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Arterial Ulcers - Overview

Arterial Ulcers - Overview

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Arterial Ulcers - Overview

Overview

    This topic provides a list of Guidelines, Quality Measures and other resources on Arterial Ulcers. See topic "Arterial Ulcers - Introduction and Assessment" for a review and framework for assessment of arterial ulcers, including epidemiology, risk factors, etiology, pathophysiology, history, physical examination, diagnosis, differential diagnoses, documentation and ICD-10 coding. For management of arterial ulcers see "Arterial Ulcers - Treatment", and "Arterial ulcer - Surgical Treatment". For patient education, see topic "Patient Education - Arterial Ulcer" (coming soon).

    EVIDENCE BASED CLINICAL GUIDELINES

    Below is a list of the some of the most recent evidence-based guidelines on arterial ulcers, and associated vascular conditions (e.g., peripheral artery disease, chronic limb-threatening ischemia, acute limb ischemia) 

    Evidence-based guideline, YearPublishing Organization, Country or Region
    Links
    Arterial Ulcers

    Wound healing society 2014 update on guidelines for arterial ulcers, 2014
    Wound Healing Society, USA
    Guideline (Free)
    2014 Guideline for Management of Wounds in Patients With Lower-Extremity Arterial Disease (LEAD): An Executive Summary, 2014
    Wound, Ostomy and Continence Nurses Society, USA
    Guideline (Paid
    )
    Associated Vascular Conditions

    Editor's Choice - European Society for Vascular Surgery (ESVS) 2020 Clinical Practice Guidelines on the Management of Acute Limb Ischaemia, 2020
    European Society for Vascular Surgery, Europe
    Guideline (Free)
    Global vascular guidelines on the management of chronic limb-threatening ischemia, 2019
    European Society for Vascular Surgery, Society for Vascular Surgery, World Federation of Vascular Societies, Global
    Guideline (Free)
    Editor's Choice - 2017 ESC Guidelines on the Diagnosis and Treatment of Peripheral Arterial Diseases, in Collaboration With the European Society for Vascular Surgery (ESVS), 2017
    European Society of Cardiology, European Society for Vascular Surgery, Europe
    Guideline (Free)
    2016 AHA/ACC Guideline on the Management of Patients With Lower Extremity Peripheral Artery Disease: Executive Summary, 2016
    American College of Cardiology, American Heart Association, USA
    Guideline (Free)

    QUALITY MEASURES

    Relevant Quality Measures are listed below. Diabetic foot ulcer quality measures are also included, as arterial ulcers frequently present with mixed etiology (ischemic and neuropathic).  

    SettingCMS ProgramDeveloped byMeasure IDTitleYear/ Description/ Benchmark (when available)
    OutpatientQPP - MIPS (*)
    US Wound Registry
    CDR1
    Outcome measure: Adequate Off-loading of Diabetic Foot Ulcers at each visit, appropriate to location of ulcerPercentage of visits in which diabetic foot ulcers among patients aged 18 years and received adequate off-loading during a 12-month reporting period, stratified by location of the ulcer. As a benchmark, among eligible providers reporting this measure, per visit off-loading of DFUs is now achieved 59 % of the time
    OutpatientQPP - MIPS (*)
    US Wound RegistryCDR2Outcome measure: Diabetic Foot Ulcer (DFU) Healing or Closure
    Percentage of diabetic foot ulcers among patients age 18 or older that have achieved healing or closure within 6 months, stratified by the Wound Healing Index. Healing or closure is defined as complete epithelialization without drainage or the need for a dressing over the closed ulceration, although venous compression would still be required.
    OutpatientQPP - MIPS (*)
    US Wound Registry and the Undersea and Hyperbaric Medical Society (UHMS)
    CDR8Appropriate use of hyperbaric oxygen therapy for patients with diabetic foot ulcerPercent of diabetic foot ulcers graded stage 3 or higher on the Wagner Grading System for Diabetic Foot Infections that received HBOT appropriately, among diabetic foot ulcers receiving HBOT during the reporting period. Prior to receiving HBOT patients must have met the following criteria: Have a diabetic foot ulcer that has not achieved 30% closure after four weeks of treatment, adequate offloading of the diabetic foot ulcer at each visit for four weeks of treatment, vascular screening performed, measurement of BMI with follow-up MIPS #128. As a benchmark, In 2000, the OIG published a report called, “Hyperbaric Oxygen Therapy, Its Use and Appropriateness,” in which it estimated that 32% of payments for HBOT were paid in error ($14.2 million that year). A 2013 retrospective study found that 60% of the diabetic foot ulcers treated with HBOT in the study sample were Wagner Grade 2, confirming that Medicare coverage guidelines of reserving HBOT for Wagner 3 and above were not being followed.[1]
    Outpatient
    QPP - MIPS (*)
    US Wound Registry 
    USWR22
    Patient Reported Nutritional Assessment and Intervention Plan in Patients with Wounds and Ulcers

    The percentage of patients aged 18 years and older with a diagnosis of a wound or ulcer of any type who self-report nutritional screening with a validated tool (such as the Self-MNA® by Nestlé) as well as food insecurity assessment, AND for whom the clinician provides an intervention plan within the 12-month reporting period.


    Outpatient
    QPP - MIPS (*)
    US Wound Registry 
    USWR23
    Non Invasive Arterial Assessment of patients with lower extremity wounds or ulcers for determination of healing potential
    Percentage of patients aged 18 years or older with a non healing lower extremity wounds or ulcers that underwent a non-invasive arterial assessment once in a 12 month period, stratified by ABI, perfusion pressure, or oximetry. Data from the USWR indicates that fewer than 10% of patients with chronic non-healing leg ulcers undergo any type of vascular assessment (ABI, transcutaneous oximetry or skin perfusion pressure) even at hospital based outpatient wound centers. 
    Outpatient
    QPP - MIPS (*)
    US Wound Registry
    USWR24
    Patient Reported Experience of Care: Wound Outcome
    All eligible patients with wounds or ulcers who completed of Wound Outcome Questionnaire who showed 10% improvement at discharge or transfer to another site of care during the 12 month reporting period.
    OutpatientQPP - MIPS (*)
    US Wound Registry
    USWR27
    Assessment of Nutritionally At-Risk Patients for Malnutrition and Development of Nutrition Recommendations/Interventions by a Registered Dietitian Nutritionist
    Percentage of patients age 18 years and older who are nutritionally at-risk that have documented nutrition intervention recommendations by a registered dietitian nutritionist or clinical qualified nutrition professional if identified with moderate or severe malnutrition as part of a nutrition assessment. A study by Sherry et. al (2017) demonstrated that only 65% of patients who screened positive for malnutrition risk received any referral to a nutrition professional or an order for nutritional support.[2]
    OutpatientQPP - MIPS (*)
    US Wound Registry
    USWR28
    Obtaining Preoperative Nutritional Recommendations from a Registered Dietitian Nutritionist (RDN) in Nutritionally At-Risk Surgical Patients
    Percentage of patients age 18 years and older who have undergone a surgical procedure and were identified to be at-risk for malnutrition based on a malnutrition screening OR who were referred to a registered dietitian nutritionist or clinically qualified nutrition professional and have a preoperative nutrition assessment which was documented in the medical record along with documentation of any recommended nutrition interventions. 
    OutpatientQPP - MIPS (*)
    MedicareMIPS1Diabetes: Hemoglobin A1c Poor Control
    Percentage of patients 18-75 years of age with diabetes who had hemoglobin A1c > 9.0% during the measurement period
    Outpatient
    QPP - MIPS (*)
    MedicareMIPS 126Diabetes Mellitus: Diabetic Foot and Ankle Care, Peripheral Neuropathy - Neurological Evaluation
    Percentage of patients aged 18 years and older with a diagnosis of diabetes mellitus who had a neurological examination of their lower extremities within 12 months
    OutpatientQPP - MIPS (*)
    MedicareMIPS 127Diabetes Mellitus: Diabetic Foot and Ankle Care, Ulcer Prevention - Evaluation of Footwear
    Percentage of patients aged 18 years and older with a diagnosis of diabetes mellitus who were evaluated for proper footwear and sizing
    Outpatient
    QPP - MIPS (*)
    Medicare
    MIPS 128
    Preventative Care and Screening: Body Mass Index (BMI) Screening and Follow-Up

    Percentage of patients aged 18 years and older with a BMI documented during the current encounter or during the previous twelve months AND with a BMI outside of normal parameters, a follow-up plan is documented during the encounter or during the previous twelve months of the current encounter


    Outpatient
    QPP - MIPS (*)
    MedicareMIPS 131
    Pain Assessment and Follow-Up
    2019 measure Percentage of visits for patients aged 18 years and older with documentation of a pain assessment using a standardized tool(s) on each visit AND documentation of a follow-up plan when pain is present

    * The Quality Payment Program (QPP) was implemented in the U.S. by Medicare in 2017. Merit-based incentive payment system (MIPS) is designed for eligible clinicians who bill under Medicare Part B. Grayed out measures were retired/deleted.

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    REFERENCES

    1. Margolis, David J; Gupta, Jayanta; Hoffstad, Ole; Papdopoulos, Maryte; Glick, Henry A; Thom, Stephen R; Mitra, Nandita et al. Lack of effectiveness of hyperbaric oxygen therapy for the treatment of diabetic foot ulcer and the prevention of amputation: a cohort study. Diabetes Care. 2013;volume 36(7):1961-1966.
    2. Sherry CL, Sauer AC, Thrush KE et al. Assessment of the Nutrition Care Process in US Hospitals Using a Web-Based Tool Demonstrates the Need for Quality Improvement in Malnutrition Diagnosis and Discharge Care. Current developments in nutrition. 2017;volume 1(11):e001297.
    Topic 761 Version 1.0

    SUBTOPICS

    Evidence-based review on arterial ulcer. Framework for assessment of patients with arterial ulcers. Includes concise abstract and comprehensive resources on the condition (e.g. epidemiology, risk factors, etiology, pathophysiology, history, physical examination, diagnosis, differential diagnoses, documentation and ICD-10 coding)

    Concise Algorithm for Assessment of Arterial Ulcer for use at point-of-care. Comprehensive topic including epidemiology, risk factors, etiology, pathophysiology, history, physical examination, diagnosis, differential diagnoses, documentation and ICD-10 coding. Free Abstract Summary

    This topic covers surgical management of arterial ulcers (AUs) with focus on surgical indications and selection criteria.