A Deeper Understanding of Wound Care - Episode 4
Peter L. Salgo, MD: I’m assuming treating these wounds properly is the best route to get from wound to no wound infections. How does a patient know if the patient is getting optimal care? For that matter, how do we measure, as a profession? How do we measure optimal care? Is there some metric out there? Notice the profound silence here.
Samuel D. Young, MD, MBA, CPE, CHCQM: That remains a problem in medicine in general. What is the appropriate measurement for value delivery in healthcare? We’re trying to get at that answer. Ultimately it has to come back to what we call patient-reported outcomes, which remain very scarce right now, validated patient-reported outcomes.
Then of course the cost associated with those outcomes. Unfortunately, right now a patient just can’t know for certain the quality of care they’re receiving in an easy fashion. The same way that you could go on the Internet and figure out what’s the best vehicle for you. There is tons of information out there, but there’s not enough information on providers and on the delivery of healthcare.
Peter L. Salgo, MD: All right, what about us? If a patient can’t tell, can we tell? Do we know, someone comes in and says, “I’ve got this wound and I had this, this, and this done,” can you sitting here say a priori, that’s proper treatment, that’s improper treatment, can you say that?
Robert J. Snyder, DPM, MSc, CWSP, FFPM RCPS: There are people like us sitting at this table who have a better opportunity to make a guestimate as to whether that patient is doing the right thing and getting the right care. I would say on average patients don’t know, and frankly the clinicians don’t know. They’re just not educated, because they’re marginalizing to a large extent what these wounds can do and what the impact can be.
Peter L. Salgo, MD: That’s interesting to me because I started thinking about this knowing I was going to be here today. It occurred to me that nobody really pays attention to this, at least almost nobody, the way they probably should. These are huge problems.
Michael T. Kazamias, MS, DPM: Exactly. The focus, as physicians and in the community as a whole, the focus is generally on the comorbidity. Why did this person get a wound? But more often than not the cost driver to a complication regarding the comorbidity is the actual wound.
Peter L. Salgo, MD: It’s the 800-pound gorilla in the room.
Michael T. Kazamias, MS, DPM: Correct.
Peter L. Salgo, MD: Right. We’ve got this thing.
Michael T. Kazamias, MS, DPM: Exactly. We’re treating the condition as a chronic condition. The problem is the chronic wound doesn’t have the same level of treatment as a chronic condition. There are protocols, there are centers of excellence, but no standardization tools to be able to execute those standards of excellence in those protocols across all venues of care.
Peter L. Salgo, MD: Let’s lay it out for those watching, listening to us today. A chronic wound improperly addressed, whatever that may be, because you pointed out how vague that is. The quality meter wiggles a lot. What are you looking at? If you’re not treating it right, what are the complications? What do patients get?
Robert J. Snyder, DPM, MSc, CWSP, FFPM RCPS: Depending on the comorbidity, diabetes certainly would be the most significant. Patients very often develop infections. Those infections seed to bone. Often these….
Peter L. Salgo, MD: So osteomyelitis.
Robert J. Snyder, DPM, MSc, CWSP, FFPM RCPS: Osteomyelitis. These patients have peripheral arterial disease, both large and small vessels. They often need some type of vascular intervention to improve that scenario.
Peter L. Salgo, MD: So, say surgery.
Robert J. Snyder, DPM, MSc, CWSP, FFPM RCPS: Surgery.
Peter L. Salgo, MD: Either with a catheter or otherwise.
Robert J. Snyder, DPM, MSc, CWSP, FFPM RCPS: That’s correct. Unfortunately patients will succumb to amputations. Now once those amputations occur, not only is their quality of life significantly altered, but their morbidity certainly, and mortality, increases exponentially and many of them are dead within 5 years.
Peter L. Salgo, MD: One thing you didn’t mention, I’m sure not intentionally, is sepsis.
Robert J. Snyder, DPM, MSc, CWSP, FFPM RCPS: Right.
Peter L. Salgo, MD: In other words, you get this suppurating infection, whether or not you’re going to have increased trouble with diabetes or amputation or osteomyelitis, get bacteremic and all heck can break loose. I’d say all hell breaks loose but this is television, so we can’t do that. Sepsis alone will drive you.
Michael T. Kazamias, MS, DPM: Well, sometimes even trying to treat the comorbidity or the problem actually leads to making it more difficult to treat the wound. As Dr Snyder mentioned, you have a diabetic patient with a diabetic ulceration, there’s a lot of difficulty there. They have poor circulation and they have problems with their heart, so they end up having other vascular issues. What is prescribed for dealing with that complication of diabetes, which is cardiac rehabilitation, adversely affects the patient with a chronic wound on the foot because they can’t move, they can’t do the exercises in order to be able to do that. It’s a very complicated problem, sort of a lot of chefs in the room and a lot of cooking that needs to be done to properly treat that wound.
Robert J. Snyder, DPM, MSc, CWSP, FFPM RCPS: I wanted to get back to the marginalization issue, because there have been some studies done that showed that neuropathic ulcers in patients with diabetes have a higher mortality rate in 5 years than cancers, particularly prostate and breast cancer, and Hodgkin disease. If you think in terms of the fact that a generalist clearly would not treat cancer in his office, that patient would be referred to an oncologist, the same does not hold true of a chronic wound. That patient presents to a family practice physician who will treat that patient not really understanding what the potential ramifications are.
Peter L. Salgo, MD: You know that prism is really interesting, because it is true for a lot of different chronic conditions. If you tell somebody, “You’ve got heart failure and your rejection fraction is, pick a number, 20%,” that person leaves the office going, “Eh, I’ve got heart disease, I can live with it,” doesn’t realize the morbidity in 5 years, the mortality in 5 years is higher than lots of cancer. If you said, “You’ve got cancer,” they leave the office with a different mindset altogether. These wounds fall into that latter category of really bad, really morbid, and lethal. How do we change the perspective for providers, so they understand what’s going on?
Robert J. Snyder, DPM, MSc, CWSP, FFPM RCPS: I think as wound care professionals we have an obligation to really educate the generalist. I think education is multipronged. First and foremost, the patient, the doctor who’s treating or the healthcare professional who is treating that patient, the caregiver, and also the generalist. Because the generalist really often is the gatekeeper. If you’re thinking in terms of dollars, that gatekeeper very often will hold on to that patient for a significant period. The wound will not heal, and then the patient winds up in the emergency department with necrotizing fasciitis and sepsis as you pointed out.
Peter L. Salgo, MD: This is a difficult problem.