The Need For Quality Indicators In Wound Care

A ogni ucello suo nido e bello.
(To every bird his nest is beautiful.)
-Italian Proverb

  At a recent wound care meeting, a program director proudly exclaimed from the lectern that her wound center’s healing rate was an unbelievable 96 percent. “Unbelievable” was my impression as well. I had no doubt that her center had good healing rates, but like the bird in the Italian proverb, every good program director believes that his or her center is the best. Certainly, as a medical director, I would not have it any other way; however, this creates a problem when it comes to evaluating performance and quality. Clearly, the implication from her presentation was that good wound centers have high healing rates. Unfortunately, nothing could be further from the truth. In fact, healing rates are a poor indicator of quality. The real problem is that there are no reliable quality indicators in the wound care field.

  The National Quality Forum (NQF) is charged with identifying and validating quality measures. But the recently published list of quality measures (QM) is not even remotely applicable to the wound care field. Thus far, the NQF has not been receptive to wound care QMs, and I am persuaded that if the wound care community does not establish bona-fide QMs, they will be thrust upon us.

  What are quality indicators? They are objective, easily verifiable measures of good clinical practice. In wound care, for example, it is clear that off-loading for diabetic foot ulcers (DFU) is an essential part of the patient’s care plan. Therefore, off-loading for DFU would be an excellent measure. Other potential QMs include:
    •The number of patients with venous disease who receive compression
    •The use of vascular testing for all patients with lower extremity wounds
    •The percentage of diabetic patients undergoing hyperbaric oxygen therapy who receive pre- and post-capillary glucose levels
    •The percentage of pressure ulcer patients who receive nutritional screening
    •The percentage of patients who receive adequate wound bed preparation prior to the use of advanced modalities.

  I am always amazed at how many terrific ideas are born on the ride to the airport. On one such ride, Dr. Caroline Fife brought us up to date on the NQF and wound care QIs. I will attempt to do justice to her excellent presentation:
    •PQRS is the Physician Quality Reporting System, previously known as PQRI (any advanced practitioner with a tax ID number can participate). Quality measures allow anyone with a tax ID to get either bonus money or by 2015, to not get money taken away for failure to meet quality measure standards.
    •Every specialty is creating quality measures except wound care, because we don't have a recognized specialty society.
    •The Centers for Medicare Services (CMS) identifies priorities for the development of quality measures and forwards them to the National Quality Forum (NQF).
    •The NQF then goes to the various national organizations to determine expertise levels for a particular specialty. You can’t submit a quality measure that they have not asked for. If it does not fit with one of their CMS-driven initiatives, the NQF won't evaluate it.
    •In general, if the NQF doesn't endorse a measure, CMS won't adopt it.

    •Wound care can't get measures because
      •1) we have no specialty and
      •2) CMS says it is not a priority. Dr. Fife submitted a "measures set" a year ago and the NQF refused it.

    •Quality measures must undergo exhaustive testing. For most specialties, a society covers the cost of creating a registry and then uses the data collected to validate the proposed measures.

  At this point, I was ready to jump out of the car. However, there may yet be hope for wound care. As health care reform moves toward the development of Accountable Care Organizations (ACO), we may have an opportunity to have our case heard. ACOs will need quality measures.

  The shared ride back to the airport group decided that the wound healing community should take on the challenge of developing quality measures for our field. The project could come under the aegis of the Alliance of Wound Care Stakeholders. I would encourage anyone interested in this project to contact me. Similarly, I would suggest that industry considers supporting this effort, as it is likely to affect all of the stakeholders in the wound care arena. To quote Dr. Fife, “We are going to create quality measures which include the use of products and at some point we are also going to test them.“ Industry should recognize their self-interest in this process.

   “Chi bene incomincia è a metà dell'opera.” (Well begun is half done.) We should set our minds to the task before the bureaucrats define what excellence in wound care means.

Dr. Thomas E. Serena, MD, FACS, MAPWCA, FACHM, is the founder and CEO of the Serena Group™ family of companies operating wound and hyperbaric centers across the United States, providing point-of-care services for nursing facilities, managing inpatient wound care teams, and consulting for more than two dozen industry partners worldwide. Dr. Serena is the medical director for New Bridge Medical Research, a not-for-profit company dedicated to advancing the science of wound healing. In this capacity, he has conducted more than 50 clinical trials, published over 100 scientific papers, and given more 250 invited lectures across the globe. He is the vice president of the American College of Hyperbaric Medicine, sits on the board of the Association for the Advancement of Wound Care, and is a former board member of the Wound Healing Society. Currently, he serves as chairman of the AAWC Global Volunteers. He has taught wound care and conducted research in Rwanda, Cambodia, and Haiti.