I’ve attached a link to a Kaiser Health News article that came out today (June 28) about Hyperbaric Oxygen Therapy (HBOT) that is less than flattering, and another in the Washington Post printed yesterday by the same author.
Some of the battles we face in hyperbaric medicine and wound care are of our own making, and some are not. Because non-healing wounds are a SYMPTOM of a disease, rather than a disease itself we remain the ugly step children of other specialties. Chronic non-healing wounds cost more than heart-failure and have a higher mortality rate than breast or colon cancer but there is no comparable investment in research. The American Diabetes Association’s Dr. Cefalu can make dismissive comments regarding the evidence based for HBOT in diabetic foot ulcers (DFUs), but I wonder if he’s ever had to write a personal check to fund his research, like many (if not most) of us in the field of hyperbaric medicine have?
By the way, below is a link to a new guideline synthesis for diabetic foot ulcers which shows how the strength of evidence for HBOT compares with other interventions, and the answer is – favorably. Multimillion dollar clinical trials of cellular products have thus far enrolled only Wagner 1 diabetic foot ulcers, whereas HBOT studies have enrolled Wagner 3 DFUs – the ones at risk of amputation. I have already blogged about the Fedorko trial from Canada, which determined outcome by showing wound photographs to surgeons and asking whether they would amputate a patient with that wound, rather than using the actual outcome of patients treated with HBOT. Many patients who were allocated to the “photo-amputated” category have posted You tube videos of themselves walking around on two legs with healed wounds.
Here’s what is NOT incorrect about the articles below. HBOT has been improperly used by some individuals and institutions. As someone who spent a long time trying to understand how best to use transcutaneous oximetry, the misuse of TCOM as a way to “get patients in the chamber” really upsets me. The reason there is a question as to whether HBOT works for diabetic foot ulcers is because some patients have received HBOT who didn’t need it because they were going to get well anyway, and some patients received it who likely could not be helped. Both of those problems could be solved by using the proper kind of decision tree.
I provided a practical and cost effective approach to the use of HBOT for DFUs in a recent article in Plastic and Reconstructive Surgery. You can view the entire article for free here:
What’s true about these two unflattering articles is that HBOT isn’t effective when it’s used in the wrong patients. For example, there are patients getting HBOT who have not been properly screened for arterial disease, or properly off loaded, and that’s why HBOT is under a “prior authorization” mandate in some states that is likely to be expanded. That’s also why the US Wound Registry (USWR) has developed an “Appropriate use of HBOT for diabetic foot ulcers” quality measure. This measure is hard to pass. I’ll describe it more in a future post.
HBOT can save diabetic limbs from amputation when it is used appropriately. Sadly, it is not always used appropriately. If clinicians want to demonstrate that they are following evidence based guidelines and using HBOT appropriately for DFUs, they can demonstrate this by reporting the Appropriate use quality measure through the USWR. This measure can be reported for MIPS credit through the USWR Qualified Clinical Data Registry. Only physicians committed to the highest level of clinical excellence can succeed with this quality measure. I wonder what kind of article would have been written about the value of HBOT in diabetic foot ulcers, if every hyperbaric medicine practitioner had been reporting HBOT quality measures?
Longer article more details:
Quality Matters. Do the Right Thing.