Specifics on the cost of wound care driven by comorbidities such as diabetes, peripheral vascular disease, and neuropathies.
Peter L. Salgo, MD: Let’s put some numbers on this then. Financial impact, if you will. Diabetic, foot ulcers, the impact of this problem to the nation. How big is it? How much does it cost?
Michael T. Kazamias, MS, DPM: It is the major complication associated with diabetes generally. Diabetes can be well managed. There are many diabetic patients who never get a wound. If you want to ascribe a cost to diabetes, the wound is the primary driver.
Peter L. Salgo, MD: It’s the driver.
Michael T. Kazamias, MS, DPM: Absolutely. That’s what turns manageable diabetes into a very high cost center.
Peter L. Salgo, MD: That’s an important statistic to know. What about peripheral vascular disease [PVD] as divorced from diabetes. People have PVD without diabetes. How does the cost of that compare, for example, to diabetes?
Michael T. Kazamias, MS, DPM: If it’s not appropriately diagnosed or appropriately managed, if there isn’t the ability to work with or see a vascular surgeon, it depends on the level of specialty care and what environment the patient is trying to navigate in, based on their particular circumstance, whether it’s a payer environment or not.
Robert J. Snyder, DPM, MSc, CWSP, FFPM RCPS: I’m going to make a comment that may shock you.
Peter L. Salgo, MD: I’m easily shocked apparently. I’ve been shocked a lot so far.
Robert J. Snyder, DPM, MSc, CWSP, FFPM RCPS: Fifty percent of all diabetic patients who have non-traumatic amputations never have a vascular evaluation of any kind.
Peter L. Salgo, MD: I’m shocked. That’s insane.
Robert J. Snyder, DPM, MSc, CWSP, FFPM RCPS: It shows you the range of how these patients can potentially be treated.
Peter L. Salgo, MD: If I understand what you’re telling me, and I’m not trying to be facetious here. We have a disease. One of the major complications of this disease is vascular disease with poor perfusion to the distal extremities, and it’s a known offender in this regard. I’m speechless. It’s doesn’t happen very often, but I’m speechless.
Robert J. Snyder, DPM, MSc, CWSP, FFPM RCPS: Something else to keep in mind, with the new endovascular techniques being so advanced and often so successful, it’s still shocking to me that so many people never have the ability to get to that specialist.
Peter L. Salgo, MD: Nobody looks at their peripheral pulses?
Robert J. Snyder, DPM, MSc, CWSP, FFPM RCPS: I’m not saying nobody, but I’m saying 50%.
Peter L. Salgo, MD: It’s rare, 50%.
Robert J. Snyder, DPM, MSc, CWSP, FFPM RCPS: Fifty percent have never had a vascular evaluation of any kind, including an ankle-brachial index, nothing.
Peter L. Salgo, MD: Look at peripheral pulses, look at the skin color, look at capillary refill. They don’t do that?
Robert J. Snyder, DPM, MSc, CWSP, FFPM RCPS: Fifty percent of those patients don’t ever have a vascular examination.
Peter L. Salgo, MD: It makes me sad.
Samuel D. Young, MD, MBA, CPE, CHCQM: This speaks to the segmentation issue in medicine. You go to this specialist for this treatment, and that specialist thinks within the specialty box and maybe doesn’t make the appropriate referral or think outside what other issues underlie this condition that I’m treating. We need to break this down, break the silos.
Michael T. Kazamias, MS, DPM: We mentioned earlier specialists. Expanding on the point brought across by Dr Snyder, that specialist from a managed care perspective or from a payer perspective can be an organization. We talked earlier about carving out wound care as a chronic entity. If you establish an organization comprised of a multidisciplinary group of specialists in a risk-bearing entity where it is carved out, then you start bringing the advantages that managed care has brought to other chronic conditions where it’s better quarterbacked or better managed.
Robert J. Snyder, DPM, MSc, CWSP, FFPM RCPS: I had one other comment, you had mentioned….
Peter L. Salgo, MD: He keeps shocking me. Please bring it on.
Robert J. Snyder, DPM, MSc, CWSP, FFPM RCPS: You had mentioned peripheral arterial disease. I’m doing some work with the Critical Limb Ischemia Association, and we’re looking at creating a checklist for the generalist to make sure that an appropriate referral is made. As you know, checklists have to be very specific and very short so that they’re easily used and comprehended.
Peter L. Salgo, MD: Or they’re driven by the EMR [electronic medical record] and they’re annoying. So go ahead.
Robert J. Snyder, DPM, MSc, CWSP, FFPM RCPS: In this case, we’re trying to keep it medically oriented. The point that I’m going to tell you is, the first question is, did you take the patients’ shoes and socks off? It gets that rudimentary.
Peter L. Salgo, MD: Really?
Robert J. Snyder, DPM, MSc, CWSP, FFPM RCPS: In many clinicians’ offices who are practicing general medicine, either they’re not even addressing the patient, or if they do, they tell them to strip to their shoes and socks. They don’t even evaluate their lower extremities.
Peter L. Salgo, MD: The pun is so obvious. They’re not just addressing the patient, they’re failing to undress the patient.
Robert J. Snyder, DPM, MSc, CWSP, FFPM RCPS: It shows you how simplistic we really have to get.
Peter L. Salgo, MD: It’s rudimentary, isn’t it? I know we’ve discussed this. Why doesn’t somebody lay out the hidden costs of wounds caused by these comorbidities, other than treating the injury itself. Where are the hidden costs centers to America?
Michael T. Kazamias, MS, DPM: Well, we talked earlier about the bureaucratic cost.
Robert J. Snyder, DPM, MSc, CWSP, FFPM RCPS: I really love that comment.
Michael T. Kazamias, MS, DPM: The cost of treating the wound. There’s the physiological time, which incidentally is very hard to pin down. If you were to look up what is the length of time that it takes to heal a stage 4 pressure ulcer, the literature is varied. There’s a consensus that it takes over 120 days. Now, is that 120 days a physiological reason for why the wound can’t heal? We accept it, wow, these take a long time. But what happens is, and I think we’ll get to this in subsequent questions, is the industry as a whole or medical care as a whole is firmly established in establishing a chronicity over a 30-day period of time for that wound. Then we start looking at other “high-cost modalities” to bring them in as magic bullets.
Peter L. Salgo, MD: In other words, they have to meet that threshold to get the money.
Michael T. Kazamias, MS, DPM: The cost versus time matter in determining what it takes to heal a wound. If a home care agency identifies a wound, a pressure ulcer that requires a low-air-loss mattress, it can take 2 weeks to be able to get that order or that indication to the gatekeeper’s desk, to the provider for actionable information. In our work, we found out that we could heal the vast majority of wounds in under a 90-day period, and it had nothing to do with using magic bullets. What it had to do with was proper coordination of care and cutting out the red tape. Now, what’s that cost?
Peter L. Salgo, MD: It’s not to anyone’s advantage.
Robert J. Snyder, DPM, MSc, CWSP, FFPM RCPS: Something else to keep in mind, there is some good evidence that shows that the earlier you institute any kind of advanced therapy, the better the patient will do.
Peter L. Salgo, MD: Doesn’t that fall under the duh category?
Michael T. Kazamias, MS, DPM: That’s where risk comes in.
Robert J. Snyder, DPM, MSc, CWSP, FFPM RCPS: That’s where the risk comes in.
Michael T. Kazamias, MS, DPM: A risk entity where managed care plans have the latitude to be able to do that, can establish mechanisms by which the most appropriate care in a well regulated environment can be instituted early on, so that a stage 4 doesn’t have to be going through the stage 2 and 3 to be able to have the appropriate care at a level 4.