Dressing Up: the Case for Advanced Wound Care

Although countless wounds occur each year, chronic and complex wounds require the most skill, time and resources to heal. Venous leg ulcers, pressure ulcers and diabetic foot ulcers are the most common types, accounting for more than 90% of chronic wounds, and although healing often follows a predictable course, some may remain unhealed for many years.

According to Professor Peter Vowden, professor of wound healing research at Bradford Hospitals NHS Trust: "The complex pathophysiology of chronic wounds and impaired healing is beginning to be understood. The challenge for healthcare providers is to use this understanding to achieve cost-effective care."

IMPROVED WOUND HEALING

It is widely accepted that best practice in chronic wound care begins with moist wound healing. Moist wound dressings create an environment that supports the cells responsible for wound repair while preventing further damage.

These dressings also reduce the pain associated with dressing changes and provide better healing rates more cost-effectively than older gauze-based dressings, which tend to dry out and cause damage on removal.

Dressings such as alginates, hydrocolloids, foams, collagens and hydrogels are just a few moist healing options that have been available since the 1980s, and most wound care experts agree that moist wound healing techniques should be adopted. Despite this consensus of opinion, many chronic wounds are still covered with gauze dressings.

At the same time, new, advanced therapy options are rapidly entering the market, which offer alternatives to traditional wound care methods when treating complex and chronic wounds. However, this has resulted in an Atlantic divide, with a recent study indicating that while 80% of US hospitals are using advanced wound care methods, 80% of European hospitals are still using traditional therapies. This can be attributed to different cost factors and healthcare delivery methods in individual countries.

Modern approaches have been more rapidly adopted by private insurers in the US, who tend to track cost on a comprehensive basis across the full care continuum and have consequently been able to see economic advantages over the long-term of advanced treatments for chronic and hard-to-heal wounds.

However, government-funded healthcare systems in the US and Europe are often concerned with unit cost. They track costs per episode for a wound and do not evaluate the full cost beyond the normal estimated healing time, making traditional methods seem more cost-effective.

CALCULATING COST

Identifying the costs associated with treating wounds is rarely simple, as wounds can be related to secondary diagnoses. Compounding this issue are the vastly different settings in which treatment is delivered. All of these variables complicate the tracking cost and outcome.

Vowden explains: "The standard quoted cost in healing a venous leg ulcer in the UK using traditional full air compression bandaging and a simple dressing is probably in the order of £1,000. Now, clearly you can use an advanced product, but if you give that to everybody at the start of their care that care will probably end up being more expensive.

"The difficulty is that there are a number of good bioengineered skin products today that are very effective, but if you do a cost analysis, it can be difficult to prove they are cost-effective when a dressing that costs £2.50 is replaced with one costing £500."

Care delivery systems are also a major obstacle to more homogenous wound care practice. In the US, virtually all wound care is administered directly by a physician in a clinical setting. This allows enormous scope for storage, consistency in practice and the planning of treatments far in advance when ordering supplies. The downside is that the cost to the patient and the healthcare system is much higher.

Vowden says: "In the UK, we have a different system of delivering wound care: a lot of it is nurse-based. Overall, the UK is considered to be very advanced in the way it delivers wound care because it has moved away from doctor-administered treatment, significantly reducing the cost.

Many advanced products require substantial infrastructure for delivery. For example, if the treatment requires the application of cells, there must be a way of handling, storing and growing these cells. Likewise, producing expensive growth factors requires specialist care with a complex skill mix for delivery.

Vowden says: "The reason I think things move quickly in the US is that care is given by a specialist wounds physician. That doesn’t apply in a lot of areas across Europe, which is why there is more use of traditional methods.

"In many ways, the manufacturers haven’t considered how an advanced product is going to be used. They’ve established that it works. What they haven’t demonstrated is that it works in a specific healthcare system. The NHS is not going to change the way it delivers care just because of a wonderful new product. New techniques must fit in with the way care is delivered."

CATCHING UP WITH THE US

For Europe to adopt more advance wound care techniques, two things need to occur, according to Vowden. "First, I don’t think advanced techniques alone are the answer because they will inevitably be expensive," he says. "What we need is a mechanism that allows the correct patient for a particular treatment to be identified at an early stage. If you can get away with ten treatments at £2.50 plus nursing time, and you know that the wound is going to heal, why spend £800 on day one?

"Also, the medical field has an excellent armamentarium of diagnostic tests to direct the appropriate treatment. Wound care doesn’t have any particular diagnostic tests, and therefore it is difficult to select patients for a particular treatment. Manufacturers seeking to break into the universal wound care market with advanced products must show that their products are cost-effective. Then they will be taken up and offered to patients.

"Wounds are very common; they are looked after by a number of different specialties, and because of that, we keep reinventing the wheel. By that, I mean the vascular surgeon, rheumatologist and geriatrician all look after wounds, as do all surgeons, but we’re not good at exchanging information between the groups because wound care by itself doesn’t really exist as a specialty."

Often, there are very good ideas and developments in one branch of medicine or nursing which take too long to reach the rest of the wound care world. Vowden says: "What we need to do is start working together on the principles of healing wounds rather than looking at them from the point of view of the dermatologist or the rheumatologist."

To truly deliver advanced wound treatment in Europe, manufacturers need to understand how the product is to be used in the field and practitioners must enter the debate about the best ways to deliver advanced treatments in a cost-effective manner.