Chronic Wound Image Augmentation and Assessment Using Semi-Supervised Progressive Multi-Granularity EfficientNet.

Goal: Augment a small, imbalanced, wound dataset by using semi-supervised learning with a secondary dataset. Then utilize the augmented wound dataset for deep learning-based wound assessment. Methods: The clinically-validated Photographic Wound Assessment Tool (PWAT) scores eight wound attributes: Size, Depth, Necrotic Tissue Type, Necrotic Tissue Amount, Granulation Tissue type, Granulation Tissue Amount, Edges, Periulcer Skin Viability to comprehensively assess chronic wound images. A small corpus of 1639 wound images labeled with ground truth PWAT scores was used as reference. A Semi-Supervised learning and Progressive Multi-Granularity training mechanism were used to leverage a secondary corpus of 9870 unlabeled wound images. Wound scoring utilized the EfficientNet Convolutional Neural Network on the augmented wound corpus. Results: Our proposed Semi-Supervised PMG EfficientNet (SS-PMG-EfficientNet) approach estimated all 8 PWAT sub-scores with classification accuracies and F1 scores of about 90% on average, and outperformed a comprehensive list of baseline models and had a 7% improvement over the prior state-of-the-art (without data augmentation). We also demonstrate that synthetic wound image generation using Generative Adversarial Networks (GANs) did not improve wound assessment. Conclusions: Semi-supervised learning on unlabeled wound images in a secondary dataset achieved impressive performance for deep learning-based wound grading.

Assessment, prevention and management of skin tears in older people.

Skin tears are common injuries that result from mechanical forces. Older people with fragile skin are at greater risk of this type of wound. They are usually categorised as acute wounds that typically heal in 7-21 days but the healing process can be disrupted, leading to chronic, non-healing wounds. They have the potential to compromise quality of life and disrupt daily activities, so it is important to identify risk factors and implement prevention strategies for those at risk. An interdisciplinary approach has a pivotal role in promptly and precisely identifying skin tears, and the use of evidence-based interventions for efficient skin damage management can enhance the recovery process. This article adopts a case study approach to explore the prevention, evaluation and treatment of skin tears, using the case of an individual living with a skin tear in a community setting.

Burden of Chronic Nonhealing Wounds: An Overview of the Worldwide Humanistic and Economic Burden to the Healthcare System.

Chronic wounds have long been a significant public health concern, but the true impact of these wounds is unknown since research designs and measuring techniques vary, leading to inconsistent estimates. The definition of a wound is a loss of epithelial continuity caused by damage to the tissue. The following conditions can cause chronic wounds: panniculitis, pyoderma gangrenosum, traumatic, neurological, metabolic, hematologic, neoplastic, or infection-related. The growing global incidence of diabetes and the aging population necessitate greater attention to chronic wounds. Regrettably, it is sad that significant healthcare institutions have overlooked wound research. The study of health-related illnesses and occurrences in particular populations, including their distribution, frequency, and determinants, and the application of this research to control health problems.

Artificial intelligence in wound care: diagnosis, assessment and treatment of hard-to-heal wounds: a narrative review.

OBJECTIVE: The effective assessment of wounds, both acute and hard-to-heal, is an important component in the delivery by wound care practitioners of efficacious wound care for patients. Improved wound diagnosis, optimising wound treatment regimens, and enhanced prevention of wounds aid in providing patients with a better quality of life (QoL). There is significant potential for the use of artificial intelligence (AI) in health-related areas such as wound care. However, AI-based systems remain to be developed to a point where they can be used clinically to deliver high-quality wound care. We have carried out a narrative review of the development and use of AI in the diagnosis, assessment and treatment of hard-to-heal wounds. We retrieved 145 articles from several online databases and other online resources, and 81 of them were included in this narrative review. Our review shows that AI application in wound care offers benefits in the assessment/diagnosis, monitoring and treatment of acute and hard-to-heal wounds. As well as offering patients the potential of improved QoL, AI may also enable better use of healthcare resources.

Patient-Centered Chronic Wound Care Mobile Apps: Systematic Identification, Analysis, and Assessment.

Background: The prevalence of chronic wounds is predicted to increase within the aging populations in industrialized countries. Patients experience significant distress due to pain, wound secretions, and the resulting immobilization. As the number of wounds continues to rise, their adequate care becomes increasingly costly in terms of health care resources worldwide. eHealth support systems are being increasingly integrated into patient care. However, to date, no systematic analysis of such apps for chronic wounds has been published. Objective: The aims of this study were to systematically identify and subjectively assess publicly available German- or English-language mobile apps for patients with chronic wounds, with quality assessments performed by both patients and physicians. Methods: Two reviewers independently conducted a systematic search and assessment of German- or English-language mobile apps for patients with chronic wounds that were available in the Google Play Store and Apple App Store from April 2022 to May 2022. In total, 3 apps met the inclusion and exclusion criteria and were reviewed independently by 10 physicians using the German Mobile App Rating Scale (MARS) and the System Usability Scale (SUS). The app with the highest mean MARS score was subsequently reviewed by 11 patients with chronic wounds using the German user version of the MARS (uMARS) and the SUS. Additionally, Affinity for Technology Interaction (ATI) scale scores were collected from both patients and physicians. Results: This study assessed mobile apps for patients with chronic wounds that were selected from a pool of 118 identified apps. Of the 73 apps available in both app stores, 10 were patient oriented. After excluding apps with advertisements or costs, 3 apps were evaluated by 10 physicians. Mean MARS scores ranged from 2.64 (SD 0.65) to 3.88 (SD 0.65) out of 5, and mean SUS scores ranged from 50.75 (SD 27) to 80.5 (SD 17.7) out of 100. WUND APP received the highest mean MARS score (mean 3.88, SD 0.65 out of 5) among physicians. Hence, it was subsequently assessed by 11 patients and achieved a similar rating (uMARS score: mean 3.89, SD 0.4 out of 5). Technical affinity, as measured with the ATI scale, was slightly lower in patients (score: mean 3.62, SD 1.35 out of 6) compared to physicians (score: mean 3.88, SD 1.03 out 6). Conclusions: The quality ratings from physicians and patients were comparable and indicated mediocre app quality. Technical affinity, as assessed by using the ATI scale, was slightly lower for patients. Adequate apps for patients with chronic wounds remain limited, emphasizing the need for improved app development to meet patient needs. The ATI scale proved valuable for assessing technical affinity among different user groups.

Identifying health-related quality of life concepts to inform the development of the WOUND-Q.

OBJECTIVE: The impact of hard-to-heal wounds extends beyond traditional clinical metrics, negatively affecting a patient's health-related quality of life (HRQoL). Yet treatment outcomes are seldom measured from the patient's perspective. The purpose of the present study was to perform in-depth qualitative interviews with patients diagnosed with varying types of hard-to-heal wounds to identify outcomes important to them. METHOD: Participants were recruited from wound care clinics in Canada, Denmark, the Netherlands and the US, and were included if they had a hard-to-heal wound (i.e., lasting ≥3 months), were aged ≥18 years, and fluent in English, Dutch or Danish. Qualitative interviews took place between January 2016 and March 2017. An interpretive description qualitative approach guided the data analysis. Interviews were audio-recorded, transcribed and coded line-by-line. Codes were categorised into top-level domains and themes that formed the final conceptual framework. RESULTS: We performed 60 in-depth interviews with patients with a range of wound types in different anatomic locations that had lasted from three months to 25 years. Participants described outcomes that related to three top-level domains and 13 major themes: wound (characteristics, healing); HRQoL (physical, psychological, social); and treatment (cleaning, compression stocking, debridement, dressing, hyperbaric oxygen, medication, suction device, surgery). CONCLUSION: The conceptual framework developed as part of this study represents the outcome domains that mattered the most to the patients with hard-to-heal wounds. Interview quotes were used to generate items that formed the WOUND-Q scales, a patient-reported outcome measure for patients with hard-to-heal wounds.

Assessment of nurses' level of knowledge of the management of chronic wounds.

BACKGROUND: Chronic wounds are a challenge and a major cause of morbidity. A wound is considered chronic if healing does not occur within the expected time frame depending on the etiology and location of the wound. OBJECTIVE: To assess the level of knowledge about chronic wound management of postgraduate nurses in different areas of the health system and their previous satisfaction with the training received during their undergraduate studies. DESIGN: Cross-sectional study of a health system of 95,000 inhabitants and 557 nursing professionals working in it. PARTICIPANTS: Nurses working in the study health system and in areas with care for patients with chronic wounds in social, primary and hospital care. RESULTS: Survey results described a low knowledge of chronic wound management in general. Data on knowledge according to area of work showed that nurses in primary care had the highest knowledge of wound etiology. Nurses working in health and social care were most knowledgeable in diagnostic knowledge. Hospital nurses showed the lowest knowledge overall. A relationship was observed when nurses had a master's degree followed by an expert with better knowledge in the test. In addition, nurses reported little training in chronic wounds during their university studies (69.73 %, n = 106). CONCLUSIONS: Therefore, a review of this point should be considered to improve the management of chronic wounds and their correct approach among nursing students. A review of continuing and even specialised training needs in the clinical care setting should also be considered.

Comparing the wound healing potential of natural rubber latex serum and F1-protein: An in vivo approach.

Chronic wounds pose significant health concerns. Current treatment options include natural compounds like natural rubber latex (NRL) from Hevea brasiliensis. NRL, particularly the F1 protein fraction, has demonstrated bioactivity, biocompatibility, and angiogenic effects. So far, there is no study comparing F1 protein with total NRL serum, and the necessity of downstream processing remains unknown. Here, we evaluated the angiogenic potential of F1 protein compared to total NRL serum and the need for downstream processing. For that, ion exchange chromatography (DEAE-Sepharose), antioxidant activity, physicochemical characterization, cell culture in McCoy fibroblasts, and wound healing in Balb-C mice were performed. Also, the evaluation of histology and collagen content and the levels of inflammatory mediators were quantified. McCoy fibroblast cell assay showed that F1 protein (0.01 %) and total NRL serum (0.01 %) significantly increased cell proliferation by 47.1 ± 11.3 % and 25.5 ± 2.5 %, respectively. However, the AA of F1 protein (78.9 ± 0.8 %) did not show a significant difference compared to NRL serum (77.0 ± 1.1 %). F1 protein and NRL serum were more effective in wound management in rodents. Histopathological analysis confirmed accelerated healing and advanced tissue repair. Similarly, the F1 protein (0.01 %) increased collagen, showing that this fraction can stimulate the synthesis of collagen by fibroblastic cells. Regarding cytokines production (IL-10, TNF-α, IFN-γ), F1 protein and NRL serum did not exert an impact on the synthesis of these cytokines. Furthermore, we did not observe statistically significant changes in dosages of enzymes (MPO and EPO) among the groups. Nevertheless, Nitric Oxide dosage was reduced drastically when the F1 protein (0.01 %) protein was applied topically. These findings contribute to the understanding of F1 protein and NRL serum properties and provide insights into cost-effectiveness and practical applications in medicine and biotechnology. Therefore, further research is needed to assess the economic feasibility of downstream processing for NRL-based herbal medicine derived from Hevea brasiliensis.

Fabrication, Characterization, and In Vitro Cytotoxicity Assessment of Tri-Layered Multifunctional Scaffold for Effective Chronic Wound Healing.

Chronic wounds have been a global health risk that demands intensive exploration. A tri-layered biomaterial scaffold has been developed for skin wounds. The top layer of the scaffold is superhydrophobic, and the bottom layer is hydrophilic, both of which were electrospun using recycled expanded polystyrene (EPS) and monofilament fishing line (MFL), respectively. The intermediate layer of the scaffold comprised hydrogel by cross-linking chitosan (CS) with polyethylene glycol. The surface morphology, surface chemistry, thermal degradation, and wettability characteristics of each layer of the scaffold were examined. Also, the antibacterial activity and in vitro cytotoxicity study on the combined tri-layered scaffold were assessed against Escherichia coli (E. coli) and Staphylococcus aureus (S. aureus). Data revealed exceptional water repellency of the heat-treated electrospun top superhydrophobic layer (TSL) with a high-water contact angle (WCA) of 172.44°. A TSL with 15 wt% of micro-/nano-inclusions had the best thermal stability above 400 °C. The bottom hydrophilic layer (BHL) displayed a WCA of 9.91°. Therapeutically, the synergistic effect of the combined tri-layered scaffold significantly inhibited bacteria growth by 70.5% for E. coli and 68.6% for S. aureus. Furthermore, cell viability is enhanced when PEG is included as part of the intermediate CS hydrogel layer (ICHL) composition.

Chronic wound prevalence and the associated cost of treatment in Medicare beneficiaries: changes between 2014 and 2019.

OBJECTIVE: To determine the cost of wound care and prevalence of chronic wounds for Medicare beneficiaries in the aggregate, by wound type, and by setting between the years 2014 and 2019. METHODS: This retrospective analysis of Medicare claims data included beneficiaries who experienced episodes of care for diabetic foot ulcers and infections; arterial ulcers; skin disorders and infections; surgical wounds and infections; traumatic wounds; venous ulcers and infections; unspecified chronic ulcers; and others. The 2014 data were based on a Medicare 5% Limited Data Set whereas for 2019 the data used were for all fee-for-service Medicare beneficiaries. Three methods were used to generate expenditure estimates: (a) a low (Medicare provider payments when the wound was a primary diagnosis, excluding any kind of deductible); (b) mid (primary plus secondary diagnosis with weighted attribution); and (c) high (primary or secondary diagnosis). The main outcomes were the prevalence of each wound type, Medicare expenditure for each wound type and aggregate, and expenditure by type of service. RESULTS: Over the 5-year period the number of Medicare beneficiaries with a wound increased from 8.2 million to 10.5 million. Wound prevalence increased by 13% from 14.5% to 16.4%. Over the 5-year period, the Medicare beneficiaries with the largest increase in chronic wound prevalence were those aged <65 years (males: 12.5% to 16.3%; females: 13.4% to 17.5%). The largest changes in terms of wound prevalence were increases in arterial ulcers (0.4% to 0.8%), skin disorders (2.6% to 5.3%), and decreases in traumatic wounds (2.7% to 1.6%). Expenditures decreased regardless of the three methods used with a reduction of $29.7 billion to $22.5 billion for the most conservative method. Except for venous ulcers in which costs per Medicare beneficiary increased from $1206 to $1803, cost per wound decreased with surgical wounds remaining the most expensive to treat (2014: $3566; 2019: $2504), and the largest decrease for arterial ulcers ($9651 to $1322). Hospital outpatient fees saw the largest reduction ($10.5 billion to $2.5 billion) although home health agency expenditures decreased from $1.6 billion to $1.1 billion. Physician offices saw an increase from $3.0 billion to $4.1 billion and durable medical equipment increased from $0.3 billion to $0.7 billion. CONCLUSIONS: It appears that chronic wound care expenditures have shifted to the physician's office from the hospital-based outpatient department. Given that the prevalence of chronic wounds is increasing, especially among the disabled under 65, it will be important to know whether these shifts have positively or negatively affected outcomes.

HighlightsIn 2014 chronic wounds impacted 14.5% of Medicare beneficiaries but this increased to 16.3% by 2019. The group of Medicare beneficiaries most affected in terms of chronic wound prevalence over the 5-year period were those aged <65 years (males: 12.5% to 16.3%; females: 13.4% to 17.5%). The largest changes in terms of prevalence were increases in arterial ulcers (0.4% to 0.8%), skin disorders (2.6% to 5.3%), and traumatic wounds (2.7% to 1.6%)Over the 5-year period, regardless of the method used, there was a decrease in chronic wound-related costs ($29.7 billion in 2014 to $22.5 billion in 2019 for the most conservative method: Medicare provider payments when the wound was a primary diagnosis, excluding any kind of deductible). Surgical complications still represent the largest wound category of costs with a small decrease from 2014 to 2019 of $6.1 billion to $5.9 billion. Based on the most conservative method, there was a very large cost reduction observed for outpatients from $10.5 billion to $2.5 billion with a correspondingly smaller decrease for inpatients of $5.3 billion to $4.2 billion, but an increase from $3.0 billion to $4.1 billion for physician offices. In addition, while durable medical equipment increased from $0.3 billion to $0.7 billion, home health agency expenditures decreased from $1.6 billion to $1.1 billion.Our data suggest that while most of the cost remains in the subacute setting it has shifted to the physician's office from the hospital-based outpatient department. Given the increasing prevalence of chronic wounds, especially among the disabled under 65, it will be important to know whether these shifts have positively or negatively affected outcomes.

Updates on Recent Clinical Assessment of Commercial Chronic Wound Care Products.

Impaired wound healing after trauma, disorders, and surgeries impact millions of people globally every year. Dysregulation in orchestrated healing mechanisms and underlying medical complications make chronic wound management extremely challenging. Besides standard-of-care treatments including broad spectrum antibiotics and wound-debridement, novel adjuvant therapies are clinically tested and commercialized. These include topical agents, skin substitutes, growth factor delivery, and stem cell therapies. With a goal to overcome factors playing pivotal role in delayed wound healing, researchers are exploring novel approaches to elicit desirable healing outcomes in chronic wounds. Although recent innovations in wound care products, therapies, and devices are extensively reviewed in past, a comprehensive review summarizing their clinical outcomes is surprisingly lacking. Herein, this work reviews the commercially available wound care products and their performance in clinical trials to provide a statistically comprehensive understanding of their safety and efficacy. The performance and suitability of various commercial wound care platforms, including xenogeneic and allogenic products, wound care devices, and novel biomaterials, are discussed for chronic wounds. The current clinical evaluation will provide a comprehensive understanding of the benefits and drawbacks of the most-recent approaches and will enable researchers and healthcare providers to develop next-generation technologies for chronic wound management.

Cost-Effectiveness of PHMB & betaine wound bed preparation compared with standard care in venous leg ulcers: A cost-utility analysis in the United Kingdom.

BACKGROUND: Wounds cost £8.3 billion per year in the United Kingdom (UK) annually. Venous leg ulcers (VLUs) account for 15% of wounds and can be complicated to heal, increasing nurse visits and resource costs. Recent wound bed preparation consensus recommends wound cleansing and biofilm disrupting agents. However, inert cleansers such as tap water or saline are inexpensive, an evaluation of evidence is required to justify the higher upfront costs of treatment with active cleansers. We undertook a cost-effectiveness analysis of the use of a biofilm disrupting and cleansing solution and gel, Prontosan® Solution and Gel X, (PSGX) (B Braun Medical), as compared to the standard practice of using saline solution, for treating VLUs. METHODS: A Markov model was parameterised to one-year costs and health-related quality of life consequences of treating chronic VLUs with PSGX versus saline solution. Costs are viewed from a UK healthcare payer perspective, include routine care and management of complications. A systematic literature search was performed to inform the clinical parameters of the economic model. Deterministic univariate sensitivity analysis (DSA) and probabilistic sensitivity analysis (PSA) were undertaken. RESULTS: For PSGX an Incremental Net Monetary Benefit (INMB) of £1,129.65 to £1,042.39 per patient (with a Maximum Willingness to Pay of £30k and £20k per QALY respectively), of which cost savings are £867.87 and 0.0087 quality-adjusted life years (QALYs) gain per patient. PSA indicates a 99.3% probability of PSGX being cost-effective over saline. CONCLUSIONS: PSGX for the treatment of VLUs is dominant compared with saline solution in the UK with expected cost-savings within a year and improved patient outcomes.

Assessment of microcirculatory changes in local tissue oxygenation after revascularization for peripheral arterial disease with the Hyperview®, a portable hyperspectral imaging device.

OBJECTIVES: The Hyperview® is a hyperspectral camera, which can be used to assess the microcirculation of patients with peripheral arterial disease (PAD) and/or diabetes mellitus (DM). It measures local tissue oxygenation in concentrations of oxyhemoblobin (OXY), deoxyhemoglobin (DEOXY), and O2-saturation (O2-SAT) in arbitrary units. The aim of this validation study is to assess whether the Hyperview® is able to monitor microcirculatory changes after revascularization in patients with PAD. METHODS: In this prospective observational cohort study, 50 patients with PAD were included who were scheduled for endovascular, hybrid, or open revascularization. The ankle-brachial index (ABI), systolic toe pressure (TP) (in case of DM), and a set of Hyperview® measurements of the plantar region were recorded before and after treatment. Changes in pre- and postoperative measurements were assessed with the paired t-test. RESULTS: Some 38 patients underwent endovascular revascularization and eight patients underwent hybrid or open vascular surgical revascularization. After revascularization, the ABI improved from 0.58 to 0.80 (p < 0.001). OXY increased from 72.6 to 77.8 (p = 0.134). DEOXY decreased from 69.1 to 55.0 (p < 0.001). O2-SAT increased from 51.3 to 58.1 (p < 0.001). TP improved from 50.6 to 61.9 mmHg (p = 0.065) but was measured in only 16 patients. CONCLUSION: The Hyperview® is able to observe changes in the microcirculation after revascularization in terms of DEOXY and O2-SAT. The results of this study are a promising step into the validation of the Hyperview®.

Challenges around quantifying uncertainty in a holistic approach to hard-to-heal wound management: Health economic perspective.

Treatment of hard-to-heal wounds involves a holistic approach for choosing between available treatment options. However, evidence for informing these choices is sparse, introducing uncertainty into decisions about the optimum treatment pathways that reflect the vast heterogeneity in this patient population. This paper discusses the existing clinical and health economic literature in order to provide insight into sources of uncertainty in the evaluation of the holistic approach to management of the hard-to-heal wounds, and how this uncertainty can be appropriately reflected in research. We identified three key sources of uncertainty in the evaluation of chronic wound treatments, namely heterogeneity in aetiology and patient populations, heterogeneity in treatment pathways, and challenges around capturing all relevant outcomes. Reflecting these complexities requires sophisticated modelling of treatment sequencing and long-term outcomes. The paper discusses how the scope specification, scenario analyses, and sensitivity analyses can be used to fully characterise analytical uncertainty.

Superabsorbent Wound Dressing for Management of Patients With Moderate-to-Highly Exuding Chronic Leg Ulcers: An Early Stage Model-Based Benefit-Harm Assessment.

The aim of the research is to assess the benefit-harm of superabsorbent polymers wound dressings based on polyacrylate polymers (SAPs) compared with standard of care (SoC) dressing mix for patients with moderate-to-highly exuding hard-to-heal leg ulcers. The SoC dressings mix was composed of other superabsorbents in 29% of cases, antimicrobials 26%, foams 20%, alginates 5%, and other dressings 19% weighted according to their frequency. We have used the decision-analytic modeling method, Markov process, as an adequate analytical solution for medical prognosis. We have combined the systematic literature search to identify the most relevant inputs for the analysis, with available patient-level clinical data concerning benefits of superabsorbent to generate a robust prediction of patient-relevant outcomes, including healing rates and health-related quality of life. Besides, we have qualitatively described adverse events associated with those treatments. Our research indicates that SAPs when compared with SoC dressing mix in a patient with moderate-to-highly excluding leg ulcers are leading to an improved healing rate with an absolute risk difference of 2.20% in 6 months and a relative risk of 1.07 in favor of SAP dressings. The attributable fraction among those exposed to SAP dressings of 6.6%, meaning that 6.6% of the healed ulcers could be attributed to having had the SAP dressing treatment instead of the SoC dressing treatment. Besides, SAP dressings lead to improved quality of life measured as incremental quality-adjusted life weeks (QALWs) of 0.13 QALWs.

Hyaluronic acid treatment versus standard of care in chronic wounds in a German setting: Cost-effectiveness analysis.

Background and Aims: Chronic wounds are a major burden for worldwide health care systems. In the management of chronic wounds several strategies with innovative and active agents emerged in the past few years, such as hyaluronic acid containing wound dressings. Evidence comparing the cost-effectiveness of hyaluronan and standard of care dressings (hydrofiber with silver) is still missing. The aim of the study is thus, to assess the cost-effectiveness of hyaluronan versus standard of care dressings (hydrofiber with silver) in chronic wounds from a German statutory health insurance perspective. Methods: A decision tree was modeled to quantify the cost and healing rate at 12 weeks for the hyaluronan and silver dressings strategies. Input parameters were collected literature-based, accounting for healing rates, dressing prices and prices for dressing changes and associated home care. Parameter uncertainty was accounted for by one-way and probabilistic sensitivity analysis. Results: Hyaluronic acid showed a better healing rate (60.68%) and noticeable lower cost (749.80 Euro) compared to standard of care (silver containing) dressings (59.62%; 883.05 Euro), resulting in an Incremental Cost Effectiveness Ratio of -12,570.57. The hyaluronan approach is hence a dominant strategy in chronic wound management. Sensitivity analysis confirmed these results, giving a range of 60%- 70% of cost-effective scenarios. Conclusions: Hyaluronic acid dressings showed to be a clinical more effective strategy at significantly lower cost in chronic wounds compared to standard of care (hydrofiber with silver).

Skin Ulcers are Predictors of 30-Day Hospital Readmission, But are Under-represented in the DRG Coding: A Retrospective Case-Control Study From an Italian Internal Medicine Unit.

This study retrospectively analyzes all consecutive patients who underwent during a year hospital readmissions, defined as an admission to a hospital within 30 days of discharge, to an Italian Internal Medicine ward. All these data were compared with those from patients who underwent only 1 hospital admission in the same period. The aim of this study was to identify potential novel risk factors for hospital readmissions. In 2018, a total of 3012 patients were hospitalized. Among these, 14.1% (n = 426; mean age, 79.7 ± 11.9; range, 23-100) were defined as readmissions; data were compared with controls (n = 420; 13.9%; mean age, 75.9 ± 14.7; range, 22-99) who had only 1 hospitalization. Cases showed a significantly higher prevalence than controls regarding cerebrovascular disease (77.2% vs 48.1%), cognitive impairment (51.8% vs 26.9%), congestive heart failure (47.6% vs 20.2%), chronic kidney disease (31.7% vs 13.1%), and chronic obstructive pulmonary disease (23.0% vs 14.5%). Skin ulcers were significantly more prevalent among cases (45.1% vs 17.6%). Diagnosis-related group (DRG) analysis showed a higher proportion of "infectious disease" (24.4% vs 15.0%) among the cases than in controls. Despite skin ulcers were very frequent among cases and controls (45.1% vs 17.6%), they were codified as "skin wound" DRG only in 1.4% and 0.2%, respectively. At the DRGs analysis, sepsis (31.6% vs 19.1%), pneumonia (17.1% vs 7.6%), and kidney failure (9.6% vs 3.8%) represented the main significant cause of death in cases compared to controls. Our study confirms that readmissions to Internal Medicine departments are related to the severity of chronic diseases affecting patients. Skin ulcers are present in about half of patients who will be early readmitted within 30 days, but they are almost never reported in DRGs, so more accurate coding is needed. Key challenges for the future are sepsis prevention measures and investing resources in chronic disease assistance, including skin ulcer chronic management.

People with chronic wounds cared for at home in Belgium: Prevalence and exploration of care integration needs using health care trajectory analysis.

BACKGROUND: Little is known about the prevalence of people with chronic wounds cared for at home and their care integration needs in Belgium. In high-income countries, chronic wounds are associated with ageing processes, chronic diseases and social and financial vulnerability, resulting in multiple needs. To meet these needs, many health care providers (with nurses figuring prominently) are involved. This can lead to fragmented health care trajectories and the need to strengthen care coordination. OBJECTIVES: This study aims to estimate the prevalence of people with chronic wounds cared for at home in Belgium. It also seeks to explore their health care trajectories and the risk of fragmentation of care to inform policy makers, care providers and research. DESIGN: Cross-sectional. SETTING(S): Home care. PARTICIPANTS: Routinely collected data of reimbursed care of 3467 people with a chronic wound cared for at home in 2018. METHODS: We applied a stratification method to our sample based on health care trajectories. First, we constructed individual sequences of care received during the year. Then we summarised the health care events using a K-mers approach. Finally, a multinomial mixture model was used on the previously obtained summary to cluster individuals according to their health care trajectories. Afterwards, other epidemiological, socioeconomic and health care use indicators were calculated for each health care trajectory group. We also estimated the prevalence of people with chronic wounds treated at home. RESULTS: We constructed six health care trajectory groups for two age categories (<65 and ≥65 years) showing different intensity of care use and type of care. In some health care trajectory groups, generalist care was found to be predominant. In others, specialist care appeared more prevalent. Depending on the health care trajectory group, a significant proportion of people had multiple care providers involved (mainly nurses, medical specialists and GPs), and many of them also had multiple transitions between care settings. The prevalence of people with chronic wounds treated at home rises significantly with age: 0.3%, 95%CI (0.2%-0.4%) for people aged under 65, 2.5%, 95%CI (2.3%-2.8%) for people aged 65 and over. CONCLUSION: A significant proportion of people with chronic wounds experienced multiple transitions and met many health care providers. This can lead to complex trajectories and risk of fragmentation. Nurses, who are intensively involved in wound care at home, with the appropriate skills, could play a 'reference' role to promote continuity of care and better coordination. REGISTRATION: Not registered.

An overview of the prevention and management of wound infection.

A wound can be defined as infected when the presence and subsequent proliferation of microorganisms leads to a local or systemic response in an individual. Wound infection is associated with delayed healing, wound chronicity, increased risk of hospital admission, loss of limb or digit and increased healthcare costs. The presence of biofilm is also recognised as a challenge in infected wounds and is associated with chronicity and delays in healing. Identifying and managing wound infection early can contribute to faster wound healing, thus reducing the risk of negative outcomes. This article details the pathophysiology, risk factors and signs and symptoms of wound infection. It also outlines various prevention and management options for wound infection.

The patient behind the wound assessment and plan.

OBJECTIVE: Hard-to-heal wounds are a common problem, worsened by ageing, and the increased prevalence of diabetes and morbid obesity. The provider-patient relationship has undergone a transformation, from a paternalistic to a mutual participation model, in which 'the physician tries to enter the patient's world to see the illness through the patient's eyes'. The indepth assessment of the impact of psychosocial, physical issues and provider-patient dynamics is crucial to wound healing and patient wellbeing. It can customise future treatment including physical therapy, psychological and social interventions to improve outcomes. METHOD: A new health-related quality of life instrument (HRQOL) proposal based on a survey consisting of 20 questions was completed by patients as a pilot project. The psychosocial, physical and provider-patient dynamics were evaluated. A total wound impact score (WIs) was tabulated, ranging from 20-80 points. A wound assessment and plan (PBW-AP) was created. RESULTS: In our sample of 25 patients, 75% experienced a moderate WIs (50-69) and 5% experienced a severe WIs (31-49). Feeling angry about having a wound was reported by 40% of patients. A majority of patients (60%) thought about their wounds >1 hour per day. Importantly, 24% answered that their primary care physicians never mentioned their wounds. CONCLUSION: It is important for all physicians taking care of patients with hard-to-heal wounds to see 'the patient behind the wound'. The PBW-AP algorithm is an individualised, multidisciplinary assessment and intervention based on a WIs. It is designed not only to identify but also to tackle psychosocial, physical, and provider-patient issues, to improve overall quality of life, patient satisfaction and clinical outcomes. Based on the results, the PBW-AP algorithm was designed to be used at initial and subsequent visits as a roadmap for problem identification and intervention.