Partnerships Between Podiatrists and Vascular Surgeons in Building Effective Wound Care Centers

Abstract

This practice memo, a collaborative effort between the Young Physicians' Program of the American Podiatric Medical Association (APMA) and the Young Surgeons Committee of the Society for Vascular Surgery (SVS), is intended to aid podiatrists and vascular surgeons in the early years of their respective careers, especially those involved in the care of patients with chronic wounds. During these formative years, learning how to successfully establish an inter-professional partnership is crucial in order to provide the best possible care to this important patient population.

The majority of chronic wounds present on the lower extremity, with the prevalence in the adult population between 0.18 and 1.3% [1]. Chronic wounds represent a growing, worldwide, and silent epidemic that is resulting in a public health and economic threat in the United States [2]. With the physical and emotional burden on patients, loss of productivity for afflicted individuals and their families, and the increasing amount of money spent on wound care, this condition is a major burden to our society. Approximately 12% of individuals with a foot ulcer will require some level of amputation, which further burdens the patient with additional loss of productivity and increased comorbidity [2]. Chronic wounds encompass a vast array of etiologies including diabetes, trauma, venous disease, ischemia, pressure, infection, radiation, vasculitis, and many more. Caring for each wound type can be complex and time consuming, requiring multidisciplinary expertise with varying treatment requirements. By some estimates the prevalence of nonhealing chronic wounds in the United States is around 2%, affecting over 6 million individuals and growing [2-4]. Not surprisingly, the costs associated with treating chronic wounds also are growing rapidly. Although difficult to calculate the exact burden, it is thought that more than $25 billion is currently being spent in the United States to address chronic wounds [1,2].

Before the establishment of dedicated wound care centers, patients would receive wound treatment from the specialists they visited, typically without careful monitoring and oftentimes with minimal facilities and resources available for debridement and other advanced treatments [5]. As both podiatrists and vascular surgeons are often at the frontline of wound care in the current health-care environment, these specialists now have a unique opportunity to bring together a multidisciplinary team to advance the delivery of wound care and become physician leaders in dedicated wound care centers.

Clinical Effectiveness of Wound Care Centers

Although it is difficult to directly compare outcomes before and after the advent of wound care centers due to the varied and often poorly documented wound care prior to such organizations, examining surrogate markers of success, such as amputation and limb salvage rates, can help us understand the clinical effectiveness and impact of wound care centers. Some studies have demonstrated a reduction in major amputation rates from 36.4% to 6.7% among people with diabetes treated at by a multidisciplinary team [6]. Protocol-based multidisciplinary wound care has also been shown to have significantly improved outcomes with other patient populations and wound types including pressure and venous stasis ulcers [7-11].

There also is some suggestion that the streamlined approach provided by a modern wound care center may potentially play a role in decreasing length of stay (LOS) for patients undergoing lower-extremity arterial bypass surgery. A recent study found that noninfectious wound complications (eg, wound dehiscence, lymph leak, nonhealing surgical wounds, etc) were among the strongest factors associated with an increased LOS [12]. These authors [12]. suggest that patients remained in the hospital to treat these issues, and LOS could potentially be decreased by streamlining postoperative care as well as preventing complications.

In addition to benefitting patients, multidisciplinary wound care centers allow for and encourage collaboration across health-care disciplines and enhance educational opportunities. Thus, providers also benefit from multidisciplinary care by gaining increased clinical efficiency, more easily developing patient referrals, and realizing opportunities for clinical research [13].

Cost Effectiveness of Wound Care Centers

A comprehensive team approach to wound care has not only been demonstrated to improve outcomes, but also to be cost effective [14-16]. The care of chronic wounds, as previously discussed, is associated with significant direct and indirect costs. Direct costs include items such as supplies, caregiver time, consultations and labs, etc. Indirect costs include days lost from work, treatment complications, costs of waste, and other opportunity costs.

Fife and Carter [17]. looked at wound care outcomes and associated costs among patients treated at US outpatient wound care centers. The average cost to heal a wound was $3,927. The cost to heal increases as the number of comorbid conditions increases; however, diabetic foot ulcers are the most expensive type of chronic ulcer, with an average cost per wound of $5,391. Not surprisingly, for patients followed for long periods, the cost of care increased as treatment duration lengthened. Driver et al [18]. also demonstrated higher costs for diabetic patients, documenting the cost of managing a diabetic foot ulcer patient (including inpatient and outpatient treatment) to be $17,245.

Although it is difficult to calculate the costs of all downstream complications from chronic wounds, one outcome that is often evaluated, particularly for diabetic foot ulcers is amputation. Amputations have substantial direct and indirect costs, totaling more than $43,000 for minor (below the ankle) and more than $63,000 for major (above the ankle) amputations [19]. Several studies, however, have demonstrated that the establishment of multidisciplinary teams to manage diabetic foot ulcers is cost effective, particularly in the long term [20-23]. For example Ollendorf, et al [20]. developed a model to specifically evaluate the effects of different types of interventions on diabetic patients. After applying the model to a hypothetical cohort of 10,000 individuals with diabetes, they demonstrated that a multidisciplinary clinic could avoid 47% of amputations, which translates into $740,677 in potential savings over 1 year. With the addition of other risk reduction strategies such as patient and provider education and insurance coverage for therapeutic shoes, they demonstrated a 3-year potential savings of between $2,900 to $4,442 per person, corresponding to a total potential benefit range of $2 to $3 million over 3 years [20].

Provider Staffing and the Multidisciplinary and Interdisciplinary Wound Team

Multidisciplinary care for patients with ischemic wounds increases amputation-free survival as compared to standard wound care, [24]. and the multidisciplinary limb salvage team approach heals neuroischemic wounds and decreases readmissions that are frequent in this patient population [25]. Thus, a successful wound care center is a truly multidisciplinary endeavor.

Several aspects of the patient's clinical condition need to be successfully managed and coordinated in order to promote efficient wound healing [26]. Many patients with problematic wounds have diabetes mellitus and need optimum management of diabetes in addition to topical wound care and offloading to expedite wound healing. Wound debridements and assessment of the need for revascularization are essential. Repeated debridements may be necessary, and consistent follow-up provided by a multidisciplinary team is instrumental in ensuring patient adherence. The inconvenience and logistical complexity of seeing multiple specialty providers and having several imaging or procedure appointments at different locations and times may result in poor follow-up, compliance, and outcomes. Thus, space and time for a coordinated clinic where multiple appointments can be arranged in a single time block further help to remove these barriers and allow for consistent follow-up.

Staffing of a multidisciplinary wound care center involves a group of dedicated providers from several disciplines. Podiatrists have an array of topical treatment options and an understanding of foot biomechanics that allow specific off-loading approaches to promote wound healing. Complex wounds may require rotational or free flaps for tissue coverage and thus participation by plastic surgeons. Bony abnormalities such as malunions or Charcot's arthropathy may benefit from intervention by podiatric surgeons to reconstruct the foot to correct abnormal pressure points. Total contact casting may be required to off-load pressure points and allow wound healing. Infectious disease specialist care may be required for infected wounds with soft-tissue contamination or osteomyelitis, as well as for determining the appropriate antibiotic coverage and duration. Good blood glucose control in individuals with diabetes shortens diabetic foot ulcer healing time, [27]. and endocrinologist involvement in a wound care center with a diabetic patient population is essential to ensure control of blood glucose levels. Optimizing nutrition (including albumin and Vitamin D) to improve healing outcomes could ideally be done by a staff nutritionist. Vascular surgeon commitment and participation also is critical as patients may need timely revascularization for wound healing. Physicians specializing in wound care, including general surgeons, podiatrists, or vascular surgeons, should lead these multidisciplinary teams and ensure the presence and involvement of all participants. The precise composition of the multidisciplinary team may vary from region to region depending on patient needs—but at a minimum, vascular surgeons and podiatrists should constitute the essential backbone of the team, with the addition of other providers as needed [13].

Having a clinic that is well staffed for the management of complicated wounds is essential to improve efficiency. For example, layered dressings may be removed by assistants, to allow providers to examine the patient once the wound is exposed. Reapplication of topical agents or rewrapping is then done by the assistant, to allow for the provider to examine additional patients. Coordination by physician assistants or nurse practitioners also is instrumental to ensuring good transitions in care and coordination of inpatient and outpatient services. Finally, a summary letter with the recommendations for each patient should be drafted to the referring physicians to effectively communicate the overall plan for the wound.

Partnerships Between Vascular Surgeons and Podiatrists in Wound Care Centers

Because many wounds seen at a wound care center are of the lower extremity and related to diabetes mellitus, both podiatrists and vascular surgeons share a unique role in leading the care of these patients. A typical initial focus of lower-extremity wounds takes into account four areas of concern: arterial or venous pathologies, skin health, neurologic disorders, and structural abnormalities [28]. Following a comprehensive evaluation by both the podiatrist and vascular surgeon, coordination with the patient's primary-care physician should then take place while a treatment plan is formulated to take advantage of the technologies available to the wound care center. The broad-based training in lower-extremity wound evaluation ideally positions podiatrists and vascular surgeons to recognize the need to judiciously recruit specialists, as well as to provide surgical debridement services and, possibly, bony reconstructions of the foot and ankle as needed.

As the number of diabetic foot and ischemic wounds is increasing in the United States, and as many of these patients seek care at dedicated wound care centers, the composition of the multidisciplinary team can vary greatly depending on local need and the availability of specialists. For vascular surgeons, on-site consultation is extremely valuable to streamline the evaluation and care of the chronic wound patient, as well as to remove as many of the logistical barriers to good follow-up and care as possible.

Conclusions

The complementary partnership between podiatrists and vascular surgeons in the modern wound care center is of paramount importance in good wound care and the prevention of lower-extremity amputations. Only through coordinated dedication and effort of both of these disciplines will the delivery of care of a wound care center be maximized.

Financial Disclosure: None reported.

Conflict of Interest: None reported.

Dual Publication: This article is a joint publication of JAPMA and the Journal of Vascular Surgery. Both the American Podiatric Medical Association and the Society for Vascular Surgery hold the copyright.