As I think about the national epidemic of diabetes and my own struggles in caring for these patients, I’m convinced this is an example of the emerging theory of “simplexity” — a concept that considers a potential relationship between complexity and simplicity that’s the subject of a 2008 book by Time magazine’s Jeffrey Kluger. In the book, Kluger explores this phenomenon with a variety of examples, including how an apparently simple house plant can be more complicated than a modern industrial plant and how 90 percent of money that’s donated to help cure the world’s diseases is only given to research supporting 10 percent of those diseases. Consider: Adult-onset diabetes (responsible for most cases in the US) is caused primarily by obesity and poor lifestyle choices. Diabetes, which can be “cured” by diet and exercise, will kill more people in the US than AIDS will. (If AIDS could be cured in this manner, what type of initiatives would we see across the US?) Diabetes leads to diabetic foot ulcers (DFUs), nearly 85 percent of which can be treated by offloading, a relatively simple treatment that is poorly reimbursed and unlikely to be properly implemented at even the most sophisticated wound centers. Diabetes leads to peripheral vascular disease (PVD), a primary cause of lower extremity limb loss. However, for the past 10 years, every randomized controlled trial to prove the efficacy of a new DFU treatment has excluded patients with PVD. There are virtually no new treatments on the horizon for PVD, with the exception of some vascular growth factor trials that are far from commercialization. However, diabetic patients whose blood sugars are under control are more likely to heal their ulcers and are less likely to have end-organ disease like PVD. Still, reimbursement for diabetic education is poor and almost no wound centers offer this service. We know what needs to be done in order to manage this disease – eat right, lose weight, exercise, offload, control blood sugar, and screen for vascular disease. This may all seem simple in scope; however, care delivery is actually very complex.
A Closer LookThis edition of TWC features an article by Cornelius A. Davis III, MD (with whom I had the privilege of collaborating for many years), that deals with the link between DFUs and heart health and offers an insider perspective from TWC board member Tere Sigler, PT, CWS, CLT-LANA, on diabetes screening in place at her Georgia wound clinic; an expert review of diabetes nutritional guidelines by Nancy Collins, PhD, RD, LD/N, FAPWCA and Colleen Sloan, RD, LD/N; and an intriguing piece on the difficulties wound care clinicians may face when seeking continued diabetes education by wound nurse Jill Henneberg, BSN, RN. Additionally, TWC board member Donna Cartwright, MPA, RHIA, CCS, RAC, FAHIMA, provides us with a primer on diabetes documentation “buzzwords” that will soon become familiar as ICD-10-CM approaches (revealing that there really doesn’t seem to be a “simple” part at all to the payment side related to diabetes care) and popular columnist and fellow TWC founding board member Kathleen Schaum, MS, continues her 2013 “Business Briefs” update with an article on Medicare payment changes for HOPDs and physicians. As you read the articles, see if you find them to be examples of simplexity in action. Noted professor Peter Wipperman has suggested that as the complexity of our world continues to grow, we will have to stop striving to make “optimal” decisions and instead concentrate on making judgments that are “just good enough.” Somehow, that doesn’t seem an adequate way to approach the care of our patients. We hope this issue of TWC offers more insight. Additionally, this fascinating film featuring Dean Ornish, MD, founder and president of the nonprofit Preventive Medicine Research Institute and clinical professor of medicine at the University of California, San Francisco, is relevant to what we discuss in our current issue of TWC (www.escapefiremovie.com) and this very editorial. I encourage all clinicians to watch it. Caroline Fife, MD, FAAFP, CWS, co-editor of TWC, chief medical officer at Intellicure Inc.
From the Editor