Clinical and economic burden of wound care in the tropics: a 5-year institutional population health review.

The aim of this study is to evaluate the clinical and economic burden of wound care in the Tropics via a 5-year institutional population health review. Within our data analysis, wounds are broadly classified into neuro-ischaemic ulcers (NIUs), venous leg ulcers (VLUs), pressure injuries (PIs), and surgical site infections (SSIs). Between 2013 and 2017, there were a total of 56 583 wound-related inpatient admissions for 41 461 patients, with a 95.1% increase in wound episodes per 1000 inpatient admissions over this period (142 and 277 wound episodes per 1000 inpatient admissions in 2013 and 2017, respectively). In 2017, the average length of stay for each wound episode was 17.7 days, which was 2.4 times that of an average acute admission at our institution. The average gross charge per wound episode was USD $12 967. Among the 12 218 patients with 16 674 wound episodes in 2017, 71.5% were more than 65 years of age with an average Charlson Comorbidity Index (CCI) of 7.2. Half (51.9%) were moderately or severely frail, while 41.3% had two or more wound-related admission episodes. In 2017, within our healthcare cluster, the gross healthcare costs for all inpatient wound episodes stand at USD $216 million within hospital care and USD $596 000 within primary care. Most NIU patients (97.2%) had diabetes and they had the most comorbidities (average CCI 8.4) and were the frailest group of patients (44.9% severely frail). The majority of the VLU disease burden was at the specialist outpatient setting, with the average 1-year VLU recurrence rate at 52.5% and median time between healing and recurrence at 9.5 months. PI patients were the oldest (86.5% more than 65 years-old), constituted the largest cohort of patients with 3874 patients at an incidence of 64.6 per 1000 admissions in 2017, and have a 1-year all-cause mortality rate of 14.3%. For SSI patients, there was a 125% increase of 14.2 SSI wound episodes per 1000 inpatient admissions in 2013 to 32.0 in 2017, and a 413% increase in wound-related 30-day re-admissions, from 40 in 2013 (4.1% of all surgeries) to 205 (8.3% of all surgeries) in 2017. The estimated gross healthcare cost per patient ranges from USD $15789-17 761 across the wound categories. Similar to global data, there is a significant and rising trend in the clinical and economic burden of wound care in Tropics.

Digital ulcers in systemic sclerosis: their epidemiology, clinical characteristics, and associated clinical and economic burden.

BACKGROUND: To determine the frequency and clinical characteristics of systemic sclerosis-related digital ulcers, and associated direct health care costs, quality of life, and survival. METHODS: Digital ulcers (DUs) were defined as an area with a visually discernible depth and a loss of continuity of epithelial coverage. DU severity was calculated based on the physician reported highest number of new DUs at clinical review (mild = 1-5 DUs, moderate 6-10 DUs, severe > 10 DUs). Healthcare use was captured through data linkage, wherein SSc clinical data captured prospectively in a dedicated clinical database were linked with health services databases to capture hospital admissions, emergency department (ED) presentations and ambulatory care (MBS) utilization and cost for the period 2008-2015. Healthcare cost determinants were estimated using logistic regression. RESULTS: Among 1085 SSc patients, 48.6% experienced a DU over a mean follow-up of 5.2 ± 2.5 years. Those who developed DUs were more likely to have diffuse disease subtype (34.9% vs 18.2%, p < 0.001), anti-Scl-70 antibody (18.9% vs 9.3%, p < 0.001), and a younger age at SSc onset (43.6 ± 13.9 vs 48.8 ± 14.0 years, p < 0.001) in addition to reduced health-related quality of life (HRQoL) measured by the SF-36 but without a significant impact on survival. SSc patients with a history of a DU utilized significantly more healthcare resources per annum than those without a DU, including hospitalizations, ED presentation, and ambulatory care services. Total healthcare services, excluding medications, were associated with an annual excess cost per DU patient of AUD$12,474 (8574-25,677), p < 0.001, driven by hospital admission and ED presentation costs. CONCLUSION: DUs place a large burden on the patient and healthcare system through reduced HRQoL and increased healthcare resource utilization and associated cost.

Incremental Health Care Expenditure of Chronic Cutaneous Ulcers in the United States.

Importance: Despite the increasing incidence of chronic cutaneous ulcers (CCUs), limited information exists regarding their incremental economic burden. Objective: To provide nationally representative estimates regarding the incremental health care cost of CCUs, controlling for comorbidities and sociodemographic characteristics. Design, Setting, and Participants: This retrospective analysis used 9 years of longitudinal data from the Medical Expenditure Panel Survey (MEPS; January 1, 2007, through December 31, 2015). Patients with CCUs were identified using Agency for Healthcare Research and Quality-produced software that included several codes from the International Classification of Disease, 9th Revision Clinical Modification, for chronic ulcers of the skin. A cross-validated 2-part generalized linear model estimated the adjusted incremental expenditure for individuals with CCUs while controlling for comorbidities and sociodemographic covariates. Data were analyzed from July 1 through September 1, 2018. Main Outcomes and Measures: Incremental cost of CCUs, total cost of care, and expenditures associated with inpatient care, outpatient care, prescription medications, emergency department visits, and home health care. Results: A total of 288 698 patients (52.4% female; mean [SD] age, 38.2 [22.4] years) were included, of whom 1786 had CCUs and 286 912 did not. Patients with CCUs were more likely to be female (1078 [60.4%]), non-Hispanic (1388 [77.7%]), previously or currently married (1440 [80.6%]), and covered by Medicaid/Medicare (852 [47.7%]) and had a lower income (954 [53.4%]) when compared with patients without CCUs (P < .001 for all). The mean (SD) annual cost of care per patient with CCUs was greater than 4 times that of patients without CCUs ($17 958 [$1031.90] vs $4373.20 [$48.48]). After controlling for Charlson comorbidity index and sociodemographic factors measured in MEPS, the cost of care for patients with CCUs was 1.73 times as high as that of patients without CCUs (95% CI, 1.53-1.96; P < .001), and patients with CCUs were estimated to incur $7582.00 (95% CI, $6201.47-$8800.45) more in annual health care expenditures. When accounting for the prevalence of CCUs (0.6%), CCUs were associated with more than $16.7 billion per year in population-level US health care expenditures. Among patients with CCUs, mean annual expenditures rose from the 2010-2012 to 2013-2015 periods in association with prescription medications ($3117.26 to $6169.12), outpatient care ($3568.06 to $5920.75), and home health care ($1039.54 to $1670.56). Conclusions and Relevance: Results of this study suggest that chronic cutaneous ulcers are associated with substantial incremental increases in annual health care expenditure. Expenses for patients with CCUs are increasing, particularly with regard to outpatient cost of care and prescription medication expenditure. As health care costs rise, investigators must identify strategies to prevent and treat CCUs.

Increasing productivity with smartphone digital imagery wound measurements and analysis.

OBJECTIVE: The primary aim was to determine the productivity increase using digital imagery for better documentation and analysis. A case series was done in a specialised care centre with patients managed with advanced dressings and using state-of-the-art smartphone technology for documentation to save costs and time. METHOD: Wounds were cleansed and debrided before using the application to photograph, document, measure and analyse the wounds. The smartphone app was oriented parallel to the plane of the wound, where possible, to obtain accurate measurements. A longitudinal study report was generated for each wound and showed the progress of the wound healing until the wound was closed. RESULTS: A sample size of 60 patients consisting of wounds from different locations, and a total of 203 measurements and analyses were conducted over a period of seven months. The wound monitoring app proved to be effective for wound monitoring and required less than two hours' training. A report summary of wounds recorded could also be generated automatically through the dashboard. All 60 patients' cases were automatically recorded, measured and presented into reports for use in clinical analysis. There was a significant time savings (27 hours per day for a specialised care centre with 10 nurses) increase over manual wound documentation and measuring methods. CONCLUSION: The app provided a non-contact, easy to use, reliable and accurate smart wound management solution for clinicians and physicians to track wound healing in patients. The app could also be used by patients and caregivers for home monitoring of their wounds.

Comparative cost and clinical effectiveness of clostridial collagenase ointment for chronic dermal ulcers.

Chronic dermal ulcers affect approximately 2.4-4.5 million people in the USA and are associated with loss of function, decreased quality of life and significant economic burden. Debridement is a critical component of wound care involving removal of nonviable tissue from chronic wounds to stimulate the granulation and epithelialization process. Clostridial collagenase ointment has been used as a method of wound debridement for more than 50 years and is currently the only enzymatic debriding ointment with US FDA approval. This review discusses the results of recent real-world studies that build upon the evidence demonstrating the clinical effectiveness, cost-effectiveness and safety of clostridial collagenase ointment across wound types and care settings.

The financial and quality-of-life cost to patients living with a chronic wound in the community.

Chronic wounds are associated with financial and personal costs. The system level expense associated with chronic wounds has been established, however, the out-of-pocket cost incurred by individuals who self-fund has not been the focus of extensive investigation. Recently, there has been renewed interest in evaluating quality of life, in line with the shift to patient enablement and self-care in chronic disease management. The objectives of this research were to describe the out-of-pocket wound treatment costs and the quality of life of people who have chronic wounds. A questionnaire incorporating the Cardiff Wound Impact Schedule and purpose-designed instruments was completed by a non-probability, convenience sample of 113 people in Australia and Wales. Data was analysed using descriptive statistics. The sample was on average 63·6 years of age and had wounds that were on an average 109 weeks duration. Participants had spent on average AU$2475 on wound dressing products since the wound started, and AU$121·82 in the most recent 28 days which represented 10% of their disposable income. Health-related quality of life was sub-optimal, 6/10 (ave) according to the Cardiff Wound Impact Schedule. Younger participants reported significantly poorer quality of life on all CWIS sub-scales when compared to older participants. This study found that chronic wounds present a significant financial cost to individuals who must self-fund their wound dressings and other wound treatment related expenses. Participants who had access to wound product subsidisation also experienced personal financial costs. People who have chronic wounds experience sub-optimal quality of life therefore this condition is also costly to the individual's well-being. The quality of life of younger people has not received adequate attention and requires further consideration given the many years that younger people may have to live with this debilitating and often recurrent condition. Continued action is required to reduce the financial and personal costs experienced by people who have chronic wounds. It is imperative that healthcare funding is directed to people who have chronic wounds, in particular to alleviate the out-of-pocket costs experienced by self-funders. Continued attention to the quality of life of people who have chronic wounds is required to minimise the negative effects of this condition and enhance well-being.

Wound management for the 21st century: combining effectiveness and efficiency.

Treatment of wounds of different aetiologies constitutes a major part of the total health care budget. It is estimated that 1·5-2 million people in Europe suffer from acute or chronic wounds. These wounds are managed both in hospitals and in community care. The patients suffering from these wounds report physical, mental and social consequences of their wounds and the care of them. It is often believed that the use of wound dressings per se is the major cost driver in wound management, whereas in fact, nursing time and hospital costs are together responsible for around 80-85% of the total cost. Healing time, frequency of dressing change and complications are three important cost drivers. However, with the use of modern, advanced technology for more rapid wound healing, all these cost drivers can be substantially reduced. A basic understanding of the terminology and principles of Health Economics in relation to wound management might therefore be of interest.

Reduction in wound healing times, cost of consumables and number of visits treated through the implementation of an electronic wound care system in rural Australia.

Globally, wound care costs the health care system 2-3% of the total expenditure on health, which equates to several billion dollars annually. To date, there are little data on the cost and healing rates of various wounds. This has been partly because of the difficulty in tracking wound management as the majority of wound care data has been focused on retrospective data from hospitals, general practice clinics and aged care facilities. This study reports on wound healing and cost of wounds collected from a larger project using the mobile wound care (MWC) electronic documentation system, which has been described elsewhere. The study involved 2350 clients from four health service districts in the Gippsland region in rural Australia who received treatments as part of the MWC research project (2010-2012), with a total of 3726 wounds identified (so an average of 1·6 wounds per client). By the end of the data collection period, 81% of these wounds had healed. A significant drop in healing time, cost of consumables and number of visits was found across the 3-year period.

Cost consequences due to reduced ulcer healing times - analyses based on the Swedish Registry of Ulcer Treatment.

Resource use and costs for topical treatment of hard-to-heal ulcers based on data from the Swedish Registry of Ulcer Treatment (RUT) were analysed in patients recorded in RUT as having healed between 2009 and 2012, in order to estimate potential cost savings from reductions in frequency of dressing changes and healing times. RUT is used to capture areas of improvement in ulcer care and to enable structured wound management by registering patients with hard-to-heal leg, foot and pressure ulcers. Patients included in the registry are treated in primary care, community care, private care, and inpatient hospital care. Cost calculations were based on resource use data on healing time and frequency of dressing changes in Swedish patients with hard-to-heal ulcers who healed between 2009 and 2012. Per-patient treatment costs decreased from SEK38 223 in 2009 to SEK20 496 in 2012, mainly because of shorter healing times. Frequency of dressing changes was essentially the same during these years, varying from 1·4 to 1·6 per week. The total healing time was reduced by 38%. Treatment costs for the management of hard-to-heal ulcers can be reduced with well-developed treatment strategies resulting in shortened healing times as shown in RUT.

[Impact of topical application of autologous platelet-rich gel on medical expenditure and length of stay in hospitals in diabetic patients with refractory cutaneous ulcers].

OBJECTIVE: To evaluate the potential financial benefit of topical application of autologous platelet-rich gel (APG) in treating diabetic refractory cutaneous ulcers. METHODS: A single-center prospective randomized controlled trial was undertaken, with 117 patients with proven diabetic refractory cutaneous ulcers participating in the study. The patients who gave informed consents were randomly assigned into standard care group (n = 58) or standard care plus topical application of APG treatment group (n = 59). The outcome of healing and the medical expenditur and length of stay in the patients were compared between the two groups. RESULTS: The APG-treated group had better healing outcomes than the standard-treated group. The APG-treated group had 84.750 (50/59) complete healing and 98.31% improvement, higher than the 68.97% (40/58) and 75.86%, respectively, in the standard-treated group (P = 0.026). The median length for healing in the APG-treated patients was 36 days, shorter than the 45 days in the standard-treated patients (P = 0.012). The total medical expenditure and length of stay in hospitals were not significantly different between APG-treated patients [yen 38223 (23070-57398); 57 (41-94) days] and standard-treated patients [yen 35070 (24436-53649); 58 (31.75-58.50) days) (P = 0.455 and 0.301 respectively). Spendings on items such as medicine, artificial treatment, materials, interventional operation, surgical procedures, laboratory tests and other auxiliary examination, accommodations, meals, nursing care and debridement and dressing change were similar between the two groups (P > 0.05). CONCLUSION: There is an advantage for the topical application of APG on diabetic refractory cutaneous ulcers in terms of the healing outcomes. APG is a cost-effective choice for patients with diabetic refractory cutaneous ulcers.

Clinical evaluation of Allevyn Gentle Border Lite™ within one health trust.

This article outlines the financial cost of wound care and the importance of appropriate dressings to achieve both clinical and economic outcomes. A clinical evaluation of Allevyn Gentle Border Lite™ including 50 patients within one health trust was undertaken to assess ease of application, wear time, ease of removal, durability and patient comfort. An observation is made that wound care is complex and health professionals require a knowledge and understanding of the wound healing process, pain, dressing products, asepsis, microbiology, pharmacology, psychosocial factors, and ethics, and should possess good communication skills. A conclusion is made that the 50 patient evaluation demonstrates the flexibility of the Allevyn Gentle Border Lite, which allows for a secure fit, provides active fluid management in its control of exudates, may be applied to patients with fragile skin, thereby avoiding the need for secondary retention, and may be used on difficult-to-dress areas.

Effectiveness of topical application of amino acids to chronic wounds: a prospective observational study.

OBJECTIVE: To evaluate whether the topical application of an amino acid dressing, Vulnamin, aids the management of chronic wounds. METHOD: A total of 160 patients with non-infected cutaneous chronic wounds were recruited. Before treatment, wound size was assessed using digital planimetry. Treatment lasted for a maximum of six weeks. Wound area measurements were repeated two and six weeks after starting treatment. RESULTS: There was a significant reduction in the mean wound area after two weeks (7.4 +/- 8.7cm2) and six weeks (4.6 +/- 6.3cm2) of treatment, when compared with baseline (11.2 +/- 12.1cm2, p<0.01). At the final follow up, 23% of patients (n=36) healed and 34% (n=54) achieved a greater than 60% reduction in wound size. Seventy-six per cent (n=120) achieved positive outcomes (defined as a greater than 40% reduction in the ulcer size). CONCLUSION: Although further investigations on the potential effects of this product on chronic wound healing are required, these data suggest it may promote healing in venous, pressure and diabetic ulcers.

Human skin wounds: a major and snowballing threat to public health and the economy.

ABSTRACT In the United States, chronic wounds affect 6.5 million patients. An estimated excess of US$25 billion is spent annually on treatment of chronic wounds and the burden is rapidly growing due to increasing health care costs, an aging population and a sharp rise in the incidence of diabetes and obesity worldwide. The annual wound care products market is projected to reach $15.3 billion by 2010. Chronic wounds are rarely seen in individuals who are otherwise healthy. In fact, chronic wound patients frequently suffer from "highly branded" diseases such as diabetes and obesity. This seems to have overshadowed the significance of wounds per se as a major health problem. For example, NIH's Research Portfolio Online Reporting Tool (RePORT; http://report.nih.gov/), directed at providing access to estimates of funding for various disease conditions does list several rare diseases but does not list wounds. Forty million inpatient surgical procedures were performed in the United States in 2000, followed closely by 31.5 million outpatient surgeries. The need for post-surgical wound care is sharply on the rise. Emergency wound care in an acute setting has major significance not only in a war setting but also in homeland preparedness against natural disasters as well as against terrorism attacks. An additional burden of wound healing is the problem of skin scarring, a $12 billion annual market. The immense economic and social impact of wounds in our society calls for allocation of a higher level of attention and resources to understand biological mechanisms underlying cutaneous wound complications.

The resource costs of wound care in Bradford and Airedale primary care trust in the UK.

OBJECTIVE: To estimate the resource costs of providing wound care for the 488,000 catchment population of the Bradford and Airedale primary care trust (PCT). METHOD: A wound survey was carried out over a one-week period in March 2007 covering three hospitals in two acute trusts, district nurses, nursing homes and residential homes within the geographical area defined by the PCT. The survey included information on the frequency of dressing change, treatment time and district nurse travel time. The resource costs of wound care in the PCT were estimated by combining this information with representative costs for the UK National Health Service and information on dressing spend. RESULTS: Prevalence of patients with a wound was 3.55 per 1000 population. The majority of wounds were surgical/trauma (48%), leg/foot (28%) and pressure ulcers (21%). Prevalence of wounds among hospital inpatients was 30.7%. Of these, 11.6% were pressure ulcers, of which 66% were hospital-acquired. The attributable cost of wound care in 2006-2007 was pounds 9.89 million: pounds 2.03 million per 100,000 population and 1.44% of the local health-care budget. Costs included pounds 1.69 million spending on dressings, 45.4 full-time nurses (valued at pounds 3.076 million) and 60-61 acute hospital beds (valued at pounds 5.13 million). CONCLUSION: The cost of wound care is significant. The most important components are the costs of wound-related hospitalisation and the opportunity cost of nurse time. The 32% of patients treated in hospital accounted for 63% of total costs. Putting in place care pathways to avoid hospitalisation and avoiding the development of hospital-acquired pressure ulcers and other wound complications are important ways to reduce costs. DECLARATION OF INTEREST: John Posnett is an employee of Smith & Nephew.

Our experience with a "homemade" vacuum-assisted closure system.

BACKGROUND: Negative-pressure therapy for the closure of wounds, a technique to accelerate secondary wound healing, is clinically available as the V.A.C. system (KCI Inc, San Antonio, TX, U.S.A.). Budgetary considerations in our institution precluded widespread use of the expensive V.A.C. system in routine cases. OBJECTIVES: To develop a less expensive comparably effective dressing, based on the same principles. METHODS: We used our "homemade" system to treat 15 patients with appropriate complex wounds. Their hospital charts were reviewed and assessed retrospectively. Cost analysis was performed comparing our dressing with the V.A.C. system. RESULTS: Our homemade negative-pressure wound treatment system obtained results similar to what one could expect with the V.A.C. system in all parameters. Complications encountered were few and minor. Cost per day using our negative-pressure system for a 10 cm2 wound is about U.S. $1, as compared to U.S. $22, utilizing the V.A.C. system. CONCLUSIONS: Our homemade negative-pressure system proved to be a good cost-effective treatment for wound closure in hospitalized patients, yielding results comparable to those of the more expensive V.A.C. system.