Contribution of 30-Day Readmissions to the Increasing Costs of Care for the Diabetic Foot

SLR - December 2019 - Karan Malani

Reference: Hicks CW, Canner JK, Karagozlu H, Mathioudakis N, Sherman RL, Black III JH, Abularrage CJ. Contribution of 30-Day Readmissions to the Increasing Costs of Care for the Diabetic Foot. Journal of Vascular Surgery. 2019 Oct; 70, 1263-1270.

Scientific Literature Review

Reviewed By: Karan Malani, DPM
Residency Program: Cambridge Health Alliance – Cambridge, MA

Podiatric Relevance: Current inpatient costs of diabetic foot ulcers (DFUs) are estimated to be $1.4 billion annually in the United States. Treatment and management of DFUs requires multidisciplinary care from vascular surgeons to endocrinologists to podiatric surgeons. Specifically, the role of Podiatric surgeons is aimed towards ulcer healing and limb preservation. Between 2005-2010, hospital costs associated with inpatient care of a DFU have increased by > 30 percent due to an increasing number of procedures directed towards limb preservation in a progressively sicker population. However, the inpatient length of hospital stay has remained the same, thus indicating that readmissions are the primary cause of the increase in costs to hospital systems for treating DFUs. Currently, the costs associated with 30-day hospital readmissions for patients with DFUs are unknown. As a result, the aim of this study was to quantify the hospital costs associated with 30-day hospital readmissions for patients admitted with a DFU.   

Methods: A level IV retrospective cohort study was performed where all patients with a DFU presenting to a single hospital center from June 1, 2012 to June 31, 2016 were included. Exclusion criteria included patients without a DFU, without hospital admissions, with missing cost data, and with unsalvageable limbs. All patients received multidisciplinary care ranging from noninvasive vascular studies if indicated, imaging, revascularization procedures, wound care, antibiotics, and outpatient follow-up. The study endpoints included inpatient hospital charges (the price of care for a given service), costs (costs incurred by hospital to provide the service), professional fees (charges to providers) and net margins (revenue – cost) for DFU admissions and 30-day unplanned readmissions.       

Results: Two hundred forty-nine admissions for 150 patients were included in the study. Of the 249 admissions, 206 were index admissions without readmissions and 43 were 30-day readmissions. The most common reason for readmission was a deteriorating foot wound (n=21, 48.8 percent). The overall cost of care for patients requiring readmissions was significantly higher compared to patients not readmitted ($79,315 vs $28,977). Hospital charges, costs, and net margins were significantly greater for a patient requiring readmissions. Professional fees did not differ significantly.

Conclusions: The authors concluded that the cost of treating patients that required readmission was >2.5 times greater than for those without readmissions. The researchers attempted to tackle this issue via aggressive management using a multidisciplinary algorithmic approach. This included vascular angiographic procedures for all PAD patients with toe pressures <60 mmHg prior to undergoing podiatric debridement, placing increased emphasis on home healthcare services and rehabilitation placement to ensure adequate wound care. Since they found a majority of the readmissions occurred due to deterioration of foot wounds, they treated all forefoot and midfoot wounds with six weeks of IV antibiotics regardless of whether the final bone margins were clean. Overall, this study did manage to demonstrate the huge cost burden to hospital systems when trying to treat DFUs, especially for readmissions. The study can be used as a blueprint for all hospital systems to develop an algorithm to treat DFUs aggressively during the initial admission in order to reduce readmissions.