Keeping Patients In Your Practice: A New Paradigm For Treating Infections

   It is vital to have a network of multidisciplinary specialists to whom one can refer patients. While appropriate referrals are key to ensuring optimal outcomes, the DPM should take the lead in facilitating the best treatment choices for patient care.

   As part of the Vision 2015 program, the American Podiatric Medical Association (APMA) has committed itself to achieving the mission of universal recognition of the work of podiatric medical physicians. Vision 2015 states, “(Podiatrists) should treat the patients within their specialty without restriction.”

   In order to meet this goal, we as podiatric physicians and surgeons must begin to take more direct care of our patients. Consider our experience in diagnosing and treating patients with lower extremity infections. Historically, DPMs have referred these patients away, often to medical doctors specializing in infectious diseases. Reasons for referrals include “spreading the liability” and hoping for “quid pro quo” referrals from the infectious disease doctor. I propose that using the infectious disease colleague as a consultant and managing the patient directly will benefit the patient and the profession of podiatric medicine as a whole.

   The direct benefit to the DPM is that the patient stays in your practice and is not referred away. We have all heard the term evidence-based medicine. This concept will bring to light the patient benefits of being treated by podiatric medical professionals by taking results of actual cases and documenting the results.

Emphasizing The Use Of Research To Document The Impact Of Podiatric Care

   The APMA’s Clinical Practice Advisory Committee (CPAC) looked at new emerging technologies that are relevant to podiatry and how those technologies can act as a conduit for research in the profession. In regard to research, the APMA’s mission statement also states it will “promote, manage and advise the (APMA) members on clinical and research opportunities that demonstrate the value of healthcare provided by doctors of podiatric medicine.”

   The five goals of the CPAC are:

   • transfer information to internal and appropriate external audiences;
   • strengthen and maintain the current evidence base for the development of standards, guidelines and policies for foot and ankle care;
   • encourage the growth of research infrastructure within the profession;
   • continue to investigate and quantify the health benefits and economic impact of care provided by doctors of podiatric medicine; and
   • promote the development and implementation of performance measures for foot and ankle care.

   In regard to accomplishing the second goal, key strategies in strengthening the evidence base would be the following:

   • identify the strengths and weaknesses of current evidence and methodology; and
   • prioritize areas of evidence-based medicine that need to be evaluated.

Facilitating Evidence-Based Research With Improved Data Collection

   In 2007, the specialty podiatric home infusion company QMedRx, in collaboration with the CPAC, created a data collection tool physicians can use when patients start on home intravenous antibiotic therapy. The pharmacy provider will aggregate the information and data that the profession collects and then return the info to the profession to facilitate evidence-based research and document superior patient outcomes.

   Patient outcome data gathering will enable us to aggregate nationwide information on infection care and other disease processes affecting the podiatric physicians and their patients. This tool will enable us to use evidence-based podiatric resources for additional support and decision making to guide lower extremity medicine and surgery nationwide. The national adoption and use of this tool will help us reach the goals of the APMA Vision 2015.

   QMedRx has introduced a simplified referral form. The referral algorithm is a process flow chart that is simple and largely involves the office staff after the direction of the podiatric physician. The flow chart addresses the use of empiric therapy prior to final culture and the use of culture and sensitivity results to guide decision-making on selecting the appropriate antibiotic. The discharge from hospital algorithm is also very simple for hospitalized patients. In using this algorithm, we can guide the patient through this process and facilitate continued care with our home infusion company of choice.

Why DPMs Should Be Involved With Home Infusion Therapy

   Home infusion therapy is a common choice in other medical fields for diagnoses as disparate as parenteral nutrition, pain management, cancer chemotherapy and the treatment of infectious diseases. However, less than 3 percent of our membership consider home infusion therapy as point of care.

   Managing the home infusion therapy from point of care through conclusion allows the DPM to completely manage the patient’s lower extremity infectious disease process. This also enables the DPM to oversee and coordinate the relationship between the consulting infectious disease specialist, the clinical pharmacist and IV nursing team. Perhaps this gives us the greatest advantage to treat the patient’s infection with our unsurpassed experience.

   In addition, we will likely reduce our own medicolegal liability as we are better able to prevent poor outcomes when we are able to closely monitor the healing process. In the past, we would refer our patients out of our practice to a MD or DO for IV management of intravenous antibiotics and patient disease management. In this model, I am suggesting more of a consultation process with infectious disease specialists and subsequent medical management of this patient by the podiatric physician.

   Historically, referring the patient out of your practice for IV management of the infectious disease has potentially led the referred infectious disease physician to refer the patient to an orthopedic surgeon, general surgeon or other physician. This may result in a loss of continuity of care and increasing medical liability to the podiatric physician, who truly is the expert in the management of the foot and ankle condition being treated.

   Referring your patient out of your practice also can cause confusion, a loss of trust in terms of the patient-podiatric physician relationship and a possibly less than superior outcome for the patient.

   By maintaining the relationship with your patients and guiding their medical care, you will make the decision whether further intervention, surgery and other medical consultations would be necessary.

   The podiatric physician should choose the consulting physician. The potential benefits are really the one-stop, one-doctor concept, in which the DPM guides the patient throughout the process of infectious disease management and forms a stronger bond with this patient whether the issue is a postoperative infection, diabetic limb preservation, acute cellulitis or another cause. The DPM can arrange for hospital consultations for PICC line placement, clinical pharmacy consultation, dosage and preparation. When appropriate, one can choose the infectious disease consultant physician of choice.

   In many cases, podiatric physicians report additional practice revenue with office visits and consultations as well as starting the initial infusion within their office. Often the home infusion therapy nurse is present to provide the initial training to the patient. Follow-up visits for monitoring the infusion therapy as well as the PICC line assessment are reimbursable and are separate from wound management or the postoperative management global period.

In Conclusion

   With national data collection, practitioners will contribute and build their best practices. Providing the information to produce evidence-based medicine documentation will give us accurate and reproducible positive disease-specific outcomes. Most importantly, this information will keep the standard of care at the highest level for our patients.

Dr. Rice is a Fellow of the American College of Foot and Ankle Surgeons and is board certified in foot and ankle surgery by the American Board of Podiatric Surgery. He is in private practice at Fairfield County Foot Surgeons in Norwalk, Conn. Dr. Rice is a Clinical Instructor in the Department of Orthopedic Surgery and Rehabilitation at Yale University School of Medicine.