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A C L I N I CA L PAT H WAY TO S U C C E SS
VOLUME 3 NO. 2 SPRING 2006 A PUBLICATION OF NATIONAL HEALING CORPORATION
wound
CLI PATIENTS ARE AT A HIGH RISK OF MYOCARDIAL INFARCTION, STROKE, AND VASCULAR DEATH.
Fontaine classifications on page 2). A large percentage of patients with CLI have coexisting diseases, such as cardiovascular and renal disorders. Furthermore, since many CLI patients are (continued on page 2)
HIGHLIGHTS INSIDE
CLI non-invasive treatments...........................2-3 PAD: The forgotten risk factor ...............................4 Advise for CLI patients ..........4 Diagnosing PAD .....................5 Cost of diabetic foot ulcers ...5 Chronic kidney disease and diabetes...........................6 HBO and CLI patients ............7 Working with a Wound Healing Center ..........8
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Many non-invasive treatments are available for patients with CLI and are revolutionizing the way they are treated. These include: Balloon angioplasty and stenting: for focal segments of narrowing or short occlusions of the iliac arteries. However, according to Novo et al (2004), recent reports reveal that percutaneous transluminal angioplasty or more complex endovascular procedures (e.g. excimer laser recanalization followed by balloon angioplasty) may be useful in treating arteries below the knee. Cryoplasty: a form of angioplasty that simultaneously dilates and cools the plaque and vessel wall in the treatment area and essentially opens leg (continued on page 3)
The following chart defines the ischemic rest pain of patients without skin lesions and the presence of ulcers or gangrene.
LERICHE-FONTAINE CLASSIFICATION
STAGES Stage I Stage IIA Stage II B Stage III A SYMPTOMS Asymptomatic or effort pain Effort pain/pain-free walking distance > 200 m Pain-free walking distance < 200 m Rest pain, ankle arterial pressure > 50 mm Hg Rest pain, ankle arterial pressure < 50 mm Hg Trophic lesions, necrosis or gangrene PATHOPHYSIOLOGY Relative hypoxia Relative hypoxia Relative hypoxia Cutaneous hypoxia, tissue acidosis, ischemic neuritis Cutaneous hypoxia, tissue acidosis, ischemic neuritis Cutaneous hypoxia, tissue acidosis, necrosis PATHOPHYSIOLOGY CLASSIFICATIONS Silent arteriopathy Stabilized arteriopathy, non-invalidant claudication Instable arteriopathy, invalidant claudication Instable arteriopathy, invalidant claudication Instable arteriopathy, invalidant claudication
Stage III B
Stage IV
Evolutive arteriopathy
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performed annually in the United States (Biamino, 2004). Contradictory studies on aggressive revascularization, however, do exist. Tunis et al (1991) reported that in the United States the increased use of interventional procedures (e.g. angioplasty, including stenting implant) between 19791989 did not result in fewer amputations. The rate of amputations, in fact, increased from 1 to 24 per 100,000 cases as did bypass surgery from
TO REDUCE THE RISK OF ADVERSE CARDIOVASCULAR EVENTS, OR EVEN DEATH, PATIENTS WITH CLI ARE URGED TO STOP SMOKING AS WELL AS SEEK PROPER TREATMENT FOR HYPERTENSION, DIABETES, AND HYPERLIPIDEMIA.
continued to smoke, versus 0 to 10% in those who refrained from smoking. In fact, even patients with severe end-stage PAD can benefit from smoking cessation (Diehm et al, 2004).
Risk factors for the development of CLI include age, smoking, Normal > 0.90 and diabetes Claudication 0.50-0.90 mellitus. Diabetic Rest Pain 0.21-0.49 patients are 10 times more likely Trophic lesions Tissue Loss necrosis or gangrene to need a major amputation than 32 to 65 per 100,000 non-diabetic PAD pacases. Conversely, Novo tients, so patients are et al (2004) reported that urged to aggressively a Swedish study revealed control their diabetes and that over an eight-year maintain fasting blood period there was a sugars below 120 mg/dL decrease from 42% to and post prandial sugars 27% in primary amputa< 180 mg/dL, according to tions associated with a Diehm et al. Chronic corresponding increase in management should aim revascularizations, at normalizing glycoheresulting in an overall moglobin levels to less decrease in amputation than 7% (Diehm et al, from 61% to 47%. 2004). Whats more, major amputation is Diehm et al (2004) also more frequent among reported that amputation PAD patients who smoke rates are highly correlatheavily. To reduce the risk ed with persistent cigaof adverse cardiovascular rette smoking. In two events, or even death, series, the amputation patients with CLI are rate was between 11% urged to stop smoking as and 23% in those who
ANKLE-BRACHIAL INDEX VALUES AND CLINICAL CLASSIFICATION
well as seek proper treatment for hypertension, diabetes, and hyperlipidemia. Smoking cessation also improves the viability of graft patencies for both vein and prosthetic graft material (Diehm et al, 2004). Non-invasive tests to properly diagnose patients with PAD (as well as ascertain the severity of the limb ischemia) include measurement of the ankle/ brachial index or the ankle and toe Doppler pressures. The detection of transcutaneous PO2 and PCO2 and diagnostic imaging studies are also effective tests. It is important to note that diabetic patients often have falsely elevated ABI readings of over 1.3 (Seiman, 2000).
arteries clogged with plaque so that patients can avoid or postpone amputation (Biamino, 2004). Pharmacotherapy (e.g. prostanoids): helps blood flow in CLI patients and could save 40% of lives and limbs. However, drugs will not replace surgery in CLI patients since surgery saves approximately 60% of limbs (Diehm et al, 2004). Topical therapies and hyperbaric oxygen treat ment: appropriate when revascularization has failed or is not technically possible. Reports on the use of hyperbaric oxygen in patients with early gangrene revealed that pain relief was obtained and amputations could be postponed.
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Patients should inspect feet daily, using mirror if necessary (especially between toes, pressure areas) Patients should avoid trauma to the endangered part of the limb Patients should take medications regularly Patients should avoid pressure in any part of the limb and swelling of the leg (edema) Patients should have their blood pressure, blood sugar, and blood lipids checked regularly Patient should wear appropriate footwear once feet are healed
SOURCE: DIEHM ET AL, 2004.
PAD IS A SERIOUS CLINICAL PROBLEM, POTENTIALLY LIFE-THREATENING, AND OFTEN GOES UNDIAGNOSED (BULL 2005).
The APBI can be calculated from the pressure in the ankle vessels and the brachial pressurea reading of (54%), compared with 71% of CVD patients. Smoking is the main risk factor for PAD. Other risk factors
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Health-economic consequences of
PAD ACCOUNTED FOR 1.43 HOSPITALIZATIONS PER PATIENT PER YEAR ON AVERAGE FROM 1985 - 1995. (MIGLIACCIO-WALLE ET AL, 2005).
only alleviating the symptoms of the disease, but treating the condition itself. Treatment includes using antiplatelet agents as well as other drugs. (Migliaccio-Walle, Caro, Ishak and OBrien 2005). Although there is a lot of information on the burden and impact of myocardial infarction, little information is available on the impact of PAD on resource utilization and costs (Migliaccio-Walle et al, 2005). A recent study by Migliaccio-Walle et al examined the impact of a PAD diagnosis on resource utilization and costs by studying a group of Canadian patients with the disease for more than a decade. The study also provides the basis for examining and understanding the economic implications of emerging treatments of the disease. By treating risk factors (CVD)-related. Procedures were divided into angiography, coronary artery bypass graft, percutaneous transluminal coronary angioplasty, and PADrelated procedures such as amputation, embolectomy, or arterial surgery, for example. Hospitalization as a result of bleeds were a part of this cost analysis. Corresponding inpatient care unit costs for CVD- and bleed-related diagnoses were used and these costs were then applied on a patientby-patient basis to the resources consumed in each period (MigliaccioWalle et al).
Length of stay
The average length of hospital stay for PAD patients was 11.6 days but length of hospital stays ranged from as low as 8.7 days to as high as 45 days. Patients who were hospitalized for a bleeding event were hospitalized on average, the longest, followed by CVD-related events.
Costs
The total cost for related hospitalizations (CVD, PAD, and bleed) following a PAD diagnosis ranged from $4.5 million (Canadian dollars) in year nine to $13.3 million (Canadian dollars) in year one and the average cost per patient hospitalized as a result of CVD is approximately $76,151 (Canadian dollars).
Hospitalizations
In terms of hospitalizations, for those diagnosed with PAD, 10.7% were hospitalized about 1.08 times in the first month
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IN THE UNITED STATES, DIABETES IS THE CAUSE OF 50% OF ALL NON-TRAUMATIC LOWER EXTREMITY AMPUTATIONS AND THAT NUMBER CONTINUES TO INCREASE EACH YEAR (BROERSMA, 2004).
patients survival. Improving the level of foot care, as well as properly educating patients and nephrology health care providers on proper diabetic foot care, is the first step in increasing a patients overall survival (Broersma, 2004). In fact, for the more than 40% of U.S. patients who begin chronic dialysis, diabetes mellitus is the main cause of renal failure. According to Fotieo and Reiber (1999), diabetes mellitus affected approximately 15.7 million Americans in 1999 and its complications accounted for approximately 12% of medical expenses, amounting close to $26 billion. Whats more, patients with diabetes and chronic renal disease frequently present with a combination of devastating diabetes complicaIn the United States, diabetes is the cause of 50% of all non-traumatic lower extremity amputations and that number continues to increase each year (Broersma, 2004). Because of this, the cost of treating patients with diabetes has skyrocketed and is detrimentally affecting the patients quality of life. Multiple factors may be responsible for the vast increase in lower extremity amputation among patients with diabetes and CKD. One reason may be related to the fact that dialysis patients often lose contact with their primary care physicians once in a dialysis setting. Therefore, many CKD patients may not receive adequate medical advice on potential foot problems. According to Broersma doctors visit for those patients with neuropathy, for example. Diabetic foot assessments also should be used to identify risk factors as well as other preventative measures or potential problems. According to a study by Mazze, Etzwiler, Strock, McClave, Leigh, Owens, Deebs, Peterson and Kummer (1994), amputation rates were reduced by 28% when certain individuals were screened for high-risk foot prob lems and subsequently targeted with simple interventions, including patient education. Furthermore, patients with diabetes and CKD often have frequent contact with nephrology nurses, offering them numerous opportunities for risk assessment, education, and early intervention.
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Indications for
HBO
Medicare has approved reimbursement for HBO therapy when the following diagnoses are made: Actinomycosis Acute carbon monoxide intoxication Acute peripheral arterial insufficiency Acute traumatic peripheral ischemia Chronic refractory osteomyelitis Crush injuries and suture (reattachments) of severed limbs Cyanide poisoning Decompression illness Diabetic wounds of the lower extremities Gas embolism Gas gangrene Osteoradionecrosis Preparation and preservation of compromised skin grafts Progressive necrotizing infections Soft tissue radiation injury
Selected bibliography
Apelqvist J., Tennvall GR. (2005). Counting the Cost of the Diabetic Foot. Diabetes Voice, 50, 8-10. Biamino G. (2004). Cardiovascular Horizons Conference Presentation. Biomedical Safety & Standards (2005). CryoPlasty Therapy May Avert Amputation. Broersma A. (2004). Preventing Amputations in Patients with Diabetes and Chronic Kidney Disease. Nephrology Nursing Journal, 31 (1), 53-64. Bull M. (2005). Peripheral Arterial DiseaseThe Forgotten Risk Factor. Practice Nurse, 30, 4. Coughlin M, Shurnas P. (2003). Hallux Rigidus: Grading and Long-Term Results of Operative Treatment. The Journal of Bone and Joint Surgery, 85-A (11), 2072-2088. Diehm C, Diehm N. (2004). Non-Invasive Treatment of Critical Limb Ischemia. Current Drug TargetsCardiovascular & Haematological Disorders, 4, 241-247. Fotieo G, Reiber G. (1999). Diabetic Amputations in the VA: Are there Opportunities for Interventions? Journal of Rehabilitation & Development, 36 (1), 55-60. Grolman RE, Wilkerson DK, Taylor J, Allinson P, Zatina MA. (2001). Transcutaneous oxygen measurements predict a beneficial response to hyperbaric oxygen therapy in patients with nonhealing wounds and critical limb ischemia. The American Surgeon, 67(11):1072-9. Migliaccio-Walle K, Caro J, Ishak K, OBrien J. (2005). Costs and Medical Care Consequences Associated with the Diagnosis of Peripheral Arterial Disease. Pharmacoeconomics, 23 (7), 733-742. Mueller M, Sinacore D, Kent Hastings M, Strube M, Johnson J. (2003). Effect of Achilles Tendon Lengthening on Neuropathic Plantar Ulcers. The Journal of Bone and Joint Surgery, 85-A (8), 1436-1445. Novo S, Coppola G, Milio G. (2004). Critical Limb Ischemia: Definition and Natural History. Current Drug Targets-Cardiovascular & Haematological Disorders, 4, 219-225. Tennvall GR, Apelqvst A. (2004). Health-Economic Consequences of Diabetic Foot Lesions. Clinical Infectious Diseases, 39 (Suppl 2), S132-S138.
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QUESTIONS OR COMMENTS?
Contact Heather Cicero at 888.332.0202 or hcicero@nationalhealing.com
CLINICAL ADVISORS
Katy Rowland, RN, MBA
SVP, Clinical Services
NATIONAL HEALING
www.nationalhealing.com
2006, National Healing Corporation
CONSIDER REFERRING YOUR PATIENTS TO A WOUND HEALING CENTER FOR ADVANCED WOUND CARE IF:
A wound persists for more than 30 days with conservative treatment Your patient has a wound and also has circulatory problems, diabetes, or is obese Your patient has a wound or suffers from chronic pain and has had radiation therapy in the past Your patient has had a recent revascularization procedure or with a questionable vascular supply You are considering peripheral vascular surgical procedures or amputation.