This year, a study published in the Journal of the American Medical Association (JAMA) made a splash when its authors declared that a full half of the American population had either diabetes or pre-diabetes (i.e. borderline blood sugar) between 2008 and 2012. The vast majority of these cases are type 2 diabetes, which is often due to lifestyle factors, as opposed to type 1, which is genetic. While those numbers may seem bleak, diagnosis rates remained relatively steady throughout that period, so the researchers surmise that prevention efforts, including private workplace wellness programs, are making some impact. However, the formerly uncommon “adult onset” condition is now being diagnosed in children as young as three years old.
Workers’ comp is just one part of the diabetes care crisis, which in and of itself is linked inextricably to the nation’s obesity epidemic. So how does it all play out? We spoke to Douglas Lurie, MD of Orthopaedic Associates of New Orleans and John Kocke, RN with AMC Resources, to get the local perspective on this increasingly prevalent claimant comorbidity.
In his practice, Dr. Lurie deals primarily with non-spine injuries, focusing on the hip, knee, foot, ankle and shoulders. Such injuries are typical among workers’ comp claimants, especially in industrial settings. When asked what type of surgery creates the most potential for complications in diabetic patients, Dr. Lurie explained that foot and ankle procedures present considerable risk. This is due to a condition called microvascular disease, which affects many diabetics, especially in the feet, and causes a loss of “protective sensation.”
“What happens sometimes is that the patient has the surgery, and because they can’t feel pain like they should, they’ll walk around or put pressure on the wound and cause more damage to the tissue,” Dr. Lurie explained.
However, pain is just one part of the picture.
“The main issue is wound healing problems,” Dr. Lurie said. “And the more poorly controlled the diabetes is, the more slowly the wound heals. If the wound doesn’t heal, there is much greater risk of infection…loss of a limb [due to wound complications after surgery] is rare, but the prevalence of infection is three times greater in diabetics and infection is really what you’re watching for after surgery because it can complicate things considerably.”
John Kocke, a nurse and the founder of AMC Resources, which provides nurse case management and utilization review services for workers’ comp carriers, agreed with Dr. Lurie’s assessment.
“Delayed wound healing is definitely the most common complication,” Kocke said. “I had a case once where the injured worker walked around all day with a nail in his foot, which had gone through the sole of his boot and all the way through the foot itself and was actually poking out a little on the top of the foot. He only realized it at the end of the day when he tried to take off his boot. Because of diabetic neuropathy, he had no real feeling in his feet. He was out of work over a year with a severe diabetic foot infection and much of that time was spent in either an acute care hospital or long term care facility on potent antibiotics. Fortunately he didn’t have an amputation, but I’ve had others who did require one.”
Such complications can cause the cost of the claim to balloon, in addition to delaying return to work and prolonging pain and disability for the injured worker. This folds into the toll that diabetes takes on the American economy generally – and of course, the overall health services sector in particular – which becomes more significant every year.
The American Diabetes Association estimated in a 2013 study that the total costs of diagnosed diabetes rose to $245 billion in 2012 from $174 billion in 2007, when the cost was last examined. This figure represents a 41 percent increase over a five year period and includes $176 billion in direct medical costs and $69 billion in reduced productivity due to the disease. The organization concluded at the time that the financial calculations simply “highlighted the substantial burden that diabetes imposes on society.” Going further though, excluded in nearly all cost studies of diabetes are intangible but important factors such as pain and suffering, the resources from care provided by unpaid caregivers, and costs associated with undiagnosed diabetes.
On a local level, Louisiana’s diabetes rate outstrips the ADA’s national data. According to America’s Health Rankings’ (the longest-running annual assessment of the nation’s health on a state-by-state basis) 2015 data, 11.3 percent of the adult Louisiana population has been diagnosed with diabetes for a No. 39 ranking among all states. Further, this figure excludes those found to be pre-diabetic and diabetic children under 18. By contrast, the Louisiana rate for 1996 was 6.2 percent. Across the U.S., the diagnosed adult diabetes rate sits at 10 percent for 2015, compared to 4.4 percent in 1996.
As the nation continues to struggle with this disease as an unruly public health menace, workers’ comp stakeholders from all sides see it on the front lines. “This is a subject near and dear to the hearts of most case managers,” Kocke said. “Diabetes may well be the number one medical complication we face when considering the more serious injuries. It can turn a minor injury into something much more severe.”
Editor’s Note: The JAMA study has been criticized on the grounds that the data uses imprecise or liberally construed criteria for determining “pre-diabetic” status. In particular, changes in the definition of diabetes and the threshold for pharmaceutical intervention over time have affected statistical analyses of the disease and prevalence rates considerably. Read an examination of this problem via Health News Review here.