Could Outpatient Podiatry Clinics Provide Successful Suicide Risk Screening?

A recent study published ahead of print in the Journal of the American Podiatric Medical Association looked at the implementation of a suicide risk screening quality improvement program in an outpatient podiatry clinic and ambulatory surgical center in collaboration with a National Institute of Mental Health (NIMH) suicide prevention research team. The study authors relate that screening with the Ask Suicide-Screening Questions (ASQ) positively impacted clinical decision-making and led to enhanced quality of care for podiatry patients.

After appropriate training, office staff screened patients 18 years of age and older for suicide risk using the ASQ, a 4-item screening tool. Later, those staff members provided feedback on their experience, as well. Nearly all patients (442/470) agreed to the screening and nine of those patients (2%) screened non-acute positive; none of the patients screened positive for acute risk. Overall, the majority of clinic staff reported feeling comfortable working with patients with suicidal thoughts and thought the screening was clinically useful and appropriate.

Adam K. Spector, DPM, lead author on the study, stresses that since visits to a health care provider may often occur months or weeks before the death of an individual by suicide, medical settings are crucial for screenings and podiatrists can be valuable partners in suicide prevention.

“Once procedures and protocols are in place, screening, assessment, and appropriate referrals can be managed in less than five minutes,” he says. “Podiatrists can make a huge impact and save lives without disruption to office workflow.”

Dr. Spector shares that the two percent non-acute positivity rate was a high enough rate to warrant screening, but low enough not to overburden their busy practice.

“It opened up discussion and enabled me to treat patients better,” he relates. “For example, it enabled me to find alternative pain management solutions for a patient who had previously attempted suicide via narcotic overdose.”

Explaining that it is easy for doctors to hyperfocus on the patient's chief complaint, Dr. Spector says that physicians can actually render better overall care with knowledge about both the patient's medical and mental health. 

“I feel we have a responsibility to be trusted advocates and ask difficult questions that enable us to take care of the entire person,” he says. “If a person is suffering with suicidal thoughts, it becomes harder to take care of themselves and harder to comply with medical recommendations. Recognizing their mental health concerns and bridging them to mental health care can greatly improve their quality of life. The podiatrist may be the only person that asks them about suicide risk and could perhaps save their life.”

Lisa M. Horowitz, PhD, MPH, a study co-author and senior associate scientist in the NIMH Office of the Clinical Director in Bethesda, Md., shares the institute’s commitment to supporting suicide prevention research, exemplified in the development of the ASQ for health care providers to identify someone at risk for suicide in 20 seconds.

“The ASQ research team has been helping medical providers in emergency rooms, hospitals, and outpatient clinics implement suicide risk screening,” she explains. “Dr. Spector reached out to us because he … realized the significance of how mental health affects physical health and especially healing.” 

Since podiatrists often work on the front line of medical care, such as with limb preservation, Dr. Spector, in practice with Foot and Ankle Specialists of the Mid-Atlantic in Wheaton, Md., points out that this quality improvement study shows that suicide risk screening by medical providers makes sense and could potentially have a significant impact.

Could Total Ankle Replacement Become A Primarily Outpatient Procedure?

By Jennifer Spector, DPM, FACFAS, Managing Editor

Despite a growing focus on controlling health care costs and evaluating patient satisfaction, some surgical procedures traditionally take place nearly exclusively in an inpatient environment. Total ankle replacement is one of these procedures, and a recent study in the Journal of Foot and Ankle Surgery took a closer look at outcomes when performed on an outpatient basis at an ambulatory surgery center. A total of 51 patients met inclusion criteria for the study. Researchers performed a minimum of 12 months of follow-up (mean 20.7 months). Subjects had a mean age of 56.5 years and mean body mass index (BMI) of 30.4.

The study authors found no resultant hospital admissions or perioperative adverse medical events among those studied. They noted seven major (13.7 percent) and five minor complications (9.8 percent). Only one major complication required revision of the index procedure. At the time of the most recent follow-up, implant survivorship was 98 percent. Considering all of their data, the authors suggest that total ankle replacement could safely take place on an outpatient ambulatory basis, however they recommend further studies, specifically with larger cohorts and accounting for patient-reported outcomes.

Christopher Hyer, DPM, FACFAS, a co-author on the study, shares that he feels this study is very important, in that outpatient total ankle replacement performed as a same-day procedure could result in significant cost savings and prove better for patients.

“Currently, Medicare only reimburses for total ankle replacement in a hospital environment and requires an overnight stay,” he explains. “I feel this is an outdated policy. Thinking in this regard has changed for total knee replacement, but not yet for ankles. Hopefully this article will be a step towards modernizing present protocols.”

How Does Compact Bone Marrow Aspirate Harvest Site Affect Pain And Length Of Hospital Stay?

By Brian McCurdy, Contributing Editor

Compact bone marrow aspirate (cBMA), if harvested from multiple sites, may increase postoperative pain and lengthen hospital stay by more than a day, according to a poster presented at the most recent ACFAS Scientific Conference.

The authors conducted a retrospective review of 147 lower extremity surgeries with compact bone marrow aspirate by a single surgeon. Of these, 53 patients had compact bone marrow aspirate harvested from the calcaneus with an average length of hospital stay of 0.04178 days with 28 patients admitted. Eighty-seven patients had compact bone marrow aspirate harvested from the proximal tibia with an average length of stay of 1.322 days with 51 patients admitted. Seven patients had compact bone marrow aspirate harvested from the calcaneus and tibia with an average length of stay of 2.714 days with six patients admitted.

Study co-author Edgardo Rodriguez-Collazo, DPM, notes the advantage of compact bone marrow aspirate is to increase healing potential and decrease the inflammatory response. He adds that the bone marrow has stem cells that allow soft tissue to heal better. However, in addition to the pain from multiple harvest sites, Dr. Rodriguez-Collazo cites some downsides to compact bone marrow aspirate, including additional operative time, that harvesting must be done under anesthesia, and the additional equipment needed.

Dr. Rodriguez-Collazo, a board member and Fellow of the Association of Extremity Nerve Surgeons who practices in the Department of Surgery at AMITA Health St. Joseph Hospital in Chicago, says that compact bone marrow aspirate may have potential in several other areas, including leg length discrepancy, peripheral nerve surgery, and plastic and soft tissue surgery.