Cost-Effectiveness Analysis (CEA) of Adjunctive Hyperbaric Oxygen Therapy to Standard Wound Care Alone in Diabetic Foot Ulcer (DFU)

Herdian Pradana; Afifah Machlaurin; Ayik Rosita Puspaningtyas; Fifteen Aprila Fajrin; Ainur Rokhmah

doi:10.35451/8z370a41

Authors

Herdian Pradana Universitas Jember
Afifah Machlaurin Universitas Jember
Ayik Rosita Puspaningtyas Universitas Jember
Fifteen Aprila Fajrin Universitas Jember
Ainur Rokhmah Jember Chest Hospital

DOI:

https://doi.org/10.35451/8z370a41

Keywords:

diabetic foot ulcer, hyperbaric oxygen therapy, ; cost-effectiveness analysis, ICER

Abstract

Background: Diabetic foot ulcer (DFU) is a chronic complication of diabetes mellitus that is associated with high treatment costs and an increased risk of amputation. Hyperbaric oxygen therapy (HBOT) has been used as an adjunctive therapy to improve wound healing, yet evidence regarding its cost-effectiveness in Indonesia remains limited. Aim: This study aimed to evaluate the cost-effectiveness of HBOT compared with standard care in patients with DFU. Methods: A retrospective observational analytic study was conducted involving 80 DFU patients treated at RS Paru Jember between January 2024 and September 2025, consisting of 37 patients receiving standard care with HBOT and 43 patients receiving standard care without HBOT. Result: Clinical outcomes assessed included wound status, pain status, duration of healing, and incidence of amputation. Cost analysis was performed from the hospital perspective using direct medical costs, and cost-effectiveness was evaluated using the Incremental Cost-Effectiveness Ratio (ICER). The results showed that the HBOT group had a significantly higher proportion of wound healing compared with the non-HBOT group (21.62% vs 4.63%) and a lower rate of wound deterioration (2.7% vs 20.93%) (p=0.001). Although the mean total treatment cost was lower in the HBOT group than in the non-HBOT group (IDR 11,737,388 vs IDR 14,177,692), the difference was not statistically significant (p=0.118). ICER analysis demonstrated negative values for all evaluated outcomes, including wound healing, pain improvement, healing within six months, and prevention of amputation, indicating cost savings. Conclusion: HBOT as an adjunctive therapy for DFU provides better clinical outcomes with lower overall treatment costs and may be considered a cost-effective and economically favorable intervention.

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References

[1] Tao L, Yuan X. Efficacy and safety of hyperbaric oxygen therapy in the management of diabetic foot ulcers: A systematic review and meta-analysis. Int Wound J 2024;21:1–10. https://doi.org/10.1111/iwj.14507.

[2] McDermott K, Fang M, Boulton AJM, Selvin E, Hicks CW. Etiology, Epidemiology, and Disparities in the Burden of Diabetic Foot Ulcers. Diabetes Care 2023;46:209–11. https://doi.org/10.2337/dci22-0043.

[3] Lalieu RC, Mulder W, Raap RDB, Stolk S, Smit C, Dubois EFL, et al. Hyperbaric oxygen treatment for University of Texas grade 3 diabetic foot ulcers: A retrospective cohort study. J Wound Care 2021;30:722–8. https://doi.org/10.12968/jowc.2021.30.9.722.

[4] Narres M, Kvitkina T, Claessen H, Droste S, Schuster B, Morbach S, et al. Incidence of lower extremity amputations in the diabetic compared with the non-diabetic population: A systematic review. PLoS One 2017;12. https://doi.org/10.1371/journal.pone.0182081.

[5] Schaper NC, Netten JJ van, Apelqvist J, Bus SA, Fitridge R, Game F, et al. IWGDF Guidelines on the prevention and management of diabetes-related foot disease. Int Work Gr Diabet Foot 2023:1–349.

[6] Hutagalung MBZ, Eljatin DS, Awalita, Sarie VP, Gaby, Sianturi DA, et al. Diabetic Foot Infection (Infeksi Kaki Diabetik). J CDK 2019;46:414–8.

[7] Senneville É, Albalawi Z, van Asten SA, Abbas ZG, Allison G, Aragón-Sánchez J, et al. IWGDF/IDSA Guidelines on the Diagnosis and Treatment of Diabetes-related Foot Infections (IWGDF/IDSA 2023). Clin Infect Dis 2023:1–23. https://doi.org/10.1093/cid/ciad527.

[8] Edmonds M, Manu C, Vas P. The current burden of diabetic foot disease. J Clin Orthop Trauma 2021;17:88–93. https://doi.org/10.1016/j.jcot.2021.01.017.

[9] Ouyang H, Yang J, Wan H, Huang J, Yin Y. Effects of different treatment measures on the ef fi cacy of diabetic foot ulcers : a network 2024:1–17. https://doi.org/10.3389/fendo.2024.1452192.

[10] Id TW, Id FT, Speck P, Kaambwa B. Economic evaluations considering costs and outcomes of diabetic foot ulcer infections : A systematic review 2020:1–16. https://doi.org/10.1371/journal.pone.0232395.

[11] Sauriasari R, Yunir E, Banun A. Heliyon In-hospital costs of diabetic foot infection at a national referral hospital in Jakarta , Indonesia. Heliyon 2025;11:e41263. https://doi.org/10.1016/j.heliyon.2024.e41263.

[12] Untari EK, Andayani TM, Yasin NM, Asdie RH, Program DG, Pharmacy F, et al. Direct Medical Costs of Diabetes and the Foot Ulcer Outpatients in A General Hospital , Yogyakarta 2025;15:80–8. https://doi.org/10.22146/jmpf.90615.

[13] Oley MH, Oley MC, Kepel BJ, Faruk M, Wagiu AMJ, Sukarno I, et al. Hyperbaric Oxygen Therapy for Diabetic Foot Ulcers Based on Wagner Grading: A Systematic Review and Meta-analysis. Plast Reconstr Surg - Glob Open 2024;12:E5692. https://doi.org/10.1097/GOX.0000000000005692.

[14] Zhang Z, Zhang W, Xu Y, Liu D. Efficacy of hyperbaric oxygen therapy for diabetic foot ulcers: An updated systematic review and meta-analysis. Asian J Surg 2022;45:68–78. https://doi.org/10.1016/j.asjsur.2021.07.047.

[15] Sharma R, Sharma SK, Mudgal SK, Jelly P, Thakur K. Efficacy of hyperbaric oxygen therapy for diabetic foot ulcer, a systematic review and meta-analysis of controlled clinical trials. Sci Rep 2021;11:1–12. https://doi.org/10.1038/s41598-021-81886-1.

[16] Abidia A, Laden G, Kuhan G, Johnson BF, Wilkinson AR, Renwick PM, et al. The role of hyperbaric oxygen therapy in ischaemic diabetic lower extremity ulcers: A double-blind randomized-controlled trial. Eur J Vasc Endovasc Surg 2003;25:513–8. https://doi.org/10.1053/ejvs.2002.1911.

[17] Santema TB, Stoekenbroek RM, Van Steekelenburg KC, van Hulst RA, Koelemay MJW, Ubbink DT. Economic outcomes in clinical studies assessing hyperbaric oxygen in the treatment of acute and chronic wounds. Diving Hyperb Med 2015;45:228–34.

[18] Chuck AW, Hailey D, Jacobs P, Perry DC. Cost-effectiveness and budget impact of adjunctive hyperbaric oxygen therapy for diabetic foot ulcers. Int J Technol Assess Health Care 2008;24:178–83. https://doi.org/10.1017/S0266462308080252.

[19] Meethale Thiruvoth F, Rajasulochana SR, S MK, E S, Sivanantham P, Kar SS. Hyperbaric oxygen therapy as an adjunct to the standard wound care for the treatment of diabetic foot ulcers in Indian patients: a cost utility analysis. Expert Rev Pharmacoeconomics Outcomes Res 2022;22:1087–94. https://doi.org/10.1080/14737167.2022.2085562.

[20] Tonin FS, Aznar-Lou I, Pontinha VM, Pontarolo R, Fernandez-Llimos F. Principles of pharmacoeconomic analysis: The case of pharmacist-led interventions. Pharm Pract (Granada) 2021;19:1–10. https://doi.org/10.18549/PharmPract.2021.1.2302.

[21] Wouterse B, van Baal P, Versteegh M, Brouwer W. The Value of Health in a Cost-Effectiveness Analysis: Theory Versus Practice. Pharmacoeconomics 2023;41:607–17. https://doi.org/10.1007/s40273-023-01265-8.

[22] AlOmeir O, Almuqbil M, Alotaibi NF, Alotaibi FRN, Alnazer WR, Alenazi LK, et al. Prevalence and impact of sociodemographic factors, comorbidities, and lifestyle on diabetes complications among patients with type 2 diabetes in Riyadh. Sci Rep 2025;15:1–14. https://doi.org/10.1038/s41598-025-02559-x.

[23] IDF. IDF Diabetes Atlas 2021.

[24] Wiasa IND. Equitable National Health Insurance Towards Social Welfare. 2022.

[25] Bahati R, Kitua D, Selestine L, Mwanga A, Urio M, Mchele G, et al. Factors influencing the severity of diabetic foot ulcers: a cross-sectional study. BMC Endocr Disord 2025;25. https://doi.org/10.1186/s12902-024-01785-0.

[26] Kumar R, Singh SK, Agrawal NK, Kumar U, Kumar S, C S, et al. The Prevalence of Anemia in Hospitalized Patients With Diabetic Foot Ulcer (DFU) and the Relationship Between the Severity of Anemia and the Severity of DFU. Cureus 2023;15. https://doi.org/10.7759/cureus.41922.

[27] Coye, Tyler. Suludere M et al. The infected diabetes-related foot: Comparison of erythrocytesedementation rate/albumin and C-reactive protein/albuminratios with erythrocyte sedimentation rate and C-reactiveprotein to differentiate bone and soft tissue infections 2023.

[28] Chen HR, Lu SJ, Wang Q, Li ML, Chen XC, Pan BY. Application of hyperbaric oxygen therapy in diabetic foot ulcers: A meta-analysis. Int Wound J 2024;21:1–11. https://doi.org/10.1111/iwj.14621.

[29] Hisamuddin N, Ab N, Mohd W, Wan Z, Bajuri MY, Ortho MS, et al. Use of hyperbaric oxygen therapy ( HBOT ) in chronic diabetic wound - A randomised trial 2019;74:418–24.

[30] Lin YC, Shih JY, Lin YW, Niu KC, Hong CS, Chen ZC, et al. Hyperbaric Oxygen Therapy Improved Neovascularisation Following Limb Ischaemia—The Role of ROS Mitigation. J Cell Mol Med 2024;28:1–11. https://doi.org/10.1111/jcmm.70310.

[31] Oley MH, Oley MC, Wewengkang LAJW, Kepel BJ, Langi FLFG, Setiadi T, et al. Bactericidal effect of hyperbaric oxygen therapy in burn injuries. Ann Med Surg 2022;74:103314. https://doi.org/10.1016/j.amsu.2022.103314.

[32] Moreira Da Cruz DL, Oliveira-Pinto J, Mansilha A. the Role of Hyperbaric Oxygen Therapy in the Treatment of Diabetic Foot Ulcers: a Systematic Review With Meta-Analysis of Randomized Controlled Trials on Limb Amputation and Ulcer Healing. Int Angiol 2022;41:63–73. https://doi.org/10.23736/S0392-9590.21.04722-2.

[33] Pasek J, Szajkowski S, Oleś P, Cieślar G. Local Hyperbaric Oxygen Therapy in the Treatment of Diabetic Foot Ulcers. Int J Environ Res Public Health 2022;19. https://doi.org/10.3390/ijerph191710548.