‘Significant’ value of adding podiatrists to limb salvage alliance

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Wei Zhou

A multidisciplinary limb salvage alliance found that operating room (OR) and clinic volumes as well as work relative value units (wRVUs) all increased significantly over a three-year period after the recruitment of podiatrists into the program.

Studying data from 2015–2019, researchers found that although growth was initially attributed to the addition of vascular surgeons in 2017, podiatry accounted for a 57% increase in clinic—and a more than 60% jump in OR traffic—in the last two years.

The data, presented by Wei Zhou, professor and chief of vascular surgery at the University of Arizona in Tucson at the 2020 Western Vascular Society (WVS) virtual annual meeting (Sept. 27–29), comes from a study on the economic value of adding a podiatry service to a limb salvage alliance. Zhou is also co-director of the group in question—the Southern Arizona Limb Salvage Alliance (SALSA), which was co-founded by vascular surgeon Joseph Mills, MD, and podiatrist David G. Armstrong, DPM, in 2008.

“The benefits of close collaboration between podiatry and vascular extends beyond clinical outcome. Understanding and clearly outlining the financial advantages can help bring podiatrists into a limb salvage practice,” said Zhou.

Zhou occupies an apt vantage point.

The area in which her team operates occupies a unique geographic location, she told the WVS gathering: It is home to the largest, densest population of Native Americans in the country as well as a large Hispanic populace. Tze-Woei Tan, MBBS, one of the study co-authors, found that among Medicare beneficiaries, Native Americans have the worst outcomes for diabetic foot ulcers and infection.

SALSA’s region is home to the largest, densest population of Native Americans in the country

SALSA, a multidisciplinary “toe and flow” program now widely adopted around the world, grew out of this stark environment. The institution where they operate, Banner-University Medical Center, a safety-net hospital, treats a patient population made up of nearly 40% Hispanics and Native Americans.

Historically—based on a study by Kay R. Goshima, MD, a SALSA team member—despite a history of aggressive infrapopliteal revascularization, nearly 50% of patients required hospital readmission within six months, and over 50% saw prolonged time healing, Zhou explains.

Zhou and colleagues studied a period during which the composition of the alliance went through significant change. The number of podiatrists fell from three to one before settling at four, while the vascular surgeon contingent moved up from two to four.

Reviewing an administrative database, the investigators plumbed captured data such as monthly OR cases, clinic encounters, inpatient volume and total wRVUs generated by the SALSA team. ANOVA analysis was used to determine significant changes, while Tukey’s multiple comparison test was deployed to determine changes between years.

Some 36,000 patients were seen at the SALSA clinic and over 5,500 operative cases performed over the period. Overall, Zhou et al found 100% growth in clinic visits, operative cases and wRVUs from 2015 to 2019. “The team has grown significantly over the last five years and was significant for each year,” said Zhou “The initial growth was attributed to vascular surgeons. An increase in the podiatry complement contributed to over 100% growth in the clinic volume. Podiatry in general evaluate twice as many patients in clinic than vascular surgeons. They see up to 1,000 patients a month, while vascular surgeons typically see 300–400 patients a month.”

Initial growth in patients treated in the OR, too, was initially attributed to vascular surgeons, Zhou continued. In 2019, podiatrist recruitment contributed to an additional increase of 40%, she said. “Despite podiatric procedures being shifted from vascular surgeons to the podiatrists, in 2018 and 2019 vascular surgeons continued to see an incremental growth in OR volume. When we look at total wRVU, not surprisingly podiatry had a significant increase in wRVU in 2019, and contributed to a total 40% of group wRVU. Vascular surgery continues to enjoy 10% growth.” Inpatient consult volume was also up significantly: 100 a month for the podiatrists and 140 for the vascular surgeons.

Summing up, Zhou observed: “Podiatrists had the greatest contribution to outpatient care—up to 70% of total clinic encounters were done by podiatrists. Podiatrists contributed to up to 40% of OR cases, inpatient consultations, total wRVUs and total charges in our group. And, shifting podiatric procedures to podiatrists did not impact vascular surgeons’ productivity.”

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