Abstract and Introduction
Management of chronic wounds, specifically those of the lower extremity, varies considerably by geographic region. The consequences of low-quality care perpetuate poor outcomes and low value for patients and the health care system. The emergence of value-based health care has forced stakeholders to evaluate care from quality and cost perspectives. This review presents a replicable quality assessment model for limb salvage specialists to apply to their practices. This model will foster increased collaboration between caregivers across all disciplines in an effort to increase quality care assurances for patients with chronic wounds of the lower extremity. Current approaches to quality assessment in the management of such wounds are outlined, and areas for innovation, such as collaborative initiatives, are highlighted. Use of the Donabedian model to provide quality and value to patients undergoing treatment for chronic wounds at a tertiary limb salvage center is also described. A value-based care system can be comprehensively assessed using the Donabedian framework. A pay-for-performance approach has largely guided health care reform in the United States; however, the effects of this approach have been incongruent with its intent. Limb salvage centers work to rectify this imbalance and continually evaluate quality measures to improve care. Collaborative quality initiatives have resulted in improved outcomes and cost savings in multiple specialties, and multidisciplinary limb salvage centers may benefit from such infrastructure. Limb salvage specialists have an important role in determining whether health care quality improvements are internally or externally driven. Existing quality assessment tools are imperfect, and the consequences of low-quality care of chronic wounds can be devastating. Through collaboration across institutions and the use of validated quality assessment tools such as the Donabedian model, chronic wound specialists can be leaders in developing and implementing quality care measures.
Chronic wounds are those that do not regain normal functional and anatomic characteristics within 3 months, and they can be broadly classified into the following 4 categories: pressure ulcers, diabetic ulcers, venous ulcers, and arterial insufficiency ulcers. Data indicate that chronic wounds affect 1% to 2% of the population in economically developed countries, with rates as high as 15% in certain populations, namely Medicare beneficiaries in the United States.[1,2] Patient-reported outcomes for physical functioning and pain are consistently low in the setting of a chronic lower extremity wound, which has broad implications for quality of life, mortality, and cost. Chronic wounds are also a significant driver of cost in the US health care system. Estimated Medicare spending for all wound types was $28.1 billion to $96.8 billion in 2014; by comparison, in 2017, a total of $34.6 billion was spent on insulin and medication to treat diabetes directly. Diabetic foot ulcers, specifically, accounted for $6.2 billion to $18.7 billion of estimated Medicare spending for all wound types in 2014.
Patients with persistent wounds are at increased risk for lower extremity amputation (LEA). After LEA for chronic wounds, mortality rates rise dramatically, ranging from 60% to 80% at 5 years.[5,6] Given that diabetes-related amputations are on the rise in the United States, there is cause for concern.
Therefore, it is critical for wound care specialists to engage in cost and quality improvement efforts. If providers do not establish self-directed initiatives for quality provision, stakeholders with differing agendas may produce initiatives through insurance policy reform and governmental mandates that are counterproductive to patient care and surgical practices. The onus is on limb salvage providers to take the lead and outline quality measures to ensure internally driven quality care.
This review outlines the current approaches to quality assessment in the surgical management of chronic wounds of the lower extremity and highlights areas for innovation, such as collaborative initiatives. The authors also describe the use of the Donabedian model to provide quality and value to patients with chronic wounds at the authors' tertiary limb salvage center. The aim of this review is to offer a replicable method for limb salvage specialists to apply to their practices to foster increased collaboration between caregivers across all disciplines in an effort to increase quality care assurances for patients with chronic wounds of the lower extremity.
Wounds. 2022;34(3):75-82. © 2022 HMP Communications, LLC