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
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.
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
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
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
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