Plastic, Vascular & Podiatry the Georgetown Model

Transcription

1 Plastic, Vascular & Podiatry the Georgetown Model Christopher Attinger,, MD SVS June 15,2011 Chicago

2 Disclosure: None for this talk

3 Wound Center Financial Viability: outline Clinical success Team approach Evidence based protocols Effective clinical space Financial viability & hospital $ support Center s operational cost Admissions & operations Downstream revenue from procedures Focus: Diabetic limb salvage vs. all wounds

4 Etiology of wounds: multiple Trauma Ischemia Venous stasis Infection Complications Surgery Radiation Drug Neuropathy Biomechanical Lymphatics Autoimmune dis. Hematological Dermatologic Cancer Psychological

5 Outline: Establishing a Wound Center Team effort Medical team Nursing team Residents Physical therapy Pedorthetist Prosthetist Clinician effort Vascular surgery Podiatry Plastic surgery Micro & Nerve Orthopedics Endocrine Hospitalist Infectious disease Rheumatologist

6 Current reimbursements: Evidence-based protocols Use established protocols or design your own using current evidence Diabetic ulcers Brem H, PRS 117s: 193S-209s, 2006 Pressure ulcers Brem H, Am J Surg. 188s: 9-17, 2004 Venous stasis ulcer Brem H, Am J Surg. 188s:

7 Georgetown Wound Center Focus:

8 1990: Plastic Surgery Vascular Surgery

9 1990: 1) Wound Plastic care 2) Surgery Wound coverage 1) Bypass Vascular Surgery 2) Venous Surgery surgery

10 1993: Plastic Surgery Vascular Surgery Ortho Foot & Ankle Surgery

11 1993: 1) Wound Plastic care 2) Surgery Wound coverage 1) Bypass Vascular Surgery 2) Venous Surgery surgery Ortho Foot & Ankle Surgery 1)Charcot 2)Biomechanics 3)Osteo

12 Angiosome:

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15 Limb salvage rate: diabetic pts. 4% (37/937) major amputation rate 2.7% (25/937) Primary amputation rate 1.3% (12/937) Failed salvage attempt Evans KK, J Diabetes Complications. 2011

16 Missing: PODIATRY Plastic Surgery Vascular Surgery Ortho Foot & Ankle Surgery

17 Podiatry: Interest in every aspect of diabetic foot care Expertise in biomechanics Prophylactic foot surgery Clinical trials

18 2003 Plastic Surgery Vascular Surgery Ortho Podiatry Micro /nerve

19 Case Study Surgical Offloading Patient Information: 55 y/o WM Medical History: Diabetes Type 2 x 15 yrs Surgical History: none Wound History: none, but worsening plantar lesions despite shoegear and debridement

20 Case Study Surgical Offloading Hammertoe Correction 2-5 Tendo Achilles Lengthening

21 Post Op Result 6 weeks 6 months

22 2009: Rheum Plastic Surgery Vascular Surgery Ortho Podiatry Micro /nerve

23 2010: new additions Podiatrist / research director Plastic surgeon: Micro Sacral decubitus AWR, chest wound Hyperbarist

24 2010: Rheum Plastic Surgery HBO Vascular Surgery Ortho Podiatry Micro /nerve

25 HOW TO PAY FOR IT?

26 Wound healing center: physical plant Easy access Most patients are on crutches, wheelchairs or gurneys Close to parking or valet parking Co-located facilities Registration, x-ray, HBO, vascular testing, physical therapy, orthotic lab

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29 Wound healing center: exam rooms Multiple exam rooms MD 10 min. Nurse min. Coordinate data entry Podiatric chairs Need to be to evaluate heel Good lighting Surgical instruments Individual peel pack from O.R. Sterilization

30 Wound healing center: EMR & data base Digital photography Digital x-ray Physical therapy Hyperbaric chambers Pic hbo Non-invasive vascular lab Orthotic & prosthetic lab

31 Wound healing center: outpatient Nurse practitioner(s) Case manager Nursing director Nurses Medical assistant(s) Cast tech(s) Hyperbaric technician(s) Receptionist(s) Photographer Billing specialist(s) Data entry tech Secretary Administrator

32 Outpatient center: physician or physician equivalent Quaterback Wound specialist Podiatrist Nurse practioner Physical therapy Hyperbarist Specialist clinic Orthopedics Vascular Plastic surgery Rheumqtology / Hematology

33 Physician reimbursement: hospital based clinic Physician reimbursement is 20 % lower because he/she does not have bear cost of space, equipment and personnel Physician does have to cover cost of billing and scheduling

34 Clinic expenses: cost usually > revenue Clinic cost = direct + indirect cost Direct Personnel Supplies Indirect cost Space Maintenance Security Debt repayment

35 Clinic revenue: $$$$$$$$$$ Clinic visit & procedure Clinic fee procedure driven Hospital index for collections 0.35 Covers direct costs at best Hospital in the red for indirect costs

36 Clinic revenue: covering the indirect cost Physical therapy Ultra-sonic mist therapy Ultra-sonic debridement Radio-frequency therapy Electro-magnetic therapy Lymphatic therapy Hyperbaric oxygen

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38 CMS COVERED HBO INDICATIONS 1. Acute carbon monoxide intoxication 2. Decompression illness 3. Gas embolism 4. Gas gangrene 5. Acute traumatic peripheral ischemia. 6. Crush injuries and suturing of severed limbs 7. Progressive necrotizing infections (necrotizing fasciitis) 8. Acute peripheral arterial insufficiency 9. Preparation and preservation of compromised skin grafts 10. Chronic refractory osteomyelitis 11. Osteoradionecrosis as an adjunct to conventional treatment 12. Soft tissue radionecrosis as an adjunct to conventional treatment 13. Cyanide poisoning 14. Actinomycosis, only as an adjunct to conventional therapy 15. Diabetic wounds of the lower extremities

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40 Reimbursement: dependant on Medicare Price per dive 4 x 1/2 hour increments / dive Single fee per dive for physician

41 Hospital based outpatient wound center: administration enthusiasm? At best a break even proposition! Hence Role of inpatient volume

42 Diabetic lower extremity ulcer cost: 1995 dollars 1995 Medicare spending for rx leg ulcer $1.45 billion $3,609 / pt Total medical cost of pts. with leg ulcer vs. rest of medicare pts. $15,309 vs. $5,206 Cost distribution 74% hospital care 11% outpatient care 11% home health care 4% hospice care HARRINGTON, DIABETES CARE 23(9):1333, 2000

43 USA hospital discharges: average charges & L.O.S. for DFU vs. other Number Mean Median Mean LOS Diabetes, Total 4,548,246 14,742$ 8,761$ 6.3 Foot Ulcer 147,110 16,919$ 10,831$ 8.9 Leg Amputation 88,314 26,715$ 17,302$ 12.0 MI 256,502 24,500$ 15,354$ 6.9 CABG 116,759 51,630$ 42,728$ 9.9 Stroke 235,914 18,074$ 11,054$ 7.7

44 Amputation vs. Salvage: long term cost (1992$) Primary healing Ulcer care $ 7,500 Amputation $ 50,000 J. Intern. Med. 1994, 235:463 3 year cost post healing Ulcer $ 16,100 26,700 Foot amputation $ 43,000 Major amputation $ 63,000 Foot & Ankle 1995, 16:388

45 Team approach: limb amputations by 82 % DRIVER V; DIABETES CARE 28:248, 2005

46 Wound center focus: diabetic limb salvage? Diabetic limb salvage Specialization brings most complex wounds (stage III & IV) Highest co-morbidities (DM, PVD, CAD, CRF) High DRGs (730.1_, , 785.4)) Admissions help justify hospital support of wound center Hospital collects 65% on the dollar on inpatient care Successful limb salvage = good patient care Prolongs life Protects contra-lateral limb Decreases health costs

47 Operative patients: patients for 1237 surgeries (avg. 2.4 / patient) 109 new clinic patients (1/3) 87 old patients 218 from in-patient consults 106 from E.R. Hospital service census averages 40 patients 20 wound patients 20 consults Downstream revenue > $37,000,000

48 High inpatient volume: expensive! Nurse practitioner(s) Preoperative clearances Floor management Discharge planning Floor management Hospitalist Consult: Endocrine, Infectious Disease, Nephrology Residents, nurse practitioner(s)

49 High inpatient volume: expensive! Dedicated wound service operating rooms 2 operating rooms 12 hour cut-off for pre-booking (most cases are emergent)

50 Total wound care: optimizing in and outpatient care Admissions are kept as brief as possible (nurse practitioner & case manager key) Debridement Control infection Revascularization Close wound Patient seen as a minimum weekly Close co-ordination between visiting nurses & wound center nurses

51 Challenges: Better evidence based protocols that LIMIT procedures but ensure maximal success. New look at biofilm and infection Viable financial model with new health care bill??

52 Team approach allows diabetics To keep on trucking!

53 Thank You