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Cost-Effectiveness of Becaplermin Gel on Diabetic Foot Ulcer Healing
Changes in Wound Surface Area
Background: A comparison of the cost-effectiveness of becaplermin plus good wound care (BGWC) versus good wound care (GWC) alone in treating patients with diabetic foot ulcers (DFUs) may enable physicians and health-care decision makers in the United States to make better-informed choices about treating DFUs, which currently contribute to a substantial portion of the economic burden of diabetes.
Methods: Data from three phase III trials were used to predict expected 1-year costs and outcomes, including the average percentage reduction from baseline in wound surface area (WSA), the direct costs of DFU therapy, and the cost per cm2 of WSA reduction.
Results: At 20 weeks, the BGWC group had a statistically greater probability of complete wound closure than the GWC group (50% versus 35%; P = .015). Based on reported WSA reduction rates, DFUs in the BGWC group were predicted to close by 100% at 27 weeks, and those in the GWC group were predicted to close by 88% at 52 weeks. The GWC group had higher total estimated 1-year direct cost of DFU care ($6,809 versus $4,414) and higher cost per cm2 of wound closure ($3,501 versus $2,006).
Conclusions: Becaplermin plus good wound care demonstrated economic dominance compared with GWC by providing better clinical outcomes via faster reduction in WSA and higher rates of closure at a lower direct cost.
Although many reports have been published on the usefulness of costal cartilage grafting in the reconstruction of interphalangeal joints of fingers, there are only a few published reports on the reconstruction of interphalangeal joints of toes. We describe a 21-year-old woman with a tissue defect of the dorsum pedis and a partial defect of the interphalangeal joint of the great toe caused by a motor-vehicle accident. We attempted arthroplasty using a free latissimus dorsi myocutaneous flap and a costal osteochondral graft. The grafted rib and cartilage survived, allowing the patient to resume functional ambulation for day-to-day activities. Arthroplasty using costal osteochondral grafts seems to be an effective means of reconstructing the interphalangeal joints of toes. (J Am Podiatr Med Assoc 96(6): 508–512, 2006)
As of 2016, Medicaid accounted for nearly 20% of state general fund budgets. Optional Medicaid services like podiatry are often subject to cost-cutting measures in periods of economic downturn, as was the case in the wake of the 2007 financial crisis. Although the cuts were intended as a cost-saving measure, research indicates they had the opposite effect. The restriction and limitation of these services during the Great Recession resulted in both poorer health outcomes for beneficiaries, and poorer financial outcomes for state Medicaid programs. With states citing record levels of unemployment as of April 2020 and projecting significant declines in annual revenue in 2021, the economic conditions resulting from the COVID-19 pandemic are likely to rival those of the Great Recession. Given the historical precedent for restricting or eliminating optional Medicaid services as a cost-saving measure, it is likely that podiatric services will once again come under scrutiny. Previous efforts by state-level podiatric societies have proven successful in lobbying for the reinstatement of coverage under Medicaid by conveying evidence of the negative outcomes associated with elimination to stakeholders. The specialty must once again engage policymakers by drawing on evidence gleaned and lessons learned from past cuts of optional Medicaid services to avert counterproductive coverage restrictions intended to mitigate the financial impact of the COVID-19 pandemic.
This study evaluated the clinical effectiveness and cost-effectiveness of two different types of foot orthoses used to treat plantar heel pain. Forty-eight patients were randomly assigned to receive either a functional or an accommodative orthosis. General (EuroQol) and specific (Foot Health Status Questionnaire) health-status measures were used. Data were also collected using economic questionnaires relating to National Health Service costs for podia-try, other health-service costs, and patient costs. Data were measured at baseline and at 4- and 8-week intervals. Thirty-five patients completed the study. The results demonstrated a significant decrease in foot pain and a significant increase in foot function with the functional foot orthoses over the 8-week trial. The accommodative foot orthoses demonstrated a significant reduction in foot pain only at 4 weeks. The cost-effectiveness analysis demonstrated that functional orthoses, although initially more expensive, result in a better quality of life. Use of functional orthoses resulted in an increased cost of £17.99 ($32.74) per patient, leading to an incremental cost per quality-adjusted life year of £1,650 ($3,003) for functional orthoses. (J Am Podiatr Med Assoc 94(3): 229–238, 2004)
INTRODUCTION AND OBJECTIVES: The purpose of this study was to determine whether some foot/ankle surgeries would benefit from routine use of low molecular weight heparin (LMWH) as postoperative DVT prophylaxis.
METHODS: We conducted a formal cost-effectiveness analysis using a decision analytic tree to represent the risk of complications under a scenario of no prophylaxis and a scenario of routine LMWH prophylaxis for 4 weeks. The two scenarios were compared for five procedures: 1) Achilles tendon repair (ATR), 2) total ankle replacement (TAR), 3) hallux valgus surgery (HVS), 4) hindfoot arthrodesis (HA), and 5) ankle fracture surgery (AFS). Outcomes assessed included short and long-term costs, quality-adjusted life-years (QALYs), and incremental cost per QALY gained. Costs were evaluated from the health care system perspective and expressed in US dollars at a 2015 price base. In the short-term, routine prophylaxis was always associated with greater costs compared to no prophylaxis.
RESULTS: For ATR, TAR, HA and AFS prophylaxis was associated with slightly better health outcomes; however, the gain in QALYs was minimal compared to the cost of prophylaxis (ICER was well above $50,000/QALY threshold). For HVS, prophylaxis was associated with both worse health outcomes and greater costs. In the long-term, routine prophylaxis was always associated with worse health outcomes.
CONCLUSIONS: We conclude that the decision to use LMWH prophylaxis should not be based solely on the type of foot/ankle surgery planned. Patient factors also need to be carefully weighed.
Several investigators have reported that the presence of calcium may totally preclude resection of plaque material from the lumen of an occluded vessel. Because the authors did not support these findings, they tested the hypothesis and studied the effects of pulsed argon ion laser energy on other non-plaque but dense calcified tissue, such as cortical bone, and found that bone can be cut with ease and safety. Fresh bovine specimens were irradiated with a Spectra Physics model 170 argon ion laser, and the irradiated areas were examined, measured, and photographed.
