Diabetes impacts the whole body, but the foot can’t be forgotten [PODCAST]

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“As we know, diabetes is a comorbidity that can cause more severe symptoms in COVID-positive patients. This knowledge, along with the sense that diabetes is overwhelming the entire body, can quickly deplete a patient’s reserve of positive energy. Despite all their best efforts, diabetes is a disease that can often spiral out of control and make a patient feel helpless.

While it’s critical to maintain this “whole body” approach, it’s also important to prioritize complications. One of the most debilitating complications of diabetes is diabetic amputation, but it’s often not top of mind for many patients with diabetes — or the providers treating other diabetic complications. Yet every four minutes, a lower limb is amputated due to diabetes.”

Jon Bloom is an anesthesiologist and health care executive.

He shares his story and discusses his KevinMD article, “Diabetes impacts the whole body, but the foot can’t be forgotten.”

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Hosted by Kevin Pho, MD, The Podcast by KevinMD shares the stories of the many who intersect with our health care system but are rarely heard from.

Transcript

Kevin Pho: Hi, and welcome to the show, where we share the stories of the many who intersect with our health care system but are rarely heard from. My name is Kevin Pho, founder and editor of KevinMD. Today on the show, we have Jon Bloom. He is an anesthesiologist and a health care executive. He wrote the KevinMD article “Diabetes impacts the whole body, but the foot can’t be forgotten.” Jon, welcome to the show.

Jon Bloom: Excited to be here. Thank you for having me.

Kevin Pho: So we’ll get into the article in a little bit, but first off, can you share your story and journey to where you are today?

Jon Bloom: Sure. Well, this is normally a good three- or four-hour podcast that I would get into here, but I’ll try to give the quick version. I went into medicine really because of having amazing people around me who are physicians, and how inspiring it was. I was working at the Costco one-hour photo lab, and one of the people who was coming in, whom I got to know, was a cardiothoracic surgeon. He let me scrub in with him, and what a miraculous human he was, and what a miraculous thing he was doing. It was just so inspiring, and that was it.

I changed to pre-med, went there, and really got fascinated by technology. We did a lot of work at the University of Pittsburgh to try to overhaul the tech infrastructure that helped do medical education. I found that I really enjoyed projects and thinking about tech, although, again, I’m not a technician. I have no engineering background, and I was probably way too big for my britches in most of the things that I was getting myself into.

I fell in love with anesthesia. There was something about the science, about the care, holding this patient’s hand in this moment and trying to get them through a scary time. And it was weird, because I came in knowing I was going to be a surgeon, and I came out an anesthesiologist. That not being right is going to come up a few times in my career.

And then I went to Mass General to try to learn this field, and Mass General was an interesting place. The reason why I really wanted to go there is it had a collection of these people who were doing crazy things, not just being in the OR, not just in internal medicine. Throughout the entire hospital, there were these clinicians who wanted to change the world, and they were doing creative things, and I found that so inspiring.

To try to close up this story quickly, I met a couple of these innovators, and they wanted to throw me into some of the companies they were developing, and I just couldn’t even speak their language. They wanted me to work on marketing, and I embarrassingly didn’t actually know what that meant. I still sometimes struggle to really know what it means. And he was the first person to say, “Maybe you should check out business school. That might be an interesting way to try to learn this language.”

That’s when the ’08 crash hit. No one was doing elective cases, and so it was kind of an interesting time to think about what I might do, given that there were not that many anesthesia jobs opening up. One of my attendings was the chief medical officer of Covidien, and he ultimately hired me to be his global medical director to work on monitoring technologies. This was really my first step out of practice into an industry role, thinking about monitoring technologies.

I worked for three months at the University of Pittsburgh with the goal of then starting business school and doing cases on the weekend, but as soon as I came into the business school world, everything just started to click. And then by month three, we founded the company that I still work at today. That’s 10 years ago now, and it just sort of took off from there.

Kevin Pho: So during that 10-year journey from clinical medicine into the role of CEO of a technology company, tell me some of the challenges that you faced in making that journey.

Jon Bloom: Well, I think the one, especially as I talk to other clinicians who are thinking about doing it, is that in many ways, medicine is one of the safest careers you can have. If you work hard, you can get the scores and the ability to get into a medical school. It’s a very safe spot. You’re going to make a good salary. You’re going to, for the most part, have a place that you’re going to work at for probably the rest of your career.

So for the amount of risk tolerance you need to jump out of something so safe, when you often have this med school debt but you still have to pay up, and you really need to stay there, to jump into something like this, where we don’t pay ourselves anything and you’re going to start doing a startup, that’s a lot to deal with. So it was back to eating Top Ramen noodles and Campbell’s soup. I mean, all the worst things I could do for salt. I can only imagine what kind of salt loads I was taking.

And that was tough. It was tough knowing that I could have popped out at any minute and gotten a great job. Pittsburgh would pull me in. That was probably the toughest thing. It’s just that once you realize that this is what you have to do for your career, you have to do this, and you have to figure out how to make it work, and it doesn’t always pay well in the beginning to try to start something.

Kevin Pho: Now, we have a lot of physicians on this show and on my blog who talk about making that transition into an entrepreneurial role or an industry role. So you made that journey. What would you say is your number one tip for physicians interested in making that same transition?

Jon Bloom: In some ways, there’s always a grass-is-greener thing that people can get caught up in. So it’s really getting a good sense of your own self and the values that are most important to you, and you have to align. I really feel like you have to align your personal values to the work you do, because you’re spending most of your waking life in your job. And so for some people, it’s that moment with that patient at that bedside. That’s the magical moment. That’s a hard one, because you may not get that in some of these roles.

For me, I felt this pressure. I had it. I wanted to change the world. I wanted to do something there. And it was the recognition of how important that was, the recognition of a bunch of these other values that were really important to me, that then let me know this was the right decision. It gave me a lot of clarity that it’s not just, “Oh, that looks really interesting over there,” but, “Wow, that really aligns well with what I want.” I have to tolerate the risk. Most of these are not successful, but I just jumped into it, because it just made so much sense for me.

And I think that’s the thing. It’s such a change, and sometimes it looks cool because it’s on the other side, but it’s really good to get a good sense of what moves you and gets you super excited in the morning.

Kevin Pho: Sure, and that’s, I think, a good reason to make a big change. It’s just that self-awareness. All right, let’s transition into the KevinMD article that you wrote. It’s titled “Diabetes impacts the whole body, but the foot can’t be forgotten.” Now, for those who didn’t get a chance to read your article, can you just walk my audience through it and share the story of why you decided to write it?

Jon Bloom: Well, in many ways, I think we see diabetes costs an enormous amount in direct expenditures in the U.S. health care system, as much as, I think, north of $300 billion. And what we’ll recognize is that there was a New England Journal article that came out in, like, ’16 or ’17 that first called it out: About a third of the cost of diabetes was linked to complications of the lower extremity.

You only manage what you measure. And so for health plans, they know exactly what they’re spending on hypertension, because there are a couple of codes, so it’s easy to measure. You know exactly what you’re spending on heart failure. For diabetic foot, there are about 200 codes that make it up. When ICD-10 hit, they had so much granularity to give, not only the right, but this digit. So if you don’t know that that’s the code set, you have no idea what you’re spending on this. And it blows payers away when we can finally give them the codes. They realize, “Wow, how much we’re spending here.”

So a lot of it is just the recognition that here’s something that causes so much suffering. And actually, I believe it’s a marker of poor-quality care if you’re in an area that has a lot of amputations, because it usually means we weren’t getting our best preventative care to this patient, and we’re resorting all the way to the final step: Let’s lose the limb.

I think it was just very important to raise the awareness of something that drives, you know, it’s got twice the five-year mortality of all pooled cancers in the United States, and the cost of diabetic foot is probably half of all cancer in the United States. It’s this massive juggernaut, and it isn’t well appreciated, largely because, I think, of this issue that you manage what you measure. So it doesn’t get the fanfare of some of these other conditions.

Kevin Pho: So for those people who aren’t familiar with the effect diabetes has on the foot, give us a sense of the range of complications that one may see, and also give us a sense of why there are 200 ICD-10 codes that could describe the various permutations of a diabetic foot.

Jon Bloom: They really wanted the granularity, probably because of, like, maybe better research. Actually, I don’t know why we saw this explosion of codes. In some ways, yes, we lose our ability to really track when we go for simplicity, but simplicity can be addressed. It can be managed. And so we lost that battle a little bit, in a sense.

So yeah, diabetes is a number of things, right? High glucose is toxic to a number of things, like nerves. Atherosclerosis is affecting the blood flow, especially at the small vessels. We have very bad blood flow, so it impedes your wound healing. It impedes a number of things. If you have a history of smoking, it’s that much worse. So what ends up happening is a perfect storm.

So let’s say a patient who’s got long-standing diabetes and a fair amount of neuropathy wears a poorly fitted shoe, for example, and they start to get a friction injury breaking down the tissue on their foot. Now, they often won’t feel that, if at all. I’ve seen patients come in, and you probably have as well, who might have a tack or something they may have stepped on, and it’s been there for a while. They’ve lost that alarm system that says something’s there. Because they have impaired wound healing, the injury mechanism can often overwhelm the healing mechanism, and it can start to break down into a wound. And because sugar is an amazing medium for bacteria and bad bugs too, like some really tough-to-treat bugs, you get this perfect storm for an infected wound with bad blood flow to the area.

And now, if you catch it too late, which is the way the health care system typically works, that’s considered the most commonly done practice, you would see me in the operating room, unfortunately. Right now, we have to get rid of the diseased tissue, the poorly perfused tissue. But then it’s just too late. It’s a devastating complication. Five-year mortality in the VA, which is where we spend a lot of time, is as high as 70 percent after one of these amputations. It drives enormous costs and enormous amounts of mortality, and yet, again, the marketing for it hasn’t been that great.

Kevin Pho: So as a primary care internal medicine physician, we are trained to check the feet of all of our diabetic patients every three to six months. We do peripheral nerve tests, and we do inspection, of course. But tell us, what are some of the current ways that we should be monitoring diabetics and making sure they don’t have any foot complications?

Jon Bloom: Well, when we work with payers, we can see how often that code comes up: Do they do the foot exam? That’s not necessarily tracking what actually happens. It is not as well coded as we would hope. Actually, maybe they’re not coding some of that work. But probably step one is we need to make the patients do the best they can to do a foot exam on their own, and our clinicians do the best they can to make sure to remember to take off the socks and just get an eye on the foot. Those things will help.

A problem, though, is that the patient is going to be the first one to notice something. If there’s something happening, they’re the ones who, day to day, can hopefully see it. But remember, they have diabetic retinopathy, they have poor range of motion, and they’re often morbidly obese. So to expect that that’s going to be the best line of defense is probably a poor assumption. This patient is often also overwhelmed by their care, from the number of medications they need to take. There’s a lot that’s happening with this patient. So we need to find ways to augment the system to try to find things earlier.

With systems like ours, and I’ll try to keep it generic, because there are a number of wonderful solutions out there, the idea is: Can we know the moment we see tissue breakdown, when it’s still deep to the surface, so there isn’t anything that’s broken open, nothing to get infected yet? And if we know that moment, can we then do simple things, like have them briefly walk less? Can we have them see a clinician at that moment, when maybe it’s still just a blister, and then try to get care to them early?

That’s really where we, or companies like us, want to be a service that is a good early warning system that just says, “Hey,” so that we get eyes on this patient at this moment, often in between visits that are separated by a lot of time. And then the clinician can do whatever they think is the right thing. We’re not here to help inform care, other than to say, “This is the time to take a look at this patient.”

Kevin Pho: So give us a story or a case study of either your product or a product similar to yours. How would that be included in a typical patient workflow, and how can that better monitor their feet and alert a physician to any problems?

Jon Bloom: It’s tough to pull them all out into a singular one, but I’ll give you an example of what would typically happen for our company. We’re specifically targeting patients with usually poor access to care. It disproportionately affects minority patient populations, populations where we often see tech literacy gaps and health literacy gaps. We have a lot of work to do to help these very vulnerable patient populations stay on their own two feet.

We’ll get into their home. Our system is cellular-enabled, so you don’t have to worry about a smartphone or Wi-Fi. We wanted to make sure of that. For example, if your dad gets Wi-Fi, I know that often it’ll just keep blinking, because he often won’t be able to really get organized to figure out what’s causing it. We had to eliminate those sorts of steps. And then we just ask them to step on it for 20 seconds a day.

This is one of my old thermograms, from probably five or six years ago. It’ll generate an image like this, which allows us to look for tissue breakdown. The body responds with an inflammatory response. We’re looking for that hot spot that’s there, and if we see it, it’s typically about five weeks before the wound presents. So often, the way the boring story goes, which is the one you want, is that you see a hot spot, we have them walk less and offload, and if that doesn’t work, we send them to see the clinician. And then ideally, that’s it. Nothing else has to happen.

Unfortunately, it doesn’t always go that way. We’re not going to catch everyone. We’ll still see, even with the best systems like ours and others, that sensitivity isn’t always 100 percent, so we will miss some. The idea is that we catch them still early enough to do something about it. And then with that, you try to prevent the big amputations and the real cost associated with them, which, again, I’m happy to talk about.

I don’t want to make this necessarily a big promotional spot, but we now have wonderful data looking at amputation reduction. And then, importantly, I think systems like ours need to show impacts on resource utilization. Are these cost-effective, and ideally saving a significant amount more than the system generates in cost? You know, hospitalization rates, ER rates, and outpatient visit rates.

Kevin Pho: So why don’t you go ahead and talk a little bit about the data? Tell me how much improvement we get in amputation rates when we use these monitoring systems.

Jon Bloom: Well, right now, data suggests we prevent around 71 percent of amputations from occurring in these complex patient cohorts. In the one study we did with Kaiser Permanente, 60 percent had chronic renal failure, and there were high rates of heart failure. It’s a very complex patient. We saw a similar 71 percent reduction, and we saw complete elimination of major amputations. So thankfully, while they were with the system, no one lost more than a TMA.

We saw a 52 percent reduction in all-cause hospitalization. That one’s the interesting one, because it ties back to the paper. I’ll go back to that one in a second. There was a 40 percent reduction in all-cause ER visits and a 26 percent reduction in all-cause outpatient visits. That results in about $12,000 in savings per patient per year on average, including our users and our non-users. So the key is that we had very, very high engagement. We see that those numbers are fairly consistent. It’s a strong savings for a patient that typically hasn’t found a way to interact with the health care system very effectively.

The hospitalization one was interesting, though. Only half of the hospitalizations we prevented were diabetic foot-related. The other half were the top four DRGs, and I don’t remember the relative order, but it was CHF exacerbation, COPD exacerbation, myocardial infarction, and stroke. So we want to understand why that is the case. Now, some of them are probably causal.

So the paper that we put out, not on our technology, just trying to understand the problem, which we wrote about on KevinMD, was about the idea that you have this massive inflammatory bomb that happens in your foot, often causing bacteremia or sepsis, and it is a massive thing that causes a huge spike in hospitalization. I believe you’re three times more likely to be hospitalized, and you’re 50 percent more likely to have mortality during this episode. And because of that, you’re having higher rates of heart attack and stroke, these hypercoagulable states.

Now, for some things, like CHF and COPD exacerbation, there are other reasons there too that are driving that. But it’s just making sure that we are aware of that link. If we can prevent that inflammatory cascade in that foot, often you might not recognize why it might affect something disparate from the foot, but it has a fairly significant impact on a patient that needs a lot of care.

Kevin Pho: So if a patient takes one of the tests on your device and it shows that their foot is having some type of inflammatory response, is the next step then sending that result to the clinician to better manage their diabetes, or potentially sending them to a podiatrist? Are those generally the next steps if they see a tremendous amount of inflammation through your study?

Jon Bloom: Yeah. So what we’ll do for our patients is we give them a mat that’s in their home, and they just step on it daily. We ask them to step on it for about 20 seconds a day, and then they go on with the rest of their life. We then have a team of nurses that are tracking the data, and if we see a deviation, if you trip protocol, we’ll notify that clinician to let them know that Mr. James, for example, a made-up name, is now in protocol. And then we just follow the protocol we prearranged with that clinician.

So still, for the clinician, we’re trying to minimize the impact on their practice. We’ve notified them that this is a patient at increased risk. We’re running the instructions that they set, and if that doesn’t work, we would then escalate to be seen by the clinician. Usually we’re able to prevent roughly two-thirds of these hot spots from proceeding any further just by doing telephonic offloading. But that one-third do need to be seen, and about 76 percent of those patients have something that needs to get done.

So it’s usually sent to the podiatrist, because typically it’s callus debridement. It’s like a hard rock; everywhere you go, it’s destroying the tissue below, and you just have to debride the callus. Or if it’s a blister, or potentially it’s a 1A ulcer that has already occurred, you just want to get eyes on it the moment that it’s there and take care of it. That’s the basic workflow.

Kevin Pho: We’re talking to Jon Bloom. He is an anesthesiologist and a health care executive. He wrote the KevinMD article “Diabetes impacts the whole body, but the foot can’t be forgotten.” Jon, what are some of your take-home messages that you want to leave with the KevinMD audience?

Jon Bloom: Well, for one, I think this: You only manage what you measure. That’s a powerful thing, and most health systems and health plans aren’t necessarily aware that this is a big driver of costs until they run those codes. Those are out there in the published literature. If you’re running a real system, it’s worth being aware of what’s driving those costs. It isn’t just buried in diabetes costs. There are often very specific drivers for it that are manageable, and if not managed, it’s unmanaged.

Two is that patients who are very complex are very vulnerable patients, and I think we have to continue to recognize that they will often have health literacy gaps, tech literacy gaps, and often be overwhelmed. When I practiced, or when I trained, we called it the poorly compliant patient, which was always, you know, I’d label these patients. They’re not complying with my will, right? I’m saying, “You take this med,” but they’re not. And what we don’t often realize is that they can’t always afford that medicine. There’s often a lot more that’s there, and that label, I think, can actually be destructive, as opposed to helpful, for us as we identify how to best help this patient.

So I think recognizing the extra social system issues that may be around this patient gives us an ability to affect the actual underlying problems in many cases.

Kevin Pho: Jon, thank you so much for sharing your time and insight, and thanks again for being on the show.

Jon Bloom: Thank you for having me. I really appreciate the time.

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