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.
By Barbara J. Aung, DPM, CWS

Physicians can accomplish this via the PHM module, in which one can set parameters to recall patients for follow-up examinations. I can also send reminders to patients about recovering the covers on their orthotics, replacing the insoles in their extra depth shoes or getting a new pair of shoes if indicated by excessive wear and tear the following year. I also use this module to track patients for their yearly comprehensive diabetic foot exams, again sending reminders to patients who have not had a yearly foot exam. The PHM module also facilitates discussions about smoking cessation, weight loss measures and exercise activities, all preventive care issues.

This is what I call proactive medical decision making. I may be able to use the data on healing rates to negotiate with insurance plans in the future as well as to show quality care based on the information contained in the EHR. I can also point to patient surveys we send out to patients on the care they have received.

Prior to implementing this process, I found that I was only documenting the discussion of smoking cessation with my diabetic patients only 20 percent of the time. My history intake form contains questions on tobacco use but these questions somehow did not get translated into the dictated and/or written notes. However, with the EHR that is formatted to ask these questions that either my patient fills out or my assistant fills in, I now have documentation 100 percent of the time. The fact that I have counseled the patient on smoking cessation is clearly noted. This helps with the total care of a patient who has diabetes, whom I may be treating for a nonhealing wound.

In Conclusion
My job as a clinician is to use the evidence presented at national meetings to improve the outcomes of my patients. This may mean using a combination of modalities for the right patient at the right time. I also may be positioned to take advantage of the programs that CMS or private insurance plans may be implementing in the near future regarding an alternative method of reimbursement or supplemental reimbursement for providing what is now perceived as quality of care.

Podiatric physicians can apply this type of process to other patients as well. I am using the heel pain protocol introduced by the American College of Foot and Ankle Orthopedics and Medicine (ACFAOM) with the patient recall portion of my EHR and its health maintenance section to track the outcomes of the treatment plans I initiate for my patients. The system also enables me to follow an evidence-based approach to care with these patients.



1. Centers for Disease Control and Prevention. National Diabetes Fact Sheet, 2005.
2. American Diabetes Association. Diabetes Statistics, www.diabetes.org.
3. Reiber GE, Boyko EJ, Smith DG. Lower extremity foot ulcers and amputations in diabetes. In: Diabetes in America, 2nd edition. Harris MI, ed., U.S. Government Printing Office, Washington, DC, 1995.
4. Centers for Disease Control and Prevention. The public health burden of diabetes mellitus in the United States. In Diabetes Surveillance, 1997. Atlanta, GA, U.S. Department of Health and Human Services, Public Health Service, 1997
5. Jiwa F. Diabetes in the 1990s—an overview. Stat Bull Metrop Insur Co 78(1):2–8, 1997.
6. Plaque excision in the peripheral vasculature. Supplement to Endovascular Today. 2004;1-11.
7. Armstrong DG, Lavery LA, Wu S, Boulton AJM. Evaluation of removable and irremovable cast walkers in the healing of diabetic foot wounds. Diabetes Care 28:551-554, 2005.

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