Case 92: Managed Care: Woman with Bilateral Neuropathic Ulcers Denied Hospitalization, Discharged from Hospital before Healing but Provided Outpatient Care with Its Hazards

Born January 12th, 1953, this lady had had diabetes 23 years and had had troublesome foot ulcers 4 years before referral for evaluation by her primary care physician November 9th, 1994. She had had three hospitalizations for severe hyperglycemia in the preceding 13 months. She had been hospitalized on 3 occasions at an academic wound healing center in Philadelphia in 1992 and 1993, twice for two weeks when an osteomyelitic toe was removed on each occasion and once for one day. Her intravenous therapy had involved a subclavian line which perforated her pericardium and led to a periocardial window procedure. In September 1994, she had been hospitalized in her local community hospital and advised she had osteomyelitis in both feet. Besides insulin, her family doctor had prescribed medication for hypertension, depression and seizures: Triamterene, Vasotec, cogentin, Triflon, Klonopin and Paxil. Her pedal pulses were 2+. Light touch sensation was absent and two-point discrimination with sticks was increased to 17 cm. She could not feel the standard 5.10 fiber but could feel the 6.10 fiber on the proximal foot. Her vision was 40:200 bilaterally. With diagnoses of uncontrolled diabetes mellitus, peripheral neuropathy, multiple foot ulcers and chronic osteomyelitis of various metatarsal heads, we recommended hospitalization to initiate boot therapy. Her history revealed her ulcers were likely to recur in her home environment. The presence of ulcers on both feet makes it difficult to unweight either foot to remove the shear stresses that keep these ulcers from healing. Hospitalization and bedrest was desirable. Her HMO refused permission. She sought the opinion of two other consultants who advised hospitalization and various foot resections. The HMO now chose the option of outpatient boot therapy. She returned November 28th with her diabetes still out of control and over the next few days missed three boot appointments. She arrived December 5th in ketoacidosis. Permission for hospitalization was then granted

She returned with an obvious cellulitis in her right foot.

The ulcer under her right 1st metatarsal head had enlarged.

Her diabetes was controlled and a four dose per day insulin program instituted. She received both intravenous and local antibiotics before her Mini-Boot treatments. Her feet did well. Once her diabetes was controlled repeat renal function studies showed modest renal impairment: BUN 45 and creatinine 2.0 mg/dl. As her leukocytosis, fever and hyperglycemia abated, her HMO insisted on discharge from the hospital. She was discharged against medical advice. Her home program was to include regular weekday treatments in the office. She missed her appointments from December 14th to the 22nd. She did attend her treatments regularly in January. Unfortunately, it was obvious she was on her feet too much. She had to do her chores (cooking and laundry etc.) for her family. She did not have the balance to wear an air cast on both feet. When given a half shoe which allowed her metatarsal heads to extend in the air unsupported beyond the sole which ended in her distal arch, she was seen to walk heel-toe still weighting her metatarsal heads and dirtying her bandages and stockings.

On February 1st, 1995, her right foot was holding but the left mid-foot ulcer was deeper and broader.

She developed fever and aches, which she attributed to a 'flu infection and stayed home February 3rd to 7th. When she walked into the office on the 7th, it was apparent she was septic.

The larger ulcers on both feet were deeper...

and the 3rd left toe was swollen and cyanotic and reddening on the dorsum of the left foot pointed to cellulitis.

Again, hospitalization was discussed but she was treated as an outpatient. Her foot was infiltrated with antibiotics and pumped in the Mini-Boot. She regularly attended her treatments. .

The distal left 3rd toe mummified and her ulcers again decreased in size.

The rubor on the dorsum of the foot slowly faded. February 17th, 1995.

Her BUN was 56 mg/dl and creatinine 1.9 mg/dl. The explanation of her tests caused some alarm leading to a renal consultation and confirmation of her program: glucose and blood pressure control, use of ACE inhibitors and decreased diary intake of potassium, protein and phosphorus. Cultures of methicillin-resistant staphylococci led to the addition of intravenous Vancomycin administration by a visiting nurse. Perhaps, the increased load of fluid and salt accentuated her tendency to hypertension. In any event, she began to have headaches and large surges in her blood pressure. The feet with her regular attendance did well; the ulcers diminished in size leaving by the 31st of March but a narrow slit in the left foot. Blood pressure crises led to continual additions of antihypertensive drugs. Vasotec, Cardura, Minoxidil, Isordil and Lasix were prescribed concomitantly in the next few months. Concern for her renal status led to modification of her boot program: long boot therapy was substituted for the Mini-Boot on alternate days. She began to feel well. The kids got out of school. She missed her appointments. Her lesions enlarged throughout the summer and fall.

She was hospitalized in October for anemia. New destructive changes of osteomyelitis were noted in the 1st & 2nd metatarsal heads of both feet. Her foot ulcers again began to heal.

She became progressively pale and weak. A hemoglobin of 6.2 gm/dl led to hospitalization. Two-plus proteinuria was noted along with a serum creatinine level of 2.1 mg/dl. She received a few pints of packed red blood cells and was started on Epogen. Again she was discharged when she was stable rather than when she had received maximal hospital benefit. A hypoglycemic episode, mistaken for a TIA, took her into a nearby community hospital in December for three days. Again she missed most of her appointments in December and the 1st 17 days of January. The holidays kept her on her feet and her lesions enlarged.

January 17th, 1996. Her lesions enlarged with holiday activity, leading to a hospitalization for sepsis January 22nd.

Her lesions responded to therapy: intravenous antibiotics, daily foot soaks, local antibiotic injections and Mini-Boot therapies.

Again as she appeared to prosper, the pressure for discharge from the hospital increased and she was discharged unhealed against our advice. Further loss of kidney function was noted in March (creatinine 4.0 mg/dl, K+ 6.2 mEq/L and PO4 7.3 mg/dl and alkaline phosphatase 420). Restrictions in protein, phosphorus and potassium were emphasized and calcium carbonate was added to her program. Inguinal adenopathy led to a node biopsy in May showing follicular hyperplasia, thought to be related to her chronic inflammatory disease in her foot. Again office visits were missed through the summer. Her BUN rose as high as 107 mg/dl in July and weakness and dizziness led to a brief hospitalization in August. A fall at the end of August opened a new ulcer in her left foot. Heavy bleeding was noted from her left foot in September and her foot x-rays showed advanced osteomyelitis across the metatarsal heads.

The ulcers and osteomyelitis in the left foot led to a beneath-the-knee amputation September 26th, 1996.

Her right foot was treated during her recovery with local antibiotics and Mini-Boot therapy and came close to healing.

Again time for discharge from the hospital had come. She was transferred to a Rehabilitation hospital where presumably she was to be fitted with a prosthesis. The extra weight bearing on her unhealed right foot, however, extended her ulcers there again. An attempt at home antibiotic therapy with a visiting nurse was met with the development of a thrombosis in her subclavian vein. At present, she has not returned for boot therapy and has not had any follow-up by any physician experienced in handling problems like hers.

Comments. This lady had many strikes against her. Her years of poor diabetes control had left her with advanced peripheral neuropathy. The efforts of managed care in limiting specialty management of such patients is obviously neither good for the health of the patient or the pocketbook of the managed care organization. She had already relapsed after the care of other qualified physicians when she presented for boot therapy; she was a proven "loser" in whom standard measures were bound to fail again. Referral for boot therapy was appropriate but its execution was to prove difficult. She would not stay off her feet at home. Her poor balance made it impossible for her to wear casts or special shoes at home. She had recurrent osteomyelitis in both feet that had not been cured by standard methods in the hospital or in the home with prolonged intravenous antibiotic therapies. The latter indeed were associated with major complications: a perforated pericardium and a subclavian artery thrombosis. She was referred for boot therapy and our local antibiotic techniques. However, such an approach requires regular attendance in the office and avoidance of continued trauma to the foot. She was unable to accomplish either of these as an outpatient. When she was hospitalized and the same therapeutic techniques performed, "she suffered from galloping healing". However, when she appeared to be doing well, the managed care group insisted on discharge form the hospital. It is, of course, conceivable that had she been allowed to remain in the hospital initially, she might have healed, obtained proper shoes with molded inserts ... and still have recurrent ulcers. Clearly she was and is a difficult case but one that became impossible under her circumstances. Here the experts on the scene called for hospitalization. The "remote financial experts" said "no". Her course has been prolonged, expensive and punctuated by hospitalizations anyhow.