By Brian McCurdy, Senior Editor
Changes in Medicaid reimbursement in Arizona have led to adverse consequences for patients with diabetes, according to an abstract recently presented at the American Diabetes Association annual meeting.
In 2010, Arizona began cancelling Medicaid reimbursement coverage of podiatry visits to reduce healthcare costs. The abstract authors examined inpatient discharge records from the Agency for Healthcare Research and Quality Healthcare Cost and Utilization Project from 2006 to 2010, observing 3,845 inpatients with diabetic foot infections (DFIs). After the Medicaid reimbursement change, researchers discovered there were 56.3 percent more hospital admissions, lengths of stay were 42.1 percent longer, state inpatient charges were 52.1 percent higher, and there were 86.1 percent more severe aggregate outcomes.
The abstract authors concluded that the changes to the Medicaid program spurred a “marked worsening of patient care.” They added that “Restricting access to preventive care among people with diabetes may manifest in serious unintended consequences, particularly among the poor and underserved.”
Bruce Werber, DPM, notes that the long-term consequences of the change in reimbursement include an increase in emergency room visits, increase in hospitalizations, higher cost of wound care centers and more amputations with all of their associated costs. “The ultimate outcome is increased cost to the system and increased morbidity for the patients,” says Dr. Werber, who is in private practice in Scottsdale, Ariz.
Dr. Werber supports educating podiatrists in the Medicaid system so they can practice to the full scope of their license and their training. Calling broad cuts to podiatry “a mistake,” he suggests that instead, there could have been cuts in the scope of services such as non-emergent services for patients at minimal risk. He explains this would have cut services for conditions like bunion repair, hammertoe repair, heel pain, chronic nail issues and sports type injuries, but allowed treatment for patients with infections, wounds, fractures, diabetic renal disease or peripheral arterial disease. Dr. Werber says such cuts ultimately would have saved the system money.
“It is great that the appeals court in California found that Medicaid should include dentistry and podiatry, but ultimately our profession needs to be recognized as physicians and the need for our services is essential to the well being of all Americans,” says Dr. Werber, a Fellow of the American College of Foot and Ankle Surgeons.
For a related story, see “Favorable Ruling ...” at right.
By Brian McCurdy, Senior Editor
A recent study in the Journal of Foot and Ankle Surgery reveals that nearly half of patients with diabetic peripheral neuropathy who had a partial first ray amputation progressed to a subsequent, more proximal amputation.
The authors performed an 11-year retrospective review of 59 patients with a mean follow-up of 33.8 months. Despite the fact that all patients experienced initial amputation incision healing, 69 percent subsequently developed a mean of 3.1 foot ulcerations and 25 patients required a more proximal repeat amputation at a mean of 25 months after the initial partial first ray amputation.
The authors suggest that in this high-risk patient population, an initial proximal level amputation, such as a balanced transmetatarsal amputation, might provide a better functional and reliable residual weightbearing foot than a first ray amputation in this high-risk patient population.
A transmetatarsal amputation provides a contoured, balanced, residual forefoot — without the presence of peak pressure formation — that can routinely fit in a standard shoe with limited need for in-shoe orthosis use, according to study co-author Thomas S. Roukis, DPM, PhD, FACFAS. Furthermore, he says that amputating the toes also removes the digits as a potential source of ulceration, noting this is a common development following an isolated partial first ray amputation.
“As long as the foot is balanced to resolve any soft tissue ankle equinus or varus/valgus residual forefoot frontal plane deformities, the disadvantages are limited,” says Dr. Roukis of transmetatarsal amputations. “Excellent soft tissue handling, proper contouring of the residual metatarsal parabola and electrocautery of the residual metatarsals will limit wound healing problems, mechanical, pressure-induced wounding and ectopic bone growth respectively.”
Dr. Roukis, the President-Elect of the American College of Foot and Ankle Surgeons, has not had a patient refuse an initial transmetatarsal, Chopart or Lisfranc amputation instead of a partial first ray amputation. Patients have told him the cost of care is markedly lower following the successful healing of their transmetatarsal amputation in comparison with partial first ray amputation due to fewer office visits, debridements and in-shoe orthosis modifications.
“Most patients have been through endless rounds of wound care and the ulceration and associated care have disrupted their life to such an extent that they simply desire a foot that they can use again without the development of an ulcer every time they are active,” says Dr. Roukis, who is affiliated with the Department of Orthopedics, Podiatry and Sports Medicine at Gundersen Lutheran Medical Center in La Crosse, Wis.
By Danielle Chicano, Editorial Associate
A recent study in Diabetes Care concludes that physicians need to reevaluate the usefulness of hyperbaric oxygen therapy (HBOT) in the treatment of diabetic foot ulcers (DFUs).
The retrospective analysis of data looked at 6,259 patients with diabetes, adequate lower limb arterial perfusion and foot ulcers extending through the dermis. Researchers found that HBOT neither improved the likelihood that a wound might heal nor decreased the likelihood of amputation in patients with DFUs. Researchers also reported that in the propensity score-adjusted models, patients who received HBOT were more likely to undergo amputation and less likely to have healing of their foot wound.
Caroline Fife, MD, argues against the validity of the findings in this study. She points out that the study did not report the selection criteria for HBOT, making it unclear whether researchers properly analyzed the therapy.
“The (study’s) retrospective analysis of practice in a single wound care organization does not indicate the effectiveness of HBOT when appropriate clinical practice guidelines are followed,” notes Dr. Fife, who is in private practice in The Woodlands, Texas.
Although prospective studies have shown that HBOT may increase the likelihood of minor amputations in exchange for decreasing major amputations, Dr. Fife says the Diabetes Care study was unclear about the degree of amputation.
“The study did not distinguish between minor and major amputations when evaluating outcomes,” notes Dr. Fife, the Chief Medical Officer at Intellicure, Inc.
Dr. Fife cites an abundance of randomized, controlled trial data that supports the efficacy of HBOT. She also notes that a recent meta-analysis concluded that HBOT improved healing and reduced the risk of major amputation in patients with DFUs. Dr. Fife adds that when it comes to advanced modalities for diabetic foot ulcers, HBOT “stands alone in having RCT evidence of efficacy in Wagner 3/4 grade ulcers and hypoxic wounds.”
Dr. Fife says HBOT is indicated for patients with DFUs who fail to respond to four weeks of “adequate wound care defined as vascular screening and/or revascularization, treatment of infection, control of diabetes and aggressive offloading.” While the Diabetes Care study has not changed her view of HBOT, Dr. Fife says the study does encourage clinicians to reassess proper patient selection for HBOT.
Small Bone Innovations, Inc. has announced that U.S. surgeons have implanted more than 5,000 STAR Total Ankle Replacement Systems since the device received Food and Drug Administration (FDA) approval in May 2009. Small Bone Innovations says the STAR system is the only total ankle replacement system with published, long-term clinical results with 91 percent survivorship at an average follow-up of 9.1 years.