The Wound Care Evidence Summit will take place in Washington, D.C. April 1-2. If you are involved in this area, you need to register now because spots are limited. The meeting will convene commercial and government payer medical directors, the FDA, NIH senior staff, wound care researchers, manufacturers, and policymakers. Here’s a link to the agenda.
I thought I’d explore some of the issues that have troubled me since I got into this field.
I am exploring issues that trouble me in our field and that will be addressed at the summit. I hear payers, manufacturers, researchers and policy makers rend their clothes and pour ashes on their heads as they lament wound practitioners’ poor adherence to clinical practice guidelines. I’ve worked on this problem as hard as anyone and published more articles about it than most, but my droning is like the sound of flies buzzing. In 2010 we published an article entitled, “Why is it hard to do the right thing in wound care?” We found that only 17% of venous leg ulcers (VLUs) left a hospital-based outpatient wound clinic in adequate compression (they were being told to elevate or put in tubular bandages or ace wraps). Implementation of adequate diabetic foot ulcer (DFU) off-loading was even worse.
That’s why in 2014, the first two quality measures the US Wound Registry (USWR) submitted to CMS were adequate compression of VLUs and adequate off-loading of DFUs at each visit. In the 10 years since we published the “right thing” paper, thanks in large part to USWR quality measures, the USWR has set national benchmark rates for DFU off-loading and VLU compression, with both approaching adherence rates of 70% among practitioners who report those measures.
Every year I have to go into hand-to-hand combat with CMS to keep those two quality measures, because CMS intends to reject all “process” measures. CMS doesn’t think a process represents quality of care, even when the process is linked directly to outcome. We can prove that the better the performance rate with these two processes (along with arterial screening), the higher the healing rate of DFUs and VLUs. These two linchpin interventions hang in the balance every year, and no one but me is on the phone with CMS during those annual reviews to defend them. One year I was post-call and completely exhausted, and actually started to CRY on the phone with CMS. Yes, that year we kept off-loading and compression as quality measures because I WAS ACTUALLY CRYING. I am not proud of it, but that’s what happened. These two quality measures have dramatically increased the use of compression and offloading products, but the manufacturers of products used for offloading and compression do not support the USWR or measure development. But, that’s just me whining and I hate whiners even more than crybabies.
I used clinical practice guidelines (CPGs) to craft those quality measures, at least insofar as I was able. There are a lot of CPGs, but most of them can’t be implemented without a lot of re configuring. Whether a guideline is “implementable” refers to a set of characteristics that predict the relative ease of implementation of guideline recommendations. Instruments have been developed to guide the formulation of implementable recommendations. Australia even has “guidelines for guidelines.” I have spent the last 7 years trying to turn practice guidelines into quality measures, and then turn quality measures into clinical decision support inside wound care EHRs so that it is possible to give practitioners a “score” with regard to their implementation. I can tell you that it is darn hard to do this with the guidelines most organizations churn out. They analyze papers and then turn out guidelines that tell me, for example, that there’s no difference in the outcome of wounds debrided in the operating room vs the outpatient setting. Who cares? I am not taking patients to the operating room. If they need to go to the OR, I call a surgeon. What matters is that we get rid of the necrotic tissue, and that’s something that we DID have a quality measure for, but CMS rejected it because it was a “process.”
We’ve succeeded in turning a few core CPGs into quality measures, and we can show that they improve wound healing rates. But if you tried to turn most guidelines into implementable actions on an individual patient, and measure those actions through a quality process, you couldn’t do it because of the way they are written. However, when payers complain that they can’t be sure CPGs were followed, I have no patience. For many core PROCESSES, there are (at least for the time being) CMS-approved wound care quality measures which the USWR will license for free to any other Qualified Clinical Data Registry (QCDR). Any practitioner COULD report those quality measures to CMS through their QCDR of choice, as part of the Merit-Based Incentive Payment System (MIPS). If you want to improve adherence to evidence-based practice, then write implementable guidelines, turn them into CMS-approved quality measures and grade practitioners on their performance. In fact, PAY practitioners on the basis of their performance. I have earned the right to whine about this topic.
See you in D.C. in April. I will try not to whine or cry.
The GuideLine Implementability Appraisal (GLIA): development of an instrument to identify obstacles to guideline implementation, Shiffman, et al. BMC Medical Informatics and Decision Making 2005, 5:23doi:10.1186/1472-6947-5-23 https://rdcu.be/b1TRQ