Close the Gap in Diabetes Care With Comprehensive Wound Care

Across the US, demand for wound care continues to increase due to an aging population and greater awareness of the prevalence of wounds, especially among the chronically ill. Approximately 5 to 7 million people currently suffer from chronic wounds, with Sg2 predicting a 12% increase in outpatient demand for wound care over the next 5 years. A large part of this demand is driven by diabetic patients, currently estimated to be 10% of the population (or ~30 million people).

However, wound care has tended to fall through the cracks of the diabetes System of CARE. How can we eliminate this gap in care and better treat these patients? Comprehensive wound care programs are gaining recognition as one such solution, with the potential to offer improved, coordinated care, enhance a hospital’s stature and increase market share.

Diabetes Wound Care Is Costly and Inefficient Today
Of diabetic Medicare beneficiaries, 8% have a foot ulcer and each year about one-fourth of those patients, some 75,000 people, will undergo some form of lower-extremity amputation. The CDC estimates that the direct cost of diabetes in the US now exceeds $175 billion, and one-third of that cost ($58 billion) can be attributed to diabetic wounds and their complications, including amputations. The diabetes population represents a significant and clinically important area to target for a wound care strategy, given the high cost in dollars and patient quality of life lost due to preventable complications from the disease.

Since these patients may bounce between their primary care provider (PCP) and a vascular surgeon who they are frequently referred to for care from their PCP, they often lack one site of care responsible for treating and monitoring their wounds. If the surgeon determines there is no need for surgery they often send them back to the PCP, increasing risk of inadequate treatment and subsequent amputation.

The graphic below illustrates the many sites along the System of CARE where wound care could occur. A comprehensive wound care program can offer oversight and help coordinate care across all these sites, which could result in not only better treatment for wounds, but the salvaging or preserving of limbs. In fact, a comprehensive wound care program reduces the amputation rate for patients with chronic wounds by an estimated 60% to 80%! As such, many of these programs are self-described as limb preservation programs.

Key Elements of Successful Wound Care Programs
Comprehensive wound care programs improve quality of care, decrease IP length of stay, enhance revenue through direct wound care and downstream services, and reduce overall treatment costs in acute and long-term settings. Chronic wounds that could benefit from comprehensive programs include pressure ulcers, venous stasis ulcers, arterial ulcers and diabetic foot ulcers.

Successful programs will incorporate a multidisciplinary staff and advanced wound care technology to facilitate healing of chronic wounds and patient rehabilitation. A variety of models may be employed to provide wound care. At minimum, a dedicated program should employ a full-time nurse with experience in wound management and, preferably, accreditation by the Wound, Ostomy and Continence Nurses Society. The other critical program component is a physician leader who provides direction and oversight.

Key team members and responsibilities include:

  • Wound care specialist (PCP or podiatrist) to lead the team
  • Endocrinologist to manage other aspects of diabetic patients’ care
  • Wound care nurse coordinator to monitor patients and ensure wounds are responding to treatment
  • Vascular surgery team to assess adequacy of blood flow to affected extremity and intervene operatively if necessary

This team sees patients and evaluates wounds, educates patients and their families on wound care principles, cultures and biopsies wounds to assess infection, prescribes antibiotic therapy as needed, debrides wounds (usually in the office but sometimes in the operating room), applies dressings, ensures patients have appropriate footwear, and, perhaps most important, ensures patients have the means to off-load weight from the wound, which is critical to promote proper wound healing. All patients and families should receive education on how they can promote healing of current wounds and avoid future chronic wounds through lifestyle changes and appropriate diabetic foot care.

Considerations for HBOT Adoption and Use
Some wound care programs also use hyperbaric oxygen therapy (HBOT) as a supplement to other services. For wound healing, HBOT uses hyperbaric chambers to generate pure oxygen environments at pressures of 1.3 to 3.0 times atmospheric normal. In recent years, HBOT has become an increasingly popular treatment for chronic wounds.

CMS has reimbursed organizations for HBOT treatment of diabetic wounds of the lower extremities since 2003. In order to qualify for HBOT treatment, diabetic patients must have shown no improvement in wound healing with a 30-day course of standard wound therapy. Continued treatment with HBOT is not covered if measurable signs of healing have not been demonstrated within any 30-day treatment period.

If you choose to include HBOT in your comprehensive wound care program, it is essential that you use it with carefully selected patients. HBOT is but one tool in your arsenal of wound treatments.

Virtual Care May Increase Patient Satisfaction and Reduce Treatment Costs
Another creative approach to wound care is to incorporate virtual care into your comprehensive program. For example, some organizations are using telemedicine applications to enable close patient follow-up, such as using patients’ smartphone pictures of their wounds to monitor healing progress. As virtual care becomes more accepted by patients and physicians alike and reimbursement for virtual care increases, this is a great option to consider. By reducing the number of doctor visits required to monitor and care for wounds, it may increase patient satisfaction, possibly increase your doctors’ panel size and reduce treatment costs.

Strategies for Success
In order to successfully develop and maintain a comprehensive wound care program, consider the following strategies.

  • Target the diabetic population and build your program around this market segment.
  • Recruit physicians, podiatrists and nurse coordinators with proven expertise and interest.
  • Consider diagnostic and treatment adjuncts, such as virtual care and HBOT.
  • Develop an external and internal marketing program to educate other providers and the community about the benefits of your program for chronic wound treatment and its potential to save limbs.
  • Develop seamless care transitions between referring PCPs and your program, enabled by effective, ongoing communication.


Sources: Health in Aging website; Pressure sores: five reviews & an RCT. Bandolier; Dharmarajan TS and Ahmed S. Postgrad Med. 2003;113:77−90; Engelgau MM et al. Ann Intern Med. 2004;140:945−950; Creager M and Hiatt W. Management of Peripheral Artery Disease [Transcript]. American College of Cardiology 48th Annual Scientific Session; Reiber GE et al. Diabetes in America. 2nd ed. US Government Printing Office: 1995; Staylor A.Medtech Insight. 2009;11; O’Reilly S. Medtech Insight. 2011;13; Werner C. Medtech Insight. 2010;12; Peinemann F and  Sauerland S. Dtsch Arztebl Int. 2011;108:381–389; American Podiatric Medical Association. Diabetic wound care; Centers for Disease Control and Prevention. National Diabetes Statistics Report, 2014; Driver VR et al. J Am Podiatr Med Assoc. 2010;100:335–341; Fife CE et al. Wounds. 2012;24:10–17; FDA. Hyperbaric oxygen therapy: don’t be misled. Consumer Update: August 2013; Mayo Clinic. Hyperbaric Oxygen Therapy. November 25, 2014; Sg2 Analysis, 2015–2016. Websites accessed December 2015 and February 2016.

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As of February 11, 2016, Vizient, Inc. has completed its purchase of MedAssets Sg2 and spend and clinical resource management segments from Pamplona Capital Management, LLC. MedAssets revenue cycle business will continue to operate as a wholly-owned subsidiary of Pamplona Capital Management LLP.

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