Hyperbaric Oxygen Therapy: Panorama of Perspectives

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A common adage is that our world is in a constant state of change. Few of us would argue or disagree with this observation. The truth is that fluctuation does not just impact us globally; rather, instability in our professional world, the world of wound care, is a reality. Our professional lives are never static as we continually adjust to new products and technologies, react to changes in our regulatory and policy guidelines, and recognize the ever-increasing needs of our patients with chronic wounds. These challenges mandate that we devote significant time and energy to remain current and informed. However, on occasion it is energizing to be offered the opportunity to step back and review and refresh basic clinical concepts. This edition of Advances in Skin & Wound Care allows us that rare but wonderful opportunity.
The authors of this month’s continuing education article on “Hyperbaric Oxygen Therapy: Exploring the Clinical Evidence” (page 181) provide us with an excellent general article on this topic. It offers a solid review of basic tenets, such as the definition of hyperbaric oxygen and the mechanisms of action, including the fundamental gas laws and how the physics of administering oxygen under pressure can positively modulate the wound healing cascade. This overview is complemented by a brief discussion of the major indications for hyperbaric oxygen therapy (HBOT) and includes a concise summary of the primary evidence supporting each clinical category. The literature review is not merely a listing of commonly referenced articles, but rather the authors have judiciously selected to include a higher level of evidence by citing Cochrane data and other systematic reviews. The authors should be commended for their effort as writing a succinct article on such an expansive topic is challenging, if not nearly impossible.
Reflecting on basic academic concepts may be a welcomed diversion; regrettably, the realities of daily clinical obligations quickly end the pleasant distraction. A basic review article on HBOT needs to be tempered with real-world clinical certainties. The Affordable Care Act, Medicare Access and CHIP Reauthorization Act, and Merit-Based Incentive Payment System are impacting the practice of HBOT. Hyperbaric preauthorization is just one striking example. The transition from fee-based medicine to capitated care and a system that pays for performance and patient outcomes will also include major changes in hyperbaric utilization. The days of bolstering clinic revenue by increasing the numbers of HBOT treatments have ended. Unfortunately, overutilization of hyperbaric services has become a reality in some settings. Overutilization is a frequent topic in discussions with Medicare Administrative Contractor medical directors and is a target of the Office of Inspector General. Clinical efficacy combined with cost effectiveness must become the basis of clinical hyperbaric algorithms and replace standard order sets for 40 treatments. Hyperbaric clinicians must understand that continued overutilization could result in severe restriction and ultimately the elimination of the benefits of HBOT, which have been so well described by Lam et al in this month’s continuing education article.
I would like to thank the journal and especially the editor-in-chief, Dr Richard “Sal” Salcido, for allowing me the privilege and honor to participate in this Guest Editorial. I would like to close with a short personal commentary. The lead author of this article, Gretl Lam, BA, is a fourth-year medical student about to graduate. This observation leads me to reflect on my first article, published more than 30 years ago, when I, too, was a medical student. I would like to genuinely congratulate Ms Lam for this extra effort and on being able to publish, while navigating the challenges of a student physician.
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