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Board Review Diabetic Foot

Diabetic Foot Problems in Special Populations: Lessons Learned in the IHS

John Farris, MD

John Farris, MD describes how he instituted the organized direct care wound program at the Indian Health Services (IHS). Dr Farris reviews how diabetic foot ulcers have been difficult to treat in his community and how the program has been beneficial to the IHS and Oklahoma City Area (OKA). Not only does he describe the cost savings results, but also the rewarding clinical outcomes from implementation of an effective wound care program.

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Goals and Objectives
  1. Understand the IHS population and demographics
  2. List several diseases and complications that affect the IHS/OKA area
  3. Describe the cost burden of the diabetic foot ulcer in the IHS/OKA population
  4. Differentiate between the cost to treat model versus the cost to heal model
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  • CPME (Credits: 0.5)

    PRESENT eLearning Systems, LLC is approved by the Council on Podiatric Medical Education as a provider of continuing education in podiatric medicine.

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    Release Date: 03/16/2018 Expiration Date: 12/31/2018

  • Author
  • John Farris, MD

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  • Lecture Transcript
  • Male Speaker: Dr. Farris, he’s from Oklahoma. He is the chief medical officer of the Indian Health Service. I first met him last year and I’ve been working with he and some other colleagues in the IHS over this last year to really promote more limb salvage opportunities and limb salvage protocols within the IHS and the tribal nations and the tribal nation’s clinic. It's my great pleasure to introduce Dr. John Farris to you.

    [Applause]

    Male Speaker: Twenty minutes OK John?

    John Farris: Yeah.

    Male Speaker: Okay.

    John Farris: Good morning. I'm going to give you a brief summary of how the Oklahoma City Area Indian Health Service instituted a wound care program and why we did it. Just as a background, the IHS is a federal agency within the Department of Health and Human Services and we provide health care to Alaska Native American Indians in the United States. There's 12 IHS areas nationwide covering 37 states. And the Oklahoma City Area itself makes up the entire state of Oklahoma, all the tribes in Kansas which are four, and a portion of Texas, and one county in Nebraska. In fiscal year 2010, the Oklahoma City area user population was over 325,000 patients. The area itself encompasses 43 federally-recognized tribes but we see all Indian nations. In the Oklahoma City area consists of six hospitals, four of which are run by tribes, and 54 outpatient clinics, 44 of those are run by the tribal entities. Some breakdown of our user population by age and gender. And this is just a map of our area showing where all our hospitals and clinics are located. And this is my grandson. [Laughs]. In looking at our diagnosis in the Oklahoma City area, our leading diagnosis is diabetes and related conditions, other diagnosis, hypertension, heart-related diagnosis, depressive disorders which I contribute almost directly to the first two diagnoses and asthma and other acute respiratory diagnoses. And in the Indian population, nationally 14.2% of the adult population has a diagnosis of diabetes. This ranges by area from below of 5.5% in Alaska natives to almost 34% in Southwest Arizona. The Oklahoma City area has a 15.2% age-adjusted rate of diabetes. And I'm not telling you all anything here but complications of diabetic foot ulcers are tremendous. At any one time nationally there's probably 600,000 foot ulcers which leads to about 60,000 amputations a year. Those that persist more than four weeks have a fivefold increase of infection, risk of infection. If the patient develops an infection the risk for hospitalization goes up markedly as does the risk for amputations. At the Phoenix Indian Medical Center, neuropathic ulcerations were a leading cause of amputations. And as you’ll see on the next slide and you probably know already, foot ulceration is a significant risk factor for lower extremity amputation in our population, and weighs heavily on the mortality rates as well. Again, 5% mortality significant in anybody with the first amputation. Cost of treating ulcers or not treating them I guess is more pertinent. If the diabetic foot ulcer progresses, $24,000 versus $4,000 if you catch it early and treat it early.

    [05:03]

    If you have osteomyelitis associated, 12,000 versus 5,000. And further expenses with antibiotics, for your hospitalizations 20,000 versus 5,000 and amputations can range anywhere from 70,000 to 100,000 per patient. These are a little older figures but still significant. In 2007, cost for treating diabetic foot ulcers 174 billion nationally, 116 billion related medical costs and 58 billion for indirect cost. These are my grandsons. [Laughs]. We realize that there was definite problem in our population given the number of diabetics we had. So we started taking a look at wounds and how we could actually improve what we’re doing and improve patient’s lives and actually save lives. We looked at treatments available to our patients throughout our clinics. Most common dressing was ointment and gauze if they are lucky, wet to dry if they weren't. Many of them went as many as half a year in treatment before being referred for aggressive care. When they did get into wound management program 3/4 of them had an underlying infection. Throughout our system sometimes based on fiscal matters or just really what's available, a lot of the therapies were quite outdated. There was no formal training for wound care. And really the focus is it is in a lot of busy ambulatory centers, is just to treat the patient and not really focus on healing the wound. So they would continue to seek patients week after week after week with no progression in their wound status. There were also increasing amputations noted throughout the area associated to those who are the expenditures associated with treatment to amputation. And on average in this time span, we were spending 17,000 for even simple wounds. We did have one case and I’ll have a case comparison up here that exceeded a million dollars in a wound care patient. We took all these in and decided to maybe develop a more proactive approach than reactive approach. That's not my grandson. So we really wanted to look at what we were doing and shift from this treatment model to a healing model. We could avoid a lot of extra dollars by treating early and healing early. And also by standardizing what we do we get better results. We did this so that we could provide the service in the patient’s home community, home facility. We’ve had significant cost reduction and this mainly came from standardization and consistency in how we treat wounds, and everybody is using the same pathways, the same dressings, et cetera. So the consistency helps and improves outcomes. With providing this service in our facilities, it's easier to control the outcomes and the costs. It encourages our LPNs, our nurses, our mid-levels, our docs all to work at the highest level of their licensure. By keeping the patient home and we have developed medical homes through the Improving Patient Care initiative in Indian Health, we provide better care. We’ve also developed or have added to our regimen several advanced modalities for treating wound care which have had a different impact.

    [10:08]

    And through all of these, we’re producing a positive experience for the patient, the community and we’re also providing that access for the patient. So our wound care program treats all wounds. It's not just for diabetic foot ulcers or foot ulcers. We have standardized clinical pathways for the wound treatment and standardized medication that supply formularies that include advanced modalities. And these are some of our advanced modalities that all of our participating wound care clinics have access to. The bioengineered tissue, growth factor therapy, pulse electromagnetic field technology, ultrasound assisted wound therapy, negative pressure wound therapy and oxygen therapy. This program is designed to decrease the wound complications and amputations, and also fit the needs of our patients in their home communities. It provides a learning environment for the providers and for the patients. When we started this program, we started tracking data so we could convince administrators and area but also headquarters personnel that this a worthwhile program. It saves lives, it saves limbs. We focus on evidence-based basic and advanced wound care, and we also provide community education. And the goals again are to provide that continuity of care and the same types of outcomes and treatments throughout the area. We encourage early self-referrals, evaluation and when necessary we do refer patients out through our contract health system. Again, providing education, we raise awareness of the current wound care trends. We increased access to care for patients and access to patients for additional service. And an example of this is that again a lot of our wound care patients are diabetic. We have an endocrinologist that is basically for the area which is all of Oklahoma, Kansas, part of Texas. When a patient has identified wound care clinic as having A1c of 9 or greater it gets an immediate referral to the endocrinologist, and at times we can do that through tele-medicines or the endocrinologist just will see him at that time as well. By bringing the service into our systems, we have saved a lot of contract health dollars as well as the way the dollars are spent. We can appropriate more dollars now for heart problems versus wound care problems. These are the barriers that we’ve encountered when trying to institute this. There are some clinicians that at times can be a little hardheaded and that interferes at times. Clinicians sometimes skip or ignore the pathways altogether. A big issue is failure to identify and treat subclinical infections, not treating endermatically, inadequate offloading. Facilities at one time did not have the wound specific supplies, they do now. And there was often the wait and see medicine, dress, set and see in a couple of weeks and see what happens. And at times, there were premature discharges from the wound care clinic. And a lot of providers again have personal preference on how they want to take care of patients be it right or wrong. As far as training and tools, we’ve gone through several variations on training. At the present time, it seems to fit our facilities better, the training is customized to the provider into the facility ranging on one-on-one training to basically supportive collaboration.

    [15:06]

    We do have available again in a consistent manner several training modules that if you're starting at basic wound care, all providers, clinicians, et cetera are required to take. We have ongoing collaboration and everybody is provided with the same clinical pathways. Again, consistency is the big issue. As far as patient management, the wound care clinics are specialty clinics. They may say they're primary care providers that day but also have a visiting wound care. They're seen on a weekly basis, sometimes more often if needed, and have frequent reassessment and repositioning to make sure their healing continue. Again this is all based on close patient management, clinical collaboration and adherence to clinical pathways that we’ve instituted. We do allow and have again made referrals outside when needed. Instead of sending to everybody, we just send those that are needed. By being much more proactive in our approach, we’ve saved patients a lot, we’ve saved Indian Health Service a lot of funds. And I think we’ve made patients a lot happier. Simple wounds are much more easier to control and heal. This in itself minimizes the need for advanced therapies which in itself save some dollars. And again we’re producing a very positive experience for patients and communities. As all of you know, wounds have a golden hour, really need to be aggressive in that first four weeks. If you're not seeing any improvement, then the standard of care actually dictates for advanced therapies. Many of you have probably seen something like this. It goes from something small to something big fairly quick if intervention is not done quickly. These are some of the results of our wound care program. We’ve decreased our amputations in the wound care programs to less than 2%. And overall for the area we have 36% decrease in amputations. Virtually, all the patient show up for their appointments, virtually all of them are happy with the therapy and treatment they're getting. We’ve had over 3,000 visits the past 16 months with 446 new patients, 333 have been healed in a little over eight weeks. Just some other data to show our healing rates, we’ve got a couple of clinics that are doing a little better than the rest. The best was actually 34 days to heal. And again, the cost savings have been significant. This is just one example I was telling you about. And I’ll be on the next slide. First year of the program, we saved over $6 million in contract health funds, since then 4 to 5 million in contract health fund. This is a patient who wasn't involved in our organized wound care program, 44-year old with a scrotal abscess, had an incision and drainage that included a brief hospital postop stay without referral to wound care, became septic, exacerbating several of his other comorbidities, wound up in the ICU for several days. Cost of care was over a million dollars. Similar patient with wound care services, again had the I&D, brief stay, continued to see wound care, healed, cost was $1,500.

    [20:06]

    One of our newest clinics started in December of last year. They’ve had 71 clinic visits. Average days to heal is 20 days. Healing rate is 84% in the first quarter. And their average cost to heal is about $1,800. And again, patients are very compliant to these programs. And that's all I have. This is my son and my grandson.