Pay For Performance: How Will It Impact Diabetic Foot Care?

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Basic Interventions For Diabetic Foot Ulcer Care

• Prescribe offloading
• Screen for osteomyelitis in high risk wounds
• Monitor hemoglobin HbA1c (Level of evidence = C)
• Consider the use of growth factors for Wagner grade I or II ulcers. (Level of evidence = A)
• Consider hyperbaric oxygen therapy (HBOT) for Wagner grades III and IV(WOCN). (Level of Evidence =A)

The list above represents an abbreviation of the Wound Ostomy Continence Nurses (WOCN) guidelines for diabetic foot ulcer care. They are stratified according to the American Heart Association’s “Levels of Evidence” system.

Pay For Performance: How Will It Impact Diabetic Foot Care?
Pay For Performance: How Will It Impact Diabetic Foot Care?
Pay For Performance: How Will It Impact Diabetic Foot Care?
By Caroline E. Fife, MD

   Reportedly, only 17 percent of U.S. physicians are currently using EMRs. The Computer-based Patient Record Institute (CPRI) stated that if providers continue with their current paper systems, they will lack the tools needed to manage the quality and costs of healthcare, the scientific basis for healthcare will continue to be undermined, and healthcare reform will be impeded.3

Redefining The EMR System

Also keep in mind that the EMR offers an integration of patient information systems that captures and stores demographic, financial and medical information. They are not simply automated forms of paper charts. According to the Health Information Management Systems Society, a system meets the definition of an EMR system when it is:
   •    real time (point of care documentation);
   •    reliable (no downtime);
   •    secure (Internet systems are unlikely to meet this standard at the present time);
   •    is the legal medical record in that the system can operate in a paperless fashion;
   •    assists with evidence-based care;
   •    automates work flow; and
   •    collects the data needed for billing and clinical research.4

   While these requirements are complex and specific, in the field of wound management, they are also repetitive, relatively uniform from one patient to another, and involve a small number of procedure codes. Perhaps the most important aspect of a wound specific EMR is its effect on quality of care. For nearly two centuries, the quality of care received by a patient has been dependent on the experience of practitioner. Patients may eventually get the care they need (vascular screening, evaluation for osteomyelitis, etc.) but delays to obtaining these studies negatively affect both outcome and revenue.

How Will Pay For Performance Work For Diabetic Wound Care?

It is generally agreed that healthcare providers should perform certain clinical interventions for certain medical problems, in certain patients, and within a specific time or in a specific sequence. Implementing this requires the following things:
   •    an agreement regarding what care one ought to provide for a given clinical problem (clinical practice guidelines);
   •    the selection of specific performance criteria to decide upon the care provided; and
   •    a method of clinical surveillance to determine if the performance criteria were met.

   Most pay for performance strategies focus on various aspects of primary care. However, when reviewing a list of the 10 diagnoses for which CMS expends the largest amount of its budget, three of them are related to diabetes. It is estimated that $8.5 billion is spent for wound care products and services, according to the transcript of the March 29, 2005 Medical Carrier Advisory Meeting (MCAC). Two percent of all chronic ulcerations are caused by diabetes. The prevalence of diabetes in the population is increasing at 14 percent per year and diabetic wounds represent 80 percent of all chronic wound costs. It seems inevitable that pay for performance will reach diabetic wound care in the near future.

   At this time, several national organizations have established evidence-based guidelines, all of which are available online. Those created by the Wound Ostomy Continence Nurses (WOCN) are available at The National Quality Forum is an organization that endorses national consensus standards for measuring and publicly reporting on performance. The National Quality Forum endorsed standards will become the primary standards used to measure the quality of health care in the United States. At this time, there are only a few standards pertaining to diabetes.5-7 For an abbreviation of the WOCN guidelines for diabetic foot ulcer care, see “Basic Interventions For Diabetic Foot Ulcer Care” below.

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