Health Disparities in a Multidisciplinary Setting: Insights from Thought Leaders

Caitlin Hicks, MD:

My name is Caitlin Hicks. I'm a vascular surgeon at Johns Hopkins University School of Medicine.

Ronald Sherman, DPM:

My name is Ronald Sherman. I'm the surgical podiatrist. I am one of the principal providers at the Multidisciplinary Diabetic Foot and Wound Care Services at Johns Hopkins.

Caitlin Hicks, MD:

Yes. So we were able to show in over 600 wounds that ultimately, wound healing was predicated more on peripheral vascular disease status and the characteristics of the wound. So wound size, depth, infection levels, than a patient's socioeconomic or demographic status. This is in direct contrast with this other study that we recently published that looked at a population of patients more generally in Maryland that showed that the main driver of outcomes in patients requiring minor amputation or debridements for foot wounds was really related to a patient's socioeconomic status based on area deprivation index. So between these two studies, we've been able to show that use of a multidisciplinary team basically mitigates the socioeconomic disparities across patients and allows the patient's wound and vascular characteristics to be the main driving factors of their outcomes.

In our recent 2021 study, we used data from the Maryland Health Services Commissions and Research database, which includes all patients treated in the state of Maryland, and we we're able to follow them longitudinally over time, and we matched them using their zip code to something called an Area Deprivation Index. Area Deprivation Index is a comprehensive measure of socioeconomic status that considers a lot of things at a population level, including median household incomes, access to care, access to schooling, access to food, et cetera. And as a comprehensive way of looking at socioeconomic status. In that study, we were found an association between Area Deprivation Index, which was measured in quartiles and the patient's likelihood of wound healing after a minor amputation.

I think the main takeaway of these two studies together is that although patients, at a baseline, their health status is really predicated a lot on where they live and their socioeconomic means, you can get rid of a lot of that by serving them with a multidisciplinary team. So at Johns Hopkins, we have a multidisciplinary care team for diabetic foot wounds that includes a vascular surgeons, surgical podiatrist, wound care nurses, infectious disease doctors, et cetera. And we see patients in a one-stop shop setting. So the patients come into clinic and all of us see them in the same room, which allows us to mitigate a lot of the transportation and caregiver limitations to attaining care.

Ronald Sherman, DPM:

When these articles came out, it was highly relevant to me because the problems that were highlighted with these type of patients were three. The first one was their access to care. There's been so much made about that people with a high deprivation access had difficulty to have access to care. The second most important element was that when these patients did finally present for care, they had advanced pathology. And because it was either they were unable to get to care or they didn't understand that they should get the care, that when they finally presented to the hospital, the wounds were advanced. And then the third thing is that these individuals sometimes experience more perioperative morbidity. And those three highlights are the things that I hear all over the country from other providers that why should we even take care of these patients because of these reasons? I thought about that, and Dr. Hicks and I oftentimes speak about it, and there's a way to fix that. There's a way to get around it. There's a way to eliminate it, and that's what the Multidisciplinary Service does.

Invest in your patients. What does that mean? Invest in your patients. Provide them with the supplemental resources that they need. If you invest in the patients, you're going to get a wonderful return on investment. And therefore, by doing those things, these patients will be, just as Dr. Hicks exhibited her articles, that they're just like everybody else. They all heal the same, just give them an opportunity. You'll have less complications, less admissions, less surgery, and less amputations. So what do you do? You provide supplemental resources. One of the easiest things is transportation. You call mobility, arrange for their visits. It's not a big deal. They pick them up, they bring them either to the clinic for testing or to get their shoes. It's an easy thing. So transportation access is key.

Easy access to appointments. When these patients call up, we give them appointments. They don't have to wait a week or two. They come in, we're in the service to provide the care. That's what we do. And if these patients call up, we're going to see them. So our accessibility is paramount. When patients call for an appointment, we don't have any extended menus. That's a turnoff in my mind. Look, I've been in practice over 40 years, and even just to call a physician, you've got A, B, C, different menus. When you call our service, you get directly to our front people and they give appointments.

So if we can't see these people as often as we'd like to, how do we get around that? Well, another one of Dr. Hicks's research endeavors is something called Healthy.io. And what is that? So that's from an Israeli startup company. And what we do is we're able to review the patient's wounds and their progress by scanning their feet with their own telephone. And guess what? If they don't have their own mobile device, we actually furnish one for them. We have weekly meetings to review their wounds and to see how they're doing. Very, very good tool. One of the most important resources that we can give these people is our robust home health services. And what does that mean? Our nurses come out to see these patients. They've been trained to provide the care for the type of lymph salvage that we do. And you know what? These patients welcome these nurses to come into their homes. So the nurses are on the same page as we are to provide the perioperative work.

The other thing that's important is what Dr. Hicks said is that when the patients do see us in our multidisciplinary service, they see three physicians at the same visit. They don't have time to go to see A, B, C, D, different type of physicians. They have one visit, they see three physicians. What could be better than that? Easy access to care. Lastly, her papers discuss 30 day admission rates and reamputation rates. Because of our diabetic ulcer reduction service and our computerized assisted gait analysis, we're able to reduce those reulcerations so that our 30 day admissions has dramatically decreased as well as our reamputation rates.