Can A High-Low Ratio Help Prevent Amputation?

By Brian McCurdy, Senior Editor

      As lower-extremity amputation rates continue to be a serious concern, DPMs continue to work to find effective prevention strategies. A recent study in the Journal of Foot and Ankle Surgery examines the efficacy of using a high to low amputation ratio to identify patients who may be at a greater risk for amputation.       The study proposed and evaluated a high to low (Hi-Lo) amputation ratio as another quality measure to provide insight into high-risk foot surveillance that goes beyond foot screening. Researchers performed a secondary analysis on Medicare administrative data, which included 37,808 minor, foot-level amputations and 44,599 major amputations that were performed between 1996 and 1997. The study also calculated longitudinal trends in the Hi-Lo ratio with data from the Centers for Disease Control and Prevention (CDC) from 1992 to 2002. Researchers discovered that the adjusted mean Hi-Lo ratio was 1.35, while the lowest ratio was 0.56 and the highest was 3.43.       Study authors note that United States facilities have previously relied only on foot screenings to prevent amputation and say this may explain why amputation rates have not declined significantly. To reduce the incidence of amputation, authors argue that practitioners should use “a straightforward measure that can be implemented at any center” and propose the Hi-Lo ratio, used by the Veterans Affairs system, as an effective measure.

What Are The Ratio’s Advantages?

      The Hi-Lo ratio has several advantages that could be helpful outside the VA system, according to study co-author Jeffrey Robbins, DPM. As far as primary prevention goes, he says a healthcare program that emphasizes prevention would detect patient conditions before they progress to a point where a proximal amputation would be needed. For secondary prevention, Dr. Robbins notes if an amputation does become necessary, surgeons should perform the most distal amputation to preserve joints and reduce the weight of a prosthetic. In regard to tertiary prevention, Dr. Robbins notes that not only would the most skilled surgeons be performing the procedure but they would do the best job of predicting healing and selecting the appropriate amputation level, which would reduce the need for a subsequent amputation.       “Systems of care that coordinate primary, secondary and tertiary prevention have the best chance to preventing amputation,” says Dr. Robbins, the Director of Podiatry Service at the VA Central Office in Cleveland. “Work needs to be done in the private sector to establish the kinds of relationships that can lead to a high level of coordination for these most vulnerable patients.”       The Hi-Lo ratio suggests a multidisciplinary construct that Dr. Robbins says might include: screening procedures during primary care with control of systemic factors; examination and surveillance by podiatrists; foot surgery timed to correct limb-threatening deformities and address the early signs of infection; referral to vascular surgery for ischemic conditions; smoking cessation; and rehabilitation and prosthetic fit to reduce additional trauma and improve functional outcomes.       Study co-author David G. Armstrong, DPM, PhD, compares the Hi-Lo ratio to a cholesterol test. He says the ratio may detect if something is slightly amiss. However, a closer look might identify the high reading as related to HDL or good cholesterol. Similarly, with the Hi-Lo ratio, Dr. Armstrong says the ratio may be high because it is a tertiary center that is receiving difficult podiatric cases late in their treatment course. He says the ratio may highlight room for improvement.       “(However), this is a valuable beginning to a meaningful conversation that can help us keep a few more legs on a few more bodies,” says Dr. Armstrong, a Professor of Surgery, Chair of Research and Associate Dean at the William M. Scholl College of Podiatric Medicine at Rosalind Franklin University of Medicine in Chicago.       Dr. Armstrong notes that Dr. Robbins and study co-author James Wrobel, DPM, have helped establish “perhaps the most organized amputation prevention program in the country that emanates from the VA. It is really a model for not only our country but the rest of the world.”

PODIATRY IN PRACTICE: Sports Medicine DPM Thrives In Large Group Practice

      By Brian McCurdy, Senior Editor       Within a multidisciplinary group practice of 350 physicians, one podiatrist has carved a niche for treating sports medicine injuries in a practice arrangement that he says nets him referrals at a rate well beyond that of an average private practice.       Amol Saxena, DPM, practices at the Palo Alto Medical Foundation’s sports medicine department, which consists of himself, three fellowship-trained sports medicine orthopedists, a pediatric sports medicine specialist and a physiatrist that the group will add shortly. The department is essentially a private practice within a multidisciplinary group consisting of 350 physicians, which includes six podiatrists. As Dr. Saxena explains, this arrangement enables doctors to be paid based on how much they produce but the net return for each year is minimally negotiable.       In this and most other multidisciplinary group practices, the physicians do not make money from the radiology or durable medical equipment that they order but in general, Dr. Saxena says this is offset by the foundation’s higher patient volume as compared to a private practice. The Palo Alto group’s gross billings are 50 to 400 percent higher than the typical private practice, according to Dr. Saxena, a Fellow of the American College of Foot and Ankle Surgeons.       Dr. Saxena says the size of the large group practice provides better leverage in contracting with insurance companies, facilitating reimbursement that can be up to 50 percent higher than what one might see in a typical private practice. He notes that more than half of his surgical referrals originate from outside the Palo Alto Medical Foundation, coming from word of mouth as well as from other DPMs and MDs. He does note disadvantages in that the larger the group practice, the less say and control its practitioners have. However, he says there have been no no penalties as yet for overspending.       One plus to the practice’s arrangement is that doctors can take as much vacation and CME time as they need, and Dr. Saxena typically has been out of the office for six to eight weeks a year for meetings, sabbaticals and vacations. Despite this, Dr. Saxena says the volume of his practice has increased by 5 to 10 percent every year due to increased efficiency, more surgical volume and “working harder.” He notes the foundation’s doctors fund their own benefits and retirement.       An upcoming challenge for the Palo Alto Medical Foundation will be merging with two other large groups without sports medicine departments. He says the longtime CEO David Druker, MD, recognizes that his sports medicine department provides a profitable center of excellence.       Dr. Saxena’s group has a new 13,000-square-foot building plus a separate physical therapy and MRI area just for sports medicine patients. He says this facilitates more access and speedy recovery, which the patients love.       “The patients are demanding and may ask a lot of questions, but are very rewarding,” says Dr. Saxena. “I would not have it any other way.”

Survey Reveals Impact Of Gout

      By Brian McCurdy, Senior Editor       A recent survey suggests an increased prevalence of gout and details some of the effects of the condition upon people with gout.       According to the survey of 321 patients, 65 percent described their gout pain as the worst possible pain or close to it, and said their gout flares lasted an average of eight days. Of those polled, 72 percent related having at least one flare in the past year, according to the survey conducted by Harris Interactive. In addition, the survey says the majority of patients said gout affected activities like walking, putting on shoes and their participation in sports or recreation.       Peter Blume, DPM, agrees with an assertion in the survey that the incidence of gout is increasing. In his practice, Dr. Blume says 5 percent of patients presenting with pain have gout.       “Gout has increased a bit in my practice due to the fact that we now have an aging population utilizing diuretics and antihypertensive medications in addition to, in many cases, a poor diet,” says Dr. Blume, an Assistant Clinical Professor of Surgery in the Department of Orthopaedics and Rehabilitation at the Yale University School of Medicine.       What are the most effective treatments for gout? For acute gout pain, Dr. Blume uses a cortisone injection with local anesthetics. He combines this with twice-a-day dosing of 50 mg of indomethacin (Indocin, Merck) and 0.6 mg of colchicine. For chronic gout, he says therapy can include but is not limited to 300 mg of allopurinol (Zyloprim, Prometheus Therapeutics and Diagnostics) once a day or 0.6 mg of colchicine once a day.

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