To calculate the cost effectiveness of wound care, it is incorrect to calculate the costs of just a dressing. All aspects influencing the costs of treatment should be calculated. These include costs for the actual materials, labor, and nonmedical costs to society.
Worldwide, hospital administrators, health care professionals, governments, and insurers are trying to quell the rising costs of health care. Health care systems vary widely between countries, but the issues are the same — providing optimal care for an increasingly aging population while containing costs. In response to these trends the Agency for Health Care Policy and Research (AHCPR, 1989) was established in 1989. Its goal was to enhance the quality, appropriateness, and effectiveness of health care services for certain costly medical and surgical conditions by establishing research-based treatment guidelines.
Although chronic wound incidence and prevalence estimates vary, one can safely assume that chronic skin lesions, particularly relatively common ones such as venous leg ulcers, pressure ulcers, and diabetic ulcers, have a considerable financial impact on the total costs of health care. If such lesions are unattended or improperly managed, and the underlying pathology is not treated, morbidity is extended —negatively affecting the patient’s quality of life, while increasing management costs.
Treatment practices vary widely from clinician to clinician and are infrequently based on scientific rationale. A common myth is that the topical treatment for these types of ulcers does not really influence their healing process. In response to budgetary restrictions, many health care workers attempt to lower chronic wound treatment costs by selecting the least expensive wound care material, without regard to the clinical benefits of the dressing, its appropriateness to the patient’s condition, or the status of the ulcer. The U.S. government, accrediting agencies, and medical and scientific researchers have begun addressing these costly misconceptions. The purpose of this article is to summarize the impact that a dressing protocol may have on the cost of clinical outcomes, not just the cost of treatment.
The price of a dressing alone is not an accurate reflection of the cost effectiveness of treating a wound. According to the Federal Register (1989), a cost-effective treatment is:
Less costly and at least as effective as an alternate technology.
More effective and more costly than an alternative, but its improved health outcome justifies the additional expenditure.
Less effective and less costly than an existing alternative, but a viable alternative for some patients.
The 1995 Medical Outcome Guidelines Sourcebook (Spencer et al.. 1995) defines cost effectiveness as:
"An economic evaluation in which alternative programs, services, or interventions are compared in terms of the cost per unit clinical effect: For example, cost per life saved, cost per millimeter of blood pressure lowering, or cost per quality-adjusted-life-year gained."
Determining the Cost Effectiveness of Wound Care
The cost of treatment for conservatively managed chronic wounds (without skin grafts or flaps) to achieve the desired outcome (healing, pain relief, restoration of function or mobility, improved quality of life, debridement, or preventing recurrence) should include the following costs (international Committee on Wound Management [ICWM, 1995]):
Costs of all dressing materials.
Total nursing time needed for wound care.
Treatment of complications.
Miscellaneous financial considerations, such as time lost from work and cost of additional measurements.
Examination of each of these factors will assist in understanding their relevance in calculating the overall cost of care in a given setting.
Dressing materials
Traditionally, only the cost of the primary dressing is considered when calculating material care costs. A more comprehensive way to assess cost is to include all material-related issues that result from using the primary material. Within one type of skin lesion, the frequency of dressing changes is determined largely by the type of dressing material selected. For example. many conventional dressings, such as tulle (a close-mesh net cut into squares) and gauze, must be changed frequently, up to several times per day. If used with antiseptic creams and solutions, the frequency of change may be further increased. In contrast, many modern dressings cane remain on the wound for a much longer period. A wearing time for modern dressings of up to 7 days has j been described, resulting in reduced frequency of dressing changes when compared to conventional gauze dressings (Shannon & Miller, 1988).
The wound status and amount of exudate gener ated also plays a role in determining the dressing selection. Exuding wounds, or wounds that require debridement, demand more frequent dressing changes. The use of more absorbent modern materials can assist in lowering cost by reducing the frequency of change, or by speeding autolytic debridement in an occlusive environment.
The necessity of using multiple dressings, particularly those necessary to keep the primary dressing in place, will significantly affect cost. Nearly all conventional dressing materials require some type of secondary dressing to stay in place over the wound. Many modern dressings adhere directly to the skin around the wound and in most cases do not require secondary dressings or tape.
Along with use of multiple dressings, methods of application will also influence cost. If a dressing requires sterile technique for application over the wound, the cost of sterile supplies must be incorporated into the calculation of per unit cost of the dressing(s).
Cost for the primary and secondary dressings (tape, gauze, etc.), as well as the cost of any other materials used to secure the dressing(s) in place should be included in the calculations. In a study comparing costs of modern, occlusive dressings and conventional dressings in the treatment of burns, when all dressing-related costs were taken into account the treatment of small, partial-thickness burns was most cost effective with modern dressings, in spite of the higher cost per unit of the primary dressing (Hermans, 1990).
Cost for medication related to the treatment modality is also another factor that must be considered when calculating cost. If, for example. removal of a dressing causes pain, pain medication may be required prior to a dressing change. The cost of such medication should be included in dressing change costs (Harkiss, 1985). Thus, the number of dressing changes required to achieve healing (or other outcomes), multiplied by all material costs at each dressing change represents the total material costs (see Table 1).
Nursing time
The number of dressing changes to achieve the desired outcome, multiplied by the time necessary for a single dressing change, determines the total nursing time (see Table 1). If a patient is treated at home, travel time for the nurse should also be included in the calculation. Caregiver time is a valid component of wound care costs, and in many countries, should be the most important consideration from a financial point of view while still considering what is most appropriate for the care of the patient. when one is selecting a dressing (AHCPR, 1989).
The main factor that determines nursing costs is the time required to change the dressing. Obviously, more frequent dressing changes require more nursing time. Although many modem materials are more expensive than moist saline gauze, the added expense may be offset by savings in caregiver time (AHCPR, 1989), due to the reduction in the number of dressing changes. This difference is accentuated by caregiver travel time, if care is given in the home.
The time needed to change a dressing correlates with the materials used. For example, dressings that do not adhere to the wound bed or do not disrupt the skin around the wound can be removed easily and quickly without causing pain. Correspondingly, removal of dressings can be accomplished much faster if there is no secondary dressing or extensive taping to be removed first. The AHCPR cited five studies that found that the nursing time required to care for pressure ulcer patients treated with moist saline gauze dressings was significantly more than the time required for patients treated with modern materials (AHCPR. 1989). An average of 29.53 minutes of nursing time per pressure ulcer per day was saved when hydrocolloid dressings were used for pressure ulcer management (Brady, 1987).
The relative importance of the cost of personnel has been demonstrated in several other studies as well. A retrospective analysis of the cost of pressure ulcer care in a long-term care facility showed that total nursing costs were three to ten times higher than the cost of supplies, regardless of ulcer severity (Frantz, 1989). When studying the cost of treating venous leg ulcers on an outpatient basis. Wood and Margolis (1992) found that the average cost of physician and physical therapy care was higher than the cost of the supplies needed to treat the ulcers. In a study of the cost of materials and nursing time needed in treating venous leg ulcers, “expensive” materials were actually less costly in overall management cost than dressings generally considered less expensive (Harkiss, 1985).
Nursing costs vary by country and state. Even if the actual wound care procedures are not provided by a physician or a registered nurse, personnel costs are substantial and are increasing every year. When the cost of unhealed leg ulcers was calculated in the United Kingdom, district nurse time composed the largest component of the annual cost to the National Health System (Bosanquest, 1992). In a Swedish study of nursing care practices in managing leg and foot ulcers, visiting nurses went to patient homes to change dressings an average of 3.8 times per week (Bjellerup, Lindholm, Christensen, & Zederfeldt, 1992), again indicating that a very substantial part of all cost incurred is related to nursing time.
Healing time
Numerous articles on wound care research indicate that, for a given type of wound or ulcer, the healing time is, at least partially, determined by the way the wound is dressed. In these articles, certain dressings protected the wound from detrimental environmental effects that lead to slower healing. These effects include:
Mechanical trauma to the wound bed (Alvarez, Merztz, & Eaglestein. 1983; Gillman, 1970; Winter, 1970).
Infection (Hutchinson. 1989; Lawrence & Lilly, 1988).
Dehydration of the wound (Zawacki, 1973, 1974). It is widely accepted that an occlusive wound
environment provides faster healing (Hermans, 1987; Hermans & van Wingerden, 1990; Jonkman, 1989; May, 1984; Tjong Wai, Hermans, & Kreis, 1983; Zawacki, 1974), reduces the possibility of infection and cross contamination (Lawrence & Lilly, 1988; Hutchinson, 1989; Hermans & Hutchinson, 1990), and maintains a moist wound environment.
Long-term effects
The material used to treat a wound exerts a certain amount of influence over the way the wound heals and the cosmetic results of healing (Linsky, Rovee, & Thurman, 1981). Careful selection of appropriate dressings that promote the healing cascade and reduce the possibility of expensive “after care” is a necessary consideration of calculating cost. Reducing the incidence of hypertrophic scarring and contracture formation in burn care, for example, would diminish the necessity for expensive pressure garments and reconstructive surgery.
Other financial considerations
As previously described, the treatment of wounds and ulcers has a direct effect on health care budgets. Less appreciated, but equally important, are many other resources that are indirectly affected by these types of lesions. Among the most significant are productivity, travel cost (for home visits), hospitalization cost, and morbidity.
The presence of an unhealed wound can lead to temporary or permanent disability, causing loss of productivity. If healing time can be reduced, return to productivity is accelerated. Even if reduction by only 1 day can be achieved, it is easy to understand the magnitude of possible cost savings. The type of dressing used for wound management may itself be a cause of temporary disablement. For example, a bulky secondary dressing, wrapped around the lower arm or hand (as is often necessary to keep the primary dressing in place) could be dangerous when working with rotating machinery (drills, circle saws, etc.). In many countries it is forbidden by law to return to work with this type of dressing in place. Therefore, the presence of such a material may prohibit a person from returning to his job. A small, smooth, adherent dressing is a safe and convenient alternative to traditional bulky dressings, and may permit a person to return to work earlier, assisting in reducing the costs of lost time at work.
In one clinical study of steel workers with wounds on the lower arm or hand that were treated with modern dressings, 97% could return to their jobs immediately, and only 3% were temporarily disabled (Hermans & van Wingerden, 1990). Had the patients been treated with conventional bandages, probably all of them would have had to go on temporary sick leave. The results of this study indicate that the type of dressing chosen can play a significant role in reducing time lost from work.
Faster healing for outpatients can reduce the costs involved in traveling to and from the hospital. Travel costs are also less for patients being cared for by visiting health care professionals, if the number of visits required for wound care and dressing changes is reduced.
When modern occlusive dressings, which accel. erate the healing process, are used for hospitalized patients, more rapid healing means quicker discharge. Earlier discharge represents savings to hospitals. In the United States, for example, daily costs for hospitalization for wound and ulcer management cax range between $550 and $750 (AHCPR, 1989). Studies indicate that the incidence of pressure ulcers increases with the length of stay (AHCPR, 1989). As indicated earlier, the cost of dressings becomes insignificant when compared to the daily cost of hospitalization (MMWR, 1992).
The reduction and prevention of infection plays a significant role in reducing cost. In the United States nosocomial infections were estimated to cost the health care system more than $4.5 billion in 1992. The extra charges per infection of a surgical wound were between $3,152 and $1,617. In patients with a wound
Reducing and preventing infection plays a significant role in reducing cost. Infection, hospitalization was extended by an average of 4.8 days (MMWR, 1992). These figures do not include the cost of nosocomial infections in
long-term care, in outpatients, in patients with lower-leg amputations, or the cost of diagnosing and treating osteomyelitis secondary to an infected pressure ulcer. In a retrospective study of 4,132 wounds, the infection rate for wounds treated with traditional gauze dressings was 7.1%, whereas only 2.6% of wounds treated with an occlusive dressing became infected (Hutchinson & McGuckin, 1990). Some modern dressings also provide an effective bacterial barrier (Mertz, Marshall, & Eaglstein, 1985). Furthermore, some occlusive dressings may lower the risk of cross-contamination by reducing the dispersal of bacteria during dressing changes (Lawrence, Lilly, & Kidson, 1992).
These findings have broad implications for patients and the health care professionals caring for them. Although specific data do not currently exist, it can be assumed that the use of materials that provide bacterial barrier protection leads to lower infection rates. It can be assumed that this phenomenon will minimize the costs of treating nosocomial infections.
Prevention, as it pertains to chronic wounds, includes:
The prevention of the development of chronic wounds, such as pressure ulcers.
The prevention of infection.
The prevention of other complications requiring more extensive treatment.
The prevention of unnecessary and prolonged expenditures.
Several sub-populations in a hospital may be at higher risk of developing pressure ulcers. Hospitalized quadriplegics, elderly patients with hip or other fractures, and patients in critical care have sufficiently high incidence and prevalence rates to warrant concern (AHCPR, 1989). Even minor wounds in these types of patients can become clinically significant and costly. Therefore, preventing wounds in this population of patients becomes part of the treatment regimen. The AHCPR Guidelines for the Prevention of Pressure Ulcers recommend the use of protective dressings, such as thin hydrocolloids or films, to assist in reducing friction injuries in at-risk patients (AHCPR, 1992), indicating that small initial extra costs are sometimes necessary to avoid long-term expensive treatment. In the treatment of venous leg ulcers, the costs of compression bandages are probably easily justified by the lower incidence of recurrent ulcers.
Modern dressings have led to a reduction in the need for surgical treatment of skin lesions, particularly venous leg ulcers and pressure sores. In addition, occlusive dressings can be used instead of tangential excision in treating partial-thickness burns. This treatment option eliminates the costs and risks of surgery. enhances the quality of life, and reduces the risk of scarring (Grisolia & Pelli, 1991).
All these issues play a role in preventing the occurrence of wounds, or deterioration in already existing wounds. Although it is very difficult to quantify. prevention by using proper materials eventually may be more cost effective.
Practical Aspects of Cost Effectiveness Analysis
To study cost effectiveness, one should carefully analyze what aspects of the treatment of a given clinical condition are related to the use of a certain material. It must also be decided upfront what outcome criteria will be studied. These criteria can vary extensively, and do not only depend on the skin lesion that is to be treated, but also on the patient and on other variables such as ethical considerations. For example, it would be unethical to study healing of full-thickness burns underneath dressings, since this type of lesion should be treated by excision and grafting, and not by conventional, nonsurgical means. However, under certain circumstances one could study the speed at which granulation tissue develops under a dressing, such as when the burned area is excised but cannot be grafted in the same session.
Another example can be found in patients with advanced stages of fungating carcinoma. Many of those lesions will not heal. In these patients the outcome to be studied should, therefore, not be wound healing, but a measure more appropriate to the goals of wound care. For example, pain relief and patient comfort could be studied in relation to costs of treatment. Along these lines of thinking, there are many outcomes that can be linked to studying cost effectiveness. These include, but are not limited to
(ICWM, 1995):
Speed of debridement.
Speed of re-epithelialization.
Relapse period (important in. for example, dermatologic conditions such as psoriasis).
Speed of return to full function.
Absence of scarring (hypertrophy, keloid formation).
Quality of life (possibility of working, taking a shower).
Pain reduction.
Period of necessary hospitalization.
Prevention of recurrence.
Prevention of infection.
Conclusion
In conclusion, according to the definition stated earlier in the 1995 Medical Guidelines Sourcebook (Spencer et at., 1995), the unit of clinical effect for wound care could be the cost per square centimeter of wound or ulcer healed, or the reduction of pain with one point on a visual analogue scale. Clearly then, the influence of the dressing on the wound healing process, the physical properties of the dressing, the dressing change frequency, the cost of health care personnel, and the final cosmetic and functional results achieved should be considered when considering cost effectiveness.
It also can be surmised, then, that a reduction of healing time leads to a reduction in personnel costs, a reduction in the use of materials, and shorter periods of disablement, all of which translates into reduced management costs. The cost of dressings used for a hospitalized patient becomes negligible if a shorter healing time leads to an earlier discharge, when compared to the costs for prolonged hospitalization. Furthermore, by spending a small amount of money on prevention, later financial burden may be substantially lower. Cost-effectiveness calculations should not only consider the cost per unit of a dressing, but take all these factors into account. It is, then, safe to say that the appropriate use of many modem dressings is less costly and more effective than traditional wound management interventions.
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Michel H.E. Hermans, MD, is Medical Director, ConvaTec International, Skillman, NJ. Laura L. Bolton, PhD, is Worldwide Director, Scientific Affairs, ConvaTec International, Skillman, NJ, and Adjunct Associate Professor, UMDNJ/Robert Wood Johnson Medical School, Piscataway. NJ.
