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Doctors Digging Deeper

Unlike any other medical service, Wound Care physicians peel back a patient’s layers to uncover and treat the underlying problem that caused the wound.

Using quality data to improve patient outcomes and influence payer policies.

The US Wound & Podiatry Registries (USWR) is devoted to collecting quality patient data and using it to make a positive impact across the medical industry. We use the data we collect to publish studies that improve patient outcomes. We use data to help Wound Care providers improve their reimbursements and healing rates. We use data to help payers create focused payment regulations specific to Wound Care.

It is real-world data that can change the medical industry, and that’s what the US Wound & Podiatry Registries is all about.

The USWR is now the largest repository of structured wound care data in the world, having all patient ICD-9 or ICD-10 diagnoses, all medications, quality measure performance data, all products used, all treatments provided, and all wound outcomes in approximately 200,000 patients. Although chronically underfunded, it stays afloat from the nominal fees charged clinicians for quality reporting to CMS. For a decade, we have been preparing the USWR to be able to perform the real world trials that are needed in the field of wound care, and recently published a paper establishing standards for the use of registry data obtained directly from EHRs which we refer to as the ABCs or Analysis of Bias Criteria.

 

Report Honest Healing Rates.

Perhaps you’ve seen the buttons. Perhaps you’ve heard our Medical Director, Dr. Caroline Fife, scream her rallying cry from the podium of a major Wound Care conference.

The US Wound Registry believes that Wound Care physicians are directly responsible for the Centers for Medicare and Medicaid’s (CMS) distrust in the Wound Care practice model. But we’re working to fix that by screaming into the ears of every Wound Care provider “DO THE RIGHT THING!”

We live in a country that has valued hard work and the free market since the Mayflower let down her anchor. Our healthcare system is a business. As a result, we’ve advanced the frontiers of medical science and built the greatest medical institutions in the world. However, we have a problem. It’s estimated that at least 30% of Medicare billing is inappropriate but the Office of the Inspector General and many of the Medicare Administrative Carriers (MACs) say that an even larger percentage of Medicare billing pertaining to wound care is inappropriate. And we spend a lot on chronic wound care- perhaps $96 billion a year, according to a study we helped perform, published in Value in Health. Every time we over-utilize or fail to provide the standard of care, we are part of the problem.

We can fix this problem. We can decide to engage in transparent quality reporting. We can participate in national benchmarking. We can commit to Honest Outcomes Reporting. We can be clinicians who “Do the Right Thing” with registry reporting. We can preserve Medicare for us and the generations to come, and provide higher quality care. There is enormous pressure to keep the economic engine running at full throttle, but it’s a short-term strategy doomed to fail. Doing the right thing takes tremendous courage because it may mean reducing the bottom line. But, as de Tocqueville said, “Life is to be entered upon with courage.”

Wound Care: The Elephant in Healthcare’s Room of Peacocks.

Wound care is not a recognized medical specialty, so it has none of the organizational structure that a specialty society affords.

Although wounds affect the skin, Wound Care is only rarely practiced by Dermatologists, so it is not able to claim its own body organ or disease state. Despite the fact that chronic wounds cost Medicare more than $90 Billion dollars a year, as a country we invest almost no money in wound care research. The NIH budget for research is about $32 billion annually but only 0.1% of that is spent on wound care. That is about same amount of money spent researching Lyme disease, even though chronic wounds are more common than heart failure and perhaps three times as expensive. Unlike cardiology or surgery, Wound Care does not involve expensive medical procedures with high tech machines that attract funding from device manufacturers, and there are no costly pharmaceuticals to pique the interest of “Big Pharma.” No celebrities want to represent malodorous, draining sores. Most of the patients are chronically ill, and many are elderly. In other words, there is no funding from any sector, there is no cache, the patients are voiceless, and the practitioners have no political clout. No one really seems to care about these patients except for Wound Care practitioners themselves.

The US Wound Registry aims to change that entirely by constantly bombarding regulatory bodies with reminders of Wound Care’s influence on Medicare expenses.

Wounds are a SYMPTOM, not a disease.

Chronic wounds are not a disease, they are a SYMPTOM of a disease. As a result, a prerequisite to a wound care clinical trial is a firm belief in fairies. Nearly 20% of the wounds seen in a wound center are simply classified as “chronic ulcers” because they don’t fit into any specific wound categories. Malnutrition is rampant (and often undiagnosed) among wound center patients. More than 70% of patients with venous leg ulcers (VLUs) are obese, 40% are diabetic, and nearly 20% have concomitant arterial disease. The average patient in the USWR has 8 major comorbid diseases and is on 15 medications. Approximately 12% have heart failure, 8% require prednisone, 4% are transplant patients, and 10% are on dialysis. The most common wound type is NOT diabetic foot ulcers, but dehisced surgical wounds, something we have known from the USWR for a decade, but which was recently confirmed with data from the 5% Medicare dataset. Surgical wound dehiscence, also the most expensive wound, only occurs because patients have some underlying medical problem which prevented normal healing. About the only prospective clinical trials performed in this condition are those of negative pressure wound therapy (NPWT). Unlike venous stasis and diabetes, patients with surgical wound dehiscence are hard to put in an imaginary diagnosis box. A surgical wound dehiscence randomized clinical trial (RCT) is the scientific equivalent of the Mad Hatter’s Tea Party because it necessitates excluding all of the conditions that lead to the dehiscence.

Predicting Patient Outcomes Via the Wound Healing Index

Virtually every other specialty has developed a risk stratification for its most common, serious conditions. Risk stratification is a corrective tool that enables the reporting of patient outcome in a fair way so that physicians caring for the sickest patients are not penalized by appearing to have worse outcomes than their peers who care for less sick patients. Anesthesiology has a risk classification that is important for evaluating whether a patient should even undergo anesthesia and to understand anesthetic complications in relation to their predicted likelihood. Trauma surgeons, cardiologists and oncologists use risk classification to help patients and families understand the likelihood of patient survival in high mortality situations. Stratification also serves as way to demonstrate clinical excellence and the impact of certain therapies. Unless you know what was predicted to happen, it’s not possible to demonstrate the impact of superior care or a novel therapeutic agent. Unfortunately, since the field of wound care has lacked a risk stratification system, clinicians, hospitals, and wound center management companies have used a different method to depict wound healing rates – fabrication.

That’s why we created the Wound Healing Index (WHI): to act as a predictive model for patient outcomes based on real-world clinical data.

The USWR collaborated with Dr. Susan Horn of the Institute for Clinical Outcomes Research (ICOR) to create such a model. The project was funded through ICOR by KCI which contributed $500,000. We had hoped to create one model that worked for all wounds and but in the end, we developed 7 models, one for each major ulcer category, which we called the Wound Healing Index (WHI). It was painstaking work, analyzing the structured data from almost 70,000 wounds, identifying individual factors that were associated with failure to heal, and then creating models from those factors.

We now have a predictive model for many wound variations and their related conditions based on real-world data, rather than clinical trials of sample sizes a fraction of the size and using subjects with no related conditions.