nihb presentation january 2012 carlyle begay american indian health management policy phone: (602)...
TRANSCRIPT
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NIHB Presentation January 2012
Carlyle BegayAmerican Indian Health Management Policy
Phone: (602) 206-7992Email: [email protected]
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Wound Healing Model
Oklahoma City Area Indian Health Service: One Experience
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Access to care: Wounds Have a Golden “Hour”
• From the onset of the wound…IHS 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
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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
4
1. Lavery et al. Risk Factors for Foot Infections in Individuals With Diabetes. Diabetes Care. 2006;29:1288-93.2. Dannels E. Neuropathic foot ulcer prevention in diabetic American Indians with hallux limitus. J Am Podiatr Med Assoc. 1989;79:447-
50.3. Mayfield et al. A foot risk classification system to predict diabetic amputation in Pima Indians. Diabetes Care. 1996;19:704-9.
Diabetes Neuropathy Infection AmputationFoot Ulcer
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Amputations are a serious predictor of death…
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Consequences of Unhealed Neuropathic Ulcers
Nearly half of all
unhealed neuropathic
ulcers result in death
within 5 years
Armstrong DG. Int Wound J. 2007;4(4):286-287.
Neuropath
ic Ulcer
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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
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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
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– 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
Barriers to Wound Healing Model
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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
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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
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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
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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
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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
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Indirect Results of the Wound Program(represents amputations not associated with the Wound Management Program)
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• 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 co-morbid conditions hospital readmission and transfer to private sector ICU
• Cost of care: >$1 million
CHS Cost Savings using direct care wound program vs. traditional home self care…for example
when comparing similar wounds/patients
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Perceived Concerns
• Staffing
• Clinician participation
• Equipment for diagnostics
• Cost of supplies and medications
The solutions to these questions have already been found!
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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
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Economic impact of non-healing wounds
Don Ayers
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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
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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.
0
2
4
6
8
10
12
14
16
Perc
en
t w
ith
Dia
bete
s
White Black AmericanIndian
Hispanic Other
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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. Boulton et al. The global burden of diabetic foot disease. Lancet. 2005;366:1719-24. 2. Lavery et al. Risk Factors for Foot Infections in Individuals With Diabetes. Diabetes Care. 2006;29:1288-93.
0
10
20
30
40
50
60
70
Per
cen
t w
ith
Fo
ot
Infe
ctio
n
No Foot Ulcer Foot Ulcer
0.07%
60.7%
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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. Habib AA, Brannagan TH 3rd. Therapeutic strategies for diabetic neuropathy. Curr Neurol Neurosci Rep. 2010;10:92-100.2. O’Connell 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.
0
5
10
15
Pe
rce
nt
wit
h N
eu
rop
ath
y
Insured Americans withDiabetes
American Indians withDiabetes
7.6%
16.8%
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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
24
1. Lavery et al. Risk Factors for Foot Infections in Individuals With Diabetes. Diabetes Care. 2006;29:1288-93.2. Dannels E. Neuropathic foot ulcer prevention in diabetic American Indians with hallux limitus. J Am Podiatr
Med Assoc. 1989;79:447-50.3. Mayfield et al. A foot risk classification system to predict diabetic amputation in Pima Indians. Diabetes Care.
1996;19:704-9.
Diabetes Neuropathy Infection AmputationFoot Ulcer
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Diabetes Burden in American Indians; Lower Extremity Amputation
1. 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.
2. O’Connell 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.
0
0.5
1
1.5
2
Pe
rce
nt
wit
h A
mp
uta
tio
n
Insured Americans withDiabetes
American Indians withDiabetes
0.1%
1.8%
• 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
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Healing Neuropathic Ulcers: Results of a Meta-analysis
• 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.
Weighted Mean Healing Rates
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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 worse outcomes, including amputations.”
Note: This consensus statement also was reviewed and endorsed by the American Podiatric 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.
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Continuing Research: Healing of Diabetic Foot Ulcers After 4 Weeks
• Wounds achieving less than 53% closure at week 4 have minimal chance of healing with conventional therapy
>53% area reduction at week 4 <53% area reduction at week 4
Sheehan et al. Diabetes Care. 2003;26(6):1879-1882.
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Role of Tissue-Engineered Skin in theManagement 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.
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N=133 N=117N=133 N=117
Association Between PAR at Week 4 & DFU Closure at Week 12
• Data was dichotomized by PAR of <50% or ≥ 50% by week 4 to assess the association of PAR with DFU closure by 12 weeks
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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
Better Results Using Best Practice Model: Advanced Therapy
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Cost of Diabetes and Wound Cost of Diabetes and Wound CareCare
$174 billion: Total costs of
diagnosed diabetes in the United
States in 20071
$20 billion: Chronic wounds cost
health care systems annually2
32
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Healed Patients
-211
-120
-282
-140
-44
-218
-103
-22
-22
-240
-58
-142
-111
-261
-27
-19
-16
-7
-3
-2
-30
-30
-7
-35
-2
-10
56
42
21
71
14
63
7
14
28
70
50
42
49
-400 -350 -300 -250 -200 -150 -100 -50 0 50 100
10572
13092
15948
17459
17921
37226
56181
33331-2
33331-4
9420-2
12034
9908
7724-2
Pat
ien
t ID
Treatment Day(s)
First ClinicVisit -DateTherapyStartedDateWoundAccquired- FirstClinic VisitLast VisitDate -First ClinicVisit