Chronic wounds pose significant logistical and economic challenges for health care systems. Specialized dressings, drugs, growth factors, and cultured cells show considerable promise for improving outcomes. The sophistication of these interventions, which require greater provider expertise, has led to the development of multidisciplinary teams for delivering these treatments. However, smaller VA medical center and clinics lack the personnel and other resources necessary to support these efforts. Teleconsultation offers an opportunity to improve access to specialized wound care at VA tertiary care centers. However, there is currently no data available on whether or not teleconsultation can actually achieve the expected improvements in quality of care and reduction in morbidity.
The primary objective of the proposed research was to conduct an evaluation of the first year of the VISN 11 wound care teleconsultation program by examining differences in the following between the study group and historical controls: (1) utilization of services; (2) use of state-of-the-art treatment modalities; (3) amputation rates; and (4) quality of care as measured by various process indicators. The secondary objective was to survey all VISNs and a subset of facilities to identify the current infrastructure for managing chronic wounds, both in primary and tertiary care facilities. Data collected from this study will provide important preliminary data for the conduct of a larger scale, multi-site evaluation of a teleconsultation program for chronic wounds.
Methods for the primary objective consisted of a quasi-experimental design comparing patients enrolled in the VISN 11 teleconsultation program in FY 2008 with an historical control group of chronic wound patients seen at the Battle Creek VAMC and Grand Rapids OPC in 2005. Data sources included Austin databases for demographics, comorbidities, resource utilization, and amputation rates. VA's Computerized Patient Record System (CPRS) was used to obtain data on wound type, treatments, and processes of care. The secondary objective was attained using an observational, cross-sectional review of current wound care practices across VISNs, using primarily telephone interviews of clinical staff.
The teleconsultation system had a mixed effect on use of health services. While the frequency of traveling to the referral center was significantly reduced, inpatient admissions and days of care were not, and were actually greater for the teleconsultation group. There was no significant difference in amputation rates between the two groups. However, a significant difference between the two groups was observed for the process measures of quality. The findings from the VISN and facility interviews suggest an interest in, and need for, improving the delivery of coordinated, multidisciplinary care to chronic wound patients. Two thirds of the facilities surveyed refer their wound care patients out for specialty care, suggesting potential demand for a teleconsultation program. Some of the major challenges associated with wound care, such as inappropriate referrals, transportation issues, and scheduling and delivering follow-up care, could also be addressed by a teleconsultation program.
It is expected that this research will help pave the way for improving access to state-of-the art treatments for chronic wounds.
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