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All content following this page was uploaded by Gregory Bohn on 18 July 2018.
Disclosure: Drs. de Leon, Bohn, DiDomenico, Fearmonti, Gottlieb, Lincoln, Shah, Shaw, Taveau IV, Thibodeaux, Thom-
as, and Treadwell are consultants to KCI, an Acelity company. This article is part of an Acelity-funded supplement.
While Acelity provided editorial assistance, the views expressed regarding treatment regimen, product selection, and
usage remain exclusively those of the participating physicians.
Abstract: Many wound care centers (WCCs) provide a specialized level of care using various wound care therapies
and are managed by qualified healthcare professionals (QHPs) from different specialty backgrounds such as family
medicine, podiatry, and plastic surgery. However, these QHPs are sometimes challenged by reimbursement issues,
limited therapy and dressing options, reduced access to multidisciplinary team members, and cost-driven factors
unique to WCCs. To help address these issues, a meeting was convened by an expert panel of WCC physicians to
discuss best practices for treating complex patients in a WCC. This publication presents an overview of WCC chal-
lenges, describes a holistic approach to treating WCC patients, and provides clinical guidance on the decision-mak-
ing process for selecting optimal treatment plans for the WCC patient. Clinical cases of atypical, surgical and chronic
wounds seen in a WCC are also presented.
Key Words: wound healing, chronic wounds, advanced wound therapy, wound care center
INTRODUCTION Since the introduction of OPPS, HOPDs specialties. All of these wound healing spe-
Review of wound care centers. An aging have been opening throughout the United cialists bring their own unique professional
population with multiple comorbidi- States at a rapid pace, as have many other training with them to the field, the WCC,
ties has led to an increasing prevalence of outpatient services. The rising number of and the patient experience. Importantly,
nonhealing wounds. Meanwhile, in the malpractice claims, particularly those in- WCCs are not meant to treat any patient
United States, reductions in acute care volving treatment of diabetic foot ulcers who could just as easily be managed in a
spending have driven more care to the out- (DFUs),3 have also led to an increase in primary care physician’s office. Local cov-
patient setting.1 In 2000, the Centers for referrals of patients with DFUs and other erage determinations (LCDs) issued by
Medicare & Medicaid Services (CMS) de- complex wounds to wound care centers Medicare administrative contractors deter-
fined a payment system referred to as the (WCCs) for specialized care.3 With diabe- mine which services are “medically neces-
Medicare Outpatient Prospective Payment tes on an unprecedented rise, these WCCs sary” or covered in the HOPD;4 however,
System (OPPS), which was developed to have become a necessity for patient health in some cases, the provider is capable of
allow people who were not sick enough as well as a critical economic entity. treating the patient in the office but prefers
to warrant acute care hospitalization the Wound care centers offer a specialized to treat in a WCC. Additionally, a WCC
opportunity to receive complex services level of care with a variety of wound heal- may choose to provide preventive care after
as outpatients. Hospital-based outpatient ing services typically not available in a pri- the wound has healed, which many LCDs
wound care departments (HOPDs) began vate office. They are usually managed by specifically do not cover in HOPDs.
to appear as a result of the new OPPS and qualified health care professionals (QHP) The term “wound care center” can refer
acute care cost shifting.1,2 Reimbursement who come from many different special- to an HOPD or a free-standing wound
issues described in this publication largely ty backgrounds. These QHPs may have clinic office of a QHP. The location (e.g.,
center around CMS policies, which may or expert training in family medicine, podi- rural vs. urban or hospital vs. office build-
may not be similar to policies of private in- atry, vascular surgery, physical medicine ing) can determine level of access to var-
surance companies. and rehabilitation, plastic surgery, or other ious specialties, as well as reimbursement
no insurance requirement that a plain film would only cover the cost of one dressing is critical in decision making. The “value
be performed to evaluate for osteomyelitis in the wound/ulcer and one on the wound/ proposition” of WCCs is now changing
before any approval for an MRI. An inpa- ulcer, not three products. from generating revenue to saving overall
tient is more likely to move directly to an Additionally, there are few advanced skin costs.2 A major challenge lies in meeting
MRI to evaluate for osteomyelitis, since an substitute options for pressure ulcers, com- new OPPS regulations that demand an ex-
MRI is more sensitive, and there is a rea- pared to those for DFUs in the outpatient perienced wound center management team
sonable chance that plain film will not re- setting. However, in patients with comor- to manage documentation, processing,
veal osteomyelitis. bidities, such as patients with cancer on training, regulations, and financial review–
More advanced inpatient treatment can chemotherapy or post radiation, patients all while reducing expenses.
be applied to complex wounds/ulcers that with rheumatoid arthritis on high dose im- It was the belief of panel members that
have been open for less than 30 days but munosuppression, or nonoperative candi- WCCs can remain profitable, but only if
are starting to decline. For example, use of dates with pressure ulcers, a more advanced managed well. Collecting data on patient
advanced skin substitutes and NPWT can strategy to stimulate fibroblast function population, wound types, healing rates
be used to manage the wound for an inpa- and collagen and growth factor production and supply costs can assist in making more
tient with a surgical wound that will be even could help advance the ulcer through the sound decisions concerning product selec-
more difficult to improve after 30 days of phases of healing and potentially prevent tion. Each product or grouping of prod-
failure. Similarly, a patient with a wound/ further complications and hospitalizations. ucts (e.g., alginates, foams, collagens, etc.)
ulcer may benefit from the use of collagen Advanced care may be considered in the in- should be evaluated with some level of
to help promote granulation, an alginate patient setting for these high-risk patients evidence in literature and real-life data to
to help pack the depth, and bordered foam to reduce length of stay or reduce level of stock the most cost-effective and efficient
dressing to maintain the moist environment acuity in the next setting, but outpatients regimen of dressings at the WCC. The
and remove exudate. An inpatient would would not be covered for these therapies. system of evaluating new products should
receive all three dressings, but the CMS sur- Cost reduction in wound care centers. All be standardized and demand certain levels
gical dressing policy on a similar outpatient panel members stressed that cost containment of evidence. Ideally, products are acquired
for reporting that have been suggested by which will likely feature a bundled form of ATYPICAL WOUNDS: SPECIAL
the U.S. Wound Registry. payment. To remain profitable, it is cru- CONSIDERATIONS FOR TREATMENT
Does the therapy address pathophysiologi- cial that each WCC designate persons who Atypical wounds are also known as
cal needs of the wound? Pathophysiological closely follow the latest coverage rules that wounds of unknown etiology and are
aspects involved in normal and impaired specify coverage indications, limitations, caused by conditions or diseases that do
wound healing are detailed earlier in this and/or medical necessity, covered/non- not typically form a wound, such as auto-
manuscript. Panel members stressed the covered product codes, procedure codes immune disorders, infectious diseases, vas-
critical importance for QHPs to understand and modifiers, covered diagnosis codes, cular diseases and vasculopathies, metabol-
the complex clinical processes of normal and utilization guidelines, and documentation ic and genetic diseases, neoplasm, external
delayed wound repair, which allows QHPs guidelines.87 While it is paramount to un- factors, psychiatric disorders, and drug-re-
to better determine the pathophysiological derstand all of the current nuances of re- lated reactions. Many systemic diseases can
needs of each wound during assessment. imbursement in WCCs, future survival of present with atypical wounds. The primary
Pathophysiology is the study of the dis- each WCC will depend on how well QHPs cause of the wound can be either the sys-
ordered physiological processes associated are prepared for a reimbursement system temic disease itself (e.g., Crohn’s disease)
with or resulting from the disease or inju- tied to QMs. or an aberrant immune response due to
ry. Concepts in wound healing pathophys- Is the product/therapy available to the pa- systemic disease (e.g., pyoderma gangreno-
iology help determine the type of dressing/ tient in the wound care center and at home? sum, paraneoplastic syndrome). It has been
therapy needed, as well as when to transition Before selecting a treatment, it is import- recommended to suspect causes, other than
to a different therapy. Table 8 displays a sug- ant to determine if the product or thera- venous insufficiency, for lower leg ulcers if
gested list of dressings and therapies based py is available to the patient both within the wound has been present for longer than
on assessment and the suspected pathophys- the WCC and at home. Home health care six months, has not responded to good
iological needs of the wound and Figure 5 agencies often have a narrow selection of care, or looks atypical, such as the presence
summarizes recommended dressing/therapy products and avoid providing more expen- of necrotic tissue, exposed tendon, livedo
use by wound healing phase. sive collagen or silver dressings, or even reticularis on surrounding skin, or a deep
Is the product/therapy reimbursed in this care high quality foams and alginates. Unfortu- “punched-out” ulcer.88 Laboratory tests
setting? Payer reimbursement policies for nately, this can limit the outpatient WCC (Table 9) are recommended to screen for
products, therapies, and services rendered in in the type of wound care products they atypical wounds.88
WCCs are complex and ever changing. Cur- can use with patients who will be using Diagnosing an atypical wound. Tissue bi-
rently, it is paramount to choose individual home health agency services. In addition, opsy is recommended for differential diag-
dressings and therapies only if they are reim- certain dressings favored by QHPs may not nosis of inflammatory, microthrombotic,
bursed. However, a major shift toward qual- be allowed in the clinic due to the hospital’s and bullous disorders such as nonathero-
ity-based reimbursement is on the horizon, contractual agreements with suppliers. sclerotic ischemic ulcers (i.e., vasculitis,
vasculopathy), inflammatory conditions, a larger area of tissue may be indicated. In affect ribonucleic acid synthesis. This can af-
malignancies, infections, autoimmune bul- cases where the biopsy does not help diag- fect basal keratinocyte and collagen synthesis.
lous disorders, venous ulcers, neuropathic nose the wound etiology, panel members Some new oncology drugs also trigger skin
ulcers, medication-induced wounds, pres- recommended reviewing the patient’s med- reactions. Tracking the timing of chemo-
sure ulcers, and traumatic wounds.89 If a ical history again. For example, long-term therapy is necessary, as it can be the cycle
punch biopsy performed in an outpatient hydroxyurea treatment can lead to atypical of the medication, not just the medication
setting fails to confirm a suspected diagnosis ulcers due to cell damage. Hydroxyurea se- itself, causing the wound.
in a wound that has failed other treatment lectively kills cells during the synthesis phase Atypical Wound Treatment. Usual wound
measures, a surgical biopsy that can sample of the cell cycle (i.e., S phase) but does not care therapies are not effective in healing
CONCLUSIONS
Outpatient wound care is continuous-
ly evolving to accommodate an increased
number of patients with complex wounds
needing specialized care. As of 2016, there
is a renewed payer focus on cost contain-
ment, which includes reducing the amount
of time it takes to heal a wound. In fact,
a considerable amount of the direct and
indirect costs of wound healing depends
on time to closure. With the implemen-
tation of QMs, time to closure becomes
even more of a consideration in outpatient
Figure 11. (A) Infected deep abscess and diabetic foot ulcer infection following initial surgical
debridement. (B) The wound at 1 week following third toe amputation, surgical debridement, and wound management. Future reimburse-
hyperbaric oxygen therapy (HBOT); negative pressure wound therapy (NPWT) was initiated. (C) ment will depend in part on time to clo-
The wound at 7 weeks, following HBOT and NPWT. (D) The wound at 8 weeks (1 week after epider- sure, and allowed treatments will likely dif-
mal graft placement). (E) The wound at 10 weeks. (F) The fully reepithelialized wound at 17 weeks. fer from patient to patient, depending on
comorbidities and lifestyle factors.
care is judicious, cost-effective use of these tial incision, drainage, and resection of third To help guide decision making for payers and
evidence-based therapeutic tools to achieve metatarsal head (Figure 11A). The patient QHPs, there remains a considerable need for con-
quality measures. had a prior medical history of hypertension. trolled, comparative studies of dressings, therapies,
Case study: chronic diabetic foot ulcer with Therapy goals included debridement, pro- and various combinations of each in managing a
exposed tendon. A 54-year-old male presented motion of granulation tissue formation over variety of wound types in a real world outpatient
with an infected Wagner Grade 3 DFU with tendon and wound bed, and rapid closure. setting. Each of these comparative studies must
exposed tendon and a deep abscess post ini- Among the pathophysiological concerns include a robust cost analysis component. Even
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