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A smaller portion of insufficient use is due to lack of trained clinicians who are able to apply a TCC.¹⁸

  The aforementioned phenomenon has piqued this author’s interest in thoroughly analyzing the protocol/pathway driven model for healing DFU, and how it relates to facilities’ and clinicians’ financial motivations in choosing a particular route for healing DFU.

Healing Pathway

  The approach for managing a DFU at a wound center is shown in Figure 5. Pressure relieving options in an ambulatory patient include: diabetic shoes, modified pressure relieving shoes, foam/felt footwear, Charcot Rigid Orthotic Walkers (CROW) boots, modified removable casts, cam walkers, and TCC.

  Figure 6 shows the current recommended pathway for optimal offloading and the application of TCC.

  In the past, approximately 25% of all patients with diabetes qualified for a TCC at initial presentation to the author's clinic, as indicated in this model. The clinics viewed qualified candidates as patients with a DFU who: 1) are not infected; 2) have adequate arterial flow; 3) do not have significant edema or pain; 4) have gait stability; 5) have no automobile driving issues, or any patient safety hazards/compliance issues; 6) have Wagner 1 or 2 ulcers. It should be noted that the majority of DFU patients referred to this clinic present with poor vascular status and/or infections. Patients with adequate vascular status and no infection make likely candidates for TCC; for many practices, as high as 80% of DFU patients would be good candidates for TCC.

  Additional patients can be reconsidered for TCC after other interventions have been completed, such as infection control or vascular surgery. The TCC will reduce edema, so those patients can be casted, with the first cast change in 2–3 days to maintain adequate fitting. To address stability, a cane or walker could be added, which allows these patients to be casted. Finally, the patient needs to enlist family, friends, and community resources to help them through the treatment process, and to maximize their ability to heal. It is much easier to enlist help for a few weeks, rather than decades after losing a limb.

Methods

  Based on this clinical pathway (Figure 6) and reimbursements, a clinic model was developed.