March 2019

Delayed Charcot Diagnosis Increases Costs, Hospital Days, Amputations

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By Jonathan M. Labovitz, DPM, FACFAS, CHCQM

Early recognition and treatment of Charcot neuroarthropathy has been long considered paramount to optimizing clinical outcomes and delivering high-quality care. Without this rapid response to control the devastating effects of Charcot, patients are left with significant deformities; increased risk of ulcers, infection, and amputations; a reduced quality of life that often fails to improve; and a higher 5-year mortality rate. Regrettably, delayed diagnosis occurs frequently due to similar clinical presentations as many of the other complications of diabetes mellitus. Our study looked at public discharge records from acute care hospitals in California and compared those with a timely diagnosis and those with a delayed diagnosis of Charcot neuroarthropathy. Our hypothesis was that a delayed diagnosis of Charcot neuroarthropathy increases cost of care and healthcare utilization.

We identified 4,363 patients with Charcot neuroarthropathy as one of the top five discharge diagnoses that were discharged from California hospitals from 2009-2012. A delayed diagnosis was observed in 13.2% of the patients. The costs of the acute care stay were 10.8% greater in these patients and length of stay (LOS) was 0.8 days longer with a delayed diagnosis, both of which were significantly different from patients with a diagnosis at the time of admission (P < .05). In addition, there was a moderate correlation for cost and LOS for both the diagnosis and the delayed diagnosis groups.

When evaluating potential diagnoses often mistaken for Charcot neuroarthropathy, only diabetic foot infection resulted in significantly greater costs despite a significantly higher prevalence of diabetic foot ulcers, infections, and lower-extremity amputations in the delayed diagnosis group. A significantly greater number of chronic conditions and number of procedures performed during the hospital stay also occurred when there was a delayed diagnosis. Additional procedures strongly correlated with increased acute care costs, with each supplementary procedure resulting in additional costs of $4,800 and an increase in LOS by 1.7 days. Potentially most concerning was the 2.8% increase in the total number of lower-extremity amputations that occurred when there was a delay in the diagnosis. This resulted in an incremental cost increase of $7,201 (30.4%) and LOS increased 2.6 days (31.6%) compared to a timely diagnosis.

Because Charcot neuroarthropathy often poses a diagnostic challenge due to the clinical presentation similarities with other diabetes-related complications, a delayed diagnosis often occurs. Despite likely underestimating the total costs to the healthcare system by relying only on acute care costs, we quantified the costs and resource utilization during the hospital stay to begin evaluating the consequence of a delayed diagnosis in a value-based care system. Over a 4-year period in California, a delayed diagnosis of Charcot neuroarthropathy resulted in an additional spending of $1.15 million and 462 additional bed days. As we move to a value-based system, it is critical we see the impact of delayed diagnosis in this challenging population has potentially significant negative impact on cost as well as quality of care.

Source: Labovitz JM, Shapiro JM, Satterfield VK, Smith NT. Excess cost and healthcare resources associated with delayed diagnosis of Charcot foot. J Foot Ankle Surg. 2018;57(5):952-956.

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