Wound Recurrence and Patient Noncompliance

Considerations for addressing wound recurrence and patient noncompliance.


Peter L. Salgo, MD: This brings us to wound recurrences, which is you have treated the wound, someone’s gone home. Maybe he’s still got a hole but he’s not septic, he’s not infected. Then this person comes back. What’s the rate of readmission for recurrent wounds, wound infections, and wound problems? Do you know the number?

Robert J. Snyder, DPM, MSc, CWSP, FFPM RCPS: There are not a lot of data.

Peter L. Salgo, MD: How did I know you were going to say that?

Robert J. Snyder, DPM, MSc, CWSP, FFPM RCPS: Well, there are not a lot of data in general relating to wound care, unfortunately. The rate of recidivism can be as high as 100% in some patients.

Peter L. Salgo, MD: What’s the impact, because of readmission, because of improper treatment, then wound reopening and reinfection? Do we know that?

Michael T. Kazamias, MS, DPM: We don’t.

Peter L. Salgo, MD: I knew you’d say that, too.

Michael T. Kazamias, MS, DPM: It’s larger than we expect, that is for sure.

Peter L. Salgo, MD: After this I expect it to be quite large. So maybe we will alter that statement.

Michael T. Kazamias, MS, DPM: Absolutely.

Peter L. Salgo, MD: This is a very scary panel. This is a huge problem, seriously. It’s a huge problem without a lot of data because we haven’t been looking at it perhaps long enough and perhaps not properly, it seems to me just listening to you guys.

Michael T. Kazamias, MS, DPM: Was it a readmit to a hospital because of the same diagnosis?

Peter L. Salgo, MD: Well, CMS has got its hand in that for sure.

Michael T. Kazamias, MS, DPM: So how reliable are the data?

Peter L. Salgo, MD: Maybe they’re not going to admit to it, is that what you’re implying?

Michael T. Kazamias, MS, DPM: How reliable are the data?

Peter L. Salgo, MD: That’s all he’s going to say about it. Let’s then turn the table. Supposing you’re a clinician. Here’s somebody with an ulcer, and you tell that patient as clearly as you can, do A, do B, do C, then they’re not, what was the word you used?

Robert J. Snyder, DPM, MSc, CWSP, FFPM RCPS: Concordant.

Peter L. Salgo, MD: They’re not concordant with what you’ve told them. What is the impact on their health? Do we have any numbers of either days lost of work, days sick, days spent readmitted to the hospital? Do we know any of this? I guess what I’m asking is does it make a difference if they do what you tell them to do?

Robert J. Snyder, DPM, MSc, CWSP, FFPM RCPS: My answer again will be it depends on the individual. Some people are meticulous, others are not. Sometimes it’s just a matter of wearing appropriate diabetic shoe gear and appropriate insert and making sure that you’re wearing them appropriately, that you’re seeing your primary care doctor on a regular basis, that you are seeing your podiatrist and your ophthalmologist or optometrist on a regular basis. All these things obviously play into the situation.

Peter L. Salgo, MD: Any suggestions in the art of medicine to help get patients to do more of what you’d like them to do?

Robert J. Snyder, DPM, MSc, CWSP, FFPM RCPS: Education to me has always been the key, but it’s also been a challenge because patients have to listen to what it is you’re saying. To my point before, you have to not only educate your patient, but you have to educate the caregiver if in fact there is one. Their support system must be educated as well because very often they’re the drivers to prevent rates of recidivism.

Peter L. Salgo, MD: I took what you said quite seriously, which is because there is a punitive aspect to patients being readmitted within 30, 60, 90 days with the same issue, they’re often not coded that way, so that they can get reimbursed for care and not be punished for it. Is there a way out of that? What is the impact, if you don’t have the data, you don’t know the impact on spending for readmission, do you?

Michael T. Kazamias, MS, DPM: No.

Peter L. Salgo, MD: So that’s the answer to the second question. What about the first question?

Michael T. Kazamias, MS, DPM: That is one of the biggest challenges right now. Do we have appropriate mechanisms in place that will incentivize accurate coding?

Robert J. Snyder, DPM, MSc, CWSP, FFPM RCPS: I think patients are released too soon. I think the care is not appropriately coordinated. That continuum of care very often is not in place and these patients fall through a crack or a hole, a big black hole, and they’re not seen for weeks at a time. They’re not getting care. They’re not able to get access to a home health nurse to come into their home. Their blood sugars aren’t being checked on a regular basis. They can’t afford to buy their insulin. There are a whole host of reasons why these patients will be readmitted.

Samuel D. Young, MD, MBA, CPE, CHCQM: On the pressure ulcer subset of these wounds, we have a double-edge sword. If the pressure ulcer isn’t recognized at the point of admission to an inpatient setting, the facility will actually not be reimbursed but will be penalized because it’s considered a hospital-acquired condition.

Peter L. Salgo, MD: No good deed goes unpunished.

Samuel D. Young, MD, MBA, CPE, CHCQM: Right. So what do you do? Do you code it or don’t you, right?

Peter L. Salgo, MD: I know what’s going on in many hospitals because I talk to folks. On admission, that patient is examined microscopically. This red spot, this ulcer was present on admission, so that we can now bill for it, not our institution. We have at least 1 crack at this. But in order to improve compliance with all kinds of wound care protocols, CMS is not going to pay if you come back with the same condition 60 days later, 90 days later. To some degree, although well intentioned, I’m getting a sense from you that that’s shooting the hospital in the foot, if you will. That’s a terrible analogy. Take it and run.

Michael T. Kazamias, MS, DPM: Particularly if you have podiatrists in the room.

Peter L. Salgo, MD: Yes, I understand. It’s self-defeating. How’s that?

Michael T. Kazamias, MS, DPM: I would agree.

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