Study: Adding Podiatric Services Results In Better Preventive Care And Lower Costs
When healthcare systems incorporate podiatric services, it can decrease healthcare costs, hospitalizations and patient falls, according to a new study by the New York State Podiatric Medical Association (NYSPMA).
Incorporating podiatric care may lower healthcare costs for patients with diabetes by $510 million and also lower costs for obese patients by $1.1 billion over one year, according to the Navigant Consulting study, commissioned by the NYSPMA. The study notes that adding podiatry services and treatment may decrease falls by 36 percent in the elderly and at-risk patients, decrease opioid dispensing by 28 percent among those with podiatric-related pain, and also reduce hospitalizations for obese patients and those with diabetes.
Healthcare policies and delivery are changing to focus on primary care, population health and prevention of chronic disease complications, notes Paul Liswood, DPM, the President-Elect of the NYSPMA. As he notes, healthcare is also moving toward collaborative care models and emphasizes that podiatrists are playing a key role in keeping patients ambulatory.
“The problem is podiatrists are not getting credit for the work we do,” says Dr. Liswood. “Podiatry needs to develop materials to educate primary care providers, hospital and health systems, legislators, regulators and the public on the benefits and necessary care podiatrists provide, which improves population health.”
To that end, Dr. Liswood says the profession should develop a message that patients who see podiatrists are healthier, especially patients with diabetes and obese patients. He also suggests developing alternative payment models that include podiatrists.
What are the most effective preventive strategies for diabetic complications that DPMs can emphasize to at-risk patients? The keys for Khurram Khan, DPM, are vigilance and education. As he notes, every patient needs to be educated on the etiology, epidemiology, natural history of diabetes, risk factors and treatment options (both conservative versus surgical) guided by evidence-based medicine.
Once patients understand the process, “they will buy into why they need to care,” says Dr. Khan, an Associate Professor in the Department of Podiatric Medicine at the Temple University School of Podiatric Medicine.
In regard to vigilance, Dr. Khan says patients need to always think about the consequences of any actions, whether it is diet, high sugars or inappropriate shoe gear or activity. He says patients should check their feet and understand what their “normal” is so when something abnormal happens, they can recognize it immediately and seek medical care.
“This is not going to be a one-and-done process but a slow growth over time,” says Dr. Khan. “Some patients will get it and some will not, but as doctors and experts in the field, we need to provide the education.”
For patients with diabetes, Dr. Liswood says the best strategy to prevent amputations and foot wounds is to see a podiatrist for a foot risk assessment so the DPM can evaluate risk factors and develop a proper prevention plan.
“The public will be interested in including a podiatrist in their care if they understand the benefits of podiatric care,” says Dr. Liswood.
Are Opioids Superior To Non-Opioids For Pain-Related Function?
By Brian McCurdy, Managing Editor
Opioid treatment is not superior to non-opioid treatment when it comes to addressing pain-related function, according to a recent study.
The study, published in the Journal of the American Medical Association, compared opioid medications with non-opioid medications over 12 months for their effects on pain-related function, pain intensity and adverse effects in patients with chronic back pain or hip or knee osteoarthritis pain. Researchers focused on 234 randomized patients drawn from the Veterans Affairs system. In the opioid group, the study notes the first step of treatment included immediate-release morphine, oxycodone or hydrocodone/acetaminophen. Those in the non-opioid group received acetaminophen (paracetamol) or nonsteroidal anti-inflammatory drugs (NSAIDs). Clinicians adjusted medications within the groups according to individual patient response.
Opioid and non-opioid groups did not significantly differ in pain-related function over 12 months, according to the study. In addition, authors say adverse medication-related symptoms were significantly more common in those taking opioids over 12 months. The authors note the study results do not support starting opioid therapy for those with hip or knee osteoarthritis pain.
Robert Smith, DPM, MSc, RPh, CPed, says although physicians often prefer non-opioids for most types of chronic pain, he notes two serious drawbacks. The first is that once non-opioids reach a ceiling, increasing the dosage will not provide any further pain relief while opioids tend not to have a ceiling effect. Second, he notes non-opioids can have an adverse effect on various organ systems. For chronic pain in the lower extremity, Dr. Smith will refer the patient to a pain management professional after discussing all treatment options with the patient.
“Opioids reduce pain by working on special pain receptors in the nervous system, primarily located in the brain and spinal cord,” notes Dr. Smith, who is in private practice in Ormond Beach, Fla. “On the other hand, non-opioids work more directly on injured body tissues. The opioids decrease the body’s awareness of the pain whereas the non-opioids affect some of the chemical changes that normally take place wherever body tissues are injured or damaged.”
Although most non-opioids are quite safe when patients use them for temporary acute pain, Dr. Smith says problems such as liver or kidney damage may arise when people take them over a long period of time for chronic pain, especially in the case of large quantities of non-opioids.
Can Cryopreserved Placental Membrane Facilitate DFU Healing?
By Brian McCurdy, Managing Editor
Cryopreserved placental membranes can facilitate healing of diabetic foot ulcers (DFU), according to an abstract submitted to the Symposium on Advanced Wound Care Spring (SAWC Spring)/Wound Healing Society meeting.
The abstract authors assessed 350 diabetic foot ulcers of at least 0.25 cm2 that were treated with viable cryopreserved placental membranes (Grafix, Osiris Therapeutics). Utilizing electronic health records, researchers found that wound closure occurred in 59.4 percent of wounds at a median of 42 days and four applications of placental membrane. The authors added that at 12 weeks, patients had a 71 percent probability of wound closure.
Abstract co-author Katherine Raspovic, DPM, cites multiple benefits of placental membranes, including their ability to act as a “protective layer” against further infection for the wound/ulcer. In addition, she says placental membranes can reduce inflammation and help with scar reduction.
Abstract co-author John S. Steinberg, DPM, FACFAS, cites strong clinical data supporting the use of placental membranes.
“Given the wide ability of cryopreserved placental membranes to stimulate tissue growth and wound healing, I would certainly consider them for use in other wound types as long as underlying etiology factors are addressed first,” notes Dr. Steinberg, a Professor in the Department of Plastic Surgery at MedStar Washington Hospital Center in Washington, DC, and President of the American College of Foot and Ankle Surgeons.
Physicians can use cryopreserved placental membranes for any DFU that is experiencing a delay in healing, according to Dr. Raspovic, an Assistant Professor in the Department of Orthopaedic Surgery at University of Texas Southwestern Medical Center. However, before using the membranes, she says one must address factors such as arterial flow, nutritional status, blood glucose control, proper offloading and any concerns for infection. Dr. Raspovic notes cryopreserved placental membranes are also indicated for venous leg ulcerations.
The SAWC Spring/Wound Healing Society meeting will be held April 25–29 in Charlotte, NC. For more info, go to www.sawcspring.com.