title: Burden of Infected Diabetic Foot Ulcers on Hospital Admissions and Costs.
abstract: BACKGROUND
  Costs related to diabetic foot ulcer (DFU) care are greater than $1 billion annually and rising. We sought to describe the impact of diabetes mellitus (DM) on foot ulcer admissions in the United States, and to investigate potential explanations for rising hospital costs.
  
  
  METHODS
  The Nationwide Inpatient Sample (2005-2010) was queried using International Classification of Diseases, 9th Revision (ICD-9) codes for a primary diagnosis of foot ulceration. Multivariable analyses were used to compare outcomes and per-admission costs among patients with foot ulceration and DM versus non-DM.
  
  
  RESULTS
  In total, 962,496 foot ulcer patients were admitted over the study period. The overall rate of admissions was relatively stable over time, but the ratio of DM versus non-DM admissions increased significantly (2005: 10.2 vs. 2010: 12.7; P < 0.001). Neuropathy and infection accounted for 90% of DFU admissions, while peripheral vascular disease accounted for most non-DM admissions. Admissions related to infection rose significantly among DM patients (2005: 39,682 vs. 2010: 51,660; P < 0.001), but remained stable among non-DM patients. Overall, DM accounted for 83% and 96% of all major and minor amputations related to foot ulcers, respectively, and significantly increased cost of care (DM: $1.38 vs. non-DM: $0.13 billion/year; P < 0.001). Hospital costs per DFU admission were significantly higher for patients with infection compared with all other causes ($11,290 vs. $8,145; P < 0.001).
  
  
  CONCLUSIONS
  Diabetes increases the incidence of foot ulcer admissions by 11-fold, accounting for more than 80% of all amputations and increasing hospital costs more than 10-fold over the 5 years. The majority of these costs are related to the treatment of infected foot ulcers. Education initiatives and early prevention strategies through outpatient multidisciplinary care targeted at high-risk populations are essential to preventing further increases in what is already a substantial economic burden.
authors.affiliation: Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, The Johns Hopkins Hospital, Baltimore, MD.
authors.forename: Caitlin W
authors.initials: CW
authors.lastname: Hicks
authors.affiliation: Center for Surgical Trials and Outcomes Research, Department of Surgery, The Johns Hopkins Hospital, Baltimore, MD.
authors.forename: Shalini
authors.initials: S
authors.lastname: Selvarajah
authors.affiliation: Division of Endocrinology & Metabolism, Department of Medicine, The Johns Hopkins Hospital, Baltimore, MD; Diabetic Foot and Wound Service, The Johns Hopkins Hospital, Baltimore, MD.
authors.forename: Nestoras
authors.initials: N
authors.lastname: Mathioudakis
authors.affiliation: Diabetic Foot and Wound Service, The Johns Hopkins Hospital, Baltimore, MD; Department of Orthopedic Surgery, The Johns Hopkins Hospital, Baltimore, MD.
authors.forename: Ronald E
authors.initials: RE
authors.lastname: Sherman
authors.affiliation: Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, The Johns Hopkins Hospital, Baltimore, MD; Diabetic Foot and Wound Service, The Johns Hopkins Hospital, Baltimore, MD.
authors.forename: Kathryn F
authors.initials: KF
authors.lastname: Hines
authors.affiliation: Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, The Johns Hopkins Hospital, Baltimore, MD.
authors.forename: James H
authors.initials: JH
authors.lastname: Black
authors.affiliation: Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, The Johns Hopkins Hospital, Baltimore, MD; Center for Surgical Trials and Outcomes Research, Department of Surgery, The Johns Hopkins Hospital, Baltimore, MD; Diabetic Foot and Wound Service, The Johns Hopkins Hospital, Baltimore, MD. Electronic address: cabular1@jhmi.edu.
authors.forename: Christopher J
authors.initials: CJ
authors.lastname: Abularrage
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D000671:Amputation, Surgical / Q000191:economics; D016208:Databases, Factual; D017719:Diabetic Foot / Q000191:economics* / Q000453:epidemiology / Q000382:microbiology / Q000628:therapy; D005260:Female; D016523:Foot Ulcer / Q000191:economics* / Q000453:epidemiology / Q000382:microbiology / Q000628:therapy; D017721:Hospital Costs / Q000639:trends; D006801:Humans; D023821:Limb Salvage / Q000191:economics; D008297:Male; D008875:Middle Aged; D010343:Patient Admission / Q000191:economics* / Q000639:trends; D012189:Retrospective Studies; D012307:Risk Factors; D013997:Time Factors; D014481:United States / Q000453:epidemiology; D014946:Wound Infection / Q000191:economics* / Q000453:epidemiology / Q000382:microbiology / Q000628:therapy; D055815:Young Adult