We talk a lot about the importance of offloading in preventing diabetic foot ulcer recurrence. We talk about it in guidelines. We talk about it in lectures. We talk about it with our patients. But the conversation too often stops at the clinic door — and it almost never reaches the people who write the checks.
This new cost-effectiveness analysis from Bus, van Netten, Schouten, and Dijkgraaf at Amsterdam UMC takes on that exact gap. Using data from the DIAFOS randomized controlled trial — which enrolled 171 participants at high risk for plantar foot ulcer recurrence across 10 Dutch centers — they modeled the economics of using in-shoe plantar pressure measurement to guide and improve custom-made footwear versus standard (non-pressure-guided) custom footwear.
The findings are intuitive but important to see quantified. The intervention group had fewer ulcer recurrences (38.8% vs. 44.2%) over 18 months. While the pressure-guided approach did cost more upfront — about €492 per participant for equipment, training, and modifications — those costs were more than offset by reduced downstream ulcer treatment expenses. The net result: a mean cost savings of €436 per participant. The incremental cost-effectiveness ratio (ICER) was -€8,124, meaning that for every ulcer prevented, the healthcare system saved over eight thousand euros. The probability of cost-effectiveness was 81%.
But here is where it gets really compelling. In the subgroup of patients who were adherent to wearing their prescribed footwear — defined as wearing it for more than 80% of daily steps, objectively measured — ulcer recurrence dropped by a statistically significant 22 percentage points. Cost savings rose to €1,170 per participant, and the probability of cost-effectiveness climbed to 94%. That is 16 out of 17 patients for whom this represents efficient healthcare delivery.
This matters for several reasons. First, prevention in the diabetic foot has always suffered from a peculiar economic handicap: the costs come first, and the savings come later. That temporal asymmetry makes it hard to justify investment to payers and hospital administrators. Studies like this one help close the business case. Second, the analysis shows that adherence is not just a clinical variable — it is an economic one. The same device that helps us build better footwear also helps us build a better argument for reimbursement, but only if patients actually wear what we prescribe. Indoor-specific custom footwear, as the authors note, may be one way to close that gap, since adherence is lowest at home where barefoot weight-bearing is most common.
There are limitations to acknowledge. The analysis used a partial healthcare perspective rather than a full societal one, meaning it did not capture family costs, lost productivity, or quality-adjusted life years. Ulcer treatment costs were drawn from the Eurodiale reference data rather than prospectively collected. And the time horizon was 18 months — shorter than the full arc of a foot at risk, where recurrence can happen for years. All of these factors likely underestimate the true economic advantage of the intervention.
The IWGDF already recommends pressure-guided offloading in custom footwear for people with a history of plantar ulceration. This analysis gives us the economic scaffolding to support that recommendation. As someone who has spent a career arguing that we can and should measure what we manage in the diabetic foot, I find this work from the Amsterdam group both rigorous and welcome. Pressure data should not be a luxury — it should be a standard of care. And now we have the numbers to prove that the investment pays for itself.
Bus SA, van Netten JJ, Schouten DR, Dijkgraaf MGW. Cost-Effectiveness of Pressure-Guided-Offloading-Improved Custom-Made Footwear for People with Diabetes at High Risk of Plantar Foot Ulceration. Diabetology. 2026;7(4):70. doi: 10.3390/diabetology7040070
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