chronic wound track
DESCRIPTION
Heal Ohio 2008. Chronic Wound Track. Plan. Update / Overview: Mostow Topical Oxygen: Gordillo New treatment(s): Lee Lymphedema: Beinlich and Fruscella Prosthetic venous Valve: Treating Disease not Symptoms: Schmidt. Wound Type. Prevalence. Estimated Annual Direct Cost (USD). Venous. - PowerPoint PPT PresentationTRANSCRIPT
Heal Ohio 2008
Plan
Update / Overview: Mostow Topical Oxygen: Gordillo New treatment(s): Lee Lymphedema: Beinlich and Fruscella Prosthetic venous Valve: Treating
Disease not Symptoms: Schmidt
Extent of the Problem
$Many billions8
• Dr visits: $520/pt8
• Hospital: $16,000/pt8
>$6 billion6
$Many billions3
Estimated Annual Direct Cost (USD)
10-18% (acute care)Up to 28% (extended care)7
882,0004,5
2.5 million1,2
Prevalence
Pressure
Diabetic
Venous
Wound Type
1Philips T, et al. J Am Acad Dermatol. 1994;31:49-53.2Brem H, et al. Am J Surg. 2004;188(1A Suppl): 1-8.3Based on estimated prevalence of 2.5 million and actual mean direct cost of $9685/person : Olin et al. Vasc Med. 1999;4:1-7.4Based on 14.7 million diabetics: CDC, 2005, 6% of whom expected to develop ulcers over 3 years: 5Ramsey SD, et al. Diabetes Care. 1999;22(3):382-87.6Direct costs of treating non-infected diabetic foot ulcers; Gordois A, et al. Diabetes Care. 2003;26:1790-5.7Cuddigan J, et al. for the National Pressure Ulcer Adv Panel. Adv Skin Wound Care. 2001;14:209-15.8Costs in 1996 and 1998, Kumar RN, et al. Adv Skin Wound Care. 2004;17(3):143-9.
Pt=patient
Needs debridement
Undermining
Infection
Co-morbidities
Evaluate with EBM criteria
Facts
Facts are stubborn things; and whatever may be our wishes, our inclinations, or the dictates of our passions, they cannot alter the state of facts and evidence.John Adams, second president
EBM
"the conscientious, explicit and judicious use of current best evidence in making decisions about the care of individual patients,"
-David L. Sackett, MD, professor of medicine at Oxford University
EBM problems
“Tools” are tough to put into practice Limited help in the many “gray areas” of
medicine (when there just isn’t good evidence…yet)
Even with internet resources, translation to individual patients not always straightforwardClinical judgementPatient preferences.
EBM problems
Evidence presentation issuesRelative risksAbsolute risksEX: RR 0.5 for outcome (50% decreased
risk) vs. 8/1000 vs. 4/1000○ Presentation of data can affect physician
interpretation & practice patterns
EBM concerns
Litigation misuse of EBM Managed care misuse of EBM “Evidence” versus “I know my patients
are getting better with what I’m doing”Clinical judgment vs self-delusionAutonomy issues
EBM Answers
Nothing wrong with evidence Evidence just tells you what happens
under certain circumstancesDoc still has to translate how that pertains to
your patient’s circumstances…your patient may differ in important ways
Question
Is pentoxifylline (Trental) of any benefit for patients with venous leg ulcers?MethylxanthineIncreased filterability of RBCsSuppressed synthesis of TNF-alpha from
lipopolysaccharide (LPS)-stimulated human monocytes in cell cultures and in vivo
Question Resource “Prefiltered” evidence-based medicine
resourcesBest Evidence ($85, CD…ACP)
○ www.acponline.org/catalog/electronic/best_evidence.htmACP Journal Club
○ www.acponline.org/journals/acpjc/jcmenu.htmEffective Clinical Practice (ACP online journal)
○ www.acponline.org/journals/ecp/index.htmlCochrane Library ($225 full / Abstracts free)
○ www.updateusa.com/cochrane/cochrane-frame.htmClinical Evidence (BMJ publication)
○ www.evidence.org
“Prefiltered” resources
Updated Methodologically sound studies Clinically important studies Easy to search
Cochrane Review
http://www.cochrane.org Skin group Abstracts available free! Full reviews in your library….
General medical questions Textbooks may be better Uptodate
www.uptodate.com ($495)
Scientific American Medicinewww.samed.com ($245 w/ print / $159
online only)
Medline
Textbooks
emedicine (www.emedicine.com) Electronic Text of Dermatology
(www.telemedicine.org) Habif’s Clinical Dermatology
(at www.medscape.com)
Pentoxifylline & VLUs
Randomized, double blind placebo controlled trial of pentoxifylline in the treatment of venous leg ulcersBMJ. 1999;319:875-878. Dale JJ, et al.
Pentoxifylline 400mg tid as adjunct to standard compression therapy
200 patients randomized
Pentoxifylline & VLUs
Outcome: healing by 24 weeks
Pentoxifylline Placebo
64% healed 53% healed
P < 0.05; trend noted at week 8-10 and continued
Cochrane Database of Systematic Reviews April 2007Trental as adjunct to compression tx: 12 trials, 864 participantsRR healing 1.41 (95% CI 1.19-1.66)
Pentoxifylline & VLUs
Twelve trials involving 864 participants were included.
Combining 11 trials that compared pentoxifylline with placebo or no treatment (with or without compression) demonstrated that pentoxifylline is more effective than placebo in terms of complete ulcer healing or significant improvement (RR 1.70, 95% CI 1.30 to 2.24).
Pentoxifylline & VLUs
Pentoxifylline plus compression is more effective than placebo plus compression (RR 1.56, 95% CI 1.14 to 2.13).
Pentoxifylline in the absence of compression appears to be more effective than placebo or no treatment (RR 2.25, 95% CI 1.49 to 3.39).
Compression for VLUs Established as very important for wound
healing Cochrane review: 22 trials
Compression better than no compression and elastic better than non-elastic
Check the pulse (or ABI > 0.8 with good waveforms)
Make sure it’s tolerable and used!
Unna boot vs. other “wraps” Unna’s boot: zinc oxide
paste & gauze Multi-layer compression
dressing advantages (more continuous pressure)
Compression for prevention! Studies lacking Prevention is often difficult “sell”
Memory issues? Telling the future?○ See Stumbling on Happiness (Dan Gilbert)
Learning
Even while men teach, they learn.Seneca, statesman
Creative Minds
Creative minds have always been known to survive any kind of bad trainingPsychoanalyst Anna Freud, quoted in The
Buffalo News
Truth
Believe in those who are seeking the truth; doubt those who find itFrench author Andre Gude, quoted in The
Pittsburgh Post-Gazette
Einstein discovers that time is actually money.
Chronic Wound Track
Update / Overview: Mostow Topical Oxygen: Gordillo New treatment(s): Lee Lymphedema: Beinlich and Fruscella Prosthetic venous Valve: Treating
Disease not Symptoms: Schmidt