Heal Ohio 2008

Plan

Update / Overview: Mostow Topical Oxygen: Gordillo New treatment(s): Lee Lymphedema: Beinlich and Fruscella Prosthetic venous Valve: Treating

Disease not Symptoms: Schmidt

Extent of the Problem

$Many billions8

• Dr visits: $520/pt8

• Hospital: $16,000/pt8

>$6 billion6

$Many billions3

Estimated Annual Direct Cost (USD)

10-18% (acute care)Up to 28% (extended care)7

882,0004,5

2.5 million1,2

Prevalence

Pressure

Diabetic

Venous

Wound Type

1Philips T, et al. J Am Acad Dermatol. 1994;31:49-53.2Brem H, et al. Am J Surg. 2004;188(1A Suppl): 1-8.3Based on estimated prevalence of 2.5 million and actual mean direct cost of $9685/person : Olin et al. Vasc Med. 1999;4:1-7.4Based on 14.7 million diabetics: CDC, 2005, 6% of whom expected to develop ulcers over 3 years: 5Ramsey SD, et al. Diabetes Care. 1999;22(3):382-87.6Direct costs of treating non-infected diabetic foot ulcers; Gordois A, et al. Diabetes Care. 2003;26:1790-5.7Cuddigan J, et al. for the National Pressure Ulcer Adv Panel. Adv Skin Wound Care. 2001;14:209-15.8Costs in 1996 and 1998, Kumar RN, et al. Adv Skin Wound Care. 2004;17(3):143-9.

Pt=patient

Needs debridement

Undermining

Infection

Co-morbidities

Evaluate with EBM criteria

Facts

Facts are stubborn things; and whatever may be our wishes, our inclinations, or the dictates of our passions, they cannot alter the state of facts and evidence.John Adams, second president

EBM

"the conscientious, explicit and judicious use of current best evidence in making decisions about the care of individual patients,"

-David L. Sackett, MD, professor of medicine at Oxford University

EBM problems

“Tools” are tough to put into practice Limited help in the many “gray areas” of

medicine (when there just isn’t good evidence…yet)

Even with internet resources, translation to individual patients not always straightforwardClinical judgementPatient preferences.

EBM problems

Evidence presentation issuesRelative risksAbsolute risksEX: RR 0.5 for outcome (50% decreased

risk) vs. 8/1000 vs. 4/1000○ Presentation of data can affect physician

interpretation & practice patterns

EBM concerns

Litigation misuse of EBM Managed care misuse of EBM “Evidence” versus “I know my patients

are getting better with what I’m doing”Clinical judgment vs self-delusionAutonomy issues

EBM Answers

Nothing wrong with evidence Evidence just tells you what happens

under certain circumstancesDoc still has to translate how that pertains to

your patient’s circumstances…your patient may differ in important ways

Question

Is pentoxifylline (Trental) of any benefit for patients with venous leg ulcers?MethylxanthineIncreased filterability of RBCsSuppressed synthesis of TNF-alpha from

lipopolysaccharide (LPS)-stimulated human monocytes in cell cultures and in vivo

Question Resource “Prefiltered” evidence-based medicine

resourcesBest Evidence ($85, CD…ACP)

○ www.acponline.org/catalog/electronic/best_evidence.htmACP Journal Club

○ www.acponline.org/journals/acpjc/jcmenu.htmEffective Clinical Practice (ACP online journal)

○ www.acponline.org/journals/ecp/index.htmlCochrane Library ($225 full / Abstracts free)

○ www.updateusa.com/cochrane/cochrane-frame.htmClinical Evidence (BMJ publication)

○ www.evidence.org

“Prefiltered” resources

Updated Methodologically sound studies Clinically important studies Easy to search

Cochrane Review

http://www.cochrane.org Skin group Abstracts available free! Full reviews in your library….

General medical questions Textbooks may be better Uptodate

www.uptodate.com ($495)

Scientific American Medicinewww.samed.com ($245 w/ print / $159

online only)

Medline

Textbooks

emedicine (www.emedicine.com) Electronic Text of Dermatology

(www.telemedicine.org) Habif’s Clinical Dermatology

(at www.medscape.com)

Pentoxifylline & VLUs

Randomized, double blind placebo controlled trial of pentoxifylline in the treatment of venous leg ulcersBMJ. 1999;319:875-878. Dale JJ, et al.

Pentoxifylline 400mg tid as adjunct to standard compression therapy

200 patients randomized

Pentoxifylline & VLUs

Outcome: healing by 24 weeks

Pentoxifylline Placebo

64% healed 53% healed

P < 0.05; trend noted at week 8-10 and continued

Cochrane Database of Systematic Reviews April 2007Trental as adjunct to compression tx: 12 trials, 864 participantsRR healing 1.41 (95% CI 1.19-1.66)

Pentoxifylline & VLUs

Twelve trials involving 864 participants were included.

Combining 11 trials that compared pentoxifylline with placebo or no treatment (with or without compression) demonstrated that pentoxifylline is more effective than placebo in terms of complete ulcer healing or significant improvement (RR 1.70, 95% CI 1.30 to 2.24).

Pentoxifylline & VLUs

Pentoxifylline plus compression is more effective than placebo plus compression (RR 1.56, 95% CI 1.14 to 2.13).

Pentoxifylline in the absence of compression appears to be more effective than placebo or no treatment (RR 2.25, 95% CI 1.49 to 3.39).

Compression for VLUs Established as very important for wound

healing Cochrane review: 22 trials

Compression better than no compression and elastic better than non-elastic

Check the pulse (or ABI > 0.8 with good waveforms)

Make sure it’s tolerable and used!

Unna boot vs. other “wraps” Unna’s boot: zinc oxide

paste & gauze Multi-layer compression

dressing advantages (more continuous pressure)

Compression for prevention! Studies lacking Prevention is often difficult “sell”

Memory issues? Telling the future?○ See Stumbling on Happiness (Dan Gilbert)

Learning

Even while men teach, they learn.Seneca, statesman

Creative Minds

Creative minds have always been known to survive any kind of bad trainingPsychoanalyst Anna Freud, quoted in The

Buffalo News

Truth

Believe in those who are seeking the truth; doubt those who find itFrench author Andre Gude, quoted in The

Pittsburgh Post-Gazette

Einstein discovers that time is actually money.

Chronic Wound Track

Update / Overview: Mostow Topical Oxygen: Gordillo New treatment(s): Lee Lymphedema: Beinlich and Fruscella Prosthetic venous Valve: Treating

Disease not Symptoms: Schmidt