Cost-effectiveness of laser Doppler imaging in burn care in the Netherlands

Background: Early accurate assessment of burn depth is important to determine the optimal treatment of burns. The method most used to determine burn depth is clinical assessment, which is the least expensive, but not the most accurate.Laser Doppler imaging (LDI) is a technique with which a more accurate (>95%) estimate of burn depth can be made by measuring the dermal perfusion. The actual effect on therapeutic decisions, cli

Cost-effectiveness of laser Doppler imaging in burn care in the Netherlands

textabstractBackground: Early accurate assessment of burn depth is important to determine the optimal treatment of burns. The method most used to determine burn depth is clinical assessment, which is the least expensive, but not the most accurate.Laser Doppler imaging (LDI) is a technique with which a more accurate (>95%) estimate of burn depth can be made by measuring the dermal perfusion. The actual effect on therapeutic decisions, cli

Psychometric Performance of the Stony Brook Scar Evaluation Scale and SCAR-Q Questionnaire in Dutch Children after Pediatric Surgery

Introduction: The growing population of survivors following pediatric surgery emphasizes the importance of long-term follow-up. The impact of surgical scars on daily life can be evaluated through patient-reported outcome measurements. The Stony Brook Scar Evaluation Scale (SBSES) and SCAR-Q questionnaire are two interesting instruments for this purpose. We evaluated their psychometric performance in Dutch children after pediatric surgery. Methods: After English–Dutch translation, we evaluated—following the COSMIN guidelines—the feasibility, reliability (internal and external), and validity (construct, criterion, and convergent) of the SBSES and SCAR-Q in Dutch patients &lt; 18 years old with surgical scars. Results: Three independent observers completed the SB for 100 children (58% boys, median age 7.3 (IQR 2.5–12.1) years) in whom surgery had been performed a median of 2.8 (0.5–7.9) years ago. Forty-six of these children (61% boys, median age 12.1 (9.3–16.2) years) completed the SCAR-Q. Feasibility and internal reliability (Cronbach’s alpha &gt; 0.7) was good for both instruments. For the SB, external reliability was poor to moderate (interobserver variability: ICC 0.46–0.56; intraobserver variability: ICC 0.74). For the SCAR-Q, external reliability was good (test–retest agreement: ICC 0.79–0.93). Validity tests (construct, criterion, and convergent) showed poor to moderate results for both instruments. Conclusions: The Dutch-translated SBSES and SCAR-Q showed good feasibility and internal reliability. External reliability and validity were likely affected by differences in conceptual content between the questionnaires. Combining them would provide insight in the impact of scars on patients. Implementation of these instruments in longitudinal follow-up programs could provide new insights into the long-term psychological outcome after pediatric surgery.</p

Burns to the head and neck: epidemiology and predictors of surgery

BACKGROUND: The face is a frequent site of burn, but prevalence rates vary and reports are often limited to one healthcare setting. We examined the incidence of facial burns in the Netherlands in Emergency Departments (ED), hospitals and burn centres. Additionally, we identified which patient, injury and burn-related characteristics were predictors of facial burns, facial surgery and facial reconstruction in burn centres. METHODS: A retrospective, observational study was conducted including data from the Dutch Injury Surveillance System, the National Hospital Discharge Register and burn centres in a 5-year period (2003-2007). RESULTS: Facial burn incidences per 100,000 were 15.1 for ED visits, 1.3 for hospital admissions and 1.4 for burn centre admissions. A total of 2691 patients were admitted to Dutch burn centres; 47.5% (n=1277) had facial burns of which 20.5% received primary facial surgery and 5.3% received facial reconstruction in follow-up. Predictors of facial burns and facial surgery were identified. Predictors of facial reconstructive surgery were burns to the neck (ventral), fire/flame burns and number of facial surgeries in the acute phase of the burn. CONCLUSIONS: One in five patients with facial burns admitted to a Dutch burn centre received primary facial surgery and 1 in 20 received facial reconstructive surgery within a follow-up of minimum 2 years

Burns to the head and neck:epidemiology and predictors of surgery

BACKGROUND: The face is a frequent site of burn, but prevalence rates vary and reports are often limited to one healthcare setting. We examined the incidence of facial burns in the Netherlands in Emergency Departments (ED), hospitals and burn centres. Additionally, we identified which patient, injury and burn-related characteristics were predictors of facial burns, facial surgery and facial reconstruction in burn centres. METHODS: A retrospective, observational study was conducted including data from the Dutch Injury Surveillance System, the National Hospital Discharge Register and burn centres in a 5-year period (2003-2007). RESULTS: Facial burn incidences per 100,000 were 15.1 for ED visits, 1.3 for hospital admissions and 1.4 for burn centre admissions. A total of 2691 patients were admitted to Dutch burn centres; 47.5% (n=1277) had facial burns of which 20.5% received primary facial surgery and 5.3% received facial reconstruction in follow-up. Predictors of facial burns and facial surgery were identified. Predictors of facial reconstructive surgery were burns to the neck (ventral), fire/flame burns and number of facial surgeries in the acute phase of the burn. CONCLUSIONS: One in five patients with facial burns admitted to a Dutch burn centre received primary facial surgery and 1 in 20 received facial reconstructive surgery within a follow-up of minimum 2 years

Topical treatment for facial burns

Background: Burn injuries are an important health problem. They occur frequently in the head and neck region. The face is the area central to a person's identity that provides our most expressive means of communication. Topical interventions are currently the cornerstone of treatment of burns to the face. Objectives: To assess the effects of topical interventions on wound healing in people with facial burns of any depth. Search methods: In December 2019 we searched the Cochrane Wounds Specialised Register; the Cochrane Central Register of Controlled Trials (CENTRAL); Ovid MEDLINE (including In-Process & Other Non-Indexed Citations); Ovid Embase and EBSCO CINAHL Plus. We also searched clinical trials registries for ongoing and unpublished studies, and scanned reference lists of relevant included studies as well as reviews, meta-analyses and health technology reports to identify additional studies. There were no restrictions with respect to language, date of publication or study setting. Selection criteria: Randomised controlled trials (RCTs) that evaluated the effects of topical treatment for facial burns were eligible for inclusion in this review. Data collection and analysis: Two review authors independently performed study selection, data extraction, risk of bias assessment and GRADE assessment of the certainty of the evidence. Main results: In this first update, we included 12 RCTs, comprising 507 participants. Most trials included adults admitted to specialised burn centres after recent burn injuries. Topical agents included antimicrobial agents (silver sulphadiazine (SSD), Aquacel-Ag, cerium-sulphadiazine, gentamicin cream, mafenide acetate cream, bacitracin), non-antimicrobial agents (Moist Exposed Burn Ointment (MEBO), saline-soaked dressings, skin substitutes (including bioengineered skin substitute (TransCyte), allograft, and xenograft (porcine Xenoderm), and miscellaneous treatments (growth hormone therapy, recombinant human granulocyte-macrophage colony-stimulating factor hydrogel (rhGMCS)), enzymatic debridement, and cream with Helix Aspersa extract). Almost all the evidence included in this review was assessed as low or very low-certainty, often because of high risk of bias due to unclear randomisation procedures (i.e. sequence generation and allocation concealment); lack of blinding of participants, providers and sometimes outcome assessors; and imprecision resulting from few participants, low event rates or both, often in single studies. Topical antimicrobial agents versus topical non-antimicrobial agents. There is moderate-certainty evidence that there is probably little or no difference between antimicrobial agents and non-antimicrobial agents (SSD and MEBO) in time to complete wound healing (hazard ratio (HR) 0.84 (95% confidence interval (CI) 0.78 to 1.85, 1 study, 39 participants). Topical antimicrobial agents may make little or no difference to the proportion of wounds completely healed compared with topical non-antimicrobial agents (comparison SSD and MEBO, risk ratio (RR) 0.94, 95% CI 0.68 to 1.29; 1 study, 39 participants; low-certainty evidence). We are uncertain whether there is a difference in wound infection (comparison topical antimicrobial agent (Aquacel-Ag) and MEBO; RR 0.38, 95% CI 0.12 to 1.21; 1 study, 40 participants; very low-certainty evidence). No trials reported change in wound surface area over time or partial wound healing. There is low-certainty evidence for the secondary outcomes scar quality and patient satisfaction. Two studies assessed pain but it was incompletely reported. Topical antimicrobial agents versus other topical antimicrobial agents. It is uncertain whether topical antimicrobial agents make any difference in effects as the evidence is low to very low-certainty. For primary outcomes, there is low-certainty evidence for time to partial (i.e. greater than 90%) wound healing (comparison SSD versus cerium SSD: mean difference (MD) –7.10 days, 95% CI –16.43 to 2.23; 1 study, 142 participants). There is very low-certainty evidence regarding whether topical antimicrobial agents make a difference to wound infection (RR 0.73, 95% CI 0.46 to 1.17; 1 study, 15 participants). There is low to very low-certainty evidence for the proportion of facial burns requiring surgery, pain, scar quality, adverse effects and length of hospital stay. Skin substitutes versus topical antimicrobial agents. There is low-certainty evidence that a skin substitute may slightly reduce time to partial (i.e. greater than 90%) wound healing, compared with a non-specified antibacterial agent (MD –6.00 days, 95% CI –8.69 to –3.31; 1 study, 34 participants). We are uncertain whether skin substitutes in general make any other difference in effects as the evidence is very low certainty. Outcomes included wound infection, pain, scar quality, adverse effects of treatment and length of hospital stay. Single studies showed contrasting low-certainty evidence. A bioengineered skin substitute may slightly reduce procedural pain (MD –4.00, 95% CI –5.05 to –2.95; 34 participants) and background pain (MD –2.00, 95% CI –3.05 to –0.95; 34 participants) compared with an unspecified antimicrobial agent. In contrast, a biological dressing (porcine Xenoderm) might slightly increase pain in superficial burns (MD 1.20, 95% CI 0.65 to 1.75; 15 participants (30 wounds)) as well as deep partial thickness burns (MD 3.00, 95% CI 2.34 to 3.66; 10 participants (20 wounds)), compared with antimicrobial agents (Physiotulle Ag (Coloplast)). Miscellaneous treatments versus miscellaneous treatments. Single studies show low to very low-certainty effects of interventions. Low-certainty evidence shows that MEBO may slightly reduce time to complete wound healing compared with saline soaked dressing (MD –1.7 days, 95% CI –3.32 to –0.08; 40 participants). In addition, a cream containing Helix Aspersa may slightly increase the proportion of wounds completely healed at 14 days compared with MEBO (RR 4.77, 95% CI 1.87 to 12.15; 43 participants). We are uncertain whether any miscellaneous treatment in the included studies makes a difference in effects for the outcomes wound infection, scar quality, pain and patient satisfaction as the evidence is low to very low-certainty. Authors' conclusions: There is mainly low to very low-certainty evidence on the effects of any topical intervention on wound healing in people with facial burns. The number of RCTs in burn care is growing, but the body of evidence is still hampered due to an insufficient number of studies that follow appropriate evidence-based standards of conducting and reporting RCTs

Economic burden of burn injuries in the Netherlands: A 3 months follow-up study

Introduction Burn care has rapidly improved in the past decades. However, healthcare innovations can be expensive, demanding careful choices on their implementation. Obtaining knowledge on the extent of the costs of burn injuries is an essential first step for economic evaluations within burn care. The objective of this study was to determine the economic burden of patients with burns admitted to a burn centre and to identify important cost categories until 3 months post-burn. Patients and methods A prospective cohort study was conducted in the burn centre of Maasstad Hospital Rotterdam, the Netherlands, including all patients with acute burn related injuries from August 2011 until July 2012. Total costs were calculated from a societal perspective, until 3 months post injury. Subgroup analyses were performed to examine whether the mean total costs per patient differed by age, aetiology or percentage total body surface area (TBSA) burned. Results In our population, with a mean burn size of 8%, mean total costs were €26,540 per patient varying from €742 to €235,557. Most important cost categories were burn centre days (62%), surgical interventions (5%) and work absence (20%). Flame burns were significantly more costly than other types of burns, adult patients were significantly more costly than children and adolescents and a higher percentage TBSA burned also corresponded to significantly higher costs. Discussion and conclusion Mean total costs of burn care in the first 3 months post injury were estimated at €26,540 and depended on age, aetiology and TBSA. Mean total costs in our population probably apply to other high-income countries as well, although we should realise that patients with burn injuries are diverse and represent a broad range of total costs. To reduce costs of burn care, future intervention studies should focus on a timely wound healing, reducing length of stay and enabling an early return to work

Assessing Health-Related Quality of Life of Adult Patients with Intermediate Burns: The Added Value of an Itching and Cognition Item for the EQ-5D: A Retrospective Observational Study

The EQ-5D is increasingly used to assess the health-related quality of life (HRQL) of adult patients with intermediate burns. However, this generic instrument may lack sensitivity, as important problems for burn patients, such as itching and cognition problems are not included in this instrument. This retrospective observational study investigates the value of adding an itching and cognition item to the EQ-5D-3L. Patients completed the EQ-5D-3L, and the Patient and Observer Scar Assessment Scale (POSAS), including an itching item and an extra cognition item three months postburn. The potential added value of an itching and cognition item was studied by distribution, informativity, convergent validity, dimension dependency, and explanatory analyses. In total, 120 patients were included of whom 65% reported itching and 23% reported cognition problems. Adding an itching item to the EQ-5D improved the discriminatory power and informativity of the EQ-5D-3L, but barely increased the explanatory power (0.4%) and decreased the convergent validity (r = −0.529 vs. r = −0.612). In contrast, adding a cognition item slightly improved the informativity and discriminatory power. Moreover, convergent validity (r = −0.617 vs. r = −0.612) and explanatory power increased (4.0%). In conclusion, adding an itching item to the EQ-5D-3L provides some additional information, however, the added value is small, whereas adding a cognition item improved the measurement properties of the EQ-5D-3L in our sample and should be considered when assessing HRQL in adult patients with intermediate burns

Cost-Effectiveness of Laser Doppler Imaging in Burn Care in The Netherlands: A Randomized Controlled Trial

Background: In patients with burns, an early accurate diagnosis of burn depth facilitates optimal treatment. Laser Doppler imaging combined with clinical assessment leads to an accurate estimate of burn depth. However, the actual effects of the introduction of laser Doppler imaging on therapeutic decisions, clinical outcomes, and costs are unknown. Methods: A randomized controlled trial was conducted in the Dutch burn centers, including 202 patients with burns of indeterminate depth. In the standard care group, estimation of burn depth was based on clinical assessment only; in the laser Doppler imaging group, clinical assessment and laser Doppler imaging were combined. Primary outcome was time to wound healing. Furthermore, therapeutic decisions and cost-effectiveness were analyzed. Results: Mean time to wound healing was 14.3 days (95 percent CI, 12.8 to 15.9 days) in the laser Doppler imaging group and 15.5 days (95 percent CI, 13.9 to 17.2 days) in the standard care group (p = 0.258). On the day of randomization, clinicians decided significantly more often on operative or nonoperative treatment in the laser Doppler imaging group (p < 0.001), instead of postponing their treatment choice. Analyses in a subgroup of admitted patients requiring surgery showed a significant earlier decision for surgery and a shorter wound healing time in the laser Doppler imaging group. Mean total costs per patient were comparable in both groups. Conclusions: Laser Doppler imaging improved therapeutic decisions. It resulted in a shorter wound healing time in the subgroup of admitted patients requiring surgery and has the potential for cost savings of Euro875 per scanned patient