Turning Evidence Into Practice: A Guide To Treating Chronic Wounds In The Diabetic Foot

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Foot complications have become one of the leading causes of hospitalization for patients with diabetes and the patients hospitalized with a diabetic foot ulcer (DFU) can expect a 59 percent longer length of stay than hospitalized diabetic patients without
Fourteen to 20 percent of patients with a DFU will require a lower extremity amputation (LEA). The author notes that once a person has one amputation, he or she will require another amputation within three to five years.
If the results indicate the presence of vascular disease, the author will refer the patient to a vascular surgeon or interventionalist colleague for further vascular assessment and possible endovascular intervention with the SilverHawk (FoxHollow) as show
Here one can see a wound after six weeks of Apligraf. The author touts Apligraf’s ability to close a chronic wound in the shortest period of time.
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Author(s): 
By Barbara J. Aung, DPM, CWS

In reading many of the recent articles in podiatry publications, we will need to expand our vocabularies to include various new phrases. These phrases will include pay for performance, evidence-based medicine or evidence based treatment plans, and evidence-based treatment guidelines. Electronic medical records (EMR) and electronic health records (EHR) will be linked to evidence-based guidelines at the point of care. These changes are also reverberating within the primary care settings and in other selected specialties.

What can this mean for any practitioner let alone the solo practitioner who may not have the financial and/or infrastructure resources that large multispecialty clinics often do?

Practitioners will need to answer other questions as well. Why should they implement an EMR/EHR? How does the podiatrist translate evidence that may or may not yet exist for therapies and procedures one performs in practice? What are the financial and human resource impacts to his or her practice? Should the practitioner initiate EMR/EHR in his or her practice now or wait for governmental agencies to provide their “free computer software”?

One of the first areas that CMS and some insurance plans have targeted for these quality improvement projects is in the arena of diabetes management and wound care as it relates to people with diabetes. Podiatry Today has recently published articles regarding these issues (see “Pay For Performance: How Will It Impact Diabetic Foot Care?,” page 20, June issue) and the American Podiatric Medical Association (APMA) has recently provided the membership information on the quality measures that podiatrists most likely can report to the Center for Medicare and Medicaid Services (CMS).

Given these developments, I started thinking about how I could position my practice to be more proactive as a leader in the realm of treating lower extremity wounds in people with diabetes. I started by gathering guidelines and protocols that have been published in the treatment of diabetic foot ulcers, including guidelines from the American College of Foot and Ankle Surgeons (ACFAS) and the International Diabetes Federation (IDF).

Understanding The Impact Of Diabetes And Lower Extremity Complications
We have all seen the facts and figures surrounding diabetes and the lower extremity complications associated with the disease. Of the estimated 22 million Americans with diabetes, 15 to 20 percent will develop a foot ulcer during their lifetime. Foot complications have become one of the leading causes of hospitalization for patients with diabetes and the patients hospitalized with a diabetic foot ulcer (DFU) can expect a 59 percent longer length of stay than hospitalized diabetic patients without a foot ulcer.1,2

Despite all the efforts to prevent amputation in the last 10 years, the incidence of lower extremity amputation in people with diabetes continues to rise. Fourteen to 20 percent of patients with a DFU will require a lower extremity amputation (LEA). What concerns me the most is the fact that once a person has one amputation, he or she will require another amputation within three to five years, Often, a higher level of amputation will be required. Revision to a higher level occurs 15 percent of the time. In these cases, researchers have noted operative mortality at 7 percent. Indeed, 50 percent of patients with diabetes who undergo a second amputation at a high level are likely to become bedridden or die in two years.3-5

Given the fact there is only a 50 percent chance that people with diabetes who undergo a second amputation will be alive in three years, preventing amputations is more imperative than ever. The direct costs for an ulcer and amputation by level are as follows:4

Foot ulcer $16,580
Transmetatarsal amputation $25,241
Transtibial amputation $31,436
Transfemoral amputation $32,214

These numbers do not take into account the cost of disability to the families whose loved one had to undergo the emotionally and financially devastating procedure of amputation.

Have We Become Complacent With Chronic Wounds?
There is an increasingly urgent need for highly efficacious, cost-effective treatments for diabetic foot ulcers given the diabetes epidemic that is occurring in the United States.

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