Kathryn Vowden

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

Objective To estimate the prevalence of wounds managed by the UKs 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 £5.3 billion. This was reduced to between £5.1 and £4.5 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 UKs NHS, comparable to that of managing obesity (£5.0 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.

Preventing venous ulcer recurrence: a review

This review article examines the available evidence on both the primary and secondary prevention of venous ulceration, exploring both the individual, social and financial implications of system failures that allow patients to remain at increased risk of recurrent ulceration. The role of both venous disease assessment and corrective superficial venous surgery are discussed in the light of recently published randomised controlled studies on the role of superficial venous surgery as both an adjunct to ulcer healing and ulcer prevention.

The prevalence, management and outcome for patients with lower limb ulceration identified in a wound care survey within one English health care district

482 people with leg ulcers were identified among those receiving health care in Bradford, UK. Of these wounds 195 (40.4%) were venous leg ulcers. Typically the people who experienced these wounds were elderly Caucasian females however a sub-group of younger males of Asian descent were seen to experience ulcers involving neuropathy. The leg ulcers were typically small in size although 33 people had wounds over 25 cm2 in surface area. The leg ulcers tended to persist with many present for at least 1 year with 4 wounds active for over 5 years. 205 people had experienced previous episodes of leg ulcer occurrence. Of the leg ulcers encountered 18.0% (n = 87) were infected and where wounds were swabbed for their microbial burden MRSA was identified in 8.5% of cases. Use of Doppler ultrasound to assess the aetiology of the wound had been performed in 66.4% of cases and where wounds remained undiagnosed (n = 69) only 8 had been Doppler assessed. While 75% of all venous leg ulcers received compression 48 people with venous leg ulcers did not have compression applied to their wound.

A survey of wound care provision within one English health care district

Wound healing remains a largely overlooked area despite the perceived large numbers of people with wounds and the high costs of treatment. The lack of visibility for wounds and wound healing may in part stem from the fragmented nature of the available data on wound occurrence often limited to descriptions of specific wound types within single care settings. A survey was undertaken across all care providers serving the population of Bradford, UK to identify the number of people with wounds, the characteristics of their wounds and the allocated interventions used to prevent and heal wounds. In March 2007, 1735 completed questionnaires were returned each marking the most severe wound experienced by a patient. The overall prevalence of wounds was 3.55 people with wounds per 1000 population (prevalence 0.355% 95% CI 0.33-0.37%). Almost one third (n = 556) of the people with wounds were located in acute care settings with the remainder spread across several community locations including residential and nursing homes. The most prevalent forms of wound were acute wounds (n = 826) followed by leg ulcers (n = 482) and pressure ulcers (n = 363). A previous survey with broadly similar methodology had shown a lower prevalence of wounds (0.279% 95% CI 0.26-0.29%) with this difference perhaps explained by different data collection methodologies within the nursing home sector that resulted in a 100% return compared with 50% in the earlier survey.

The prevalence, management, equipment provision and outcome for patients with pressure ulceration identified in a wound care survey within one English health care district

The prevalence of pressure ulceration within the population receiving health care in Bradford, UK was 0.74 people with a pressure ulcer per 1000 population (95% CI 0.6-0.8). This prevalence includes a number of tertiary referrals and if these are removed the prevalence falls to 0.71 people with a pressure ulcer per 1000 population. Of the pressure ulcers encountered 195 (53.7%) were classed as grade 2 pressure ulcers with 80 grade 3 wounds and 40 grade 4 pressure ulcers. Forty-eight pressure ulcers were identified as grade 1 wounds but the accuracy of this classification may be in doubt given that 24 apparent grade 1 pressure ulcers were reported to have visible wound beds with common reports of slough and granulation tissue. Severe pressure ulcers differed from less severe partial thickness wounds--grade 3 and 4 pressure ulcers tended to be larger, of longer duration, with greater coverage of the wound bed with necrotic tissue and less granulation and epithelial tissue. Wound exudate was heavier where people presented with severe pressure ulcers while there was a greater probability of wound infection (37.5% of grade 4 pressure ulcers were infected). Given these challenges it was perhaps unsurprising that people with severe pressure ulcers were more likely to have been risk assessed, to have had a critical incident form completed (although only 35% of grade 4 pressure ulcers were identified as having been reported on a critical incident form), to be provided with a powered PR mattress in bed and to be dressed with an antimicrobial dressing. The time to treat each severe pressure ulcer tended to be longer than was the treatment times for less severe wounds. Only 40 people with pressure ulcers (11%) as their most serious wound were located in hospital, suggesting that current pressure ulcer epidemiology and costs may be understated given their reliance on previous hospital based surveys of pressure ulcers. Another potential confounder of pressure ulcer epidemiological studies may be the number of nursing home beds in the surveyed population. On breaking down the Bradford audit data by postcode the pressure ulcer prevalence ranged between 0.13 and 1.39 people with a pressure ulcer per 1000 population with the higher prevalence proportions found in postcodes with large numbers of nursing home beds. It would appear to be prudent to record the number of nursing home beds within community based populations where pressure ulcers (and potentially other wounds) are being recorded.

Vacuum Assisted Closure: Recommendations for Use: A Consensus Document

international group of experts (see below) to provide guidance on the successful integration of vacuum assisted closure therapy (V.A.C. Therapy) into clinical practice. The document specifically reviews its potential use in the following selected indications*: diabetic foot ulcers, complex leg ulcers, pressure ulcers, dehisced sternal wounds, open abdominal wounds and traumatic wounds. In addition, it considers quality of life and cost-effectiveness, both of which are gaining importance when evaluating treatment. This document highlights questions for future research and is designed to be practical and adaptable for local use in countries worldwide.

New techniques for wound debridement.

Debridement is a crucial component of wound management. Traditionally, several types of wound debridement techniques have been used in clinical practice such as autolytic, enzymatic, biodebridement, mechanical, conservative sharp and surgical. Various factors determine the method of choice for debridement for a particular wound such as suitability to the patient, the type of wound, its anatomical location and the extent of debridement required. Recently developed products are beginning to challenge traditional techniques that are currently used in wound bed preparation. The purpose of this review was to critically evaluate the current evidence behind the use of these newer techniques in clinical practice. There is some evidence to suggest that low frequency ultrasound therapy may improve healing rates in patients with venous ulcers and diabetic foot ulcers. Hydrosurgery debridement is quick and precise, but the current evidence is limited and further studies are underway. Debridement using a monofilament polyester fibre pad and plasma‐mediated bipolar radiofrequency ablation are both very new techniques. The initial evidence is limited, and further studies are warranted to confirm their role in management of chronic wounds.

The prevalence, management and outcome for acute wounds identified in a wound care survey within one English health care district

This paper reports the characteristics and local management of 826 acute wounds identified during an audit across all health care providers serving the population of Bradford, UK. Of the wounds encountered 303 were traumatic wounds and 237 primary closures with smaller numbers of other acute wound types. Of the 303 traumatic wounds 174 occurred in women (57.4%). Men predominated in the under 45s (65M:26F), this being largely accounted for by hand and finger trauma (n = 62) particularly in patients of working age (M32:F12). Women predominated in the over 65s (50M:130F), this being largely accounted for by lower limb traumatic wounds (M24:F91), the majority of these being in patients 65 and over (M14:F82). In this sub-group of 96 patients 25 had wounds of 6 weeks or longer duration, only 3 had undergone Doppler assessment and only 2 received compression bandaging. Typically these wounds were of recent origin and small in size (under 1 week and less than 5 cm2 in surface area) however exceptions occurred where 10 people had wounds over 25 cm2 in area while 3 wounds had been present for over 5 years. 101 (12.2%) of the encountered wounds were considered to be infected although the practice of wound swabbing in the presence of presumed infection seemed inadequate with 37.6% of all infected acute wounds not being swabbed while 97 non-infected wounds were swabbed. Where wounds were swabbed 4.5% were found to be MRSA positive. Across all acute wound types (with the sole exception of primary closures) antimicrobial wound dressings were the most prevalent form of dressing and covered 56 (55.4%) of all infected wounds.

Development of a generic wound care assessment minimum data set

BACKGROUND At present there is no established national minimum data set (MDS) for generic wound assessment in England, which has led to a lack of standardisation and variable assessment criteria being used across the country. This hampers the quality and monitoring of wound healing progress and treatment. AIM To establish a generic wound assessment MDS to underpin clinical practice. METHOD The project comprised 1) a literature review to provide an overview of wound assessment best practice and identify potential assessment criteria for inclusion in the MDS and 2) a structured consensus study using an adapted Research and Development/University of California at Los Angeles Appropriateness method. This incorporated experts in the wound care field considering the evidence of a literature review and their experience to agree the assessment criteria to be included in the MDS. RESULTS The literature review identified 24 papers that contained criteria which might be considered as part of generic wound assessment. From these papers 68 potential assessment items were identified and the expert group agreed that 37 (relating to general health information, baseline wound information, wound assessment parameters, wound symptoms and specialists) should be included in the MDS. DISCUSSION Using a structured approach we have developed a generic wound assessment MDS to underpin wound assessment documentation and practice. It is anticipated that the MDS will facilitate a more consistent approach to generic wound assessment practice and support providers and commissioners of care to develop and re-focus services that promote improvements in wound care.

Cohort study evaluating pressure ulcer management in clinical practice in the UK following initial presentation in the community: costs and outcomes

Objectives The aim of this study was to estimate the patterns of care and annual levels of healthcare resource use attributable to managing pressure ulcers (PUs) in clinical practice in the community by the UK’s National Health Service (NHS), and the associated costs of patient management. Methods This was a retrospective cohort analysis of the records of 209 patients identified within a randomly selected population of 6000 patients with any type of wound obtained from The Health Improvement Network (THIN) Database, who developed a PU in the community and excluded hospital-acquired PUs. Patients’ characteristics, wound-related health outcomes and healthcare resource use were quantified over 12 months from initial presentation, and the corresponding total NHS cost of patient management was estimated at 2015/2016 prices. Results 50% of all the PUs healed within 12 months from initial presentation, but this varied between 100% for category 1 ulcers and 21% for category 4 ulcers. The mean time to healing ranged from 1.0 month for a category 1 ulcer to 8 months for a category 3/4 ulcer and 10 months for an unstageable ulcer. Patients were predominantly managed in the community by nurses with minimal clinical involvement of specialist clinicians. Up to 53% of all the ulcers may have been clinically infected at the time of presentation, and 35% of patients subsequently developed a putative wound infection a mean 4.7 months after initial presentation. The mean NHS cost of wound care over 12 months ranged from £1400 for a category 1 ulcer to >£8500 for the other categories of ulcer. Additionally, the cost of managing an unhealed ulcer was 2.4 times more than that of managing a healed ulcer (mean of £5140 vs £12 300 per ulcer). Conclusion This study provides important insights into a number of aspects of PU management in clinical practice in the community that have been difficult to ascertain from other studies, and provides the best estimate available of NHS resource use and costs with which to inform policy and budgetary decisions.