The costs of non-training in chronic wounds : estimates through practice simulation

The high prevalence and incidence rates of chronic wounds represent high financial costs for patients, families, health services, and for society in general. Therefore, the proper training of health professionals engaged in the diagnosis and treatment of these wounds can have a very positive impact on the reduction of costs. As technology advances rapidly, the knowledge acquired at school soon becomes outdated, and only through lifelong learning can skills be constantly updated. Information and Communication Technologies play a decisive role in this field. We have prepared a cost estimate model of Non-Training, using a Simulator (Web Based System – e-fer) for the diagnosis and treatment of chronic wounds. The preliminary results show that the costs involved in the diagnosis and treatment of chronic wounds are markedly higher in health professionals with less specialized training

Health economic burden that wounds impose on the National Health Service in the UK

OBJECTIVE: To estimate the prevalence of wounds managed by the UK's National Health Service (NHS) in 2012/2013 and the annual levels of healthcare resource use attributable to their management and corresponding costs. METHODS: This was a retrospective cohort analysis of the records of patients in The Health Improvement Network (THIN) Database. Records of 1000 adult patients who had a wound in 2012/2013 (cases) were randomly selected and matched with 1000 patients with no history of a wound (controls). Patients' characteristics, wound-related health outcomes and all healthcare resource use were quantified and the total NHS cost of patient management was estimated at 2013/2014 prices. RESULTS: Patients' mean age was 69.0 years and 45% were male. 76% of patients presented with a new wound in the study year and 61% of wounds healed during the study year. Nutritional deficiency (OR 0.53; p<0.001) and diabetes (OR 0.65; p<0.001) were independent risk factors for non-healing. There were an estimated 2.2 million wounds managed by the NHS in 2012/2013. Annual levels of resource use attributable to managing these wounds and associated comorbidities included 18.6 million practice nurse visits, 10.9 million community nurse visits, 7.7 million GP visits and 3.4 million hospital outpatient visits. The annual NHS cost of managing these wounds and associated comorbidities was pound5.3 billion. This was reduced to between pound5.1 and pound4.5 billion after adjusting for comorbidities. CONCLUSIONS: Real world evidence highlights wound management is predominantly a nurse-led discipline. Approximately 30% of wounds lacked a differential diagnosis, indicative of practical difficulties experienced by non-specialist clinicians. Wounds impose a substantial health economic burden on the UK's NHS, comparable to that of managing obesity ( pound5.0 billion). Clinical and economic benefits could accrue from improved systems of care and an increased awareness of the impact that wounds impose on patients and the NHS.Ye

A randomised trial to compare the performance of Oxyzyme® and Iodozyme® with standard care in the treatment of patients with venous and mixed venous/arterial ulceration

This study was to evaluate the potential benefits of two products (Oxyzyme® and Iodozyme®) into a leg ulcer service in South Staffordshire, UK. A randomised controlled trial (RCT) was used to evaluate time to ulcer healing, quality of life, pain and cost effectiveness. 100 patients were randomised to receive either Oxyzyme/Iodozyme (active group) or standard care (control group) with venous or mixed arterio-venous ulcers. Patients were evaluated weekly up to 12 weeks, with further follow up at 24 weeks. Whilst there was a small benefit in terms of healing over follow up using the Cox Proportional Hazards Model, this did not achieve a standard level of statistical significance (hazard ratio = 1.13, 95%CI 0.64 to 2.02, p = 0.67) after adjustment for confounding factors. Patients with high protease activity showed an improved and faster healing in the active group, (HR = 1.35, 95%CI 0.63, 2.87) p = 0.44. The active group required significantly fewer dressing changes (14.8 versus 10.0, p = 0.033). Despite the dressing costs being higher, there was a significantly lower cost of nursing time, leading to a greater cost effectiveness in terms of cost per healed ulcer (£977 versus £1071. A Markov model used to assess cost effectiveness in the main trial found that the control group had slightly better outcomes (12 more ulcer free weeks), but at a substantially greater cost (£5031). When those with high protease activity the cost in the active group dominated, with lower cost (−£2450) and an improved outcome (29 more ulcer free weeks). Health related quality of life (HRQoL) and pain significantly improved over the assessment period, though there was no difference between the treatment groups. The use of Oxyzyme® and Iodozyme® could provide better value for money in the management of venous and mixed arterio-venous ulcers than standard care in a community leg ulcer service

Wound bed preparation: A novel approach using HydroTherapy

Wounds that fail to heal quickly are often encountered by community nursing staff. An important step in assisting these chronic or stalled wounds progress through healing is debridement to remove devitalised tissue, including slough and eschar, that can prevent the wound from healing. A unique wound treatment called HydroTherapy aims to provide an optimal healing environment. The first step of HydroTherapy involves HydroClean plus™, this dressing enables removal of devitalised tissue through autolytic debridement and absorption of wound fluid. Irrigation and cleansing provided by Ringer’s solution from the dressing further removes any necrotic tissue or eschar. Once effective wound bed preparation has been achieved a second dressing, HydroTac™, provides an ongoing hydrated wound environment that enables re-epithelialisation to occur in an unrestricted fashion. This paper presents 3 case studies of slow healing wounds treated with HydroClean plus™ which demonstrates effective wound debridement

Supervised exercise training as an adjunct therapy for venous leg ulcers: a randomised controlled feasibility trial

Background Venous leg ulcers (VLUs) are typically painful and heal slowly. Compression therapy offers high healing rates; however, improvements are not usually sustained. Exercise is a low‐cost, low‐risk and effective strategy for improving physical and mental health. Little is known about the feasibility and efficacy of supervised exercise training used in combination with compression therapy patients with VLUs. Objectives To assess the feasibility of a 12‐week supervised exercise programme as an adjunct therapy to compression in patients with VLUs. Methods This was a two‐centre, two‐arm, parallel‐group, randomized feasibility trial. Thirty‐nine patients with venous ulcers were recruited and randomized 1 : 1 either to exercise (three sessions weekly) plus compression therapy or compression only. Progress/success criteria included exercise attendance rate, loss to follow‐up and patient preference. Baseline assessments were repeated at 12 weeks, 6 months and 1 year, with healing rate and time, ulcer recurrence and infection incidents documented. Intervention and healthcare utilization costs were calculated. Qualitative data were collected to assess participants’ experiences. Results Seventy‐two per cent of the exercise group participants attended all scheduled exercise sessions. No serious adverse events and only two exercise‐related adverse events (both increased ulcer discharge) were reported. Loss to follow‐up was 5%. At 12 months, median ulcer healing time was lower in the exercise group (13 vs. 34·7 weeks). Mean National Health Service costs were £813·27 for the exercise and £2298·57 for the control group. Conclusions The feasibility and acceptability of both the supervised exercise programme in conjunction with compression therapy and the study procedures is supported

The Debrisoft ® monofilament debridement pad for use in acute or chronic wounds: A NICE medical technology guidance

As part of its Medical Technology Evaluation Programme, the National Institute for Health and Care Excellence (NICE) invited a manufacturer to provide clinical and economic evidence for the evaluation of the Debrisoft ® monofilament debridement pad for use in acute or chronic wounds. The University of Birmingham and Brunel University, acting as a consortium, was commissioned to act as an External Assessment Centre (EAC) for NICE, independently appraising the submission. This article is an overview of the original evidence submitted, the EAC’s findings and the final NICE guidance issued. The sponsor submitted a simple cost analysis to estimate the costs of using Debrisoft® to debride wounds compared with saline and gauze, hydrogel and larvae. Separate analyses were conducted for applications in home and applications in a clinic setting. The analysis took an UK National Health Service (NHS) perspective. It incorporated the costs of the technologies and supplementary technologies (such as dressings) and the costs of their application by a district nurse. The sponsor concluded that Debrisoft® was cost saving relative to the comparators. The EAC made amendments to the sponsor analysis to correct for errors and to reflect alternative assumptions. Debrisoft® remained cost saving in most analyses and savings ranged from £77 to £222 per patient compared with hydrogel, from £97 to £347 compared with saline and gauze, and from £180 to £484 compared with larvae depending on the assumptions included in the analysis and whether debridement took place in a home or clinic setting. All analyses were severely limited by the available data on effectiveness, in particular a lack of comparative studies and that the effectiveness data for the comparators came from studies reporting different clinical endpoints compared with Debrisoft®. The Medical Technologies Advisory Committee made a positive recommendation for adoption of Debrisoft® and this has been published as a NICE medical technology guidance (MTG17).The Birmingham and Brunel Consortium is funded by NICE to act as an External Assessment Centre for the Medical Technologies Evaluation Programme

Community Nurses' Judgement for the Management of Venous Leg Ulceration: A Judgement Analysis

Background: Nurses caring for the large numbers of people with leg ulceration play a key role in promoting quality in health via their diagnostic and treatment clinical judgements. In the UK, audit evidence suggests that the quality of these judgements is often sub optimal. Misdiagnosis and incorrect treatment choices are likely to affect healing rates, patients’ quality of life, patient safety and healthcare costs. Objectives: To explore the diagnostic judgements and treatment choices of UK community nurses managing venous leg ulceration. Design: A judgement analysis based on Brunswik's psychological Lens Model theory. Setting: UK community and primary care nursing services. Participants: 18 community generalist nurses working in district (home) nursing teams and general practitioner services and 18 community tissue viability specialist nurses. Methods: During 2011 and 2012, 36 nurses made diagnostic judgements and treatment choices in response to 110 clinical scenarios. Scenarios were generated from real patient cases and presented online using text and wound photographs. The consensus judgements of a panel of nurses with advanced knowledge of leg ulceration judged the same scenarios and provided a standard against which to compare the participants. Correlations and logistic regression models were constructed to generate various indices of judgement and decision “performance”: accuracy (Ra), consistency (Rs) and information use (G) and uncertainty (Re). Results: Taking uncertainty into account, nurses could theoretically have achieved a diagnostic level of accuracy of 0.63 but the nurses only achieved an accuracy of 0.48. For the treatment judgement (whether applying high compression was warranted) nurses could have achieved an accuracy of 0.88 but achieved only an accuracy of 0.49. This may have been due to the nurses giving insufficient weight to the diagnostic cues of medical history and appearance of the leg and ulcer and insufficient weight to the treatment cues of type of leg ulcer and pain. Conclusion: Clinical judgements and decisions made by nurses managing leg ulceration are complex and uncertain and some of the variability in judgements and choices can be explained by the ways in which nurses process the information and handle the uncertainties, present in clinical encounters

Spatio-temporal Models of Lymphangiogenesis in Wound Healing

Several studies suggest that one possible cause of impaired wound healing is failed or insufficient lymphangiogenesis, that is the formation of new lymphatic capillaries. Although many mathematical models have been developed to describe the formation of blood capillaries (angiogenesis), very few have been proposed for the regeneration of the lymphatic network. Lymphangiogenesis is a markedly different process from angiogenesis, occurring at different times and in response to different chemical stimuli. Two main hypotheses have been proposed: 1) lymphatic capillaries sprout from existing interrupted ones at the edge of the wound in analogy to the blood angiogenesis case; 2) lymphatic endothelial cells first pool in the wound region following the lymph flow and then, once sufficiently populated, start to form a network. Here we present two PDE models describing lymphangiogenesis according to these two different hypotheses. Further, we include the effect of advection due to interstitial flow and lymph flow coming from open capillaries. The variables represent different cell densities and growth factor concentrations, and where possible the parameters are estimated from biological data. The models are then solved numerically and the results are compared with the available biological literature.Comment: 29 pages, 9 Figures, 6 Tables (39 figure files in total