A growing body of research, as well as first-hand accounts from clinicians on the ground, indicate that a significant percentage of patients with chronic wounds have delayed preventative and emergent wound care during the COVID-19 pandemic.1 While it will take time to assess the full impact of these trends, existing evidence suggests delayed wound care can result in more severe infections, increased hospital admissions, and lead to more amputations.2 Therefore, it will be critical for providers, hospitals, outpatient departments, payers and policymakers to understand and plan for a surge in patients with untreated and unmanaged non-healing wounds and related acute-on-chronic complications as a result of delayed care during the COVID-19 pandemic.
The “Pandemic Within the Pandemic”
Conservative estimates put the prevalence Medicare beneficiaries who are impacted by wounds at about 15% (8.2 million), with diabetic infections comprising the second largest category.3 Before the COVID-19 public health emergency, it was typical for patients to present weekly or bi-weekly for regular wound care services. In the early lockdown stage of the pandemic, most outpatient wound care clinics suspended operations, leaving many of these patients in limbo.1,4
Even as lockdowns eased and outpatient appointments resumed, many patients may have chosen to avoid appointments out of fear of exposure to COVID-19.4 Access to wound care has also varied across regions and localities given different regulations and restrictions at the state level.
Now, more than a year into the pandemic, access has not fully recovered--and rising COVID-19 infection rates powered by the new Delta variant suggest delayed preventive and emergent wound care may be continuing trends, particularly in communities where cases are spiking. A survey of wound care clinicians from this past March confirmed what many, including myself, suspected: the vast majority of practices reported a decrease in current patient visits as compared to prepandemic numbers.5 Further, 57% of respondents said that wound severity has either increased or significantly increased since the start of the pandemic.5
These findings are unsurprising and reflect broader trends in delayed care across the US healthcare system during COVID-19.For example, ambulatory care sites, such as outpatient centers, saw as much as a 60% decrease in patient visits in early 2020.6 Physician offices experienced a similar decline. According to a survey conducted by the American Medical Association (AMA), Medicare spending in the physician office setting saw a $9.4 billion reduction—a 19% decrease relative to projected spending levels—in the first half of 2020.7 These figures are consistent with findings published by the CDC, which estimates that 40% of adults avoided seeking medical care due to pandemic-related fears following the initial onset of the public health emergency.8
Estimating the Impact
It is going to take years to understand the full impact of delayed wound care during COVID-19, but early evidence paints a dire picture of what is to come.
One of the most harrowing consequences of untreated non-healing wounds--particularly diabetic foot ulcers (DFUs)--is that they can become so complex, with concomitant depth, infection, and ischemia that the only recourse is amputation. If you think this is a rare occurrence, guess again. There were an estimated 130,000 lower limb amputations among patients with diabetes in the United States in 2016, the last year statistics are available—and at least 85% of leg amputations are preceded by a DFU.9-11
Sadly, preliminary data show that the pandemic-related delays have only made this crisis worse. The marked increase in the rate of untreated diabetic wounds and wound-related amputations over the course of the last year has led some researchers to describe the situation as a “pandemic within a pandemic.”12 One study, conducted at a Level One Trauma Center in Ohio, found that patients with diabetes were 10.8 times more likely to undergo any level of amputation and 12.5 times more likely to undergo a major amputation during the COVID-19 pandemic.2 And the results from another study showed that during COVID-19 lockdowns, “patients with diabetes admitted to a tertiary care center for DFU had a more than threefold risk of amputation compared with those in 2019.”13
The toll an amputation takes on the body and mind cannot be understated. Patients who undergo a major lower extremity amputation must contend with permanent mobility limitations alongside higher risk of comorbid conditions, including depression and social isolation.14,15 Furthermore, post-amputation mortality rates remain high—at 27.3% within 1 year, and 63.2% within 5 years following amputation.15,16
Strategies to Save Limbs and Lives
With limbs and lives at stake, how can health care leaders prepare now for a potential influx of patients who present with more severe chronic wounds, and who may necessitate more aggressive treatment approaches in the following weeks and months? Solutions should focus on encouraging care delivery in low-risk settings, expanding access to evidence-based treatment approaches, and allocating additional resources to beleaguered patients and providers.17,18
Encouraging patients to seek high-quality wound care in either physician offices or hospital outpatient settings will help ensure patients can continue receiving the care they need while avoiding potentially crowded or overburdened treatment environments.12,17,18
It will also be incumbent upon clinicians to utilize evidence-based treatment approaches that lower the risk of infection and amputation. In recent years, a number of advanced therapies have shown through clinical studies to improve outcomes and support healing across a wide array of wound types, including DFUs19-21 and VLUs.22 These therapies have also been shown to reduce downstream costs associated with treatment and management of chronic diabetic wounds, a key advantage to patients and payers alike.23
Further, ensuring providers and patients can benefit from federal efforts to improve America’s health care infrastructure would go a long way towards confronting the wound care pandemic. There is a high concentration of lower extremity wounds in rural and underserved areas – places where health care is often more difficult to access. Providers in these areas have experienced strain in recent years which has only been accelerated by the pandemic. Further, evidence suggests that Black, Hispanic, and Native American patients with diabetic wounds are more likely to be at risk of lower extremity amputation and face additional barriers to accessing quality care.24,25 Additional resources must be directed towards communities in need, so that providers from general practitioners to wound care clinicians can continue to keep their doors open.
Finally, state-level efforts to expand access to Medicaid has potential to not only increase access to wound care, but also decrease DFU-related amputations.26,27 A study published last year showed a 17% decrease in the risks of (DFU-related) amputation among patients who resided in states that adopted Medicaid expansion in 2014.28 State and federal policymakers as well as patient advocacy groups should consider this fact when discussing how to address long-term public health goals.
About the Author
David G. Armstrong, DPM, MD, PhD, is professor of surgery at the University of Southern California. He holds a Master of Science in Tissue Repair and Wound Healing from the University of Wales College of Medicine and a PhD from the University of Manchester College of Medicine, where he was appointed Visiting Professor of Medicine. He is founder and co-Director of the Southwestern Academic Limb Salvage Alliance (SALSA). He is founding co-editor of the American Diabetes Association’s (ADA) Clinical Care of the Diabetic Foot, now entering its fourth edition. Dr Armstrong directs USC’s National Science Foundation-funded Center to Stream Healthcare in Place (C2SHiP), placing him at the nexus of the merger of consumer electronics, wearables and medical devices in an effort to maximize hospital-free and activity-rich days.
1. Shin L, Bowling FL, Armstrong DG, Boulton AJM. Saving the diabetic foot during the COVID-19 pandemic: a tale of two cities. Diabetes Care. 2020;43(8):1704-1709. doi: 10.2337/dc20-1176
2. Casciato DJ, Yancovitz S, Thompson J, et al. Diabetes-related major and minor amputation risk increased during the COVID-19 pandemic. J Am Podiatr Med Assoc. 2020;3:20-224. doi: 10.7547/20-224.
3. Nussbaum SR, Carter MJ, Fife CE, et al. An economic evaluation of the impact, cost, and medicare policy implications of chronic nonhealing wounds. Value in Health. 2018;21(1):27-32. doi: 10.1016/j.jval.2017.07.007.
4. Isaac A, Lepow BD. DFU outpatient management: Urgent or emergent? Podiatry Today. March 2021. Accessed September 16, 2021. https://www.podiatrytoday.com/dfu-outpatient-management-urgent-or-emergent
5. Cole W. A look at the impact of the covid-19 pandemic on wound care practices one year later. Today’s Wound Clinic. March 2021. Accessed September 16, 2021. https://www.todayswoundclinic.com/articles/look-impact-covid-19-pandemic-wound-care-practices-one-year-later
6. Mehrota A, Chernew ME, Linetsky D, Hatch H, Cutler DA. What impact has covid-19 had on outpatient visits? The Commonwealth Fund. May 19, 2020. Accessed September 15, 2021. https://www.commonwealthfund.org/publications/2020/apr/impact-covid-19-outpatient-visits
7. Robeznieks A. Physician survey details depth of pandemic's financial impact. American Medical Association. October 28, 2020. Accessed September 16, 2021. https://www.ama-assn.org/practice-management/sustainability/physician-survey-details-depth-pandemic-s-financial-impact
8. Czeisler MÉ, Marynak K, Clarke KE, et al. Delay or avoidance of medical care because of COVID-19–related Concerns — United States, June 2020. MMWR Morb Mortal Wkly Rep 2020;69:1250–1257. doi: http://dx.doi.org/10.15585/mmwr.mm6936a4external icon
9. Centers for Disease Control and Prevention. National Diabetes Statistics Report, 2020. https://www.cdc.gov/diabetes/pdfs/data/statistics/national-diabetes-statistics-report.pdf.
10. Singh N, Armstrong DG, Lipsky BA.JAMA. 2005;293(2):217-228. doi: 10.1001/jama.293.2.217.
11. Armstrong DG, Boulton AJM, Bus SA. Diabetic foot ulcers and their recurrence. N Engl J Med 2017;376(24):2367–2375. http://dx.doi.org/10.1056/NEJMra1615439
12. Rogers LC, Snyder RJ, Joseph WS. Diabetes-related amputations: a pandemic within a pandemic. J Am Podiatr Med Assoc. 2020;20- 248. DOI: 10.7547/20-248 .
13. Caruso, P et al. Diabetic foot problems during the covid-19 pandemic in a tertiary care center: The emergency among the emergencies. Diabetes Care 2020 Oct; 43(10): e123-e124.
14. Pedras S, Meira-Machado L, Couto de Carvalho A, Carvalho R, Pereira MG. Anxiety and/or depression: which symptoms contribute to adverse clinical outcomes after amputation? J Ment Health.2020;1–9. http://dx.doi.org/10.1080/09638237.2020.1836554
15. Armstrong DG, Swerdlow MA, Armstrong AA, Conte MS, Padula WV, Bus SA. Five-year mortality and direct costs of care for people with diabetic foot complications are comparable to cancer. J Foot Ankle Res 2020;13(1):16. https://doi.org/10.1186/s13047-020-00383-2
16. Meshkin DH, Zolper EG, Chang K, et al. Long-term mortality after nontraumatic major lower extremity amputation: a systematic review and meta-analysis. J Foot Ankle Surg. 2020;60(3):567-576.
17. Rogers LC, Armstrong DG, Capotorto J, et al. Wound center without walls: the new model of providing care during the COVID-19 pandemic. Wounds 2020;32(7):178-185.
18. Rogers LC, Lavery LA, Joseph WS, Armstrong DG. All feet on deck: the role of podiatry during the COVID-19 pandemic: preventing hospitalizations in an overburdened healthcare system, reducing amputation and death in people with diabetes. J Am Podiatr Med Assoc 2020; http://dx.doi.org/10.7547/20-051
19. Veves A, Falanga V, Armstrong DG, Sabolinski ML; Apligraf Diabetic foot ulcer study. Graftskin, a human skin equivalent, is effective in the management of noninfected neuropathic diabetic foot ulcers: a prospective randomized multicenter clinical trial. Diabetes Care. 2001;24(2):290-295.
20. Edmonds M; European and Australian Apilgraf Diabetic Foot Ulcer Study Group. Apligraf in the treatment of neuropathic diabetic foot ulcers. Int J Low Extrem Wounds 2009;8(1):11-18. doi: 10.1177/1534734609331597.
21. Serena TE, et al. J Comp Eff Res. 2019. doi:10.2217/cer-2019-0142
22. Falanga V, Sabolinski M. A Bilayered living skin construct (APLIGRAF®) accelerates complete closure of hard‐to‐heal venous ulcers. Wound Repair Regen. 1999;7(201-207)
23. Kirsner RS. Clinical evidence for and cost-effectiveness of advanced cellular tissue products for the treatment of diabetic foot ulcers. Am J Manag Care. 2018;24 (SP14):SP607-SP608.
24.. Tan TW, Shih CD, Concha-Moore KC, et al. Disparities in outcomes of patients admitted with diabetic foot infections [published correction appears in PLoS One. 2019;11;14(4):e0215532]. PLoS One. 2019;14(2):e0211481. Published 2019 Feb 4. doi:10.1371/journal.pone.0211481
25. Tan T, Armstrong DG, Concha-Moore KC, et al Association between race/ethnicity and the risk of amputation of lower extremities among Medicare beneficiaries with diabetic foot ulcers and diabetic foot infections. BMJ Open Diabetes Research and Care 2020;8:e001328. doi: 10.1136/bmjdrc-2020-001328
26. Skrepnek GH, Mills JL, Armstrong DG. Foot-in-wallet disease: tripped up by “cost-saving” reductions? Diabetes Care 2014;37(9):e196-7. http://dx.doi.org/10.2337/dc14-0079
27. Brewer TW, Lanese BG, Appel CL, Cairns JS, Armstrong DG. Past as prologue: the effects of the COVID-19 economic downturn on Medicaid coverage for podiatry services. J Am Podiatr Med Assoc 2020; 20-225.http://dx.doi.org/10.7547/20-225
28. Tan TW, Calhoun E, Knapp SM, Marrero DG, Zhou W, Armstrong DG. ADA Presidents' Select Abstract: The Affordable Care Act Medicaid expansion xorrelated with reduction in lower extremity amputation among minorities with diabetic foot ulcerations. Presentation. American Diabetes Association 80th Scientific Sessions June 14, 2020. Available from: https://plan.core-apps.com/tristar_ada20/abstract/1f366b32-bc4c-4bb2-90a5-325c86d544f5