Response to comment on Londahl et al: hyperbaric oxygen therapy facilitates healing of chronic foot ulcers in patients with diabetes. Diabetes Care 2010;33:998-1003.

There is increasing evidence for the use of hyperbaric oxygen therapy (HBOT) in selected patients with chronic diabetic foot ulcers (1). However, several issues still need to be answered, including health economics.

In an editorial commenting on our study, Lipsky and Berendt (2) reported costs between $50,000 and $200,000 for a full course of HBOT treatment in the U.S. Van der Staal et al. (3) report significantly lower cost/reimbursement in the Netherlands at €6,916 for 40 HBOT sessions. Our Hyperbaric Centre in the southern part of Sweden is reimbursed €9,462 for 40 HBOT sessions, whereas at another Swedish center, the same treatment schedule is reimbursed with €21,505. It must further be stated that these European figures only include HBOT. Accompanying expenses such as traveling and hotel costs are not included. In summary, the cost of a full course HBOT treatment for diabetic foot ulcer varies considerably from one center to another and might depend on set-up costs, ongoing costs, reimbursement systems, and number of patients treated per center.

Of more importance than the actual cost is the full health economical evaluation of a treatment. Some health economic analyses evaluating the cost-effectiveness of HBOT in diabetic foot ulcer treatment have been published, but they are limited by deficient primary clinical data and should be interpreted with caution (4–6). Still, these studies suggest a potential cost-effectiveness of HBOT, i.e., a crude analysis of the small but high-quality double-blind randomized clinical trial by Abidia et al. (5), only taking HBOT and dressing costs into account, suggests a saving of £2,960 per patient during the 1st year of follow-up (4).

However, the cost-effectiveness of HBOT could not be considered as established as long as robust health economic data—based on evaluation of large placebo-controlled randomized clinical trials evaluating the effect of HBOT as adjunctive treatment in a selected and specified population of patients with chronic diabetic foot ulcers—is lacking. The health economic analysis of HBOT in the setting of the Hyperbaric Oxygen Therapy in Diabetics with Chronic Foot Ulcers (HODFU) study is ongoing, hopefully making some more information available.