Pursuing the Path to Specialized Wound Care: The ACWHTR Perspective

Today’s Wound Clinic recently asked key opinion leaders to comment on the potential of wound care to become a recognized medical specialty. This article is authored by members of the American College of Wound Healing and Tissue Repair.

Caring for chronic wounds is one of medicine’s  earliest practices. The ancient world often utilized potions, ointments, and magic when treating these types of wounds. Over time, as scientific development shifted and improved, wound care also progressed. Modern wound care began during the 20th century as a larger number of topical preparations for treatments and more research into wounds were being introduced. The first conference on wound healing was held in February 1968 (Dunphy/Hunt meeting)¹ and, in 1970, the first wound healing text to be considered “classic,” Surgery and Biology of Wound Repair, was written by Erle E. Peacock and Walton Van Winkle (published by W.B. Saunders, Philadelphia, PA).¹ As the field flourished with mostly nurses providing primary care, other specialties caught interest. Physical therapists, with the use of energy-based modalities, began to approach wound healing. As the prevalence of diabetic foot ulcers increased, so did attention from podiatrists. Primary care providers entered the field with the emergence of outpatient wound clinics and hyperbaric oxygen therapy. The medical industry continued to be intrigued as dressings advanced (along with a better understanding of wounds and wound care).

Today, the United States alone spends an estimated $25 billion per year on the treatment of chronic wounds,² a number that is set to increase as healthcare costs grow with the aging population and higher prevalence of chronic diseases. About 1-2% of the populations in developed countries will experience a chronic wound during their lifetime.³ In 2016, 6.5 million people developed a chronic wound,^4,5 and in U.S. critical care settings, prevalence is 22%, with about 90% of those hospitalized with pressure ulcers being covered by government health programs.⁶ The number of hospital patients who develop pressure ulcers has risen by 63% over the last 10 years and nearly 60,000 deaths occur annually from hospital-acquired pressure ulcers,⁷ which the Centers for Medicare & Medicaid Services stopped paying for as of October 2008 because they can “reasonably be prevented through the application of evidence-based guidelines.”⁸ Diabetic ulcers add $9-13 billion per year to diabetes costs,⁹ and about 25% of those living with diabetes will experience a foot ulcer during their lifetime.⁹ Some studies have revealed that 57% of these patients will also require amputation. Even more, within five years of an amputation, the mortality rates for patients living with diabetes sits between 39-68% (if the wound is not treated), according to one study.¹⁰ In addition to pressure and diabetic ulcers, approximately 7 million people in the U.S. live with venous insufficiency, for which 1 million will experience a venous leg ulcer (VLU).¹¹ The recurrence rate for these ulcers is high, fluctuating between 54-78%.¹² Both VLUs and arterial leg ulcers are rising as a result of the aging population. Lastly, there is a large need for postsurgical wound care. In the U.S., there are more than 100 million surgeries performed per year, according to the World Health Organization (including inpatient and outpatient procedures). An average of 4% of surgical interventions become infected¹³ while wound care accounts for nearly 4% of the total health system costs.¹³ Apart from the financial aspect, the issue of quality of life for patients is a factor, as wounds also affect a patient socially and psychologically.

Need For “Specialty” Wound Care

With the current increasing number of wound care patients living in the United States, as well as concomitant advances in technology, the recognition of wound care as a board-approved medical specialty (or subspecialty) is certainly long overdue. It will continue to be a necessity for wound care providers to increase their knowledge and skill set in order to remain informed on new literature and research, as well as to be able to address complex patients. This can be assured through achieving certification in wound healing through an academic-based clinical residency/fellowship training program. As with the generally increasing number of specialties, board certification has been shown to improve quality of care by setting education and training requirements, providing legitimate examination processes, and educating and protecting the public. Utilizing proper dressings and integrating best-practice techniques translates to better care with reduced costs. Therefore, establishing the status of wound care in medicine can affect system costs, innovation, and patients’ quality of life.

In recognition of the need for truly specialized wound care board certification, key opinion leaders and professionals from clinical, research, and industry divisions throughout the field of wound care met in December 2009 to create a 501(c)(3) nonprofit organization committed to advancing this field. That organization, the American College of Wound Healing and Tissue Repair (ACWHTR), is based in Chicago, IL, and utilizes a physician-based clinical fellowship curriculum to train medical professionals in wound care. The primary objective of the ACWHTR since then has been to create a formal wound care specialty (or subspecialty) in medicine and surgery, along with a board-certification process for physicians. ACWHTR officials believe this will aid in applying a common curriculum within university-based medical school programs for those physicians who desire wound healing specialization. Under the direction of William J. Ennis, DO, MBA, FACOS, the University of Illinois Hospital and Health Sciences System became the first academic sponsor for this fellowship, developing the wound healing and tissue repair section within the vascular surgery division at the University of Illinois at Chicago in January 2008. The fellowship is available for residents who have completed residency programs and are board eligible in internal medicine, family medicine, or general surgery. The fellow goes through a year of training, managing a variety of wound care-related problems and learning the multidisciplinary nature of the field. 

Certification Process

In their efforts to gain appropriate status for wound care as a specialty (or subspecialty) in medicine, the ACWHTR is in the process of obtaining certification from the Accreditation Council for Graduate Medical Education (ACGME). Because wound care is not currently recognized as a specialty under the ACGME, ACWHTR officials will have to apply in a different way than that of other recognized specialty areas of care. First, the ACWHTR must demonstrate to the ACGME that there is a need for a wound care specialty, which is currently being discussed as of press time. Once the ACGME deliberates and (presumably) recognizes wound care as its own specialty, the ACWHTR, along with other interested programs, can then apply for its own fellowship to be accredited by the ACGME. In order to be accredited, programs must adhere to ACGME and specialty requirements. (Visit www.acgme.org/portals/0/pfassets/programrequirements/CPRs_2017-07-01.pdf for more information.)

As the potential for an ACGME accreditation is sought, the hope will remain for more programs to adopt the current curriculum for wound care training to allow for standardization of care, improvement of outcomes, and innovation of current and future wound care practice. As we continue to learn more about chronic wounds, it is our duty as an industry to keep pace with current technology and trends to provide quality, evidence-based care to our patients. n

Karen Imma Gellada is a former fellow for the section of wound healing and tissue repair at the University of Illinois at Chicago. She finished her family medicine residency at the University of Illinois College of Medicine at Peoria. She is board certified in family medicine and previously worked in primary care and urgent care. Marissa Ruggiero is a gap-year student from the University of Notre Dame who’s matriculating to medical school in the fall and is currently working at the University of Illinois at Chicago as a research specialist in the wound healing and tissue repair department.

References

1. Cohen IK, Diegelmann RF. How the wound healing society began. Wound Repair Regen. 2002;10(3):195-7. 

2. Sen CK, Gordillo GM, Roy S, et al. Human skin wounds: a major and snowballing threat to public health and the economy. Wound Repair Regen. 2009;17(6):763-71.

3. Gottrup F. A specialized wound-healing center concept: importance of a multidisciplinary department structure and surgical treatment facilities in the treatment of chronic wounds. Am J Surg. 2004;187(5A):38S–43S. 

4. Singer AJ, Clark RA. Cutaneous wound healing. N Engl J Med. 1999;341(10):738–46. 

5. Crovetti G, Martinelli G, Issi M, et al. Platelet gel for healing cutaneous chronic wounds. Transfus Apher Sci. 2004;30(2):145–51. 

6. Shahin ES, Dassen T, Halfens RJ. Pressure ulcer prevalence and incidence in intensive care patients: a literature review. Nurs Crit Care. 2008;13(2):71–9. 

7. Greenwald L. Medicare Deadline Spurs Hospitals to Prevent Pressure Ulcers. E-Zine. 2007. Accessed online: https://ezinearticles.com/?medicare-deadline-spurs-hospitals-to-prevent-pressure-ulcers&id=846302

8. CMS. Medicare program; changes to the hospital inpatient prospective payment systems and fiscal year 2008 rates. Fed Regist. 2007;72(162):47201–06. 

9. McCall B. Huge Burden of Foot Ulcers Doubles Diabetes Costs in US. Medscape. 2014. Accessed online: www.medscape.com/viewarticle/821908

10. Reiber GE. The epidemiology of diabetic foot problems. Diabet Med. 1996;13 (Suppl 1):S6-S11.

11. Aydin A, Shenbagamurthi S, Brem H. Lower extremity ulcers: venous, arterial, or diabetic? Emerg Med. 2009;41(8):18–24. 

12. Marston WA, Crowner J, Kouri A, Kalbaugh CA. Incidence of venous leg ulcer healing and recurrence after treatment with endovenous laser ablation. J Vasc Surg Venous Lymphat Disord. 2017;5(4):525-32.

13. Posnett J, Gottrup F, Lundgren H, Saal G. The resource impact of wounds on healthcare providers in Europe. J Wound Care. 2009;18(4):154-61.