ASK THE EXPERT: DR. JASON FORBES
ASK THE EXPERT
Jason Forbes, DO, is the Medical Director and wound care expert at Mercy - Springfield Wound Care & Hyperbarics in Missouri. He attended Medical School at Oklahoma State University - Tulsa and his residency at Alliance Health Durant-Family Medicine. He has been using SnaphotNIR since 2021.
How has the implementation of SnapshotNIR impacted your practice and helped you to improve patient outcomes?
Initially, I used Snapshot on new patients with lower extremity ulcers to screen for arterial disease and on hyperbaric patients to verify improved oxygenation of tissues. The device works to both quickly and efficiently answer the most important question: Will this ulcer heal? The immediate impact was identifying patients with PAD on their first wound care visit and getting them referred for vascular intervention weeks earlier than our historical average. The Snapshot images gave our providers objective information to share with our vascular surgeons to justify urgent appointments. The result is more efficient and cost-effective medical care.
Recently, I have started using Snapshot to verify adequate surgical debridement of fibrotic ulcers. These tend to be among the most difficult ulcers to heal because it’s hard to know if the wound bed is viable enough to support granulation. They tend to have friable capillaries that bleed easily with superficial debridement, but it has always been a challenge for me to know if the base was healthy enough. Using Snapshot post-debridement can give objective proof that the ulcer has been cleaned to a viable base. Several of my patients are seeing improvement in ulcers that have been stalled for many weeks due to more effective debridements.
Some unanticipated benefits of using Snapshot have been the patient’s reactions to the information. Many patients are visibly relieved to be told that their circulation is adequate for healing. They have immediate hope that an ulcer that has held them hostage for months, even years, can heal. Other patients (or their caretakers) are incredulous about routine debridements. “How is it ever going to heal if you keep cutting it?” they ask. Showing before and after debridement images of the ulcer base has convinced many skeptics of the benefits of bioburden reduction. Both situations encourage patient compliance and enthusiasm which are essential components of healing.
When you first decided to include SnapshotNIR for tissue viability assessment at your wound care and hyperbaric facility, you started with a clear plan. Can you share how you developed a protocol to ensure a consistent approach to care?
I was first introduced to NIR spectroscopy through a vascular surgery colleague. He was the first to recognize the potential for significantly improved efficiency between our clinics with the technology. At that time, we weren’t aware of any other clinics using Snapshot so we couldn’t get honest feedback from other practitioners but there was so much potential in our area of greatest inefficiency that we decided we had to find a way to trial the camera.
To properly trial the device, we had to set some objective goals to measure. That was the impetus that eventually led us to an imaging protocol. The framework was built from my experience with transcutaneous oximetry. The values between TcPO2 and NIR are roughly transposable at the decision-making levels, so we started there to define “normal” and “abnormal.” Over the next several months, we met with the vascular surgeon several times to compare Snapshot numbers to clinical disease and the need for intervention. From there, the protocol almost built itself as it was clear and consistent that patients with an oxygen saturation % below 40 were high risk and needed a referral for more in-depth work-up/intervention. The area between, “you’re totally normal and I never need to check again,” and, “you probably have some arterial disease, you have some risk factors and should probably be monitored” is more subjective. I arbitrarily set that number high at first to have greater sensitivity but have since moved down about 10 percentage points as I’ve consistently had patients heal.
With respect to reimbursement, have you found it to be sufficient in your region to support the purchase and utilization of the device?
With any new device or treatment, reimbursement always lags behind what we practitioners consider reasonable. It can be frustrating to see amazing clinical outcomes repeated for months or even years before insurance companies recognize the overall value it can provide. One of the most exciting things about practicing wound care is the constant advancement in diagnostic and wound dressing technology, so pioneering comes with a predictable set of logistical roadblocks. Every time my leadership team evaluates a new product or device, there’s a subjective formula we’re ultimately applying that considers cost, ease of use, availability, superiority to current products/devices and reimbursement.
We decided that the positive effects on our workflow (especially replacing TcPO2 with NIRS) and the potential for improved patient outcomes outweighed the financial investment. We weren’t wrong. And this was starting when there was NO reimbursement. We knew at the time SnapshotNIR was purely an investment into improved efficiency. Over the past year and a half, though, my clinic has seen slow but steady adoption by third-party payers. Over the last quarter, we averaged a $66 payment per patient use. To me, that’s purely icing on the cake for what has been a paradigm shift in instant bedside vascular screening.
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