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"Management's" decision on prefab v custom made foot orthotics

Discussion in 'Biomechanics, Sports and Foot orthoses' started by Craig Payne, Jan 22, 2015.

  1. Craig Payne

    Craig Payne Moderator

    Articles:
    6

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    Over the years I have been contacted by colleagues over this issue, so I thought I would post this one here for wider discussion. It is something that is common in community health centres.
    Hopefully others can chime in here, but the bottom line for me is that the distinction between prefabs and custom is artificial (i whined here about that)

    Also, WTF are "management" doing intervening in clinical decisions?

    Its all about delivering the prescription variable that is needed for the individual patients to achieve the desired outcome. If you can do that with a prefab, then fine; but what if the variable needed can only be delivered by a prescription made device? How will "management" explain that one? Eg, IMHO, anything less than an aggressive custom made device for a stage 2 posterior tibial tendon dysfunction is falling below an acceptable standard of care; and if not done is subjecting the patient to a long term disability (the reason being is that the design features needed for a stage 2 PTTD can only be delivered with a custom made device).

    Yes, if you look at the systematic reviews and meta-analyses on custom vs premade they do superficially appear to conclude that outcomes are the same. I assume "management" has read those .... but you only have to look at the nature, design, prescription and use of the custom made devices in the studies - none of them were done in such a way that I would expect an expert clinician to use them! ....so, yes the interpretation of those systematic reviews and meta-analyses are "political" ... unless you have the knowledge and skills to understand and see the nature of the devices that were used in those studies, then you should not be applying them (or in this case, force others to alter their clinical decision making autonomy).

    It is unfortunate that so many public health services are set up in which prefabs are provided free and custom made are charged, as this just reinforces in "managements" minds the distinction, when there should not be a distinction. It should always be: what is the best way to deliver the design features needed for that patient to get the desired outcome.

    As for diabetes and falls, orthotics work, but no evidence on the types of orthoses, but the same principle: what is the best way to deliver the design features needed for that patient to get the desired outcome ..... that may be custom in some and prefab in others.

    Here are some of the previous threads on prefab v custom
     
  2. Craig Payne

    Craig Payne Moderator

    Articles:
    6
    In every study on foot orthotics, I always ask myself were the orthotics used in the study of the design and type that would typically be used in clinical practice by an expert clinician. More often than not, they don't; so the results of the study can only be applicable to the use of foot orthotics with the design features of the type used in that study. That does not mean that using foot orthoses with different design features would get a different result - it just means we do not know. ... this is way to complex for "management" to start involving themselves in clinical decisions.
     
  3. Trevor Prior

    Trevor Prior Active Member

    I agree entirely with you comments Craig although, in our NHS system, there may be a stronger financial argument for a wider use of prefab for general MSK. The issue we have is that none of the prescription variables we would use in a custom device have been validated. For diabetes, the only way one could really provide some form of evidence is to perform inshoe analysis and evaluate the loads beneath the foot - if these remain high, then change is required. Furthermore, there is now evidence of improved outcomes for specific custom devices.

    I believe one of the aims of the recent paper in JFAR (http://www.jfootankleres.com/content/7/1/49) on prescriptions variables was to provide a framework which would allow differing prescription variables to be implemented for research on flexible flat feet. Whether one agrees with all of the variables included (or not), this is an important step forward.
     
  4. fetefestive

    fetefestive Member

    My response "If someone can find me 200 patients with the same articulation axes, ligamentous laxity, joint ROM's, BMI as I, then we can start doing Cochrane standard reviews."

    Just the other day I saw a poorly designed custom orthotic that the prescriber did no biomechanical examination upon, eager I suspect, to get a no-strings attached DVA refund. They had no consideration of the material science they could take advantage of (delivering Poron/Neoprene, or Plastazote for a anhydrotic skin type of a diabetic) (instead PVC over rockhard EVA), they took no advantage of the surface area they could deliver this to i.e. RF AND--> FF (3/4 length when the patient had dress shoes in extra depth) (??? what planet are you on when you don't recognise the FF as risky area in your prescription),

    My suggestion - whether the foot can be accommodated by an off-the-shelf or requires custom made due to either therapeutic benefits proven from prior prescription, or degree of foot deformity unable to be accommodated with standard devices - charge everyone a nominal fee in that setting. Why is one person's high risk foot more important than another's just because they were fortunate enough to to not have Charcot foot ...yet?

    If prioritisation status equal then so should the fee. If one device costs more than the other then the patient should pay if they are ineligible, based off objective measures, for CAEP.

    In my primary health setting the following happens:
    1. lower priority cases which do not have a current foot problem (inc. acute or subacute) patient must agree to an application to the WA Community Aids & Equipment Program (note I do specify EXACTLY what I want in that prescription regardless of the paperwork not really taking prescription variables into account) (similar to State-Wide Equipment Program in Vic) (caveat: CAEP only fund the custom devices because they fullfill the sustainabilty test since they last years on even higher BMI patients). At least when I go through CAEP they have considered a patient's ability to pay objectively. Not many podiatrists fancy themselves social workers or accountants so CAEP require a Pension or health care card for the application.
    2. active ulcer cases the service funds the orthotics regardless of the custom or off-the-shelf design. Often it is useful to opt for off-the-shelf when ulceration is beyond subcutaneous tissue because things are likely going to change lots in the dynamics of the problem. Swanfoam or felt only comes out in scenarios like crummy shoes & unavailable moon boots in their size!!! ;)
    3. there are still things that theoretically I'd like to do for lower priority patients where the orthosis is going to help with maintaining independence in the community e.g. off-the-shelf devices. I suppose so far protocols 1. & 2. have done fine because of my triage but if you do see people lower in priority then I'd just wedge them etc to demonstrate therapeutic benefit at minimal cost off the budget & then do my application for customs. Someone else will likely chime in at this point & probably give more guidance.
    4. custom device prices are coming down with new technology & I'm aware of at least one secondary podiatry service that got a 3D scanner free of charge from a laboratory. The computers were already in the surgeries. They do a scan (free), they do the application to CAEP on the day, they wait for approval within a given funding period, they get their money from CAEP, they send the scans, the orthotics are there in 3 days. CAEP like paying the laboratory fee since funnily enough the conventional option they've followed which is getting a cast done with an orthotist & they fabricate it at their laboratory has a higher fee since it is doubling the labour costs. We know what we need therapeutically, we're best situated to deliver it cost-effectively, why not reimburse the lab fee?! is the thought process.

    My two bobs worth. I don't know why Victorian primary health services involve themselves so much with the income assessment stuff? They already have objectively assessed paperwork that cost the Commonwealth a lot of money to collect via Centrelink. Take advantage of it! No card = not eligible. I know everyone's situation is different but we do have to at least maintain some sense of objectivity. Remember most high risk patients probably go there by being of low SES anyways!
     
  5. fetefestive

    fetefestive Member

    My response "If someone can find me 200 patients with the same articulation axes, ligamentous laxity, joint ROM's, BMI as I, then we can start doing Cochrane standard reviews."

    Just the other day I saw a poorly designed custom orthotic that the prescriber did no biomechanical examination upon, eager I suspect, to get a no-strings attached DVA refund. They had no consideration of the material science they could take advantage of (delivering Poron/Neoprene, or Plastazote for a anhydrotic skin type of a diabetic) (instead PVC over rockhard EVA), they took no advantage of the surface area they could deliver this to i.e. RF AND--> FF (3/4 length when the patient had dress shoes in extra depth) (??? what planet are you on when you don't recognise the FF as risky area in your prescription),

    My suggestion - whether the foot can be accommodated by an off-the-shelf or requires custom made due to either therapeutic benefits proven from prior prescription, or degree of foot deformity unable to be accommodated with standard devices - charge everyone a nominal fee in that setting. Why is one person's high risk foot more important than another's just because they were fortunate enough to to not have Charcot foot ...yet?

    If prioritisation status equal then so should the fee. If one device costs more than the other then the patient should pay if they are ineligible, based off objective measures, for CAEP.

    In my primary health setting the following happens:
    1. lower priority cases which do not have a current foot problem (inc. acute or subacute) patient must agree to an application to the WA Community Aids & Equipment Program (note I do specify EXACTLY what I want in that prescription regardless of the paperwork not really taking prescription variables into account) (similar to State-Wide Equipment Program in Vic) (caveat: CAEP only fund the custom devices because they fullfill the sustainabilty test since they last years on even higher BMI patients). At least when I go through CAEP they have considered a patient's ability to pay objectively. Not many podiatrists fancy themselves social workers or accountants so CAEP require a Pension or health care card for the application.
    2. active ulcer cases the service funds the orthotics regardless of the custom or off-the-shelf design. Often it is useful to opt for off-the-shelf when ulceration is beyond subcutaneous tissue because things are likely going to change lots in the dynamics of the problem. Swanfoam or felt only comes out in scenarios like crummy shoes & unavailable moon boots in their size!!! ;)
    3. there are still things that theoretically I'd like to do for lower priority patients where the orthosis is going to help with maintaining independence in the community e.g. off-the-shelf devices. I suppose so far protocols 1. & 2. have done fine because of my triage but if you do see people lower in priority then I'd just wedge them etc to demonstrate therapeutic benefit at minimal cost off the budget & then do my application for customs. Someone else will likely chime in at this point & probably give more guidance.
    4. Always consider new suppliers/ways to achieve your therapeutic goal. Custom device prices are coming down with new technology & I'm aware of at least one secondary podiatry service that got a 3D scanner free of charge from a laboratory. The computers were already in the surgeries. They do a scan (free), they do the application to CAEP on the day, they wait for approval within a given funding period, they get their money from CAEP, they send the scans, the orthotics are there in 3 days. CAEP like paying the laboratory fee since funnily enough the conventional option they've followed which is getting a cast done with an orthotist & they fabricate it at their laboratory has a higher fee since it is doubling the labour costs. We know what we need therapeutically, we're best situated to deliver it cost-effectively, why not reimburse the lab fee?! is the thought process.

    My two bobs worth. I don't know why Victorian primary health services involve themselves so much with the income assessment stuff? They already have objectively assessed paperwork that cost the Commonwealth a lot of money to collect via Centrelink. Take advantage of it! No card = not eligible. I know everyone's situation is different but we do have to at least maintain some sense of objectivity. Remember most high risk patients probably go there by being of low SES anyways!
     
  6. fetefestive

    fetefestive Member

    If someone could please generate a protocol to share regarding material appropriateness, off-the-shelf vs. custom, I'd be eternally grateful.

    Philosophically, my orthosis prescription follows the principles of the medical grade footwear applications, through DVA: http://www.dva.gov.au/dvaforms/Documents/D0688.pdf

    If you could get something as concise as that then we'd be at a good starting point to advocate what clinical decision making we are doing as a profession. Constantly we are asked to justify the therapeutic benefit of what we do. If something of a similar nature, following similar principles, were generated then we'd have a good starting point when lobbying governments (Medicare AND DVA), insurers, etc.

    Just a thought!
     
  7. caf002

    caf002 Active Member

    The debate on this issues continues.
    My simple response to this (as humble as it it is) the that use of custom made foot orthoses or prefabricated foot orthoses is surely based on clinical need????
     
  8. PodAus

    PodAus Active Member

    Design vs. function?
    Pathology?
    Durability vs. term of functional assistance?
    Cost benefit?
    Footwear?
    Environment?

    etc.

    List the pertinent case factors, consider the patient requirements and the treatment goal, select the appropriate design features ~ prescription variables and then provide the device/intervention.

    If a pre-fab design matches, then use it. If not, build it.
     
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