Global Issue of Lower Extremity Wounds

Valerie Messina, RN, CWCNWound Care Nurse Consultant

Long Beach, CA

Program: What is the impact that lower

extremity wounds have on health care

systems and the community? Both the

actual cost of treating these wounds

and the “real” cost of lower extremity

wounds will be explored and

discussed. This will set the stage for the importance of this conference.

Objectives:1. Identify the economic, clinical, and social impact that lower

extremity wounds have on health care systems and the community.

2. Discuss both the actual cost of treating these wounds and the “real” cost of lower extremity wounds.

3. Describe the risk factors and etiologies of lower extremity wounds.

4. Recognize quality of life issues experienced by patients with lower extremity wounds.

5. Examine approaches to address the global issue of lower extremity wounds.

Medicare study of 2014 data:

• 14.5% of Medicare beneficiaries (8.2 million) had one type of wound or wound related infection

• Cost estimates for acute & chronic wound treatments ranged from $28.1-$96.8 billion

• Higher costs for outpatient wound care($9.9-$35.8 billion) compared with inpatient ($5.0-$24.3 billion)

1. Sen CK. Human Wounds and Its Burden: An Updated Compendium of Estimates. Advances in Wound Care 2019; 8(2):39-48. DOI:10.1089/wound.2019.0946

2. Nussbaum SR, Carter MJ, Fife CE, et al. An economic evaluation of the impact, cost, and Medicare policy implications of chronic nonhealing wounds. Value Health 2018;21:27–32.

“…chronic wounds present a rising threat to global health and economy.” (Sen KS, Advances in Wound Care 2019)

Surgical wounds largest category (4%)

Diabetic wound infections (3.4%)

Infected surgical wounds (3%)

For this study, the term “wound” was used for both ICD9 codings:

• “wound – resulting from physical trauma or surgical interventions ” and

• “ulcer – related to an underlying chronic disease.”

Nussbaum SR, Carter MJ, Fife CE, et al. An economic evaluation of the impact, cost, and Medicare policy implications of chronic nonhealing wounds. Value Health 2018;21:27–32.

Nussbaum SR, Carter MJ, Fife CE, et al. An economic evaluation of the impact, cost, and Medicare policy implications of chronic nonhealing wounds. Value Health 2018;21:27–32.

Nonhealing wounds:• Chronic - nonhealing within 1-3 months• Prevalence rate 1-2% of population in

developed countries • Not a disease but a symptom• The morbidity & associated costs including

amputation and death are largely ignored from a public policy standpoint in the US, perhaps because no specific medical specialty is responsible.

Nussbaum SR, Carter MJ, Fife CE, et al. An economic evaluation of the impact, cost, and Medicare policy implications of chronic nonhealing wounds. Value Health 2018;21:27–32.

Annual wound care products market expected

to reach $15-$22 billion by 2024

Chronic wounds present clinical, social, and economic challenges• Contribute to increasing health care costs• Aging population increases risk

• 3% of US population >65 years (55 million) have wounds = 1,650,000

• Difficult-to-treat infections and bioburdens

• Threat of diabetes and obesity worldwide increasing Sen CK. Human Wounds and Its Burden: An Updated Compendium of

Estimates. Advances in Wound Care 2019; 8(2):39-48. DOI:10.1089/wound.2019.0946

Acute wounds:

• 17.2 million hospital visits, including ambulatory/ outpatient and inpatient surgical visits (2010 data)

• Burns – 500,000 patients annually costing $1.5 billion

• Surgical site infections (SSI) costing $3.5-$10 billion annually

• Traumatic – Emergency care for MVA’s, violent attacks, crush injuries

Sen CK. Human Wounds and Its Burden: An Updated Compendium of Estimates. Advances in Wound Care 2019; 8(2):39-48. DOI:10.1089/wound.2019.0946

Risk factors:

• Age

• Nutritional status/malnutrition

• Comorbid conditions, ie. diabetes, neuropathy

• Obesity

• Smoking

• Psychosocial stress

• Immobility, paralysis

Etiologies of lower extremity wounds:• Vascular: venous, arterial, mixed• Neuropathic: Diabetes• Metabolic: Diabetes• Hematologic: Sickle cell disease• Traumatic: Pressure, injury, burns• Surgical sites• Tumors: basal cell, squamous cell• Autoimmune: SLE, Pyoderma

gangrenosum• Other skin disorders or infections

Lower extremity wounds cross most medical and surgical specialties.

Pemphigus vulgaris – autoimmune skin disorder

Diabetic foot ulcers (DFUs) • Global prevalence - 6.3%

• North America – 13%• Asia - 5.5%, Europe -5.1% , Africa - 7.2%

• DFU more prevalent in males than in females; more prevalent in type 2 than in type 1 diabetic patients.

• Patients with DFU were older, had a lower body mass index, longer diabetic duration, had more hypertension, diabetic retinopathy, and smoking history than patients without DFU.

Zhang P, Lu J, Jing Y, Tang S, Zhu D, Bi Y. Global epidemiology of diabetic foot ulceration: a systematic review and meta-analysis. Ann Med 2017;49:106–116.

Diabetic foot ulcers (DFUs) • Lead to about 100,000 lower extremity amputations

per year in America. • Extensive patient education, early assessment, &

aggressive treatment reduce amputations, length of stay and costs

• Limb preservation teams have shown reduced major limb amputations, decreased length of stay and total cost of care

Driver VR, Fabbi M, Lavery LA, Gibbons G. The costs of diabetic foot: the economic case for the limb salvage team. J Vasc Surg 2010;52(3Suppl): 17S–22S.

Venous leg ulcers (VLUs)

• Overall global prevalence 1% rising to 3% in > 65 population

• 70% of lower extremity ulcers caused by chronic venous insufficiency

• Cost $2.5 billion in US annually

• Result in the loss of 4.6 million work-days annually

Xie T, Ye J, Rerkasem K, Mani R. The venous ulcer continues to be a clinical challenge: an update. Burns Trauma 2018;6:18.

Sen CK. Human Wounds and Its Burden: An Updated Compendium of Estimates. Advances in Wound Care 2019; 8(2):39-48. DOI:10.1089/wound.2019.0946

Quality of Life Issues related to LE Wounds

• Limb loss - risk or actual

• Pain

• Inability to perform ADL’s

• Sleep disturbances

• Adherence to wound care regimen

• Mobility issues

• Malodourous/draining wounds

This Photo by Unknown Author is licensed under CC BY-NC-ND

Psychosocial impact of wounds on patients• Difficulty coping• Loneliness• Separation from active social life• Depression• Negative body image

Upton D, South F. The psychological consequences of wounds — a vicious circle that should not be overlooked. Wounds uk, 2011, Vol 7(4):136-138.

It is possible that a negative spiral will occur in which the wound causes a negative emotional state that impairs wound healing and in turn, leads to increased negative emotions and actions.

This Photo by Unknown Author is licensed under CC BY-NC-ND

Financial Impact to the patient

• Loss of work time

• Loss of income

• Health care costs

Patients may ask - do I buy groceries or wound care supplies?

This Photo by Unknown Author is licensed under CC BY-NC-ND

Goals for improving lower extremity wound care

• Early identification & care

• Improve access to limb salvage programs

• Improve diabetic foot ulcer care

• NIH established the Diabetic Foot Consortium bringing experts across the US together to improve the care of DFU’s (2018) Ref: Sen CK. Human Wounds and Its Burden: An Updated Compendium of Estimates. Advances in Wound Care

2019; 8(2):39-48. DOI:10.1089/wound.2019.0946

Approaches to address the global issue of lower extremity wounds:

• Physician education on wound care management• Wound care continuum of care • Interprofessional team approach• Patient education• Improving “Combat” wound careSen CK. Human Wounds and Its Burden: An Updated Compendium of Estimates. Advances in Wound Care 2019; 8(2):39-48. DOI:10.1089/wound.2019.0946

Comprehensive physician education on wound care management needed

• Typical wound care education in 4 years of medical school is 9.2 hours

• Wound care specialty accreditation by the American Board of Medical Specialties is to be established by 2022

Combat wound careDept. of Defense and Dept. of Veterans Affairs provide health care for military and veterans• VA increased the budget for research

and clinical care for members with combat-related extremity trauma

• Economic burden of lower limb amputations in diabetic veterans - $206 million.

Comprehensive Wound Care Program• Addresses continuum of care • Provides access and delivery• Addresses socioeconomic issues and cultural diversity

Acute care– Hospital wound care unit– WOCN consultants– Acute Rehab Unit– Long Term Acute CarePost-acute care– Outpatient wound clinic– Skilled Nursing Facility– Home Care

Having patient advocates to assist patients through the continuum of care is key to successful outcomes.

The Interdisciplinary Approach to Wound CareWho is on the team??– Physicians/Podiatrists with wound care expertise– NPs/PA’s– CWOCNs– RNs– Physical & Occupational therapists– Dieticians– Discharge planners– Case managers– Social workers– Pharmacy– Infection Control– Hyperbaric Medicine– Vendor support for formulary and medical devices– Administrator and Medical Director

Communication between team members enhances the team approach.

Interdisciplinary approach of the patient :• Systematic assessment • Determination of the pathogenesis• Definitive diagnosis• Optimal treatment

Algae SV. Chronic leg ulcers: epidemiology, aetiopathogenesis, and management. J Ulcers 2013; 2013:9.

Patient education:• Recognition of patient’s concerns

in treatment planning• Meet requests for personalized

approaches• Shared wound care decision

making• Seek wound care treatment early

Engaging patients’ awareness and involvement in wound management is key to ensuring successful outcomes.

Model Wound Care Program for Lower Extremity Wounds• Have a vision of an optimal wound care program• Focus on limb salvage • Administrative buy-in, Medical & Program Directors lead the

team• Recruiting wound care physicians, nurses and therapists or

mentoring existing doctors and staff• Service line financials - evaluating LOS, reimbursements, costs• Evidence-based, cost effective care• Marketing your program internal and external

Meeting the challenge!

• Recruit interdisciplinary talent that work together as a team.

• Focus on education, care, and research

This Photo by Unknown Author is licensed under CC BY

Patient

Physician Wound Care Specialists

Vascular

Diabetes

Infectious Disease

Specialists

Wound Care Product/DME

Suppliers

Nurses

Therapists

WOCNs

Case Managers

Hyperbaric Therapy

Pharmacy

Goals:

• Develop improved quality measures and reimbursement models for better health outcomes

• Smarter spending for this growing population

This Photo by Unknown Author is licensed under CC BY-SA-NC

Goal:

Develop a more structured approach and proportionate investment in wound care, education, and related research to address the global impact of lower extremity wounds.

References:1. Algae SV. Chronic leg ulcers: epidemiology, aetiopathogenesis, and management. J Ulcers 2013; 2013:9.2. Driver VR, Fabbi M, Lavery LA, Gibbons G. The costs of diabetic foot: the economic case for the limb

salvage team. J Vasc Surg 2010;52(3Suppl): 17S–22S.3. Nussbaum SR, Carter MJ, Fife CE, et al. An economic evaluation of the impact, cost, and Medicare policy

implications of chronic nonhealing wounds. Value Health 2018;21:27–32.4. Sen CK. Human Wounds and Its Burden: An Updated Compendium of Estimates. Advances in Wound

Care 2019; 8(2):39-48. DOI:10.1089/wound.2019.09465. Upton D, South F. The psychological consequences of wounds — a vicious circle that should not be

overlooked. Wounds uk, 2011, Vol 7(4):136-138.6. Xie T, Ye J, Rerkasem K, Mani R. The venous ulcer continues to be a clinical challenge: an update. Burns

Trauma 2018;6:18.7. Zhang P, Lu J, Jing Y, Tang S, Zhu D, Bi Y. Global epidemiology of diabetic foot ulceration: a systematic

review and meta-analysis. Ann Med 2017;49:106–116.