NIHB Presentation January

2012
Carlyle Begay
American Indian Health Management
Policy
Phone: (602) 206-7992
Email: cbegay@aihmp.com

Wound Healing Model

Oklahoma City Area Indian Health

Service: One Experience

Access to care:
Wounds Have a Golden Hour
From the onset of the woundIHS patients
need wound care sooner than later
30 days to prevent further breakdown,
infection, progression to amputation
Standard of Care now requires definitive
care at or before 4 weeks with the
introduction of advanced therapy to
treat the wound

Complications of Diabetic Foot

Ulcers

DFUs that persist more than 4 weeks have 5-fold higher risk
of infection.1
Development of an infection in a foot ulcer increases the
risk for hospitalization 55.7 times and the risk for
amputation 155 times.1
Infected neuropathic ulcerations are the leading cause of
diabetes-related partial foot amputations at the Phoenix
Indian Medical Center.2
Foot ulceration is a significant risk factor for lowerDiabetes
Neuropathy
Foot Ulcer
Infection
Amputation
3
extremity amputation in Native American Indians.
1.
2.
3.

Lavery et al. Risk Factors for Foot Infections in Individuals With Diabetes. Diabetes Care. 2006;29:1288-93.
Dannels E. Neuropathic foot ulcer prevention in diabetic American Indians with hallux limitus. J Am Podiatr
Med Assoc. 1989;79:447-50.
Mayfield et al. A foot risk classification system to predict diabetic amputation in Pima Indians. Diabetes Care.
1996;19:704-9.

Amputations are a serious predictor of

death

Consequences of Unhealed
Neuropathic Ulcers
Nearly half of all
unhealed
neuropathic
ulcers result in

at
op
r
u
Ne

r
ce
l
cU
hi

Armstrong DG. Int Wound J. 2007;4(4):286-287.

death within 5
years

Why Organized Wound

Care?
For three reasons:
Access to care for patients
Advanced treatments previously only
available private sector providers
Ability to collaborate no matter the
skill level of the provider for a positive
patient outcome

Pre-wound model findings

From 2004 to 2005 identified:
76% of the patients had untreated or
undertreated wound infections for wound healing
The number one choice in dressings was
ointment and gauze
The average treatment time for patients was 26
weeks ! before definitive care was provided
There was a great variation among IHS
clinicians on how to provide appropriate wound
management principles

Barriers to Wound Healing Model

Lack of buy in by
clinicians and other
support services
Personal preference
practice
Skipping steps in the
pathways/care models
Failing to recognize and
treat sub-clinical infections
Inconsistent antibiotic
therapy

Inconsistent off-loading
Lack of wound specific
supplies/advanced
therapy
Wait and see medicine
Premature discharges and
inappropriate transfers
Funding not readily
available for clinic start
up

The Solution
Shift from a cost to treat model to a cost to heal
model
Cost avoidance by early intervention (more cost
efficient to heal simple wounds) and reduction in
waste through standardization
Continue to reduce costs
Standardize dressings and treatments to optimize
results
Standardize wound care processes at multiple sites
for consistent patient care and to increase patient
access

Non-Reimbursement Driven and Cost

Efficient

Best Practice models for advanced therapies

designed to be revenue neutral if not
revenue positive; and driven by the latest
best practice guidelines for wound care

Key Clinical Components

Tested Clinical Pathways that produce a consistent >95%
heal rate
Best Practice advanced therapy models
Understanding barriers to wound care
Documentation enhancement specifically for wound care and
compliance
Enhanced clinical training time

Advanced
Treatment Modalities
Ultra-sound debridement
Negative pressure wound therapy
Growth factor therapy
Pulsed Electromagnetic wound stimulation
Living Skin Equivalent Grafts for in clinic

use
Oxygen Therapy

Initial Results

March 1, 2006 thru June 30, 2007

Average patient load per day: 11 - 14

3171 total patient visits

446 new patients
333 healed patients

Healing rates reached of 96.86% in 8.43 weeks

(industry average of 81-93% in 7 16 weeks)
Reduced amputations in program to <2% with
reduced overall Area amputations of 36%; less
than 3% reoccurance rate
CHS cost savings directly attributed to wound
program of over $6 million annually

Indirect Results of the Wound

Program
(represents amputations not associated with the Wound Management Program)

CHS Cost Savings

using direct care wound program vs. traditional home self
carefor example when comparing similar wounds/patients

With Organized Direct

Care Wound Program
42 y/o male with
scrotal abscess
I&D including brief
IHS hospital post-op
stay w/referral to
wound care
Remained outpatient
w/return to work in 5
weeks
Cost of care: @
$1500

Without Organized Wound

Care
44 y/o male with scrotal abscess
referred for care at
home/private sector
management
I&D including brief hospital
post-op stay w/o referral to
wound care
Became septic
w/exacerbation of other comorbid conditions hospital
readmission and transfer to
private sector ICU
Cost of care: >$1 million

Perceived Concerns
Staffing
Clinician participation
Equipment for diagnostics
Cost of supplies and medications
The solutions to these questions have already
been found!

Where do we go from here?

1. Endorsement of the model
2. Further expansion of the model
3. Maintain the model as a proven best practice
model
4. Streamline ordering making wound care
supplies and equipment store stock items
5. Funding of the model

Economic impact of nonhealing wounds

Don Ayers

A Growing Epidemic
The worldwide diabetic population is expected
to grow from 171 million to 366 million by
2025
Foot complications are one of the most
common complications in diabetic patients
The lifetime risk of a diabetic foot ulcer (DFU)
is 15% to 25%
Approximately 15% of DFUs result in
amputation

Diabetes Prevalence in Native American Indians

Nationwide, diabetes affects more American Indian/Alaska Natives than any

other ethnic group.1

1.

Barnes et al. Advanced Data (CDC) 2005;356 1-24.

Neuropathy Leads to Diabetic Foot

Ulcers

Diabetic neuropathy is a primary cause of diabetic foot ulcers.1

Development of a diabetic foot ulcer increases the risk of a

foot infection over 2,000-fold.2

1.
2.

Boulton et al. The global burden of diabetic foot disease. Lancet. 2005;366:1719-24.
Lavery et al. Risk Factors for Foot Infections in Individuals With Diabetes. Diabetes Care. 2006;29:1288-93.

Diabetes and Serious Complications: Neuropathy

"Diabetes is the leading cause of peripheral neuropathy globally." 1

American Indians with diabetes have a greater risk (greater than 2

fold) for developing neuropathy when compared to the adult
insured US diabetic population.2

1.
2.

Habib AA, Brannagan TH 3rd. Therapeutic strategies for diabetic neuropathy. Curr Neurol Neurosci Rep. 2010;10:92-100.
OConnell et al. Racial Disparities in Health Status: A comparison of the morbidity among American Indian and U.S. adults
with diabetes. Diabetes Care. 2010;33:1463-70.

Complications of Diabetic Foot Ulcers

DFUs that persist more than 4 weeks have 5-fold higher risk of
infection.1

Development of an infection in a foot ulcer increases the risk for

hospitalization 55.7 times and the risk for amputation 155 times.1

Infected neuropathic ulcerations are the leading cause of diabetes-related

partial foot amputations at the Phoenix Indian Medical Center. 2

Foot ulceration is a significant risk factor for lower-extremity amputation in

Native American Indians. 3

Diabetes

1.
2.
3.

Neuropathy

Foot Ulcer

Infection

Amputation

Lavery et al. Risk Factors for Foot Infections in Individuals With Diabetes. Diabetes Care.
2006;29:1288-93.
Dannels E. Neuropathic foot ulcer prevention in diabetic American Indians with hallux
limitus. J Am Podiatr Med Assoc. 1989;79:447-50.
Mayfield et al. A foot risk classification system to predict diabetic amputation in Pima
Indians. Diabetes Care. 1996;19:704-9.

Diabetes Burden in American Indians;

Lower Extremity Amputation
The annual rate for a 1st lower extremity amputation in diabetic
Oklahoma Indians is 1.8%.1
Risk of amputation is 18-times higher in diabetic American Indians
compared to the adult insured US diabetic population.2

1.
2.

Lee JS, Lu M, Lee VS, Russell D, Bahr C, Lee ET: Lower extremity amputation. Incidence, risk factors, and mortality
in the Oklahoma Indian Diabetes Study. Diabetes. 1993;42:876-82.
OConnell et al. Racial Disparities in Health Status: A comparison of the morbidity among American Indian and U.S.
adults with diabetes. Diabetes Care. 2010;33:1463-70.

Healing Neuropathic
Ulcers: Results of a Metaanalysis
Weighted Mean Healing Rates

These data provide clinicians with a realistic assessment of

their chances of healing neuropathic ulcers
Even with good, standard wound care, healing neuropathic
ulcers in patients with diabetes continues to be a challenge
Margolis et al. Diabetes Care. 1999;22:692.

Consensus Conference
on Diabetic Foot Wound
Care

American Diabetes Association Consensus

Development Conference on Diabetic Foot
Wound Care convened in April 1999
Regarding the treatment of diabetic foot
wounds, the panel agreed:
Any wound that remains unhealed after 4
weeks
is cause for concern, as it is associated
with
Note: This
consensus outcomes,
statement also was reviewed
and endorsed
by the American Podiatric
worse
including
amputations.
Association.
Consensus development conference on diabetic foot wound care: 7-8 April 1999, Boston, MA.
American Diabetes Association. Diabetes Care. 1999;22(8):1354-1360.

Continuing Research:
Healing of
Diabetic Foot Ulcers After 4
Weeks

>53% area reduction at week 4

<53% area reduction at week 4

Wounds achieving less than 53% closure at week 4 have

minimal chance of healing with conventional therapy
Sheehan et al. Diabetes Care. 2003;26(6):1879-1882.

Role of Tissue-Engineered Skin in the

Management of Neuropathic Diabetic
Foot Ulcers
In 2004, Boulton and colleagues developed a
Clinical Practice article for neuropathic
diabetic foot ulcers published in The New
England Journal of Medicine
In discussing tissue-engineered skin, they
noted:
The failure to reduce the size of an ulcer
after
4 weeks of treatment that includes
appropriate debridement and pressure
reduction should prompt consideration of
adjuvant therapy.
Boulton et al. NEJM. 2004;351:48-55.

Association Between PAR at

Week 4 & DFU Closure at Week
12

N=133

N=117

Data was dichotomized by PAR of <50% or 50% by week 4

to assess the association of PAR with DFU closure by 12 weeks

Better Results Using Best Practice Model:

Advanced Therapy
Reduction in days to
heal from previous
healing data using
advanced therapy*:

From:
59.01 days to heal
To:
34.09 days to heal
*Dermagraft

Cost of Diabetes and Wound Care

$174 billion: Total costs of diagnosed

diabetes in the United States in 20071

$20 billion: Chronic wounds cost

health care systems annually2

32