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Decision and Cost-effectiveness Analyses

Mark H. Eckman, MD; Sheldon Greenfield, MD; William C. Mackey, MD; John B. Wong, MD; Sherrie Kaplan, PhD; Lisa Sullivan, PhD; Kim Dukes, MA; Stephen G. Pauker, MD

JAMA. 1995;273(9):712-720.

Abstract
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.

Design.
—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.

Setting.
—Primary care.

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

Interventions.
—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.

Main Outcome Measures.
—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.

(JAMA. 1995;273:712-720)

Author Affiliations
From the Division of Clinical Decision Making (Drs Eckman, Wong, and Pauker) and the Primary Care Outcomes Research Institute (Drs Greenfield, Sullivan, and Kaplan and Ms Dukes), Department of Medicine, and the Vascular Surgery Division, Department of Surgery (Dr Mackey), New England Medical Center and Tufts University School of Medicine, Boston, Mass.

Footnotes
Reprint requests to Division of Clinical Decision Making, Department of Medicine, New England Medical Center, Box 302, 750 Washington Ave, Boston, MA 02111 (Dr Eckman).

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