Do Trauma Patients With Diabetes Face Higher Complication Rates?

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By Brian McCurdy, Senior Editor

Patients with diabetes face a higher risk of complications in a number of areas. A large study recently published in the Archives of Surgery notes that those with diabetes also face more complications from trauma surgery.

From 1984 to 2002, researchers examined 12,489 patients with diabetes, matching their ages, sex and injury severity with 12,489 non-diabetic patients from 27 Pennsylvania trauma centers. The study concluded that patients with diabetes spent more time in the intensive care unit and received ventilator support for a longer period of time. Twenty-three percent of patients with diabetes had complications in comparison to 14 percent of those without diabetes. The study did not note a difference in mortality rates or the length of hospital stay.

Eric Espensen, DPM, has likewise seen a higher rate of complications in trauma patients with diabetes. He says the complications have usually involved a higher rate of infection, even in the face of empirically prescribed antibiotics. Dr. Espensen, the Chief of Foot Surgery at Providence St. Joseph Medical Center in Burbank, Calif., also notes an increased rate of wound dehiscence and slower rates of healing in trauma patients with diabetes.

In his clinical experience, Dr. Espensen notes that the length of hospital stay for trauma patients with diabetes tends to be longer than the hospital stay of trauma patients without diabetes.

Striving Toward Fewer Complications
What measures can hospitals take to reduce the risk of complications for trauma patients with diabetes? Dr. Espensen notes that his facility has “become much more aggressive” in the selection of antibiotics for trauma patients with diabetes. He says this includes empiric coverage for both gram positive and gram negative bacteria. His hospital has implemented stricter guidelines for managing glucose, including various tiers of sliding scales. Dr. Espensen adds that his hospital is “much more likely” to perform lower extremity non-invasive vascular studies on trauma patients with diabetes and call for vascular consults at a higher rate with this patient population.

What factors are contributing to higher complication rates in trauma patients with diabetes? Generally, Dr. Espensen says the phenomenon is due to poor management of glucose as well as various stages of progression of diabetes and generally advanced stages of peripheral vascular disease in patients with the disease.

He notes that the aforementioned contributory factors are the same for those with diabetic foot ulcers or patients with diabetes who are undergoing elective surgery. Accordingly, whether a patient with diabetes has trauma or not, Dr. Espensen says physicians should have “the same heightened level of awareness of possible complications.

“My group has taken the approach to apply these ‘higher standards of care’ to all patients, regardless of the presence of diabetes so as to provide the highest level of care to all patients,” emphasizes Dr. Espensen. “This has decreased our complication rate for all patients, diabetic or not.”

Is Hyaluronic Acid Effective For Pain From Ankle Sprains?
By Brian McCurdy, Senior Editor

Can hyaluronic acid be helpful in treating ankle sprains? A recent study in the Clinical Journal of Sport Medicine found that this modality can reduce pain in athletes with sprains and help get them back to sports earlier.

The randomized study involved 158 competitive athletes, who had sustained acute grade 1 or 2 lateral ankle sprains and were treated within 48 hours after their injuries. The study notes that about 30 percent of ankle sprains were the first sprains suffered by participants.

The treatment group received periarticular injection with hyaluronic acid and the standard of care while the control group received a placebo injection and standard of care. Researchers provided treatment at the initial visit and four days after the injury, according to the study. Researchers assessed patients on days four, eight, 30 and 90 following injury.

The study authors noted a significant reduction in the visual analogue scale (VAS) when it came to pain on weightbearing and walking on day eight for the hyaluronic acid group. The study also noted a quicker return to activity for patients treated with hyaluronic acid. On average, the return to pain-free and disability-free return to sports was 11 days for the hyaluronic acid group in comparison to 17 days for the placebo group, according to the study.

Although George Vito, DPM, has not used hyaluronic acid for ankle sprains, he said the use would be logical if the patient suffered a capsular tear, residual pain or if the injury caused articulating damage. However, he notes that insurance companies do not recognize hyaluronic acid in the treatment of ankle sprains as it is currently an off-label use.

Facilitating An Athlete’s Return To Play After An Ankle Sprain
What is the key to facilitating a return to activity for those who have suffered ankle sprains? Lawrence DiDomenico, DPM, says it depends on the severity of the injury. It is important to reduce edema and utilize some form of splinting, and follow up with early physical therapy that addresses the range of motion, notes Dr. DiDomenico, the Director of the Reconstructive Rearfoot and Ankle Surgical Fellowship within the Ankle and Foot Care Centers and the Ohio College of Podiatric Medicine.

If there is a full rupture, primary repair would permit the quickest return to activity with the least pain, according to Dr. Vito, the Director of the Atlanta Leg Deformity Correction Center in Macon, Ga. He cautions that postoperative rehabilitation can be very painful and this period may last from four to six weeks.

Medicare Physician Fee Cuts Still Up In The Air
By Brian McCurdy, Senior Editor

Although the House of Representatives recently passed legislation to stem projected cuts in the Medicare Part B physician schedule for the next two years, final Senate approval had not occurred as this issue went to press.

Payments would decrease by 10 percent in 2008 and 5 percent in 2009 and total cuts will be about 40 percent by 2016, according to the American Medical Association (AMA). However, the House recently reauthorized the State Children’s Health Insurance Program, which would increase Medicare payments by 0.5 percent in 2008 and 2009. The AMA notes that although the Senate also reauthorized the SCHIP, its version does not address the Medicare cuts.

Although the Medicare Payment Advisory Commission in March recommended giving doctors a 1.7 percent fee increase next year, MedPage Today notes that the Centers for Medicare and Medicaid Services (CMS) must reduce fees due to the sustainable growth rate (SGR) formula.

The proposed cuts are not a new phenomenon. In a position statement, the American College of Foot and Ankle Surgeons notes that CMS had proposed a 5.1 percent decrease in physician payments in 2007 and had proposed a 4.4 percent fee reduction in 2006. Congress passed legislation to avert both those cuts.

“While I am no expert in the healthcare financing system, I do believe that proposed cuts will frequently be on the table unless some fundamental changes occur,” says John Guiliana, DPM.

What can be done to fix the system to obviate the need for further physician payment reductions? Dr. Guiliana thinks the profession is already seeing changes in the Medicare physician payment system manifested in the “pay for performance” system. As he notes, evidence-based clinical practice protocols will be the basis of a new model of clinician reimbursement in healthcare.

Although many other specialties have already been assigned some benchmarks, podiatry is now limited solely to a benchmark for presurgical prophylactic antibiosis, according to Dr. Guiliana, a Fellow and Trustee of the American Academy of Podiatric Practice Management.

He thinks other benchmarks will materialize in the future and these might help lower “the costs associated with untoward and sentinel events to the point where blanket reduction proposals are eliminated.”

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