARE AND DIABETES

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Page 1: JAMES R. CHRISTINA, DPM DIRECTOR SCIENTIFIC AFFAIRS AMERICAN PODIATRIC MEDICAL ASSOCIATION FOOTCARE AND DIABETES

JAMES R . CHRISTINA, DPMDIRECTOR SCIENTIFIC AFFAIRSAMERICAN PODIATRIC MEDICAL

ASSOCIATION

FOOTCARE AND DIABETES

Page 2: JAMES R. CHRISTINA, DPM DIRECTOR SCIENTIFIC AFFAIRS AMERICAN PODIATRIC MEDICAL ASSOCIATION FOOTCARE AND DIABETES

Epidemiology of Diabetes

23.6 million in US 7.8% of population

~ 10% in District of Columbia 8.7% of those > 20 yrs old 24% of Hispanic Americans

3,651 diagnosed daily Leading cause of:

Blindness Renal Failure Amputation

5th leading cause of death

Page 3: JAMES R. CHRISTINA, DPM DIRECTOR SCIENTIFIC AFFAIRS AMERICAN PODIATRIC MEDICAL ASSOCIATION FOOTCARE AND DIABETES

Epidemiology of Amputation

>60% of all amputations involve diabetes in US

9-20% of ulcerations end in amputation

~84% of lower extremity amputations are preceded by ulceration

Page 4: JAMES R. CHRISTINA, DPM DIRECTOR SCIENTIFIC AFFAIRS AMERICAN PODIATRIC MEDICAL ASSOCIATION FOOTCARE AND DIABETES

Economic Impact of Diabetes

~ $174 BILLION Annual Cost

Per Capita Medical Expenditure

$13,243 for diabetes

$2,560 for non-diabetic

$4-28 Billion on Foot Ulceration

15 Million work days lost

59% longer duration of hospital stay for diabetic patients with foot ulcers

Page 5: JAMES R. CHRISTINA, DPM DIRECTOR SCIENTIFIC AFFAIRS AMERICAN PODIATRIC MEDICAL ASSOCIATION FOOTCARE AND DIABETES

Following the First Lower Extremity Amputation:

Contralateral amputation 68% within 5 years

Mortality Rate 50% at 3 years

Institutionalization 25% remain permanently

Lavery, van Houtum, Armstrong, Am J Med, 1997

Page 6: JAMES R. CHRISTINA, DPM DIRECTOR SCIENTIFIC AFFAIRS AMERICAN PODIATRIC MEDICAL ASSOCIATION FOOTCARE AND DIABETES

The Value of Care by a Podiatrist

Results of the Thomson Reuters Healthcare (TRH) Study

Page 7: JAMES R. CHRISTINA, DPM DIRECTOR SCIENTIFIC AFFAIRS AMERICAN PODIATRIC MEDICAL ASSOCIATION FOOTCARE AND DIABETES
Page 8: JAMES R. CHRISTINA, DPM DIRECTOR SCIENTIFIC AFFAIRS AMERICAN PODIATRIC MEDICAL ASSOCIATION FOOTCARE AND DIABETES

DETAILS OF THE STUDY

TRH using their MarketScan Data Base examined claims from 316,527 patients with commercial insurance and 157,529 patients with Medicare (and employer sponsored secondary insurance)

Study focused on one specific aspect of diabetic foot care—those patients that developed a foot ulceration.

A comparison was then made by looking at the year preceding the ulceration to see if any care from a podiatrist was provided to the patient.

Page 9: JAMES R. CHRISTINA, DPM DIRECTOR SCIENTIFIC AFFAIRS AMERICAN PODIATRIC MEDICAL ASSOCIATION FOOTCARE AND DIABETES

RATES OF RISK FACTORS ARE HIGHER AMONG COMMERCIALLY INSURED PATIENTS WITH

DIABETES WHO SEE PODIATRISTS

Population Aged 18–64

Patients with Podiatrist visit

Unmatched Comparison

Matched Comparison

Sample Size 53,582 316,527 53,578

Cardiovascular

53.3% 46.8%* 53.7%

Nephropathy 3.7% 2.4%* 3.7%

Eye 6.3% 4.2%* 6.2%

PAD 4.9% 2.7%* 4.7%

Neuropathy 4.2% 2.4%* 4.1%

Deformity 1.9% 0.7%* 1.7%*

Callus 0.3% 0.1%* 0.2%

Nail Pathology

3.7% 1.3%* 3.2%*

9

PAD = peripheral arterial diseaseComparison group consists of patients with diabetes who do not see podiatrists, matching is based on propensity scores* Statistically significant difference at P < 0.05

Page 10: JAMES R. CHRISTINA, DPM DIRECTOR SCIENTIFIC AFFAIRS AMERICAN PODIATRIC MEDICAL ASSOCIATION FOOTCARE AND DIABETES

RATES OF RISK FACTORS ARE HIGHER AMONG MEDICARE BENEFICIARIES WITH DIABETES WHO

SEE PODIATRISTS

Population Aged 65+

Patients with Podiatrist visit

Unmatched Comparison

Matched Comparison

Sample Size 43,050 157,529 43,042

Cardiovascular

64.1% 56.1%* 63.7%

Nephropathy 8.5% 5.1%* 8.4%

Eye 7.8% 5.7%* 7.6%

PAD 10.4% 6.2%* 10.2%

Neuropathy 3.7% 2.3%* 3.6%

Deformity 2.9% 1.3%* 2.6%*

Callus 0.3% 0.2%* 0.3%

Nail Pathology

6.0% 2.5%* 5.4%*

10

PAD = peripheral arterial diseaseComparison group consists of patients with diabetes who do not see podiatrists, matching is based on propensity scores* Statistically significant difference at P < 0.05

Page 11: JAMES R. CHRISTINA, DPM DIRECTOR SCIENTIFIC AFFAIRS AMERICAN PODIATRIC MEDICAL ASSOCIATION FOOTCARE AND DIABETES
Page 12: JAMES R. CHRISTINA, DPM DIRECTOR SCIENTIFIC AFFAIRS AMERICAN PODIATRIC MEDICAL ASSOCIATION FOOTCARE AND DIABETES

THE RESULTS

Average savings over a three year time period (year before ulceration and two years after ulceration):

Commercial Insurance—Savings of $19,686 per patient if they had at least one visit to a podiatrist

Medicare: Savings of $4,271 per patient if they had at least one visit to a podiatrist

Page 13: JAMES R. CHRISTINA, DPM DIRECTOR SCIENTIFIC AFFAIRS AMERICAN PODIATRIC MEDICAL ASSOCIATION FOOTCARE AND DIABETES

Comparison of healthcare costs during year before and two years after index foot ulcer diagnosis, podiatry and comparison groups

$21,518

$48,318

$19,021

$39,913

$27,730

$61,792

$19,668

$43,537

$0

$20,000

$40,000

$60,000

$80,000

$100,000

1 year before index foot ulcer

2 years after index foot ulcer

1 year before index foot ulcer

2 years after index foot ulcer

Podiatry group

Comparison Group

MedicareCommercial

Difference= $13,474***

Difference= $6,212*** Difference=

$647

Difference= $3,624***

Page 14: JAMES R. CHRISTINA, DPM DIRECTOR SCIENTIFIC AFFAIRS AMERICAN PODIATRIC MEDICAL ASSOCIATION FOOTCARE AND DIABETES

AMPUTATION REDUCTION: LIMBS SAVED

5.82%4.69%

8.49%

6.04%

0.00%

5.00%

10.00%

15.00%

Commercial Medicare

Podiatry group

Comparison GroupDifference =

2.67%*** Difference = 1.35%***

Page 15: JAMES R. CHRISTINA, DPM DIRECTOR SCIENTIFIC AFFAIRS AMERICAN PODIATRIC MEDICAL ASSOCIATION FOOTCARE AND DIABETES

ODDS OF NEGATIVE OUTCOMES WERE LOWER AMONG PATIENTS WHO SEE PODIATRISTS

15

Commercial Ins: Aged 18–64n=5,883 podiatry n=5,883 comparison

Adjusted Odds Ratio (95% Confidence Interval)

Percent Change in Odds of Outcome for Patients with Podiatry

Amputation 0.712 (0.573–0.886) 28.8% lower odds

Hospitalization 0.756 (0.712–0.867) 24.4% lower odds

Medicare:Aged 65+ n=10,165 podiatry n=10,165 comparison

Adjusted Odds Ratio (95% Confidence Interval)

Percent Change in Odds of Outcome for Patients with Podiatry

Amputation 0.775 (0.652–0.921) 22.5% lower odds

Hospitalization 0.863 (0.805–0.926) 13.7% lower odds• Logistic regression models estimated the odds of each outcome occurring

within two years of the first foot ulcer diagnosis, controlling for demographic and clinical characteristics

• Podiatric care was defined as at least three visits prior to the first foot ulcer

Page 16: JAMES R. CHRISTINA, DPM DIRECTOR SCIENTIFIC AFFAIRS AMERICAN PODIATRIC MEDICAL ASSOCIATION FOOTCARE AND DIABETES

WHAT IF EVERY AT RISK DIABETIC PATIENT SAW A PODIATRIST?

Extrapolating the results from the study:

$1.97 billion could be saved in the commercial insurance group in one year

$1.53 billion could be saved in the Medicare group in one year

$3.5 billion total savings in one year

Page 17: JAMES R. CHRISTINA, DPM DIRECTOR SCIENTIFIC AFFAIRS AMERICAN PODIATRIC MEDICAL ASSOCIATION FOOTCARE AND DIABETES
Page 18: JAMES R. CHRISTINA, DPM DIRECTOR SCIENTIFIC AFFAIRS AMERICAN PODIATRIC MEDICAL ASSOCIATION FOOTCARE AND DIABETES

Objective

To determine effectiveness of receipt of care from podiatrist and lower extremity clinician specialists (LEC specialists) on diabetes mellitus (DM)-related lower extremity amputation.

Page 19: JAMES R. CHRISTINA, DPM DIRECTOR SCIENTIFIC AFFAIRS AMERICAN PODIATRIC MEDICAL ASSOCIATION FOOTCARE AND DIABETES

Data Sources

Medicare 5 percent sample claims, 1991–2007.

Page 20: JAMES R. CHRISTINA, DPM DIRECTOR SCIENTIFIC AFFAIRS AMERICAN PODIATRIC MEDICAL ASSOCIATION FOOTCARE AND DIABETES

Data Collection

Individuals were stratified based on disease severity: Stage 1——neuropathy, paresthesia, pain in feet,

diabetic amyotrophy Stage 2——cellutis, Charcot foot Stage 3——ulcer Stage 4——osteomyelitis, gangrene

After exclusions, there were 117,879 individuals in Stage 1, 31,582 in Stage 2, 31,199 in Stage 3, 55,068 in Stage 4 subsamples, and 189,598 in the combined analysis sample.

Page 21: JAMES R. CHRISTINA, DPM DIRECTOR SCIENTIFIC AFFAIRS AMERICAN PODIATRIC MEDICAL ASSOCIATION FOOTCARE AND DIABETES

Principal Findings

Persons visiting a podiatrist and an LEC specialist within a year before developing all stage complications were between 31 percent (ulceration) and 77 percent (cellulitis and Charcot foot) as likely to undergo amputation compared with individuals visiting other health professionals.

Page 22: JAMES R. CHRISTINA, DPM DIRECTOR SCIENTIFIC AFFAIRS AMERICAN PODIATRIC MEDICAL ASSOCIATION FOOTCARE AND DIABETES

Conclusions

Visiting both a podiatrist and an LEC specialist in the year before LEC diagnosis was protective of undergoing lower extremity amputation, suggesting a benefit from multidisciplinary care

The results were most favorable to a pattern of care involving a combination of podiatrists and lower extremity specialists

Page 23: JAMES R. CHRISTINA, DPM DIRECTOR SCIENTIFIC AFFAIRS AMERICAN PODIATRIC MEDICAL ASSOCIATION FOOTCARE AND DIABETES

VALUE

Two independent large scale retrospective reviews demonstrated that care by podiatrists of persons

with diabetes resulted in decreased lower extremity complications including amputations

resulting in significant cost savings.

Page 24: JAMES R. CHRISTINA, DPM DIRECTOR SCIENTIFIC AFFAIRS AMERICAN PODIATRIC MEDICAL ASSOCIATION FOOTCARE AND DIABETES

Moving Forward

These studies involved retrospective reviews, how do we take this information and use it prospectively to improve the health of people with diabetes?

Page 25: JAMES R. CHRISTINA, DPM DIRECTOR SCIENTIFIC AFFAIRS AMERICAN PODIATRIC MEDICAL ASSOCIATION FOOTCARE AND DIABETES

Podiatrists providing foot and ankle care for all persons with diabetes

Every person with diabetes would be evaluated by a podiatrist completing a comprehensive lower extremity exam. Based on the findings of the examination, the patient would be assigned to a risk categorization and then care would be provided based on the risk classification.

Page 26: JAMES R. CHRISTINA, DPM DIRECTOR SCIENTIFIC AFFAIRS AMERICAN PODIATRIC MEDICAL ASSOCIATION FOOTCARE AND DIABETES

Category Risk Profile Evaluation Frequency 0 Normal Annual

1 Peripheral Neuropathy (LOPS) Semi-annual

2 Neuropathy, deformity, and/or PAD Quarterly

3 Previous ulcer or amputation Monthly to quarterly

Risk Categorization System:

Recommendations from the American Diabetes Association Clinical Guidelines

Page 27: JAMES R. CHRISTINA, DPM DIRECTOR SCIENTIFIC AFFAIRS AMERICAN PODIATRIC MEDICAL ASSOCIATION FOOTCARE AND DIABETES

GOALS

Reduce complications including ulcerations, hospitalizations and ultimately amputations.

Improve quality of life for people with diabetes.

Significantly reduce health care costs associated with diabetes and lower extremity complications.

Significantly reduce non-health care costs associated with lower extremity complications from diabetes.

Page 28: JAMES R. CHRISTINA, DPM DIRECTOR SCIENTIFIC AFFAIRS AMERICAN PODIATRIC MEDICAL ASSOCIATION FOOTCARE AND DIABETES

Other Benefits

Data from the Thomson Reuters Healthcare Study showed a decrease in hospitalizations from all causes, not just those related to lower extremity amputations

Podiatrists become another member of the healthcare team providing care for the patient with diabetes which provides additional checks on: Blood sugar control Blood pressure control Cholesterol regulation

Page 29: JAMES R. CHRISTINA, DPM DIRECTOR SCIENTIFIC AFFAIRS AMERICAN PODIATRIC MEDICAL ASSOCIATION FOOTCARE AND DIABETES

BARRIERS

Preventive care does have a cost associated with it: There would be increased costs with more frequent

visits based on the risk category of the patient, however, these increased costs would be minimal compared to the cost savings that would be realized by long term savings and improved quality of life.

Page 30: JAMES R. CHRISTINA, DPM DIRECTOR SCIENTIFIC AFFAIRS AMERICAN PODIATRIC MEDICAL ASSOCIATION FOOTCARE AND DIABETES

QUESTIONS?

Page 31: JAMES R. CHRISTINA, DPM DIRECTOR SCIENTIFIC AFFAIRS AMERICAN PODIATRIC MEDICAL ASSOCIATION FOOTCARE AND DIABETES

JAMES R . CHRISTINA, [email protected]

301-581-9265

THANK YOU