Improving Health Equity in Wound Care

I'm doctor Karen Cross. I am a plastic and reconstructive surgeon. I'm also a PhD scientist, so I'm an academic surgeon specializing in wound healing. Also the CEO and cofounder of Mimosa Diagnostics. Also an innovator in residence with the Nova Scotia Health Authority. So I am a physician from Canada.
 
Q: What are some challenges to health equity in the wound care space?
 
In Canada, we have a social health care system. So the patients can access the system really, and the payer is the government. So We definitely experience the system a little bit different than United States, but we experience the system very similarly. So in terms of equity, it's Our BIPOC population, so people of color who really don't get that access to care as quickly as, say, a Caucasian or someone who has Maybe more financial assets where they can access the system.

So it's the same problems. Not only that, these are vulnerable patients. So they can't really advocate for themselves. Their families don't know what to do. It is chaos in how they access the system.
 
So in general, just overall, it doesn't matter if you're Caucasian or you're black. It is very difficult to access the system or know what the entry point to the system is. But I'd also like to say, we have geographic access to care problems. So again, in Canada, it's the same as true as here. It's a lot of these patients live not in cities.
 
So they're in rural places or even 50 kilometers outside the city. You're 2 to 3 times more likely to lose your leg because of that lack of access to care. Fifty kilometers, that's not that far. And so we have to also not just look at the actual population, but where does this population live? This is especially important for us in Canada because a lot of our population lives in rural remote regions.
 
So how do we access them? And I think it's really important that we take the perspective of how do we help people age well in their own communities and create these sort of centers of excellence or neighborhoods where people can stay in their own communities versus having that commute of 3 to 4 hours. So that's also one of the barriers in access to care is that that patient needs to work or they're taking care of somebody else, that asking them to come for a clinic visit that's 3 or 4 hours away is just it's just not conducive to them taking care of
themselves.
 
Q: What are some of the contributing factors to health inequity?
 
During COVID, again, practicing at the largest wound care center in Canada, so we would see, 60 to a 100 patients a day. We do a 1,000 surgeries a year. So it's running the largest practice in Toronto before moving to Nova Scotia. What we found is 1, because we couldn't access these patients, the severity of the disease became worse. Instead of doing, say, transmetatarsal amputations, the level of amputation increased. In fact, we did more above knee amputations probably than we'd ever done in 10 years. And still that continues to happen because we were closed for a lot longer than a lot of communities in the US.
 
And so I just can't remember the last time that we were doing above knee amputations at this level or volume. Also, because I am expert in pressure injuries. I've never sent people with pressure injuries to palliative care. We are sending almost 3 to 4 people that day to palliative care with wounds. And so that was just a tragedy.
 
And most of it is because people weren't getting their checks. They weren't leaving their homes, and they weren't able again, it's access to care.
 
Q: What interventions or programs could improve health equity in wound care?
 
The first thing that needs to happen is we need these community screening program. So you need to build the expertise in the community. It's great that we have expertise in centers, but the centers need to disseminate the knowledge into the community.
 
Why can't that nurse practitioner, why can't the nurse become very skilled in risk screening, especially for the diabetic lower extremity? And there was a study published in a family medicine journal that showed that primary care physicians only do one of the 5, You know, criteria for screening and they don't even do that part accurately. Should we blame them? Absolutely not. It's education.
 
But also does it fall to them? Can we actually disseminate this service to other people who are trained. In rural Canada, so in New Brunswick, for example, we were able to train mental health nurses with technology on how to do a foot screen. This is really critical, I think, to the future when we have a lack of shortage of staff, less skilled labor at the frontline. We're gonna need to train people in different ways using technology.
 
The second is we need to start evaluating technology and how it ts with the social determinants of health. So is this technology that only works in Caucasian skin? So part of what we've been doing with Ebonie Vincent, DPM, is to try to create technology that's equitable. Can it assess people of color? Are we excluding people by putting technology in the space?
 
And I think we have responsibility as physicians to ask the questions. How does this how can this be better? So we have to start somewhere, and it's not perfect in this moment. But when you start to engage with the right people like Dr. Vincent, you're able to solve these problems. And then technology can do that, but everyone's gotta come together with the same value system to say this is important.
 
Q: What one thing can podiatrists do today in their practices to be a part of the solution?

I think really just being that early adopter of technology, working with people to say, this is an important strategy. I need to contribute to this technology or I need to contribute to this solution. Give your feedback. Be open to new ideas. The reality is we can't see these injuries in people of color like we would see them in in a white person.
 
That needs to change. And I think the first is just recognizing that there is an inequality. By just even recognizing that, people can come to the table to solve it. And we need people from all types of practices. So in private practice, academic practice, it can't just be left to those academic health centers.
 
It has to be practical solutions that t in a community or private podiatry practice. I think we've been very fortunate, really looking at what I've done as an academic surgeon to take technology from my lab into the clinical environment, so in knowledge translation, To be surrounded by like minded individuals who really just wanna elevate the standard of care for these patients, we need to better be able to assess the microcirculation of the foot and do our screening so that we change the system from a reactive to a proactive system. And I feel like that's what we're doing with our relationships with podiatrists all over the country, but especially with Dr. Vincent.