Foot infections in diabetic patients. Decision and cost-effectiveness analyses.
OBJECTIVE
To examine the cost-effectiveness of approaches to the diagnosis and treatment of patients with type II (non-insulin-dependent) diabetes mellitus (NIDDM) who have foot infections and suspected osteomyelitis.


METHODS
Decision and cost-effectiveness analyses were performed using a Markov model. We examined the prevalence of osteomyelitis, the major complications and efficacies of long-term antibiotic therapy and surgery, and the performance characteristics of four diagnostic tests (roentgenography, technetium Tc 99m bone scanning, indium in 111-labeled white blood cell scanning, and magnetic resonance imaging). Data were drawn from the English-language literature using MEDLINE searches and bibliographies from selected articles.


METHODS
Primary care.


METHODS
Patients with NIDDM who had foot infections and suspected osteomyelitis but no signs of systemic toxicity.


METHODS
Following hospitalization for surgical débridement and intravenous antibiotic therapy: (1) treatment for presumed soft-tissue infection, (2) culture-guided empiric treatment for presumed osteomyelitis, (3) 71 combinations of diagnostic tests preceding antibiotic therapy for osteomyelitis, (4) 71 combinations of tests preceding amputation, and (5) immediate amputation.


METHODS
Quality-adjusted life expectancy, average costs.


RESULTS
Culture-guided empiric treatment for osteomyelitis with 10 weeks of oral antibiotic therapy has similar effectiveness to testing followed by a long course of antibiotic therapy if any test result is positive. However, empiric treatment is the least expensive strategy.


CONCLUSIONS
Noninvasive testing adds significant expense to the treatment of patients with NIDDM in whom pedal osteomyelitis is suspected, and such testing may result in little improvement in health outcomes. In patients without systemic toxicity, a 10-week course of culture-guided oral antibiotic therapy following surgical débridement may be as effective as and less costly than other approaches.
Division of Clinical Decision Making, New England Medical Center and Tufts University School of Medicine, Boston, MA 02111.
M H
MH
Eckman
S
S
Greenfield
W C
WC
Mackey
J B
JB
Wong
S
S
Kaplan
L
L
Sullivan
K
K
Dukes
S G
SG
Pauker
D000671:Amputation, Surgical / Q000191:economics; D000900:Anti-Bacterial Agents / Q000191:economics / Q000627:therapeutic use; D017281:Cost of Illness; D003362:Cost-Benefit Analysis; D003646:Debridement / Q000191:economics; D003661:Decision Support Techniques; D003924:Diabetes Mellitus, Type 2 / Q000150:complications / Q000191:economics*; D017719:Diabetic Foot / Q000150:complications / Q000191:economics* / Q000517:prevention & control*; D017721:Hospital Costs; D006801:Humans; D008279:Magnetic Resonance Imaging / Q000191:economics; D010019:Osteomyelitis / Q000191:economics / Q000209:etiology* / Q000517:prevention & control*; D011788:Quality of Life; D011859:Radiography / Q000191:economics; D011877:Radionuclide Imaging / Q000191:economics
D000900:Anti-Bacterial Agents