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Tettelbach WH, Driver V, Oropallo A, Kelso MR, Niezgoda JA, Wahab N, Jong JLD, Hubbs B, Forsyth RA, Magee GA, Steel P, Cohen BG, Padula WV. Dehydrated human amnion chorion membrane to treat venous leg ulcers: a cost-effectiveness analysis. J Wound Care 2024; 33:S7. [PMID: 38457298 DOI: 10.12968/jowc.2024.33.sup3.s7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/10/2024]
Affiliation(s)
- William H Tettelbach
- RestorixHealth, Metairie, LA, US
- College of Podiatric Medicine, Western University of Health Sciences, US
- Duke University School of Medicine, Department of Anesthesiology, US
- Onsite Advanced Care, Salt Lake City, UT, US
- American Professional Wound Care Association, US
| | - Vickie Driver
- Wound Care and Hyperbaric Centers at INOVA Healthcare, US
- Wound Care Collaborative Community, US
| | - Alisha Oropallo
- Comprehensive Wound Healing Center, US
- Hyperbarics at Northwell Health, US
| | | | | | - Naz Wahab
- Wound Care Experts, US
- HCA Mountain View Hospital, US
- Roseman University College of Medicine, US
- Common Spirit Dignity Hospitals, US
| | | | | | - R Allyn Forsyth
- MiMedx Group, Inc., US
- Department of Biology, San Diego State University, US
| | | | | | - Benjamin G Cohen
- Stage Analytics, Baltimore, MD, US
- Department of Pharmaceutical & Health Economics, Mann School of Pharmacy & Pharmaceutical Sciences, University of Southern California, Los Angeles, CA, US
- The Leonard D. Schaeffer Center for Health Policy & Economics, University of Southern California, Los Angeles, CA, US
| | - William V Padula
- Stage Analytics, Baltimore, MD, US
- Department of Pharmaceutical & Health Economics, Mann School of Pharmacy & Pharmaceutical Sciences, University of Southern California, Los Angeles, CA, US
- The Leonard D. Schaeffer Center for Health Policy & Economics, University of Southern California, Los Angeles, CA, US
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Tettelbach WH, Driver V, Oropallo A, Kelso MR, Niezgoda JA, Wahab N, Jong JLD, Hubbs B, Forsyth RA, Magee GA, Steel P, Cohen BG, Padula WV. Dehydrated human amnion/chorion membrane to treat venous leg ulcers: a cost-effectiveness analysis. J Wound Care 2024; 33:S24-S38. [PMID: 38457290 DOI: 10.12968/jowc.2024.33.sup3.s24] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/10/2024]
Abstract
OBJECTIVE To evaluate the cost-effectiveness of dehydrated human amnion/chorion membrane (DHACM) in Medicare enrolees who developed a venous leg ulcer (VLU). METHOD This economic evaluation used a four-state Markov model to simulate the disease progression of VLUs for patients receiving advanced treatment (AT) with DHACM or no advanced treatment (NAT) over a three-year time horizon from a US Medicare perspective. DHACM treatments were assessed when following parameters for use (FPFU), whereby applications were initiated 30-45 days after the initial VLU diagnosis claim, and reapplications occurred on a weekly to biweekly basis until completion of the treatment episode. The cohort was modelled on the claims of 530,220 Medicare enrolees who developed a VLU between 2015-2019. Direct medical costs, quality-adjusted life years (QALYs), and the net monetary benefit (NMB) at a willingness-to-pay threshold of $100,000/QALY were applied. Univariate and probabilistic sensitivity analyses (PSA) were performed to test the uncertainty of model results. RESULTS DHACM applied FPFU dominated NAT, yielding a lower per-patient cost of $170 and an increase of 0.010 QALYs over three years. The resulting NMB was $1178 per patient in favour of DHACM FPFU over the same time horizon. The rate of VLU recurrence had a notable impact on model uncertainty. In the PSA, DHACM FPFU was cost-effective in 63.01% of simulations at the $100,000/QALY threshold. CONCLUSION In this analysis, DHACM FPFU was the dominant strategy compared to NAT, as it was cost-saving and generated a greater number of QALYs over three years from the US Medicare perspective. A companion VLU Medicare outcomes analysis revealed that patients who received AT with a cellular, acellular and matrix-like product (CAMP) compared to patients who received NAT had the best outcomes. Given the added clinical benefits to patients at lower cost, providers should recommend DHACM FPFU to patients with VLU who qualify. Decision-makers for public insurers (e.g., Medicare and Medicaid) and commercial payers should establish preferential formulary placement for reimbursement of DHACM to reduce budget impact and improve the long-term health of their patient populations dealing with these chronic wounds. DECLARATION OF INTEREST Support for this analysis was provided by MiMedx Group, Inc., US. JLD, and RAF are employees of MiMedx Group, Inc. WHT, BH, PS, BGC and WVP were consultants to MiMedx Group, Inc. VD, AO, MRK, JAN, NW and GAM served on the MiMedx Group, Inc. Advisory Board. MRK and JAN served on a speaker's bureau. WVP declares personal fees and equity holdings from Stage Analytics, US.
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Affiliation(s)
- William H Tettelbach
- RestorixHealth, Los Angeles, CA, US
- College of Podiatric Medicine, Western University of Health Sciences, US
- Duke University School of Medicine, Department of Anesthesiology, US
- American Professional Wound Care Association, US
| | - Vickie Driver
- Wound Care and Hyperbaric Centers at INOVA Healthcare, US
- Wound Care Collaborative Community, US
| | - Alisha Oropallo
- Comprehensive Wound Healing Center, US
- Hyperbarics at Northwell Health, US
| | | | | | - Naz Wahab
- Wound Care Experts, NV, US
- HCA Mountain View Hospital, US
- Roseman University College of Medicine, US
- Common Spirit Dignity Hospitals, US
| | | | | | - R Allyn Forsyth
- MiMedx Group, Inc., GA, US
- Department of Biology, San Diego State University, CA, US
| | | | | | | | - William V Padula
- Stage Analytics, Suwanee, GA, US
- Department of Pharmaceutical & Health Economics, Mann School of Pharmacy & Pharmaceutical Sciences, University of Southern California, Los Angeles, CA, US
- The Leonard D. Schaeffer Center for Health Policy & Economics, University of Southern California, Los Angeles, CA, US
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Tettelbach WH, Driver V, Oropallo A, Kelso MR, Niezgoda JA, Wahab N, Jong JLD, Hubbs B, Forsyth RA, Magee GA. Treatment patterns and outcomes of Medicare enrolees who developed venous leg ulcers. J Wound Care 2024; 33:S12-S13. [PMID: 38457293 DOI: 10.12968/jowc.2024.33.sup3.s12] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/10/2024]
Affiliation(s)
- William H Tettelbach
- RestorixHealth, Metairie, LA, US
- College of Podiatric Medicine, Western University of Health Sciences, US
- Duke University School of Medicine, Department of Anesthesiology, US
- Onsite Advanced Care, Salt Lake City, UT, US
- American Professional Wound Care Association, US
| | - Vickie Driver
- Wound Care and Hyperbaric Centers at INOVA Healthcare, US
- Wound Care Collaborative Community, US
| | - Alisha Oropallo
- Comprehensive Wound Healing Center, US
- Hyperbarics at Northwell Health, US
| | | | | | - Naz Wahab
- Wound Care Experts, US
- HCA Mountain View Hospital, US
- Roseman University College of Medicine, US
- Common Spirit Dignity Hospitals, US
| | | | | | - R Allyn Forsyth
- MiMedx Group, Inc. US
- Department of Biology, San Diego State University, US
| | - Gregory A Magee
- Keck School of Medicine, University of Southern California, US
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Tettelbach WH, Driver V, Oropallo A, Kelso MR, Niezgoda JA, Wahab N, De Jong JL, Hubbs B, Forsyth RA, Magee GA. Treatment patterns and outcomes of Medicare enrolees who developed venous leg ulcers. J Wound Care 2023; 32:704-718. [PMID: 37907359 DOI: 10.12968/jowc.2023.32.11.704] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2023]
Abstract
OBJECTIVE To retrospectively evaluate the comorbidities, treatment patterns and outcomes of Medicare enrolees who developed venous leg ulcers (VLUs). METHOD Medicare Limited Data Standard Analytic Hospital Inpatient and Outpatient Department Files were used to follow patients who received medical care for a VLU between 1 October 2015 and 2 October 2019. Patients diagnosed with chronic venous insufficiency (CVI) and a VLU were propensity matched into four groups based on their treatment regimen. Episode claims were used to document demographics, comorbidities and treatments of Medicare enrolees who developed VLUs, as well as important outcomes, such as time to ulcer closure, rates of complications and hospital utilisation rates. Outcomes were compared across key propensity-matched groups. RESULTS In total, 42% of Medicare enrolees with CVI (n=1,225,278), developed at least one VLU during the study, and 79% had their episode claim completed within one year. However, 59% of patients developed another VLU during the study period. This analysis shows that only 38.4% of VLU episodes received documented VLU conservative care treatment. Propensity-matched episodes that received an advanced treatment or high-cost skin substitutes for a wound which had not progressed by 30 days demonstrated the best outcomes when their cellular, acellular, matrix-like product (CAMP) treatment was applied weekly or biweekly (following parameters for use). Complications such as rates of infection (33%) and emergency department visits (>50%) decreased among patients who received an advanced treatment (following parameters for use). CONCLUSION Medicare enrolees with CVI have diverse comorbidities and many do not receive sufficient management, which contributes to high rates of VLUs and subsequent complications. Medicare patients at risk of a VLU who receive early identification and advanced CAMP treatment demonstrated improved quality of life and significantly reduced healthcare resource utilisation.
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Affiliation(s)
- William H Tettelbach
- HCA Healthcare, Mountain Division, US
- College of Podiatric Medicine, Western University of Health Sciences, US
- Duke University School of Medicine, Department of Anesthesiology, US
- Association for the Advancement of Wound Care, US
- American Professional Wound Care Association, US
- MiMedx Group Inc., GA, US
| | - Vickie Driver
- Wound Care and Hyperbaric Centers at INOVA Healthcare, US
- Wound Care Collaborative Community, US
| | - Alisha Oropallo
- Comprehensive Wound Healing Center, US
- Hyperbarics at Northwell Health, US
| | | | | | - Naz Wahab
- Wound Care Experts, NV, US
- HCA Mountain View Hospital, US
- Roseman University College of Medicine, US
- Common Spirit Dignity Hospitals, US
| | | | | | - R Allyn Forsyth
- MiMedx Group Inc., GA, US
- Department of Biology, San Diego State University, US
| | - Gregory A Magee
- Keck School of Medicine, University of Southern California, US
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Tettelbach WH. TIMERS evolution: focus on a new categorisation and best practice related to biomaterials in tissue repair and regeneration. J Wound Care 2023; 32:S3-S4. [PMID: 37121664 DOI: 10.12968/jowc.2023.32.sup5.s3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/02/2023]
Affiliation(s)
- William H Tettelbach
- Duke University School of Medicine, Department of Anesthesiology, NC, US. Western University of Health Sciences, College of Podiatric Medicine & Surgery, CA, US. MIMEDX Group, Inc., GA, US. American Professional Wound Care Association, LA, US. Association for the Advancement of Wound Care, PA, US. Western Peaks Specialty Hospital, UT, US. Institute of Skin Integrity and Infection Prevention, University of Huddersfield, UK
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Alston D, Eggiman E, Forsyth RA, Tettelbach WH. Pyoderma gangrenosum and dehydrated human amnion/chorion membrane: a potential tool for an orphan disease. J Wound Care 2022; 31:808-814. [DOI: 10.12968/jowc.2022.31.10.808] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Objective: Pyoderma gangrenosum (PG) is an often-misdiagnosed, painful, inflammatory and ulcerative skin disorder. It is an orphan disease, where standard wound treatments such as sharp surgical debridement are contraindicated. This retrospective case series sought to evaluate the application of dehydrated human amnion/chorion membrane (DHACM) as a skin substitute in cases that were refractory to a range of standard-of-care techniques. Method: This retrospective case series involved wounds which failed to close with standard escalating treatments, including anti-inflammatory and immunosuppressive therapies. Subjects were transitioned to DHACM and wound sizes were monitored until closure. Results: Wounds (n=5) for all three subjects had stalled with standard therapies for at least 2.5 months but responded quickly to routinely applied DHACM treatments, and closure was achieved in each case. Conclusion: This retrospective pilot case series examined the use of DHACM as an alternative wound treatment for PG patients failing standard therapies. DHACM treatments re-initiated the trajectory towards wound closure for each stalled PG ulcer. The results suggest a treatment algorithm starting with early recognition, wound closure via treatment escalation, and lastly a gradual reduction in treatment for durable closure. DHACM treatment should be formally evaluated as an adjunct to PG ulcers that have remained refractory to more commonly used immunomodulating therapies.
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Affiliation(s)
- Dylan Alston
- Intermountain Southridge Clinic Dermatology, Riverton, UT, US
| | | | - R Allyn Forsyth
- MIMEDX Group, Inc, US
- Department of Biology, San Diego State University, San Diego, CA, US
| | - William H Tettelbach
- MIMEDX Group, Inc, US
- College of Podiatric Medicine, Western University of Health Sciences, CA, US
- Duke University School of Medicine, Department of Anesthesiology, NC, US
- Association for the Advancement of Wound Care, US
- Western Peaks Specialty Hospital, UT, US
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Tettelbach WH, Cazzell SM, Hubbs B, DeJong JL, Forsyth RA, Reyzelman AM. Outcomes for Medicare debridement intervals receiving dehydrated human amnion/chorion membrane. J Wound Care 2022; 31:886. [DOI: 10.12968/jowc.2022.31.10.886] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- William H Tettelbach
- MIMEDX Group, Inc., GA, US
- College of Podiatric Medicine, Western University of Health Sciences
- Duke University School of Medicine, Department of Anesthesiology, NC, US
- American Professional Wound Care Association, LA, US
- Association for the Advancement of Wound Care, PA, US
| | | | | | | | - R Allyn Forsyth
- MIMEDX Group, Inc., GA, US
- Department of Biology, San Diego State University, San Diego, CA, US
| | - Alexander M Reyzelman
- Department of Medicine California School of Podiatric Medicine at Samuel Merritt University, CA, US
- Co-Director, UCSF Center for Limb Preservation and Diabetic Foot Center for Clinical Research, San Francisco, CA, US
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Tettelbach WH, Cazzell SM, Hubbs B, Jong JLD, Forsyth RA, Reyzelman AM. The influence of adequate debridement and placental-derived allografts on diabetic foot ulcers. J Wound Care 2022; 31:S16-S26. [PMID: 36113857 DOI: 10.12968/jowc.2022.31.sup9.s16] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
OBJECTIVE To determine the role of debridement when patients are using placental-derived allografts (PDAs), data from two prospective, multicentre, randomised controlled trials (RCTs) were evaluated for the quality or adequacy of debridement on diabetic foot ulcers (DFUs) treated with PDAs. Results were compared with real-world findings via a retrospective analysis of 2015-2019 Medicare claims for DFUs. METHOD Debridement adequacy in the prospective RCTs was adjudicated by three blinded wound care specialists. Treatments included two PDAs, dehydrated human amnion/chorion membrane (DHACM, n=54) or dehydrated human umbilical cord (DHUC, n=101), compared with standard of care (SOC, n=110). The key outcome was the influence of adequate debridement on rates of complete closure within 12 weeks. Additionally, a retrospective analysis of 2015-2019 Medicare claims for DFUs that received routine debridement at intervals ranging from every 1-7 days (18,900 total episodes), 8-14 days (35,728 total episodes), and every 15 days or greater (34,330 total episodes) was performed. RESULTS Within the RCTs, adequate debridement occurred in 202/265 (76%) of patients, 90/110 (82%) SOC ulcers, 45/54 (83%) of DHACM-treated ulcers, and in 67/101 (66%) of DHUC-treated ulcers. Complete closure occurred in 150/202 (74%) of adequately debrided ulcers, and in only 13/63 (21%) of ulcers without adequate debridement, p<0.0001. Debridement was the most significant factor for closure even when controlling for other clinical characteristics. Within the Medicare claims data 21% (18,900/88,958) of episodes treated with SOC only had debridement intervals of ≤7 days. Short debridement intervals in combination with the use of DHACM demonstrated statistically significant better outcomes than SOC including: 65% fewer major amputations (p<0.0001), higher DFU resolution rates (p=0.0125), 42% fewer emergency room visits (p<0.0001) and reduced usage of other hospital resources (admissions and readmissions). CONCLUSION Prospectively collected data examining the quality of debridement and retrospectively analysed data examining the frequency of debridement supports routine adequate wound debridement, particularly at intervals of seven days, as an essential component of wound care. Optimal use of placental-derived allografts improves outcomes and lowers the use of healthcare resources.
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Affiliation(s)
- William H Tettelbach
- MIMEDX Group, Inc., GA, US.,College of Podiatric Medicine, Western University of Health Sciences.,Duke University School of Medicine, Department of Anesthesiology, NC, US.,American Professional Wound Care Association, LA, US.,Association for the Advancement of Wound Care, PA, US.,Western Peaks Specialty Hospital, UT, US
| | | | | | | | - R Allyn Forsyth
- MIMEDX Group, Inc., GA, US.,Department of Biology, San Diego State University, San Diego, CA, US
| | - Alexander M Reyzelman
- Department of Medicine California School of Podiatric Medicine at Samuel Merritt University, CA, US.,Co-Director, UCSF Center for Limb Preservation and Diabetic Foot Center for Clinical Research, San Francisco, CA, US
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Tettelbach WH. The importance of debridement and practising what we preach. J Wound Care 2022; 31:S3. [PMID: 35797251 DOI: 10.12968/jowc.2022.31.sup7.s3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Tettelbach WH, Armstrong DG, Chang TJ, Jong JLD, Glat PM, Hsu JH, Kelso MR, Niezgoda JA, Labovitz JM, Hubbs B, Forsyth RA, Cohen BG, Reid NM, Padula WV. Cost-effectiveness of dehydrated human amnion/chorion membrane allografts in lower extremity diabetic ulcer treatment. J Wound Care 2022; 31:S10-S31. [PMID: 35148642 DOI: 10.12968/jowc.2022.31.sup2.s10] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
OBJECTIVE To evaluate the cost-effectiveness and budget impact of using standard care (no advanced treatment, NAT) compared with an advanced treatment (AT), dehydrated human amnion/chorion membrane (DHACM), when following parameters for use (FPFU) in treating lower extremity diabetic ulcers (LEDUs). METHOD We analysed a retrospective cohort of Medicare patients (2015-2019) to generate four propensity-matched cohorts of LEDU episodes. Outcomes for DHACM and NAT, such as amputations, and healthcare utilisation were tracked from claims codes, analysed and used to build a hybrid economic model, combining a one-year decision tree and a four-year Markov model. The budget impact was evaluated in the difference in per member per month spending following completion of the decision tree. Likewise, the cost-effectiveness was analysed before and after the Markov model at a willingness to pay (WTP) threshold of $100,000 per quality adjusted life year (QALY). The analysis was conducted from the healthcare sector perspective. RESULTS There were 10,900,127 patients with a diagnosis of diabetes, of whom 1,213,614 had an LEDU. Propensity-matched Group 1 was generated from the 19,910 episodes that received AT. Only 9.2% of episodes were FPFU and DHACM was identified as the most widely used AT product among Medicare episodes. Propensity-matched Group 4 was limited by the 590 episodes that used DHACM FPFU. Episodes treated with DHACM FPFU had statistically fewer amputations and healthcare utilisation. In year one, DHACM FPFU provided an additional 0.013 QALYs, while saving $3,670 per patient. At a WTP of $100,000 per QALY, the five-year net monetary benefit was $5003. CONCLUSION The findings of this study showed that DHACM FPFU reduced costs and improved clinical benefits compared with NAT for LEDU Medicare patients. DHACM FPFU provided better clinical outcomes than NAT by reducing major amputations, ED visits, inpatient admissions and readmissions. These clinical gains were achieved at a lower cost, in years 1-5, and were likely to be cost-effective at any WTP threshold. Adoption of best practices identified in this retrospective analysis is expected to generate clinically significant decreases in amputations and hospital utilisation while saving money.
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Affiliation(s)
- William H Tettelbach
- MIMEDX Group, Inc., US.,College of Podiatric Medicine, Western University of Health Sciences, US.,Duke University School of Medicine, Department of Anesthesiology, US.,Association for the Advancement of Wound Care.,Western Peaks Specialty Hospital, US.,Encompass Health & Rehabilitation Hospital of Utah, US
| | - David G Armstrong
- Southwestern Academic Limb Salvage Alliance (SALSA).,Keck School of Medicine, University of Southern California, Department of Surgery, US
| | | | | | | | | | | | | | | | | | - R Allyn Forsyth
- MIMEDX Group, Inc., US.,Department of Biology, San Diego State University, San Diego, California, US
| | | | | | - William V Padula
- Monument Analytics, Baltimore, MD, US.,Department of Pharmaceutical & Health Economics, School of Pharmacy, University of Southern California, Los Angeles, CA, US.,The Leonard D. Schaeffer Center for Health Policy & Economics, University of Southern California, Los Angeles, CA, US.,Department of Acute & Chronic Care, Johns Hopkins School of Nursing, Baltimore, MD, US
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Armstrong DG, Tettelbach WH, Chang TJ, De Jong JL, Glat PM, Hsu JH, Kelso MR, Niezgoda JA, Tucker TL, Labovitz JM. Observed impact of skin substitutes in lower extremity diabetic ulcers: lessons from the Medicare Database (2015-2018). J Wound Care 2021; 30:S5-S16. [PMID: 34256590 DOI: 10.12968/jowc.2021.30.sup7.s5] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
OBJECTIVE To evaluate large propensity-matched cohorts to assess outcomes in patients receiving advanced treatment (AT) with skin substitutes for lower extremity diabetic ulcers (LEDUs) versus no AT (NAT) for the management of LEDUs. METHOD The Medicare Limited Dataset (1 October 2015 through 2 October 2018) were used to retrospectively analyse people receiving care for a LEDU treated with AT or NAT (propensity-matched Group 1). Analysis included major and minor amputations, emergency department (ED) visits and hospital readmissions. In addition, AT following parameters for use (FPFU) was compared with AT not FPFU (propensity-matched Group 2). A paired t-test was used for comparisons of the two groups. For comparisons of three groups, the Kruskal-Wallis test was used. A Bonferroni correction was performed when multiple comparisons were calculated. RESULTS There were 9,738,760 patients with a diagnosis of diabetes, of whom 909,813 had a LEDU. In propensity-matched Group 1 (12,676 episodes per cohort), AT patients had statistically fewer minor amputations (p=0.0367), major amputations (p<0.0001), ED visits (p<0.0001), and readmissions (p<0.0001) compared with NAT patients. In propensity-matched Group 2 (1131 episodes per cohort), AT FPFU patients had fewer minor amputations (p=0.002) than those in the AT not FPFU group. CONCLUSION AT for the management of LEDUs was associated with significant reductions in major and minor amputation, ED use, and hospital readmission compared with LEDUs managed with NAT. Clinics should implement AT in accordance with the highlighted parameters for use to improve outcomes and reduce costs.
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Affiliation(s)
- David G Armstrong
- Southwestern Academic Limb Salvage Alliance (SALSA), US
- Keck School of Medicine, University of Southern California, Department of Surgery, US
| | - William H Tettelbach
- MIMEDX Group, Inc., US
- College of Podiatric Medicine, Western University of Health Sciences, US
- Duke University School of Medicine, Department of Anesthesiology, US
- Association for the Advancement of Wound Care, US
- Western Peaks Specialty Hospital, US
- Encompass Health and Rehabilitation Hospital of Utah, US
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Clarke CE, Tettelbach WH. Unique closure of Gustilo IIIA fracture with a hard-to-heal lower extremity wound. J Wound Care 2021; 30:S24-S27. [PMID: 33573493 DOI: 10.12968/jowc.2021.30.sup2.s24] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Consistently achieving wound closure requires a broad understanding of wound physiology, anatomy and wound healing phases. The multifaceted principles of wound closure are comprised of: perfusion evaluation; diabetes control; nutritional optimisation; infection control; mechanical stress avoidance; oedema management; wound bed preparation; and community care. Optimisation of each element is crucial to timely and durable resolution of acute and hard-to-heal wounds. This objective is realisable only through an interdisciplinary approach to wound healing. The reconstructive ladder represents the graduation of complex wound management as applied by the specialty of plastic surgery. The approach to reconstruction typically begins with the least invasive option, which is considered reliable. However, there are instances when the most reliable option on the reconstructive ladder is not a viable option and creative solutions for wound closure are required. The following case report demonstrates a unique approach to lower extremity salvage in a subacute compound fracture surgical site infection using a limited reconstructive ladder.
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Affiliation(s)
| | - William H Tettelbach
- 2 Medical Affairs, MiMedx Group, Inc., Marietta, GA.,3 Medical Director of Wound Care-Western Peaks Specialty Hospital, Bountiful, UT.,4 Adjunct Assistant Professor of Undersea & Hyperbaric Medicine-Duke University School of Medicine, Durham, NC.,5 Adjunct Professor of Podiatric Medicine & Surgery-Western University of Health Sciences, Pomona, CA
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Moffat AD, Weaver LK, Tettelbach WH. Compromised breast flap treated with leech therapy, hyperbaric oxygen, pentoxifylline and topical nitroglycerin: A case report. Undersea Hyperb Med 2015; 42:281-284. [PMID: 26152110] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
INTRODUCTION Hyperbaric oxygen (HBO2) is often indicated in compromised surgical flaps. Although limited to animal models and human case reports, the utilization of leech therapy (Hirudo medicinalis) with HBO2 provides better outcomes than each modality alone. Topical nitroglycerin and pentoxifylline are also frequently used adjunctively for compromised flaps. We present a case of successful breast flap salvage utilizing a combination of leech therapy, HBO2, topical nitroglycerin and pentoxifylline. CASE REPORT A 34-year-old female, one day post-status cosmetic breast reduction mammoplasty developed a dusky discoloration of the left nipple areolar complex, indicating imminent flap failure. The patient was immediately treated with topical nitroglycerin, oral pentoxifylline, and referred for HBO2. After her first HBO2 treatment, there was clinical improvement to the superior portion of the areolar flap, with little improvement inferiorly where the discoloration had remained essentially unchanged. To address this, we added leech therapy and discontinued the topical nitroglycerin. Ceftriaxone for Aeromonas prophylaxis was started, and leeches were attached two at a time and removed from the area once feeding had ceased. These were applied three times per day for three days while receiving HBO2 twice per day for six days. The patient's flap improved and completely healed by Week 8 without need for further surgery. CONCLUSION This is the first case to our knowledge of successful breast flap salvage using a combination of leech therapy, HBO2, topical nitroglycerin and pentoxifylline.
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Evans RS, Kuttler KG, Simpson KJ, Howe S, Crossno PF, Johnson KV, Schreiner MN, Lloyd JF, Tettelbach WH, Keddington RK, Tanner A, Wilde C, Clemmer TP. Automated detection of physiologic deterioration in hospitalized patients. J Am Med Inform Assoc 2015; 22:350-60. [PMID: 25164256 PMCID: PMC5566187 DOI: 10.1136/amiajnl-2014-002816] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2014] [Revised: 06/23/2014] [Accepted: 07/15/2014] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVE Develop and evaluate an automated case detection and response triggering system to monitor patients every 5 min and identify early signs of physiologic deterioration. MATERIALS AND METHODS A 2-year prospective, observational study at a large level 1 trauma center. All patients admitted to a 33-bed medical and oncology floor (A) and a 33-bed non-intensive care unit (ICU) surgical trauma floor (B) were monitored. During the intervention year, pager alerts of early physiologic deterioration were automatically sent to charge nurses along with access to a graphical point-of-care web page to facilitate patient evaluation. RESULTS Nurses reported the positive predictive value of alerts was 91-100% depending on erroneous data presence. Unit A patients were significantly older and had significantly more comorbidities than unit B patients. During the intervention year, unit A patients had a significant increase in length of stay, more transfers to ICU (p = 0.23), and significantly more medical emergency team (MET) calls (p = 0.0008), and significantly fewer died (p = 0.044) compared to the pre-intervention year. No significant differences were found on unit B. CONCLUSIONS We monitored patients every 5 min and provided automated pages of early physiologic deterioration. This before-after study found a significant increase in MET calls and a significant decrease in mortality only in the unit with older patients with multiple comorbidities, and thus further study is warranted to detect potential confounding. Moreover, nurses reported the graphical alerts provided information needed to quickly evaluate patients, and they felt more confident about their assessment and more comfortable requesting help.
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Affiliation(s)
- R Scott Evans
- Homer Warner Center for Informatics Research, Intermountain Healthcare, Salt Lake City, Utah, USA
- Biomedical Informatics, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Kathryn G Kuttler
- Homer Warner Center for Informatics Research, Intermountain Healthcare, Salt Lake City, Utah, USA
- Pulmonary and Critical Care, Intermountain Medical Center, Murray, Utah, USA
| | - Kathy J Simpson
- Shock Trauma Intensive Care, Intermountain Medical Center, Murray, Utah, USA
| | - Stephen Howe
- Homer Warner Center for Informatics Research, Intermountain Healthcare, Salt Lake City, Utah, USA
| | - Peter F Crossno
- Pulmonary and Critical Care, Intermountain Medical Center, Murray, Utah, USA
| | - Kyle V Johnson
- Homer Warner Center for Informatics Research, Intermountain Healthcare, Salt Lake City, Utah, USA
| | - Misty N Schreiner
- Shock Trauma Intensive Care, Intermountain Medical Center, Murray, Utah, USA
| | - James F Lloyd
- Homer Warner Center for Informatics Research, Intermountain Healthcare, Salt Lake City, Utah, USA
| | - William H Tettelbach
- Hyperbaric Medicine, Wound Care & Infectious Diseases, Intermountain Healthcare, Salt Lake City, Utah, USA
- Department of Anesthesiology, Duke University School of Medicine, Durham, North Carolina, USA
| | - Roger K Keddington
- Intensive Medicine/Emergency Services, Intermountain Healthcare, Salt Lake City, Utah, USA
| | - Alden Tanner
- Shock Trauma Intensive Care, Intermountain Medical Center, Murray, Utah, USA
| | - Chelbi Wilde
- Shock Trauma Intensive Care, Intermountain Medical Center, Murray, Utah, USA
| | - Terry P Clemmer
- Critical Care Medicine, LDS Hospital, Salt Lake City, Utah, USA
- Department of Medicine, University of Utah School of Medicine, Salt Lake City, Utah, USA
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Hagedorn CH, Tettelbach WH, Panella HL. Development and characterization of polyclonal antibodies against a conserved sequence in the catalytic domain of protein kinases. FEBS Lett 1990; 264:59-62. [PMID: 1692542 DOI: 10.1016/0014-5793(90)80764-a] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Using a synthetic oligopeptide (CGGGTPEYLAPEGGK) crosslinked to keyhole limpet hemocyanin we have raised polyclonal rabbit antibodies against a 9 residue homologous region found in the catalytic domain of most protein kinases. These antibodies reacted during Western immunoblotting with cAMP dependent protein kinase catalytic subunit, phosphorylase kinase gamma subunit and calcium calmodulin dependent protein kinase II which have homologous sequences of GTPEYLAPE, GTPSYLAPE and GTPGYLSPE, respectively. Five other protein kinases did not react with anti-GTPEYLAPE antibodies during Western immunoblotting. Affinity-purified antibodies were able to detect as little as 50 ng of cAMP dependent protein kinase and 200 ng of Ca2+/calmodulin dependent protein kinase II. Immunoblotting of A431 cell plasma membrane vesicles indicated the presence of an approximately 55 kDa protein that contains the conserved sequence and is likely to be a protein kinase. Antibodies directed against conserved sequences present in protein kinases, or possibly other enzymes, may be useful in identifying previously uncharacterized enzymes at the protein level.
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Affiliation(s)
- C H Hagedorn
- Department of Medicine, Vanderbilt University School of Medicine, Nashville, TN 37232
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