care setting, and case mix severity to control for variables associated with
different settings.
Introduction
Healing rates have become both clinical and marketing tools for many
wound care centers. The recording and reporting of clinical results are
imperative in today's health care marketplace. Published articles, however,
rarely stratify a patient's risk in outpatient settings. Patients not seen in
clinic for 30 consecutive days are considered lost to follow-up and that
clinical episode is closed out from the data set. For example, a patient
presents for a consult with a venous leg ulceration of 1-year duration that
was unsuccessfully treated in a primary care physician's office. The wound
carries a heavy bioburden and fibrin load requiring an office-based
debridement followed by 3 weeks of moist dressings and compression. The
patient fails to improve and is admitted to the hospital for 1 week of
treatment including intravenous (IV) antibiotics and surgical debridement.
On discharge from the hospital, the patient is transferred for a 6-week stay
in a sub-acute unit. A total of 8 weeks later, the same patient returns to the
outpatient clinic from home due to a plateau in healing after 2 weeks of
home health therapy and is re-enrolled in the clinic as a new patient. The
wound is now 75% smaller in area than at the time of the original consult.
Compression and moist dressings are again applied and the wound
completely heals in 5 weeks. The various outcomes from this single case
include, 1 year of treatment without improvement in a primary care office, a
new consult lost to follow-up without healing in 3 weeks in the wound clinic,
a hospital stay of 5 days with an increase in wound size status post surgical
debridement, a 6 week sub-acute stay with a 50% volume reduction in 6
weeks, home health care for 2 weeks with no change in wound size, and a
completely healed wound treated in 5 weeks in the outpatient clinic. The
"episode of care" outcome, however, describes a venous leg ulceration that
required 69 weeks of therapy including primary care visits, wound clinic
treatment for 8 weeks, home health care for 2 weeks, a sub-acute care stay
of 6 weeks, and 1-week hospitalization. This clinical example is a common
scenario and represents the importance of defining the site of care when
analyzing wound healing data. Each point along the continuum of care acts
as a "silo" of care and not part of a larger system of care. Additionally,
current reimbursement policies create the potential for each site of care to
maximize economic outcomes that may not make clinical or economic sense
if the entire "episode of care" was integrated across settings. Concepts such
as pay for performance are a step in the right direction, but also focus on
achieving benchmarks from individual sites of care and, therefore, fail to
achieve true integration across care settings.
The authors have created an integrated care approach to wound
healing using a combination of strategically aligned groups that do not
function under the same corporate umbrella. Patients are seen in an
outpatient, not for- profit, hospital-based wound clinic. In addition, inpatient
wound care is provided for a second hospital that belongs to a completely
different not-for-profit organization. The clinic admits directly to both of the
hospitals in which inpatient care is provided. The authors' sub-acute wound
unit is a privately owned for-profit center with no formal business
relationship to either hospital. The home health agencies are operated by
each of the 2 previously described hospitals. The authors' prosthetics and
orthotics group provide services at all locations and are a small privately
held firm. The specialists that consult and work with the authors' team are
mainly from private practice models. The entire team, including physicians,
are salaried and have no volume or procedure-driven economic incentives at
any of the sites of care. The single most difficult aspect of providing care in
this model is case management. Not only does it represent the most time
consuming component of overall patient care, it is the least economically
productive. It seems paradoxical that the most critical piece of the final
clinical outcome carries with it no form of reimbursement. The current
model encourages procedure volume and fails to reward outcomes.
Results
A total of 109 patients were enrolled in the database. There were 101
patients with 209 evaluable wounds, excluding 8 patients who had 1 visit or
a closed wound on admission. Demographics are described in Table 1 .
Although there were more women enrolled in the study, the number did not
achieve statistical significance. There were statistically more patients in the
61- to 70-year-old group than in any other group (P = 0.039). Neither age
nor sex was correlated with healing outcomes ( Table 2 ). Outcomes were
divided into 2 distinct groups. Group 1 included those patients achieving
complete healing and those with marked improvement (defined as >50%
reduction in wound volume). Group 2 consisted of patients who improved
but did not achieve 50% volume reduction, patients whose wound size
remained unchanged, and those with a deteriorating wound. Kaplan-Meier
derived median time to healing was 7.9 weeks for patients in Group1
(Figure 1). A statistically significant difference was noted when wound
outcomes were separated by wound etiology ( Table 3 ). Traumatic wounds
were noted to heal in a short time interval compared with other wound
etiologies.Wound location and initial wound volumes are described in Table
4.
Discussion
Previously published data from a single clinical team working from
two distinctly different hospital based wound programs, demonstrated that
consistent outcomes are achievable using a uniform clinical approach to
wound care.[3] Patients in that study were analyzed from a 200-bed
community hospital based wound program, and a 700-bed level 1 tertiary
center. Those outcomes, while consistent, were taken from a single care
setting. Even prior data[2] from the present authors single sub-acute
program can be further analyzed. For example, the overall healing and 50%
volume reduction group totaled only 53% in a study of 346 patients with
680 wounds published by the authors using the same clinical team that
Long-term
IV
access,
surgical
debridement,
and
medical
approximately 250 new patients to the program per year. On average, 100
patients are admitted to the hospital, with 150 admissions overall during a
1-year period (a 50% re-admission rate). Therefore, 40% of all patients seen
in the clinic require at least a 1-day stay in the acute care setting.
Approximately 25% of admitted patients are transferred to the sub-acute
program. In total, therefore, only 10% of all patients seen in the authors'
outpatient wound clinic are admitted to the sub-acute program. It is fair to
assume that these patients represent a medically complex subgroup from
the original cohort.The healing rates in the acute care and sub-acute care
settings, therefore, would not be expected to mirror each other.
Predictors of Healing
Specialized wound centers have been shown to achieve improved
healing rates compared to more fractionated care. [4] However, comparisons
between centers are difficult and possibly misleading. Would an outpatient
center that primarily focuses on venous leg ulcers demonstrate an
equivalent healing rate compared to a vascular surgery based program that
treats critical limb ischemia? Keyser[5] reported an 88% healing rate for
diabetic foot ulcers, while others report healing rates of 38%. [6,7] One report
in the literature quotes 100% healing in an outpatient clinic. [8] Further
research is needed to define the parameters that underlie such varying
outcomes. Outcomes of success and mortality are now in the public domain
for coronary artery bypass grafting at most hospitals. Clearly, there are
differences in outcomes between high volume centers of excellence and
those from less experienced centers. The wide variation in healing rates -reported in the literature from 38% to 100% -- probably reflect case mix and
reporting differences rather than wide clinical variation. [6-8]
In addition to the outcomes reporting problem, there is a relative
absence of wound care education for healthcare professionals. A recent
survey of medical school curricula reveals, on average, a medical student
receives only 9 hours of education on wound healing over a 4-year
expertise
in
wound
healing,
it
is
not
surprising
that
instrument
(RAI)
which
contains
information
on
clinical,behavioral, and social status of nursing homes. [11,12] The RAI consists
of the MDS, utilization guidelines, and Resident Assessment Protocols
(RAP).[11] When a patient has a particular MDS status that matches a trigger
for a RAP,1 or more of 18 problem-based RAPs are performed. Several MDS
criteria have been validated as predictors of pressure ulcer development.
Vap et al[13] determined that the MDS was less sensitive but more specific in
predicting the development of a pressure ulcer compared with the more
popular Braden Score. Bates-Jensen et al[14] found problems using a
patient's bed bound status, one of the MDS quality indicators, because of
significant underreporting in the facility. In another study, Bates-Jensen et
al[15] were unable to correlate nursing homes with low pressure ulcer
prevalence with improved clinical care processes.
Despite conflicting reports it appears that overall quality of care has
improved in nursing homes since the release of the MDS. [16] Although Jones
et al have recently tried to identify clinical and functional aspects of the
patient history to predict pressure ulcer healing there is minimal published
literature on the topic.[17] Vap et al,[13] found that specific MDS components
correlate with pressure ulcer risk. We attempted to utilize some of these
parameters to determine if they could be used as predictors of wound
healing. Bedfast status, bowel incontinence, use of bed rails for transfer,
and the use of a transfer aide, were not found to have statistical correlation
with the ultimate outcome of healing or marked improvement ( Table 7 ).
Conclusion
In this prospective, longitudinal, intent-to-treat study of patients
within a comprehensive sub-acute wound program, a 41.6% healing rate
and a >50% wound volume reduction rate of 31.6% were achieved in a
median time to healing of 7.9 weeks. These results were similar to
published outcomes from a previous program managed by the authors. [2]
The similar outcomes of this study support the primary conclusion that a
wound program can be reproduced if the same clinical approach is taken,
regardless of physical plant, staffing, and ownership of a nursing home.
However, a comparison of these results to published healing rates from an
outpatient, hospital based wound clinic run by the same clinical team using
the same protocols of assessment and care, highlight the importance of
identifying the population under study, early intervention, and the clinical
site of care. Additionally, readily available MDS criteria may prove useful for
the prediction of wound development, but are unlikely to assist a clinician in
predicting who will respond to therapy.
It is evident that some form of wound indexing or severity indices are
needed to help wound care clinicians maximize clinical outcomes and select
therapeutic options from the myriad currently available to the wound care
clinician.The wound care field is unique in that therapeutic options have
outpaced diagnostic and predictive innovation. Part of the problem is that
woundcare societies have been unable to translate cognitive and case
management work efforts into meaningful, appropriate evaluation and
management codes, and ultimately reimbursement. Wound care clinicians
can look forward to wound profiling, bioassay development, wound severity
scoring, and gene expression changes in wound tissue as described in the
eloquent work by Brem et al,[18] as a potential means to predict outcomes,
prevent occurrence, determine debridement margins, and to select the most
Wound
Care: A Clinical
Source Book
for Healthcare
in
the
treatment
of
chronic
wounds.
Am
Surg.
2004;187(5A):38S-43S.
5. Keyser JE. Diabetic wound healing and limb salvage in an outpatient
wound care program. South Med J. 1993;86(3):311-317.
6. Granowitz EV, Szostek R, Burns P, Carmel J, Emhoff TA, Brown RB.
Aetiologies and outcomes of wounds in an outpatient programme. J
Wound Care. 1998;7(8):378-380.
approach
for
efficient
and
effective
wound
healing:
inadequately
trained
in
wound
care.
Ann
Plast
Surg.
2007;59(1):53-55.
10.
Reliability estimates for the Minimum Data Set for nursing home
resident
assessment
and
care
screening
(MDS).
Gerontologist.
1995;35(2):172-178.
13.
17.
markers
in
patients
with
chronic
wounds
to
guide
surgical