by Robert B. McLafferty, MD
Over six million Americans suffer from a chronic wound. A chronic wound is defined as a wound that has failed to heal within a normal time frame; that is, 4 weeks for your average person and 2 weeks for patients with diabetes mellitus or other medical conditions that affect wound healing. There are over one million new cases of patients with chronic wounds every year. More specifically, 3.5 percent of Americans over the age of 65 have a venous stasis ulcer, and over one million Americans suffer from pressure ulcers. Of the 18 million Americans who have diabetes mellitus, 15 percent will have a non-healing ulcer at some point in their lives. Additionally, tens of thousands of Americans also suffer from critical limb ischemia, which leads to foot ulcers and gangrene.
“Ironically, despite caring for these types of patients, vascular specialists are among the rarest types of physicians who evaluate and treat patients with chronic wounds specifically in a wound care center.”
While almost every type of physician sees chronic wounds in their respective specialty, there are many types of physicians that see these patients more commonly. These include general surgeons, plastic surgeons, dermatologists, infectious disease specialists, vascular medicine specialists and vascular surgeons. The latter two types of physicians can be grouped into what one would label as a “vascular specialist.” It is this group of physicians that perhaps see the most types of chronic wounds because typically these two types of specialists commonly evaluate and treat venous leg ulcers, ischemic arterial ulcers of the feet and neuropathic diabetic foot ulcers. Ironically, despite caring for these types of patients, vascular specialists are among the rarest types of physicians who evaluate and treat patients with chronic wounds specifically in a wound care center.
The reason for this gap in vascular specialists providing care in a specialty wound care clinic may be related to the stereotypes that exist. These include such beliefs that wound care doctors have a profound lack of knowledge in caring for chronic wounds; wound care centers, and more specifically wound care nurses, are thought to turn to every type of bazaar goo, gel, and bandage without first understanding their effectiveness; some treatment options—such as hyperbaric oxygen therapy—are regarded as hocus pocus; there is said to be no difference in the outcomes for a wound center versus care by a vascular specialist; and wound care physicians are considered to be more focused on financial gain than patients.
“…the large majority of vascular specialists lack the very specific requirements based on sound evidence that are needed to heal wounds.”
Ironically, the large majority of vascular specialists lack the very specific requirements based on sound evidence that are needed to heal wounds. They evaluate their patients in the same clinic space that they see patients without wounds; follow-up in their clinic more than likely ranges from every three to six weeks; the staff in their clinic is not specifically trained in wound care; attempts to coordinate multiple home and skilled nursing facility nurses varies with inconsistent protocols; and the clinics in which they work only have the very basic types of bandages.
“Patients are much more comfortable in a specialty wound care center where all staff is specifically trained to care for patients with chronic wounds.”
Given the aforementioned challenges, there are multiple reasons for vascular specialists to participate in a wound care center and move their patients out of their “regular” clinic and into a specialty wound care clinic. In doing this, the vascular specialist, along with his or her partners, can improve efficiency. When care is performed properly on a patient with a chronic wound, it becomes time-consuming. Additionally, having the adequate amount of supplies on hand can be difficult in a regular non-wound care clinic. Moving patients into a wound care center takes burden of that care off of the regular clinic staff. Patients are much more comfortable in a specialty wound care center where all staff is specifically trained to care for patients with chronic wounds. Once chronic wound patients are transferred to a wound clinic, this frees up more time in the regular clinic and allows those physicians to see more appropriate patients.
The reason wound care is so time-consuming is that a basic algorithm must be consistently followed in order to maximize healing potential. This includes assuring adequate arterial perfusion, eliminating edema, debriding necrotic tissue, treating bioburden and infection, treating venous pathology, optimizing host factors, and applying adjuvant techniques like skin substitutes or hyperbaric oxygen therapy. Interestingly, when protocols are put in place for these steps in a specialty wound care center and all care is centric for the wound patient, efficiency dramatically increases compared to these types of patients being evaluated in a “regular” vascular specialist clinic.
Two aspects of care that make a profound difference in getting a patient with a chronic wound to heal is the ability to see the patient weekly and performing aggressive serial debridement. In a scientific study published in 2012, Dr. Robert Warriner, et al, showed a dramatic increase in healing of diabetic and venous leg ulcers in patients being seen weekly versus bi-weekly.1 For diabetic foot ulcers, the average time to heal in the weekly group was 22.8 days; and in the bi-weekly group, 70.6 days (p<0.000001). Similarly, for venous leg ulcers, the average time to heal in the weekly group was 22.1 days; and in the bi-weekly group, 77.0 days (p<0.000001).
Regular serial debridement is equally important. Cardinal, et al, determined that wound area reduction was 54 percent higher when wounds were debrided weekly for the first four weeks versus not being debrided at all.2 Even wounds that did not heal experienced a greater area of reduction when compared to those not undergoing debridement. Standard instruments used during debridement in an exam room of a wound care center, include scalpels, forceps, scissors, currettes, ronjeurs, nail clippers, biopsy punches, silver nitrate sticks, ample gauze, cautery pencil and local anesthetic. This variety of instruments is not typically found in a vascular specialists’ exam room. Other materials and supplies often found in a wound care center are specialized compression bandage systems, skin substitutes, wound vac systems and hyperbaric oxygen therapy.
Hyperbaric oxygen therapy has been studied extensively, and evidence now points to its beneficial role for a number of clinical conditions. Medicare approved conditions include diabetic lower extremity wounds, delayed radiation injury, refractory osteomyelitis, compromised skin flaps and grafts, and critical limb ischemia.
The advantages of a vascular specialist creating, participating or coordinating a wound care center are multifold. These reasons include having a multidisciplinary team of physicians on the panel, adapting a streamlined process of evaluating and treating patients, using evidence-based clinical practice guidelines, applying the latest advances in wound care, tracking outcomes more closely, and creating an atmosphere that is patient-friendly and physician-convenient.
Lastly, many vascular specialists view the time spent in a wound care center as not valuable in terms of their ability to maximize billing and collections. This may be one of the most misconstrued reasons why vascular specialists are not seeking to be a part of a wound care center, or move their patients with chronic wounds from their regular clinic to their new “half-day” in the wound care clinic. Let’s look at an example of relative value units (a measure of physician work) for a vascular surgeon. A femoral artery to popliteal artery bypass using great saphenous vein reflects approximately 26 relative value units of vascular surgeon work. This measure of work determines how much the surgeon will be paid for this operation. In contrast, a vascular specialist can rack up a total of 44 relative value units if he or she sees approximately 15 patients in a four-hour period in a wound care center, charges appropriately for their evaluation and management, completes seven debridements, applies one skin substitute, treats four patients with hyperbaric oxygen therapy, performs three nail debridements, and pares three callouses. This compares to open repair of a ruptured abdominal aortic aneurysm at 42 relative value units. The above outline of a 15-patient wound care clinic is very typical if the physician is following the clinical practice guidelines and charging appropriately.
“New physician relationships will be cultivated, which enhance practice building.”
In summary, vascular specialists are the one kind of physician that sees the most types of chronic wounds. It makes clear sense that they should create, participate or coordinate wound care centers. Moreover, doing so will also provide a new portal for referral of patients primarily coming into the wound care center. These patients may require surgery or other procedures as well. New physician relationships will be cultivated, which enhance practice building. Most importantly, the vascular specialist will become more versed in wound care and therefore be able to provide their patient with optimal care. At the very least, patients with chronic wounds deserve this from their vascular specialist.
References
1. Warriner RA, et al. More frequent visits to wound clinics results in faster times to close diabetic foot and venous leg ulcers. Adv Skin Wound Care 2012;25:494-501.
2. Cardinal M, et al. Serial surgical debridement: a retrospective study on clinical outcomes in chronic lower extremity wounds. Wound Repair Regen 2009;17:306-11.
