In reply to the letter to the editor regarding "Comparison of a twin interlocking derotation and compression screw cephalomedullary nail (InterTAN) with a single screw derotation cephalomedullary nail (proximal femoral nail antirotation): a systematic review and meta-analysis for intertrochanteric fractures".

BACKGROUND: Intertrochanteric hip fractures are common and devastating injuries, especially for the elderly. Surgical treatment is the optimal strategy for managing intertrochanteric fractures as it allows early rehabilitation and functional recovery. The relative effects of internal fixation strategies for intertrochanteric fracture after operation remain limited to relatively small studies which create uncertainty in attempts to establish evidence-based best practice. METHODS: We conducted a systematic review and meta-analysis of randomised controlled trials (RCTs) and observational studies to assess the clinical effectiveness of two commonly used intramedullary devices: a twin-screw integrated cephalomedullary nail (InterTAN) versus a single-screw cephalomedullary nail (proximal femoral nail antirotation) in patients with intertrochanteric fractures. The following outcomes were considered: revisions, implant-related failures, non-unions, pain, Harris hip score and intra-operative outcomes. Odds ratios or mean differences with 95% confidence intervals in brackets are reported. RESULTS: Six studies met the inclusion criteria: two randomised controlled trials and four observational studies enrolling 970 patients with a mean age of 77 years and 64% of patients being female. There was a statistically significant difference (p value < 0.05) for revisions OR 0.27 (0.13-0.56), implant-related failures OR 0.16 (0.09-0.27) and proportion of patients complaining of pain OR 0.50 (0.34-0.74). There was no difference in non-unions and Harris hip score (p value > 0.05). There was a significant difference in blood loss and fluoroscopy usage in favour of PFNA, while no difference in operating times was observed between the two devices. CONCLUSIONS: Our meta-analysis suggests that a twin-screw integrated cephalomedullary nail (InterTAN) is clinically more effective when compared to a single-screw cephalomedullary nail proximal femoral nail antirotation resulting in fewer complications, fewer revisions and fewer patients complaining of pain. No difference has been established regarding non-unions and Harris hip score. Intra-operative outcomes favour PFNA with less blood loss and fluoroscopy usage. Further studies are warranted to explore the cost-effectiveness of these and other implants in managing patients with intertrochanteric fractures.

Early Economic Analysis of Robotic-Assisted Unicondylar Knee Arthroplasty May Be Cost Effective in Patients with End-Stage Osteoarthritis.

Unicondylar knee arthroplasty (UKA), as an alternative to total knee arthroplasty (TKA), has been shown to be an effective option for patients with single-compartment end-stage knee osteoarthritis. Implant survival is contingent upon proper alignment, which has been improved with the advent of robotic-assisted surgery (r-UKA), but whether this outweighs the increased cost of the robotic-assist device has not been analyzed in the literature. The purpose of this study was to investigate the mid-term cost-effectiveness of r-UKA compared with UKA with traditional instrumentation (t-UKA) in the United States. A cost-effectiveness analysis using a four-state Markov model was performed using data from the 2018 National Joint Registry of England and Wales and a retrospective multicenter, cohort study on a cohort of 65-year-old patients having undergone r-UKA. The main outcome was cost per revision avoided and sensitivity analyses were conducted to evaluate the impact of using different model assumptions on the results. The Markov model illustrated that the benefit derived from r-UKA versus t-UKA was beneficial from a payer's perspective. The estimated incremental cost-effectiveness ratio (ICER) was $14,737 per revision avoided in a facility seeing 100 patients a year. Case volume was shown to be the primary variable affecting cost-effectiveness, with the value of r-UKA directly increasing with higher case volumes. Cost-effectiveness analyses demonstrated that the use of r-UKA is an effective alternative to t-UKA in patients with single-compartment knee osteoarthritis. While this study could benefit from longer follow-up clinical studies to illustrate the benefits of r-UKAs beyond the current 2 years time horizon, r-UKAs remained cost-effective, even after investigating several different assumptions.

Single-use negative pressure wound therapy reduces costs in closed surgical incisions: UK and US economic evaluation.

OBJECTIVE: Single-use negative pressure wound therapy (sNPWT) following closed surgical incisions has a demonstrable effect in reducing surgical site complications (SSC). However, there is little health economic evidence to support its widespread use. We sought to evaluate the cost-effectiveness of sNPWT compared with standard care in reducing SSCs following closed surgical incisions. METHOD: A decision analytic model was developed to explore the total costs and health outcomes associated with the use of the interventions in patients following vascular, colorectal, cardiothoracic, orthopaedic, C-section and breast surgery from the UK National Health Service (NHS) and US payer perspective over a 12-week time horizon. We modelled complications avoided (surgical site infection (SSI) and dehiscence) using data from a recently published meta-analysis. Cost data were sourced from published literature, NHS reference costs and Centers for Medicare and Medicaid Services. We conducted subgroup analysis of patients with diabetes, an American Society of Anesthesiologists (ASA) score ≥3 and body mass index (BMI) ≥30kg/m2. A sensitivity analysis was also conducted. RESULTS: sNPWT resulted in better clinical outcomes and overall savings of £105 per patient from the UK perspective and $637 per patient from the US perspective. There were more savings when higher-risk patients with diabetes, or a BMI ≥30kg/m2 or an ASA≥3 were considered. We conducted both one-way and probabilistic sensitivity analysis, and the results suggested that this conclusion is robust. CONCLUSION: Our findings suggest that the use of sNPWT following closed surgical incisions saves cost when compared with standard care because of reduced incidence of SSC. Patients at higher risk should be targeted first as they benefit more from sNPWT. This analysis is underpinned by strong and robust clinical evidence from both randomised and observational studies.

Direct and indirect economic burden associated with rotator cuff tears and repairs in the US.

OBJECTIVE: This retrospective study examined treatment characteristics and the economic burden associated with rotator cuff tears (RCT) and rotator cuff repairs (RCR). Additionally, this study aimed to explore the economic implications associated with delayed surgical intervention. METHODS: Adult RCT patients meeting eligibility criteria were identified from 1/1/2013-6/30/2017 using the IBM Watson Health MarketScan Commercial database. Patients with incident RCR within 12 months post-index and 12 months continuous enrollment after the RCR date were also analyzed. Early surgery was defined as RCR within 6 months and 1 month from the partial-thickness tear and full-thickness tear diagnoses, respectively. Patient characteristics, all-cause direct costs (plan paid and patient out-of-pocket), RCT-related costs, pre-surgical costs, post-surgical costs, and healthcare resource utilization were reported by RCT type. Attributable indirect costs, absenteeism and short-term disability (STD), were also estimated. RESULTS: 102,488 RCT patients were identified (partial-thickness tears: 46,856 [45.7%]; full-thickness tears: 55,632 [54.3%]). Fifty per cent RCT patients underwent RCR within 12-months of diagnosis. Full-thickness RCT patients had an average total baseline (one year pre-diagnosis) and post-index costs of $17,096 and $32,110, respectively. Similarly, partial thickness patients had baseline costs of $16,385 and post-index costs of $27,017. Mean all-cause annual post-surgery costs were $34,086 for patients with partial-thickness tears and $34,249 for patients with full-thickness tears, of which 40% and 38% of costs were RCT-related, respectively. Productivity losses due to absenteeism and STD in the 12-month post-surgery period averaged $5843 and $4493, respectively, for partial-thickness tear patients and $5770 and $4382, respectively, for full-thickness tear patients. Average additional spending per delayed surgical patient between diagnosis and surgery was $8524 and $3213 (both p <0.001) for partial- and full-thickness tear patients, respectively. CONCLUSIONS: This exploratory analysis indicates considerable RCT and RCR economic burden to the healthcare system. High healthcare utilization and costs highlight the importance of efficiently managing patients with RCT diagnosis. Data also suggest that early surgical intervention may be economically beneficial if surgical intervention is anticipated post-RCT.

Cost-effectiveness analysis of Coblation versus mechanical shaver debridement in patients following knee chondroplasty.

BACKGROUND: To compare costs and outcomes following knee chondroplasty with Coblation versus mechanical shaver debridement (MSD) in patients with grade III articular cartilage lesions of the knee. METHODS: A decision-analytic model was developed to compare costs and outcomes of the two methods from a US payer perspective. We used published clinical data from a single-center randomized clinical trial (RCT) designed to compare outcomes between Coblation and MSD in patients with grade III articular cartilage lesions of the medial femoral condyle. Following primary knee chondroplasty, patients experienced either treatment success (no additional surgery required) or required a revision over the 4 year follow-up period. Costs associated with the initial chondroplasty, physical therapy sessions through the 6 week postoperative period, and revision rates at 4 years post-surgery were estimated using 2018 US Medicare Physician Fee Schedule. Sensitivity analyses including a 10 year time horizon and threshold analyses were performed to test the robustness of the model. RESULTS: The estimated total cost per patient was $4614 and $7886 for Coblation and MSD, respectively, resulting in cost-savings of $3272 in favor of Coblation, making it a dominant strategy because of lower costs and improved clinical outcomes. Threshold analysis showed that Coblation remained dominant even when revision rates were assumed to increase from the base case rate of 14-66%. Sensitivity analyses showed that cost-saving results were insensitive to variations in revision rates, number of physical therapy sessions and the time horizon used. CONCLUSION: Coblation chondroplasty is a cost-saving procedure compared with MSD in the treatment of patients with grade III articular cartilage lesions of the knee.

Early Economic Evaluation Demonstrates That Noncomputerized Tomography Robotic-Assisted Surgery Is Cost-Effective in Patients Undergoing Unicompartmental Knee Arthroplasty at High-Volume Orthopaedic Centres.

BACKGROUND: For over fifty years, unicompartmental knee arthroplasty (UKA) has been used to treat single-compartment osteoarthritis of the knee and is considered a safe alternative to total knee arthroplasty (TKA). The development and use of robotic-assisted surgery (r-UKA) have made the execution of the procedure more precise, and various studies have reported improved radiographic outcomes and implant survival rates; however, its cost-effectiveness is unknown. This study aimed at assessing the cost-effectiveness of noncomputerized tomography (non-CT) r-UKA compared to the traditional unicompartmental knee arthroplasty (t-UKA) method in patients with unicompartmental knee osteoarthritis from the UK payer's perspective. METHODS: We developed a 5-year four-state Markov model to evaluate the expected costs and outcomes of the two strategies in patients aged 65 years. Failure rates for t-UKA were taken from the British National Joint Registry while data for non-CT r-UKA were obtained from a 2-year observational study. Cost was obtained from the NHS reference cost valued at 2018/19 GBP£, and a discount rate of 3.5% was applied to both costs and benefits. RESULTS: For a high-volume orthopaedic centre that performs 100 UKA operations per year, non-CT r-UKA was more costly than t-UKA but offered better clinical outcomes, and the estimated cost per QALY was £2,831. The results were more favourable in younger patients aged less than 55 and sensitive to case volumes and follow-up period. CONCLUSION: Non-CT r-UKA is cost-effective compared with t-UKA over a 5-year period. Results are dependent on case volumes and follow-up period and favour younger age groups.

Economic burden of surgical site infections within the episode of care following joint replacement.

BACKGROUND: Recent policy initiatives, including Bundled Payments for Care Improvement (BPCI) Initiative by the Centers for Medicare and Medicaid Health Services (CMS), encourage healthcare providers to manage the total episode of care, rather than just the surgical episode. Surgical site infections (SSI) following total joint replacement result in preventable morbidity and suffering for patients and excess healthcare utilization for healthcare providers. This study sought to estimate the additional resources associated with SSIs within the 90-day episode of care following hip and knee joint replacement. METHODS: Using the 2013 Nationwide Readmissions Database (NRD), healthcare resource utilization was compared between propensity score matched patient groups with and without SSI-related readmissions within the 90-day episode of care following total joint replacement. RESULTS: Surgical site infections were associated with significantly longer hospital length of stay and increased costs following hip and knee joint replacement procedures. Generalized estimating equation regression results confirmed that additional costs associated with SSIs following both cohorts were significant, with additional hospital length of stay and costs following total hip and knee replacement procedures ranging from 4.9 to 5.2 days and $12,689 to $12,890, respectively. CONCLUSION: Surgical site infections following total joint replacement account for significant additional healthcare resource use within the 90-day episode of care.

Cost-effectiveness analysis of single use negative pressure wound therapy dressings (sNPWT) compared to standard of care in reducing surgical site complications (SSC) in patients undergoing coronary artery bypass grafting surgery.

BACKGROUND: There is a growing interest in using negative pressure wound therapy in closed surgical incision to prevent wound complications which continue to persist following surgery despite advances in infection measures. OBJECTIVES: To estimate the cost-effectiveness of single use negative pressure wound therapy (sNPWT) compared to standard of care in patients following coronary artery bypass grafting surgery (CABG) procedure to reduce surgical site complications (SSC) defined as dehiscence and sternotomy infections. METHOD: A decision analytic model was developed from the Germany Statutory Health Insurance payer's perspective over a 12-week time horizon. Baseline data on SSC, revision operations, length of stay, and readmissions were obtained from a prospective observational study of 2621 CABG patients in Germany. Effectiveness data for sNPWT was taken from a randomised open label trial conducted in Poland which randomised 80 patients to treatment with either sNPWT or standard care. Cost data (in Euros) were taken from the relevant diagnostic related groups and published literature. RESULTS: The clinical study reported an increase in wounds that healed without complications 37/40 (92.5%) in the sNPWT compared to 30/40 (75%) patients in the SC group p = 0.03. The model estimated sNPWT resulted in 0.989 complications avoided compared to 0.952 and the estimated quality adjusted life years were 0.8904 and 0.8593 per patient compared to standard care. The estimated mean cost per patient was €19,986 for sNPWT compared to €20,572 for SC resulting in cost-saving of €586. The findings were robust to a range of sensitivity analyses. CONCLUSION: The sNPWT can be considered a cost saving intervention that reduces surgical site complications following CABG surgery compared to standard care. We however recommend that additional economic studies should be conducted as new evidence on the use of sNPWT in CABG patients becomes available to validate the results of this economic analysis.

Comparing the costs and outcomes of an integrated twin compression screw (ITCS) nail with standard of care using a single lag screw or a single helical blade cephalomedullary nail in patients with intertrochanteric hip fractures.

BACKGROUND: Surgical treatment is the optimal strategy for managing intertrochanteric fractures as it allows for early rehabilitation and functional recovery. The purpose of the study was to assess the cost-effectiveness of commonly used cephalomedullary nails for the treatment of unstable intertrochanteric hip fractures. METHODS: A decision analytic model was developed from a US payer's perspective using clinical data from a pairwise meta-analysis of randomised controlled trials (RCTs) and comparative observational studies comparing the integrated twin compression screw (ITCS) nail versus two single-screw or blade cephalomedullary nails [single lag screw (SLS) nail and single helical blade (SHB) nail]. The model considered a cohort of 1000 patients with a mean age of 76, as reported in the clinical studies over a 1-year time period. Cost data was obtained from the Center for Medicare and Medicaid Services website and published literature and adjusted for inflation. One-way and probabilistic sensitivity analyses were conducted to assess the effect of uncertainty in model parameters on model conclusions. RESULTS: The model estimated 0.546 quality-adjusted life years (QALYs) and 0.78 complications avoided by using the ITCS nail and 0.455 QALYs and 0.67 complications avoided for the standard of care, using SLS or SHB nails. The cost per patient was $34,336 for patients treated with an ITCS nail and $37,036 for patients treated with the standard of care respectively, resulting in a cost saving of $2700 in favour of the ITCS nail. More savings were observed when the ITCS nail was compared to the SHB ($3280 per patient) and SLS ($1652 per patient). The findings were robust to a range of both one-way and the probabilistic sensitivity analyses. CONCLUSION: In conclusion, the ITCS nail can be considered a cost saving intervention in patients undergoing intertrochanteric fracture fixation with an intramedullary device. Clinicians and policy makers should be encouraged to adopt healthcare technologies such as ITCS that will help them to provide quality healthcare despite falling budgets.

Comparison of a twin interlocking derotation and compression screw cephalomedullary nail (InterTAN) with a single screw derotation cephalomedullary nail (proximal femoral nail antirotation): a systematic review and meta-analysis for intertrochanteric fractures.

BACKGROUND: Intertrochanteric hip fractures are common and devastating injuries especially for the elderly. Surgical treatment is the optimal strategy for managing intertrochanteric fractures as it allows early rehabilitation and functional recovery. The relative effects of internal fixation strategies for intertrochanteric fracture after operation remain limited to relatively small studies which create uncertainty in attempts to establish evidence-based best practice. METHODS: We conducted a systematic review and meta-analysis of randomised controlled trials (RCTs) and observational studies to assess the clinical effectiveness of two commonly used intramedullary devices: a twin screw integrated cephalomedullary nail (InterTAN) versus a single screw cephalomedullary nail (proximal femoral nail antirotation) in patients with intertrochanteric fractures. The following outcomes were considered: revisions, implant-related failures, non-unions, pain, Harris Hip Score and intraoperative outcomes. Odds ratios or mean differences with 95% confidence intervals in brackets are reported. RESULTS: Six studies met the inclusion criteria, two randomised controlled trials and four observational studies enrolling 970 patients with mean age of 77 years, and 64% of patients were female. There was a statistically significant difference (p value < 0.05) for revisions OR 0.27 (0.13 to 0.56), implant-related failures OR 0.16 (0.09 to 0.27) and proportion of patients complaining of pain OR 0.50 (0.34 to 0.74). There was no difference in non-unions and Harris Hip Score (p value > 0.05). There was a significant difference in blood loss and fluoroscopy usage in favour of PFNA, whilst no difference in operating times were observed between the two devices. CONCLUSIONS: Our meta-analysis suggests that a twin screw integrated cephalomedullary nail InterTAN is clinically more effective when compared to a single screw cephalomedullary nail proximal femoral nail antirotation resulting in fewer complications, fewer revisions and fewer patients complaining of pain. No difference has been established regarding non-unions and Harris Hip Score. Intraoperative outcomes favour PFNA with less blood loss and fluoroscopy usage. Further studies are warranted to explore the cost-effectiveness of these and other implants in managing patients with intertrochanteric fractures.

Cost-effectiveness Analysis of Silver Delivery Approaches in the Management of Partial-thickness Burns.

INTRODUCTION: Burn injury is a common type of traumatic injury that causes considerable morbidity and mortality, resulting in about 30,000 admissions annually in specialist burn centers and costing around $1 billion per year in the United States. One percent silver sulfadiazine has been utilized widely in the management of burns and newer silver dressings are on the market, including nanocrystalline silver dressings, silver-impregnated hydrofiber dressings, and silver-impregnated foam dressings. OBJECTIVE: This study sought to determine the cost effectiveness of the newer silver dressings using clinical data from an indirect treatment comparison using silver sulfadiazine as the baseline. MATERIALS AND METHODS: A decision analytic model was developed from a US payer's perspective for burn patients with a total body surface area of < 20%. Outcomes were length of stay, infections and incidence of surgical procedures, quality adjusted life years (QALYs), and cost. RESULTS: The meta-analysis reported a statistically significant reduction in length of hospital stay and clinically important reductions in infections and incidence of surgical procedures in favor of the silver barrier dressing compared with other silver dressings. The estimated QALYs were 0.970 versus 0.969 versus 0.969 and mean cost per patient was $15,892, $23,799, and $24,269 for the nanocrystalline silver dressing, silver-impregnated hydrofiber dressing, and silver-impregnated foam dressing, respectively. The analysis showed the nanocrystalline silver dressing to be a dominant strategy (less costly with better outcomes). These findings were robust to a range of sensitivity analyses. CONCLUSIONS: According to data from an indirect treatment comparison, this analysis suggests that nanocrystalline silver dressing is the most cost-effective silver delivery system. Prospective head-to-head research on the costs and outcomes of these silver delivery systems in this patient population is necessary to validate the results of this economic evaluation.

Assessment of Risk Factors Associated With Hospital-Acquired Pressure Injuries and Impact on Health Care Utilization and Cost Outcomes in US Hospitals.

Hospital-acquired pressure injuries (HAPI) are a societal burden and considered potentially preventable. Data on risk factors and HAPI burden are important for effective prevention initiatives. This study of the 2009-2014 US Premier Healthcare Database identified HAPI risk factors and compared outcomes after matching HAPI to non-HAPI patients. The cumulative incidence of HAPI was 0.28% (47 365 HAPI among 16 967 687 total adult inpatients). Among the matched sample of 110 808 patients (27 702 HAPI), the strongest risk factors for HAPI were prior PI (odds ratio [OR] = 12.52, 95% confidence interval [CI] = 11.93-13.15), prior diabetic foot ulcer (OR = 3.43, 95% CI = 3.20-3.68), and malnutrition (OR = 3.11, 95% CI = 3.02-3.20). HAPI patients had longer adjusted length of stay (3.7 days, P < .0001), higher total hospitalization cost ($8014, P < .0001), and greater odds of readmissions through 180 days (OR = 1.60, 95% CI = 1.55-1.65). This study demonstrates how big data may help quantify HAPI burden and improve internal hospital processes by identifying high-risk patients and informing best practices for prevention.

Silver delivery approaches in the management of partial thickness burns: A systematic review and indirect treatment comparison.

Silver-containing products play an important role in the management of burn wound infections. We sought to compare the efficacy of commonly used silver delivery approaches including nanocrystalline silver, silver-impregnated hydrofiber dressing, and silver-impregnated foam dressing as the main products in the management of partial thickness burns. A systematic review was performed by searching PubMed, EMBASE, Cochrane, and other databases to identify relevant randomized controlled trials and observational studies. Due to the paucity of direct head-to-head trials, an indirect treatment comparison was performed. The use of nanocrystalline silver was associated with a statistically significant reduction in length of stay when compared to silver-impregnated hydrofiber dressing (p = 0.027) and a shorter time to healing when compared to silver-impregnated foam dressing (p = 0.0328). There were no statistically significant differences in infection rates and surgical procedures between nanocrystalline silver, silver-impregnated hydrofiber dressing, and silver-impregnated foam dressing; however, nanocrystalline silver was found to be the most beneficial for all the outcomes, including infection rates and surgical procedures, according to the Monte Carlo simulation method. In conclusion, current evidence from the published literature suggests that where the clinical and microbiological priority is to get in control of infection quickly it would seem prudent to use the most potent silver delivery system, which is nanocrystalline silver. Nanocrystalline silver may offer both clinical and economic benefits compared to alternative treatments in the management of patients with mixed burns that are at high risk of infection.

Cost-effectiveness analysis of single-use negative pressure wound therapy dressings (sNPWT) to reduce surgical site complications (SSC) in routine primary hip and knee replacements.

We sought to evaluate the cost-effectiveness of single-use negative pressure wound therapy in patients undergoing primary hip and knee replacements using effectiveness data from a recently completed non-blinded randomized controlled trial. A decision analytic model was developed from UK National Health Service perspective using data from a single-centre trial. 220 patients were randomized to treatment with either single-use negative pressure wound therapy or standard care i.e., film dressings of clinician choice and followed for 6 weeks. Outcomes included dressing changes, length of stay, surgical site complications, cost and quality adjusted life years. The randomized controlled trial reported a reduction in dressing changes (p = 0.002), SSC (p = 0.06) and LOS (p = 0.07) in favor of single-use negative pressure wound therapy compared with standard care. The model estimated 0.116 and 0.115 QALY gained, 0.98 and 0.92 complications avoided for single-use negative pressure wound therapy and standard care, respectively. The cost/patient was £5,602 ($7,954) and £6,713 ($9,559) for single-use negative pressure wound therapy and standard care respectively resulting in cost-saving of £1,132 ($1,607) in favor of single-use negative pressure wound therapy. Greater savings were observed in subgroups of higher risk patients with BMI ≥ 35 and ASA ≥ 3 i.e., £7,955 ($11,296) and £7,248 ($10,293), respectively. The findings were robust to a range of sensitivity analyses. In conclusion, single-use negative pressure wound therapy can be considered a cost saving intervention to reduce surgical site complications following primary hip and knee replacements compared with standard care. Providers should consider targeting therapy to those patients at elevated risk of surgical site complications to maximize efficiency.

A systematic review and meta-analysis of clinical outcomes associated with nanocrystalline silver use compared to alternative silver delivery systems in the management of superficial and deep partial thickness burns.

OBJECTIVE: The purpose of this systematic review and meta-analysis was to assess the clinical effectiveness of nanocrystalline silver compared to alternative silver delivery systems (silver sulphadiazine [SSD] and silver nitrate) in adults and children with superficial and deep partial thickness burns. METHODS: PubMed, EMBASE, Cochrane and other databases were searched to identify relevant randomised controlled trials and observational studies. RESULTS: Eight studies that assessed both nanocrystalline silver and SSD and one study that compared nanocrystalline silver vs. silver nitrate were identified. Nanocrystalline silver compared to SSD/silver nitrate was associated with a statistically significant reduction in infections (odds ratio [OR] 0.21, 95% CI 0.07-0.62, p=0.005), length of stay in hospital (mean difference -4.74 (95% CI -5.79 to -3.69, p=0.00001) and surgical procedures (OR 0.40, 95% CI 0.28-0.56, p=0.00001). Three studies that reported on pain had lower pain scores with nanocrystalline silver use than with SSD/silver nitrate; a high level of heterogeneity precluded pooling estimates. CONCLUSION: This comprehensive systematic review and meta-analysis of the available evidence suggest that the use of nanocrystalline silver dressings results in shorter length of stay in hospital, less pain, fewer surgical procedures and reduced infection rates compared to silver sulphadiazine/silver nitrate.

A Retrospective Comparison of the Performance of Two Negative Pressure Wound Therapy Systems in the Management of Wounds of Mixed Etiology.

Objective: Negative pressure wound therapy (NPWT) has been shown to be effective in the management of chronic and surgical wounds. The two most widely used modalities of NPWT are vacuum-assisted closure (V.A.C.) therapy (KCI, Inc., San Antonio, Texas) and the RENASYS NPWT system (Smith & Nephew, Hull, United Kingdom). This evaluation compares the performance of the two systems in the management of wounds of mixed etiology. Approach: The evaluation is based on retrospective evaluation of more than 1,000 patients treated with NPWT in a community setting in Canada. Results: Patients were well matched according to their baseline characteristics, including age, sex, and wound characteristics. No difference was seen between the two NPWT systems in terms of the percentage of patients reaching their predetermined treatment goal (90.0% and 93.6%, respectively). The time taken to achieve the treatment goal (median 8 weeks in both groups), percentage reduction in wound area (64.2% and 65.3%, respectively), and weekly rate of reduction in wound area (9.7% and 9.4%, respectively; p = 0.156). Innovation: This evaluation is believed to comprise the largest cohort of patients treated with NPWT published to date and is one of the few studies that have attempted to provide a direct comparison of the performance of alternative NPWT systems. Conclusion: Findings suggest that there are no clinically meaningful differences in the efficacy and performance of the two most widely used NPWT devices, based on consideration of a number of wound outcomes.

An Overview of Clinical and Health Economic Evidence Regarding Porcine Small Intestine Submucosa Extracellular Matrix in the Management of Chronic Wounds and Burns.

Small intestine submucosa (SIS) has been extensively evaluated in preclinical models and developed into commercially produced medical technologies intended for use in several different indications. The SIS extracellular matrix cellular and/or tissue-based product is a commercially available, porcine-derived SIS dressing. The purpose of this review was to consider the role of the SIS dressing in the management of chronic wounds and burns. Using a variety of search terms from the literature to describe the SIS dressing, the following databases were searched: PubMed, York Centre for Reviews and Dissemination database, National Health Service Economic Evaluation database, Health Technology Assessment database, and the Cochrane Library. The search identified 78 studies of which 21 met the inclusion/exclusion criteria. Of those, 14 involved chronic wounds, 3 described the management of burn wounds, and 4 were economic evaluations. The wide variety of comparative treatments and outcomes studied precluded the use of meta-analysis techniques. Study results show SIS dressings may improve outcomes in chronic wounds and cost less than several alternative biological wound treatments. Studies to examine their efficacy in burn wound management are warranted.

Estimating the Clinical Outcomes and Cost Differences Between Standard Care With and Without Cadexomer Iodine in the Management of Chronic Venous Leg Ulcers Using a Markov Model.

Chronic venous leg ulcers (VLUs) affect up to 1% of the adult population in the developed world and present a significant financial and resource burden to health care systems. Cadexomer iodine (CI) is an antimicrobial dressing indicated for use in chronic exuding wounds. The aim of this study was to estimate the cost utility of using CI + standard care (SC) - ie, high compression multicomponent bandaging including debridement - compared with SC alone in the management of chronic (>6 months' duration) VLUs from a payer's perspective. A Markov model was constructed to evaluate the cost and clinical benefits (healing and decreased infection rates) of the 2 treatment modalities over a 1-year period using data from 4 randomized, controlled clinical studies (RCTs) included in a recent Cochrane review and cost data from a recently published economic evaluation of VLUs. Costs were calculated using 2014 United States dollars; wound outcomes in- cluded complete healing in 212 patients reported in the Cochrane meta-analysis and quality-adjusted life years (QALYs), with utility values obtained from 200 patients with VLUs calculated using standard gamble. Treatment with CI over 1 year was $7,259 compared to $7,901 for SC. This resulted in a cost savings of $643/patient in favor of CI compared with SC. More patients treated with CI (61%) had their wounds healed compared to 54% treated with SC. Furthermore, patients treated with CI+SC experienced 6 additional ulcer-free weeks compared to persons treated with SC alone (ie, 25 ulcer- free weeks compared to 19 ulcer-free weeks, respectively). Overall, CI resulted in 0.03 more QALYs (ie, 0.86 QALYs compared to 0.83 for SC). The use of CI in addition to SC compared to SC alone over 52 weeks resulted in more wounds healed and more QALYs along with a decrease of overall costs The results of this study suggest CI is cost effective com- pared to SC alone in the management of patients with chronic VLUs. Prospective, controlled clinical studies are needed to elucidate the effect and cost effectiveness of CI on VLUs with and without signs of infection as compared to SC, other antiseptics, and more advanced topical treatment modalities.

Use of a portable, single-use negative pressure wound therapy device in home care patients with low to moderately exuding wounds: a case series.

Negative pressure wound therapy (NPWT) is widely used in the management of acute and chronic wounds. The purpose of this 8-week study was to evaluate outcomes of using a new canisterless, portable, single-use NPWT system in patients with wounds treated in a Canadian community healthcare setting. The device is designed to provide negative pressure at 80±20 mm Hg, 24 hours a day of continuous usage, for a maximum wear time of 7 days. Data on wound outcomes, including exudate levels, wound appearance, and wound area, were collected weekly by a Registered Nurse as part of routine practice. When treatment was discontinued, patients and nurses were asked to rate their satisfaction with the device. Data from patients who had used a conventional NPWT device to manage their wounds were retrospectively abstracted from their medical records. In the prospective study, conducted between October 2011 and July 2012, 326 patients (median age=61 years; range 17-91 years) with wounds of mixed etiology (53 pressure ulcers, 21 venous leg ulcers, 16 diabetic foot ulcers, and 15 traumatic and 221 surgical wounds) were treated for a maximum of 8 weeks with the portable NPWT device. The majority of patients (228 out of 326; 68%) achieved complete wound closure within 8 weeks of treatment. The Kaplan-Meier estimate of median time to healing of all wounds was 9 weeks. The majority of patients (318 patients, 97%) reported they were pleased or satisfied with the dressing performance. Nurses indicated satisfaction with the dressing performance for all but two patients (99%). The majority (89%) of patients managed with conventional NPWT (n=539) had an open surgical wound with moderate or high levels of exudate. Healing rates in the portable and conventional NPWT group were similar (10% to 11% per week). Portable, single-use NPWT has the potential to deliver good wound outcomes in community care settings and simplify the use of negative pressure for nurses and patients. Additional research is needed to evaluate treatment efficacy and cost effectiveness.

Applying economic evaluation to public health interventions: the case of interventions to promote physical activity.

BACKGROUND: This paper explores the application of alternative approaches to economic evaluation of public health interventions, using a worked example of exercise referral schemes (ERSs). METHODS: Cost-utility (CUA) and cost-consequence analyses (CCA) were used to assess the cost-effectiveness of ERSs. For the CUA, evidence was synthesized using a decision analytic model that adopts a lifetime horizon and NHS/Personal Social Services perspective. Outcomes were expressed as incremental cost per quality-adjusted life-year (QALY). CCA was conducted from a partial-societal perspective, including health and non-healthcare costs and benefits. Outcomes were reported in natural units, such as cases of strokes or CHD avoided. RESULTS: Compared with usual care, the incremental cost per QALY of ERS is £20 876. Based on a cohort of 100 000 individuals, CCA estimates cost of ERS at £22 million to the healthcare provider and £12 million to participants. The benefits of ERS include additional 3900 people becoming physically active, 51 cases of CHD avoided, 16 cases of stroke avoided, 86 cases of diabetes avoided and a gain of ∼800 QALYs. CONCLUSIONS: CCA might provide greater transparency than CUA in reporting the outcomes of public health interventions and have greater resonance with stakeholders involved in commissioning these interventions.