SAWC Fall: Prognostic Markers to Guide Timely Escalation in Chronic Wounds
At SAWC Fall, David Margolis, MD, PhD, outlined a pragmatic framework for using prognostic markers and early treatment response to guide decisions in diabetic foot ulcers (DFUs) and venous leg ulcers (VLUs). The approach prioritizes simple measurements, wound size, wound duration, and (for DFUs) anatomic depth, over complex technologies when forecasting healing trajectories and timing escalation to advanced therapies.
Baseline measurements anchor the strategy. Length × width recorded with a ruler closely tracks traced or digitized areas for wounds up to approximately 40 cm² and captures the majority of cases, which are typically <10 cm². Wound duration at presentation is a consistent predictor across studies, and DFUs additionally require a depth or grade assessment (eg, extension through dermis or to bone). According to Margolis, these “time-honored predictors” enable practical risk stratification at the first visit and can be combined into simple scores that sort patients into high- and low-probability healers. As he noted, “I can tell you that none of them really work any better than just the measure.”
Early trajectory over the first 4 weeks functions as a predictor, rather than a perfect surrogate, of later outcomes at 12 to 24 weeks. Across cohorts and randomized trial datasets, percent area reduction at 4 weeks yields area-under-the-curve values commonly in the mid–0.70s and, with dichotomized thresholds, sometimes in the mid–0.80s. A reduction around 50% at 4 weeks distinguishes likely healers from nonhealers; however, Margolis emphasized that this tool is directionally useful, not definitive, with performance “about 70% of the time.” His guidance was blunt: “You should see some change in four weeks. If you don’t see change, then you need to worry about your treatments.”
The session emphasized a strict reassessment window at 4 to 6 weeks. Absent improvement, clinicians should confirm fundamentals, compression adherence for VLUs, offloading for DFUs, and correct dressing selection and application, then consider escalation to advanced options that are familiar and reimbursable in their setting. In clearly poor-prognosis wounds at baseline (large, long-standing, deep), earlier escalation may be warranted rather than spending 4 weeks on standard care unlikely to succeed.
Case-mix and real-world execution were recurrent themes. Apparent improvements in program-level healing rates may reflect shifts toward easier wounds rather than better care; comparisons should adjust for baseline risk (size, duration, depth) to avoid misleading conclusions. Efficacy demonstrated in trials may not translate to effectiveness in clinic if patient-level barriers are unaddressed. Practical issues, such as providing dressings in appropriate sizes and ensuring patients can apply them, can determine whether an evidence-based plan succeeds.
Statistical considerations were presented without overcomplication. Because most wounds are small, analyses often require transformations; readers should check whether distributional assumptions were handled appropriately. Nonetheless, the central signal is consistent across designs: baseline size and duration (plus depth for DFUs) and 4-week percent change are reliable, actionable anchors for care pathways.
Key takeaways for practice
- Measure every wound at baseline (length × width), document duration, and record DFU depth/grade.
- Set a 4-week checkpoint; if ≈50% reduction is not achieved, reassess adherence and technique, then escalate therapy.
- In clearly poor-prognosis wounds, consider earlier escalation rather than waiting 4 weeks.
- Convert efficacy to effectiveness by ensuring compression, offloading, and correct dressing use.
- When benchmarking outcomes, adjust for case-mix to avoid selection-bias conclusions.
