Diabetes mellitus is one of the most common chronic medical conditions in the United States. In addition to the disease’s direct complications, most patients also have other chronic conditions and are at an increased risk for a variety of complications such as nontraumatic limb amputations. The incidence of diabetes is increasing globally; estimates are that diabetes will affect 7.7 percent of the world’s population between the ages of 20 and 79 by 2030. The prevalence may be even higher—perhaps up to 20 percent—among orthopaedic patients.

Approximately one of every seven U.S. healthcare dollars is spent on treating people with diabetes. As the incidence and prevalence of diabetes rise, so will this figure. This makes patients with diabetes an ideal population for developing cost-effective practices aimed at reducing unnecessary healthcare costs.

For orthopaedic surgeons, increased awareness of the potential perioperative complications and economic burden associated with surgical treatment of diabetic patients is an important step in improving the quality of care and reducing associated costs.

Areas for improvement: SSIs
Many orthopaedic studies have identified diabetes mellitus and perioperative glucose imbalance as predisposing risk factors for various postoperative complications such as surgical site infection (SSI) and longer hospital stays.

One study, for example, found that an SSI following orthopaedic inpatient surgery resulted in a median increase in healthcare costs of more than 300 percent, and that treatment costs for an orthopaedic patient with an infection were $17,708 higher than treatment costs for a patient without an infection.

Published rates indicate that SSIs may develop in an estimated 31,500 to 355,500 orthopaedic patients each year, leading to an annual cost of orthopaedic SSIs in the range of $558 million to $6.3 billion. Moreover, SSIs result in a mean increase in hospital stay of 32.5 days, placing an even greater burden on the hospital system.

The notion that proper perioperative blood glucose control would lead to decreased rates of SSIs and reduce related healthcare costs is obvious. A prospective study conducted on an orthopaedic patient population suggests, however, that glycemic control in practice is commonly below par.

The improper management of insulin administration by healthcare providers after patients are taken off their regular diabetes medications may be one culprit. An intervention program including the following elements could decrease severe hyperglycemic events and length of stay:

• educating healthcare providers about proper glucose control/insulin administration
• consulting an endocrinologist for all diabetic patients
• employing a more rigorous system for maintaining proper blood glucose of diabetic patients

Diabetic foot ulcers
Another diabetes-related complication that has dire economic consequences and that may necessitate orthopaedic care is the development of diabetic foot ulcers. The prevalence of diabetic foot ulcers among diabetics in the United States ranges from 4 percent to 10 percent. In 2011, between 1 million and 2.5 million Americans were afflicted with a diabetic foot ulcer.

In 2001, diabetic foot ulcers and associated amputations were estimated to cost U.S. healthcare payers $10.9 billion, with treatment for a single patient costing an average of $28,000. However, many of the etiologic factors contributing to the development of diabetic foot ulcers can be identified early and treated by orthopaedic surgeons who may be seeing diabetic patients for reasons not related to their diabetes.

Studies have shown that early recognition of pre-ulcerative inflammation using infrared skin thermometers, patient education on the importance of proper footwear, and regular monitoring of callus formation (which increases plantar pressure and may cause subsequent ulceration) result in significantly fewer diabetic foot complications and decreased rates of amputation. Thus, treatment of diabetic foot ulcers is another area where cost-effective practices aimed at early identification and patient education could reduce unnecessary healthcare costs.

Early diagnosis
It is important to note that the aforementioned costs of diabetes do not include healthcare expenses associated with undiagnosed diabetes and prediabetes, which have been shown to be an additional $18 billion and $25 billion per year, respectively. These costs can largely be attributed to complications such as hypertension and renal disease that develop in the setting of poor glucose control.

Nearly 25 percent of diabetics are unaware of their condition and data show that 10 percent of orthopaedic inpatients have elevated HbA1c values. While diabetic screening typically falls under the purview of primary care physicians (PCPs), many orthopaedic surgery patients may not have a PCP. Accordingly, increased awareness and regular screening of at-risk patients by orthopaedic surgeons could help identify diabetics before complications develop, and ensuring proper glycemic control for all orthopaedic patients may improve surgical outcomes.

Conclusion
Health outcomes in diabetic patients undergoing any type of surgery are uniformly improved by optimizing glycemic control. The orthopaedic trauma population in particular may be at risk for inadequate management of perioperative hyperglycemia due to the lack of published data.

Orthopaedic surgeons can improve outcomes and dramatically reduce healthcare costs by taking the following steps:

• Placing an increased focus on perioperative and long-term glucose control through direct patient contact and communication with patients’ PCPs or endocrinologists
• Increasing awareness and conducting regular screening of at-risk patients to improve diabetes diagnosis
• Working within their hospitals to improve perioperative management of hyperglycemia

Rishin J. Kadakia, BSc; James M. Tsahakis, BA; Neil M. Issar, BSc; Mallory Powell, BA; William T. Obremskey, MD, MPH; A. Alex Jahangir, MD; and Manish K. Sethi, MD, are all associated with the Vanderbilt Orthopaedic Institute Center for Health Policy.

References

1. Shaw JE, Sicree RA, Zimmet PZ: Global estimates of the prevalence of diabetes for 2010 and 2030. Diabetes Res Clin Prac 2010;87:4–14.
2. Schroeder JE, Liebergall M, Raz I, et al: Benefits of a simple glycaemic protocol in an orthopaedic surgery ward: A randomized prospective study. Diabetes Metab Res Rev 2012;28(1):71-75.
3. American Diabetes Association: Economic costs of diabetes in the U.S. in 2007. Diabetes Care 2008;31(3):596–615.
4. Wukich DK, Lowery NJ, McMillen RL, Frykberg RG : Postoperative infection rates in foot and ankle surgery: A comparison of patients with and without diabetes mellitus. J Bone Joint Surg Am 2010;92(2):287–295.
5. Mraovic B, Hipszer BR, Epstein RH, Pequignot EC, Parvizi J, Joseph JI: Preadmission hyperglycemia is an independent risk factor for in-hospital symptomatic pulmonary embolism after major orthopedic surgery. J Arthroplasty 2010;25(1): 64–70.
6. Olsen MA, Nepple JJ, Riew KD, et al: Risk factors for surgical site infection following orthopaedic spinal operations. J Bone Joint Surg Am 2008;90(1): 62–69.
7. Karunakar MA, Staples KS: Does stress-induced hyperglycemia increase the risk of perioperative infectious complications in orthopaedic trauma patients? J Orthop Trauma 2010;24(12):752–756.
8. Whitehouse JD, Friedman ND, Kirkland KB, Richardson WJ, Sexton DJ: The impact of surgical-site infections following orthopedic surgery at a community hospital and a university hospital: Adverse quality of life, ecess length of stay, and extra cost. Infect Control Hosp Epidemiol 2002;23(4):183–189.
9. Richards JE, Kauffmann RM, Obremskey WT, May AK: Stress-Induced Hyperglycemia is a Risk Factor for Surgical-Site Infection in Nondiabetic Orthopaedic Trauma Patients. 27th Orthopaedic Trauma Association (OTA) Annual Meeting, October 13–15, 2011.
10. Singh N, Armstrong DG, Lipsky BA: Preventing foot ulcers in patients with diabetes. JAMA 2005;293(2):217-218
11. Centers for Disease Control and Prevention. National diabetes fact sheet: National estimates and general information on diabetes and prediabetes in the United States, 2011. Atlanta, GA: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, 2011.
12. Margolis DJ, Malay DS, Hoffstad OJ, et al. Economic burden of diabetic foot ulcers and amputations. Diabetic Foot Ulcers. Data Points #3 (prepared by the University of Pennsylvania DEcIDE Center, under Contract No. HHSA290200500411). Rockville, MD: Agency for Healthcare Research and Quality. January 2011. AHRQ Publication No. 10(11)-EHC009-2-EF.
13. Boulton AJ: Pressure and the diabetic foot: Clinical science and offloading techniques. Am J Surg 2004;187(5A):17S–24S.
14. Lavery LA, Higgins KR, Lanctot DR, et al. Home monitoring of foot skin temperatures to prevent ulceration. Diabetes Care 2004;27(11):2642–2647.
15. Zhang T, Dall TM, Mann SE, et.al: The Economic costs of undiagnosed diabetes. Population Health Management, 2009;12(2);95–101.