The CRISIS of DIABETES

Diabetes is one of the fastest growing health crises. According to a recent JAMA article, “for individuals born after 1999 the estimated lifetime risk for developing diabetes is now up to 32.8% for males and 38.5% for females”. With the highest estimated lifetime risk for diabetes (up to 52.5%) in Black, American Indian, Indian and Hispanic females.

The direct and indirect cost of diabetes places an enormous burden on the health care system.

• Regarding institutional care, diabetics represent 22% of all hospital inpatient days.
• According to ADA, diabetic outpatient care represented 14% of physician office visits.

The American Diabetes Association estimates in the United States almost 50% of the cost of care is spent on hospitalization to treat diabetic complications.

Researchers estimate that the nation could easily save $2.5 billion a year by preventing diabetes complications. Complications like neuropathy and foot ulcer are common in diabetics. Foot ulcer is less common, yet still effects up to 15% of diabetics.

Also, the rate of foot ulcers have been increasing. Data from NHDS (National Hospital Discharge Surveys) showed that the rate of foot ulcers increased almost 50% between 1983 and 1990. 

Center Medicaid Services (CMS) estimates the cost of treating a pressure ulcer in acute care to be $43,180. Stage IV ulcer is particularly costly to treat; NIH estimates the cost of treating a Stage IV pressure ulcer to be up to $129,248. 

SmartSound technology, in a placebo controlled trial, healed Stage IV diabetic ulcers. It has been shown to be unmatched in "wound care". The researchers proved, "the total healing of chronic wounds" in less than 8 weeks. Demonstrating a 100% healing rate in Stage 1V ulcer.

Diabetic and Decubitus Ulcer

Strength of Evidence A 

Medical Necessity Mandates Use

Electrotherapy has been shown to promote healing and to prevent amputation even in patients with a Stage 4, non-responsive diabetic ulcer. Medical necessity mandates the use of high volt pulsed current (HVPC) when a diabetic ulcer has not healed for thirty days. This is the most researched and clinically effective form of electrotherapy and it has been given an (A) strength of evidence rating. It has been shown to control infection, stimulate fibroblast activity and heal Stage 4 diabetic ulcers. Also, therapeutic ultrasound has been shown to accelerate the early phase of wound healing, promote wound closure, and epithelialization. Recent clinical research has suggested the LED photon therapy can help prevent diabetic ulcers and stimulate healing.

Decision Memo for Electrostimulation for Wounds (CAG-00068N)

"Based on all of the evidence that we have reviewed in this matter, it is our intention to issue a positive coverage decision only on the use of electrical stimulation for chronic Stage III and Stage IV pressure ulcers, arterial ulcers, diabetic ulcers and venous stasis ulcers. Chronic ulcers are defined as ulcers that have not healed within 30 days of occurrence. The use of electrical stimulation will be covered as adjunctive therapy only after there are no measurable signs of healing for at least 30-days of treatment with standard wound therapy and must be used in addition to standard wound care."

Diabetic Neuropathy

Strength of Evidence B

Medical Groups Mandates Use In

Electrotherapy has a long history of use in controlling pain and has been shown to be effective in relieving the pain of diabetic neuropathy. In a controlled study of electrotherapy and amitriptyline published in Diabetes Care:

•             Medication reduced pain 26% 

•             Electrotherapy reduced pain 56%.

•             Electrotherapy seemed to control pain 215% better, even in patients unresponsive to medication 

Also, therapeutic ultrasound has been shown to reduce pain and promote healing in neurological conditions. It has also been shown to stimulate: nerve sprouting, regeneration, myelination, increased Schwann cell nuclei, and neural tube repair. Muorad, used a 2.25 MHz ultrasound and demonstrated regeneration of the sciatic nerve in compression injury. And ultrasound has been shown to be beneficial in treating carpal tunnel syndrome. Recent research has suggested that LED photon therapy may help to treat diabetic neuropathy and reverse sensory loss. 

Poor circulation contributes to neuropathy to foot ulcers and other complications in diabetics. Clinical research has shown that pulsed voltage can enhance blood flow and oxygen delivery to diabetic wounds; even in patients with poor circulation. 

Simultaneously pulsing ultrasound and voltage together acts as a potent vasodilator, due to the release of Nitric Oxide. Diabetics seem to have some loss of Nitric Oxide induced vasodilation. Pulsed ultrasound stimulates endothelial cells to induce Nitric Oxide and release intracellular Ca². The pulsed voltage opens inward Ca² voltage gated channels to increase Nitric Oxide Synthase expression. 

Adv Skin Wound Care. ;17 (6):284-94  15289715  Cit:7

Am J Surg. 2010 October; 200(4): 473–477.

doi:  10.1016/j.amjsurg.2009.12.021

PMCID: PMC2950802 NIHMSID: NIHMS199415

High Cost of Stage IV Pressure Ulcers

Harold Brem, MD, Jason Maggi, MD, David Nierman, MD, Linda Rolnitzky, MS, David Bell, BS, Robert Rennert, BA, Michael Golinko, MD, Alan Yan, MD, Courtney Lyder, ND, and Bruce Vladeck, PhD

Results

Nineteen patients with stage IV pressure ulcers (11 hospital-acquired and 8 community-acquired) were identified and their charts reviewed. The average hospital treatment cost associated with stage IV pressure ulcers and related complications was $129,248 for hospital-acquired ulcers during one admission, and $124,327 for community-acquired ulcers over an average of 4 admissions.

 The Lancet, Volume 332, Issue 8613, Pages 712 - 714, 24 September 1988

doi:10.1016/S0140-6736(88)90187-0

Plast Reconstr Surg. 2006 Jun;117(7 Suppl):35S-41S.

Chronic wound pathogenesis and current treatment strategies: a unifying hypothesis.

Mustoe TA, O'Shaughnessy K, Kloeters O.

Source

Division of Plastic and Reconstructive Surgery, Northwestern University, Feinberg School of Medicine, Chicago, Ill 60611, USA. tmustoe@nmh.org

Abstract

The authors propose a unifying hypothesis of chronic wound pathogenesis based on four main causative factors: local tissue hypoxia, bacterial colonization of the wound, repetitive ischemia-reperfusion injury, and an altered cellular and systemic stress response in the aged patient. Traditional strategies for the treatment of chronic wounds have shown limited success.

PMID:16799373 PubMed - indexed for MEDLINE]