Prevention of diabetes-related foot ulcers and amputations: a cost-utility analysis based on Markov model simulations

G. Ragnarson Tennvall, J. Apelqvist

We analysed the cost-effectiveness of intensified prevention in diabetic patients with different risks for foot ulcers and lower extremity amputations. Specifically, we examined whether the additional prevention costs associated with present recommendations would be offset by reduced costs of future foot ulcers and amputations. Markov-based 5-year cost-utility simulations of current versus optimal prevention were done for hypothetical cohorts of diabetic patients older than 24 years. The model included eight possible health states for four risk groups. A population of 1677 diabetes patients provided data on present foot ulcer prevention and general mortality. Optimal prevention was defined according to the International Consensus on the Diabetic Foot. Model assumptions, transition probabilities and other data included in the model were based on published literature. The main outcome measures were cumulative incidences of foot ulcers, amputations and deaths, costs, cost-effectiveness, and quality-adjusted life years. An intensified prevention strategy including patient education, foot care and footwear is cost-effective if the risk for foot ulcers and lower extremity amputations can be reduced by 25 %. This is valid for all patients with diabetes except those with no specific risk factors. Providing all diabetic patients at risk or high risk for foot ulcers and amputations with adequate prevention would be a cost-effective or even cost-saving strategy.