Has The Algorithm Been Lost In New Technology Buzz?
Asking Tough Questions About Complacency And Use Of New Products
However, none of this changes the fact that the cost of treating diabetic foot ulcers has grown to $10.91 billion per year. To repeat, the amputation rates have gone up and not down.
I submit that a significant portion of the problem is our failure to adhere to an algorithm that has been so well established by numerous authors.
What good are these new technologies if we have not yet first established whether the limb is perfused well enough to heal and, if not, make an aggressive attempt to help achieve revascularization? What good are these new technologies if we have not adequately debrided nonviable tissue, including bone and tendon if necessary, to establish a clean wound bed? What good are these new technologies if we have not identified infection and dealt with it locally and systemically? What good are these new technologies if we do not adequately offload these wounds? What good are these new technologies if we do not recognize the fluid nature of these wounds and match the dressing to the wound as the wound changes?
Our new technologies have lengthened the time between wound inspections and may have created a sense of complacency. These technologies are increasing our time to make decisions about changes in wound care and often the changes may be too late to make a difference.
We must also consider that, although it is politically unpopular to say, due to the widespread availability of these products and technologies, wound care patients may have been placed in the wrong hands. Wound care centers are becoming the new “doc-in-the-box” at every level, including hospitals, clinics and private offices. The fears that were voiced several years ago, while I served as a member of the educational team for Ortho-McNeil Pharmaceuticals during the development phase of Regranex, seem to have come true. The fear is namely that physicians may be utilizing these technologies at inappropriate times in inappropriate wounds without a clear-cut wound algorithm.
These statistics indicate to me that we are far from practicing optimal cost-efficient care in the treatment of diabetic foot ulcers. If these trends do not begin to reverse themselves, then the economic overseers in our payer system may conclude that the cost of these new technologies has not produced a net decrease in the cost of care or amputation rates. Therefore, we may see reimbursements be reduced or eliminated altogether.
When these technological advances are used in the proper setting, they can help reduce costs and increase healing rates in less time. However, before we order our next dressing or device, we need to do “first things first” and use the algorithm to support our dressing decisions. These statistics indicate to me that wound care has truly emerged as a specialty and should be practiced as such.
Dr. Brill practices at the Limb Salvage Center at the BrillStone Building and is President of the BrillStone Corporation in Dallas. He is a Fellow of the American College of Foot and Ankle Surgeons and is also a consultant in wound care and reconstructive foot and ankle surgery at the Wound Care Clinic at Presbyterian Hospital in Dallas.
Dr. Steinberg (pictured) is an Assistant Professor in the Department of Orthopaedics/Podiatry Service at the University of Texas Health Science Center.
1. Shearer A, Scuffham T, Gordois A, Oglesby A. “Predicted Cost and Outcomes from Reduced Vibration Detection in People with Diabetes in the U.S.” Diabetes Care, Volume 26, No. 8, August 2003: 2305-2310.
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5. Steed DL, Donohoe D, Webster MW, et al. “Effect of Extensive Debridement and Treatment on the Healing of Diabetic Foot Ulcers.” Journal of the American College of Surgeons (JAMCOLLSURG) 1996: 183: 61-64.