Specialty specific quality measures needed to improve outcomes in wound care

Despite the health care community's best efforts, 20% of diabetic patients who develop a diabetic foot ulcer will require some form of amputation. Those undergoing a major lower extremity amputation risk an increase in their five-year mortality rate to 56.6%, which is comparable to or higher than many forms of cancer. Given this perspective, quality measures need to be considered at each patient inflection point to drive increased compliance with best practices in order to redirect patients whose therapies fail. Medicare limited datasets (October 2015 through October 2019) retrospectively analyzed patients with diabetes receiving care for chronic lower extremity diabetic ulcers (LEDUs). The analysis demonstrated that only 21% of Medicare patients with hard-to-heal LEDUs received sharp debridement at intervals of every 7 days and less, while only 40% received sharp debridement at intervals of every 8 to 14 days. This is despite landmark prospective randomized controlled trials showing the benefits of frequent sharp debridement to patients with LEDUs. According to the Medicare data, when patients received debridement at intervals of 7 days or less with concurrently applied skin substitutes, observed amputation rates dropped by 65% to the lowest levels identified among Medicare LEDU episodes (2.1%). Optimal use of debridement and adjunctive use of skin substitutes significantly improves outcomes and lowers the use of healthcare resources. Another unexpected finding highlighted in the Medicare data analysis was that wound care providers have not been applying skin substitutes early enough. Clinical guidelines related to LEDUs have long relied on the seminal Sheehan marker study, which identified that diabetic ulcers that have not progressed to at least 53% healing after four weeks of conservative care have only a 9% chance of proceeding to closure by 12 weeks. It is therefore vital that patients move to advanced therapies within 30 to 45 days after initiation of failed conservative care; however, the Medicare claims data shows this is not happening regularly enough (average time to first skin substitute application >69 days) to benefit both the patient and the healthcare system. There is a demonstrable need for quality measures that encourage (1) frequent and adequate debridement throughout wound treatment, (2) earlier adoption of advanced treatments, such as skin substitutes, for LEDUs to align with clinical guidelines, (3) the application of skin substitutes to better align with medical evidence, which is associated with improved patient outcomes, as well as (4) expansion of best practices across all demographic and socioeconomic populations.