The SVS WIfI Classification: Does It Predict Amputation in Diabetic Patients?

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1 The SVS WIfI Classification: Does It Predict Amputation in Diabetic Patients? Christopher J. Abularrage, MD, FACS The Bertram M. Bernheim Associate Professor of Surgery Division of Vascular Surgery and Endovascular Therapy The Johns Hopkins Hospital May 25, 2017

2 DISCLOSURES Christopher Abularrage, MD No relevant financial relationship reported

3 Disclosures None

4 The Diabetic Foot Neuropathy Limb Vascular Disease Ulceration 25% Charcot Arthropathy Loss Local Trauma

5 Diabetic Foot Ulcers An Epidemic

6 Diabetic Foot Ulcers Cost

7 Diabetic Foot Ulcers Predictors of Cost

8 Predicting Risk Not All Wounds Are The Same

9 Predicting Risk Not All Wounds Are The Same

10 Predicting Risk Not All Wounds Are The Same

11 The WIfI Classification

12 The WIfI Classification

13 The WIfI Classification Validation

14 The WIfI Classification

15 The WIfI Classification Time to wound healing

16 The WIfI Classification Time to wound healing

17 The WIfI Classification Major amputation at 1 year Beropoulis et al. (Non-DM Endo) Causey et al. (Multi D) Robinson et al. (Multi D) Darling et al. (Tibial Endo) Ward et al. (Safety net) Stage 1 Stage 2 Stage 3 Stage 4 0% 2% 3% 12% 0% 8% 5% 20% 4% 16% 10% 22% 0% 10% 11% 24% 0% 14% 21% 34% Cull et al. 3% 10% 23% 40% (Any revasc) Zhan et al. 0% 0% 8% 64%

18 The Diabetic Foot How do you improve outcomes for WIfI Stage 3 & 4?

19 A multifactorial problem needs a multidisciplinary approach Podiatry and vascular surgery Consultants as necessary ID, Endo, Ortho, plastics, orthotics, Cards

20 A multifactorial problem needs a multidisciplinary approach

21 A multifactorial problem needs a multidisciplinary approach Podiatry, vascular surgery, plastics Consultants as necessary ID, Endo, Ortho, orthotics, Cards

22 A multifactorial problem needs a multidisciplinary approach

23 A multifactorial problem needs a multidisciplinary approach

24 The Johns Hopkins Experience Multidisciplinary Diabetic Foot & Wound Service Multidisciplinary team Vascular surgery, surgical podiatry, endocrinology Single clinic visit Robust home health nursing group Consultants Ortho foot & ankle, plastic surgery, ID, PMNR Inpatient/outpatient

25 The Johns Hopkins Experience Multidisciplinary Diabetic Foot & Wound Service July 2012 Dec Diabetic patients 412 wounds 58% WIfI Stage 3 or Debridments & minor amputations 118 revascularizations

26 The Johns Hopkins Experience Socioeconomic deprivation Area deprivation index

27 The Johns Hopkins Experience Multidisciplinary Diabetic Foot & Wound Service Glucose control n (%) P Baseline A1C 8.58%.0001 Nadir A1C 7.89%

28 The Johns Hopkins Experience Multidisciplinary Diabetic Foot & Wound Service Wound healing at 1 year P<.001

29 The Johns Hopkins Experience Multidisciplinary Diabetic Foot & Wound Service Major amputation at 1 year P=.56

30 The 1 Yr Major Johns Hopkins Experience Amputation Stage 1 Stage 2 Stage 3 Stage 4 Multidisciplinary Diabetic Foot & Wound Service 0% 6% 3% 6% Hopkins (DM Only) Beropoulis et al. (Non-DM Endo) Causey et al. (Multi D) Robinson et al. (Multi D) Darling et al. (Tibial Endo) Ward et al. (Safety net) Cull et al. (Any revasc) 0% 2% 3% 12% 0% 8% 5% 20% 4% 16% 10% 22% 0% 10% 11% 24% 0% 14% 21% 34% 3% 10% 23% 40% Zhan et al. 0% 0% 8% 64%

31 The Johns Hopkins Experience Multidisciplinary Diabetic Foot & Wound Service 1 year outcomes stratified by PAD Wound Healing Stage 1 Stage 4 P-value PAD 93% 69%.003 No PAD 95% 72%.02 Major Amputation PAD 1% 5%.64 No PAD 8% 10%.81

32 The Johns Hopkins Experience Multidisciplinary Diabetic Foot & Wound Service Causes of amputation All Patients (n=13) Progression of Infection (n=11) Ischemia (n=2)

33 Costs of Care

34 The Diabetic Foot & The GBR

35 The Diabetic Foot & The GBR 1. How do you control escalating costs? 2. Are WIfI Stage 4 wounds worth the effort?

36 Diabetic Limb Salvage Teams Costs Early referral=earlier presentation of disease=lower stage Lower stageàdecreased long-term costs

37 The Need for a Diabetic Foot Service Costs Single Center Study examining Outcomes Pre/Post DFS Decreased Amputations Decreased Surgeries Conclusion Early referral to DFS= 1. Earlier presentation of disease 2. Reduced delays to treatment 3. Decreased costs of care

38 The Johns Hopkins Experience Controlling costs: Downstaging new wounds n (%) New wounds after initial presentation 328 Downstaged new wound (or Stage 1) 197 (60%)

39 The Johns Hopkins Experience Readmissions n (%) Admissions 328 Surgeries d Readmissions 78 (23.8%) 30d Unplanned readmissions 61 (18.6%) DFU Related 57 (17.4%)

40 The Johns Hopkins Experience Causes of Any Unplanned Readmission Reason for Readmission n (%) Wound foot 32 (42%) Bypass wound or thrombosis 11 (14%) Gastrointestinal 8 (10%) Cardiac 6 (8%) Renal 6 (8%) Pulmonary 4 (5%) Hypo/hyperglycemia 3 (4%) Opposite leg 2 (3%) Neurologic 1 (1%) Other (PICC malfxn, IVDO) 3 (4%)

41 The Johns Hopkins Experience Overall costs of multidisciplinary care Inpt & Outpt $$$ Stage 1 Stage 2 Stage 3 Stage 4 P Net Revenue 13,022 15,776 41,119 57,277 <.001 Total Cost 13,016 15,075 37,317 52,410 <.001 Variable Direct 5,649 6,387 16,391 24,266 <.001 Variable Indirect 1,535 1,784 4,069 5,624 <.001 Fixed Direct 1,023 1,316 4,112 4,903 <.001 Fixed Indirect 4,809 5,588 12,745 17,617 <.001 Variable Net Margin 5,818 8,766 21,850 26,016 <.001 Overall Net Margin ,803 4,867.02

42 Conclusions Multidisciplinary teams improve outcomes and control costs in limb salvage Stage 4 WIfI wounds are associated with the best margin (good for institution) Downstaging of new wounds by multidisciplinary care leads to long-term controlling of costs (good for payors) SUCCESS Opening lines of communication Breaking down barriers to expeditious care

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