Peter 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.

A new pressure ulcer conceptual framework.

Aim This paper discusses the critical determinants of pressure ulcer development and proposes a new pressure ulcer conceptual framework. Background Recent work to develop and validate a new evidence-based pressure ulcer risk assessment framework was undertaken. This formed part of a Pressure UlceR Programme Of reSEarch (RP-PG-0407-10056), funded by the National Institute for Health Research. The foundation for the risk assessment component incorporated a systematic review and a consensus study that highlighted the need to propose a new conceptual framework. Design Discussion Paper. Data Sources The new conceptual framework links evidence from biomechanical, physiological and epidemiological evidence, through use of data from a systematic review (search conducted March 2010), a consensus study (conducted December 2010–2011) and an international expert group meeting (conducted December 2011). Implications for Nursing A new pressure ulcer conceptual framework incorporating key physiological and biomechanical components and their impact on internal strains, stresses and damage thresholds is proposed. Direct and key indirect causal factors suggested in a theoretical causal pathway are mapped to the physiological and biomechanical components of the framework. The new proposed conceptual framework provides the basis for understanding the critical determinants of pressure ulcer development and has the potential to influence risk assessment guidance and practice. It could also be used to underpin future research to explore the role of individual risk factors conceptually and operationally. Conclusion By integrating existing knowledge from epidemiological, physiological and biomechanical evidence, a theoretical causal pathway and new conceptual framework are proposed with potential implications for practice and research.

The effect of amelogenins (Xelma™) on hard-to-heal venous leg ulcers

With an aging population venous ulceration is likely to become an increasing problem. Despite improvements in care and the widespread introduction of compression bandaging, the mainstay of current management, a significant proportion of venous leg ulcers remain hard to heal. Therefore, a single‐blinded, randomized multicenter study was performed to compare wound size reduction using amelogenin proteins (Xelma™) formulated into a solution which forms a temporary extracellular matrix on contact with the wound bed. Propylene glycol alginate 7% served as a control. Patients were randomized to receive either amelogenin protein or control treatment. The investigational products were applied weekly under soft silicone secondary dressings for up to a maximum of 12 weeks. Compression therapy was maintained throughout the investigation. Wound size reduction was measured by tracing and all wounds were photographed. In total 123 patients were recruited, 62 patients in the amelogenin group, and 61 in the control group, respectively. Subgroup analyses were performed for ulcers with a size >10 cm2 at baseline and for ulcers of duration of >12 months. The wound size reduction was greatest in the group treated with amelogenin (33.8 vs. 25.6%, n= 117), this difference being greatest for larger ulcers (25 vs. 7.9% for ulcers>10 cm2, n= 61) and those of long duration (29.3 vs. 10.9% for ulcers >12‐month duration, n= 61).We conclude that this product may be clinically useful in the treatment of these venous leg ulcers.

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.

Reducing wound pain in venous leg ulcers with Biatain Ibu : A randomized, controlled double-blind clinical investigation on the performance and safety

Six out of 10 patients with chronic wounds suffer from persistent wound pain. A multinational and multicenter randomized double‐blind clinical investigation of 122 patients compared two moist wound healing dressings: a nonadhesive foam dressing with ibuprofen (62 patients randomized to Biatain Ibu Nonadhesive Coloplast A/S) and a nonadhesive foam without ibuprofen (60 patients to Biatain Non‐Adhesive—comparator). Patients were recruited from September 2005 to April 2006. The ibuprofen foam was considered successful if the pain relief on a five‐point Verbal Rating Scale was higher than the comparator without compromising safety including appropriate healing rate. Additional endpoints were change in persistent wound pain between dressing changes and pain at dressing change on days 1–5 (double blind) and days 43–47 (single blind). The primary response variable, persistent pain relief, was significantly higher in the ibuprofen‐foam group, as compared with the comparator on day 1–5, with a quick onset of action (p<0.05). Wound pain intensity was significantly reduced with the ibuprofen foam during day 1–5 with 40% from baseline, compared with 30% with the comparator (p<0.001). At day 43–47, the patients in the ibuprofen‐foam group had a significant (p<0.05) reemergence of persistent pain and pain at dressing change (p<0.05) when the active dressing was changed to the comparator. Wound healing was similar in the ibuprofen foam and comparator group. No difference in adverse events between the comparator and the ibuprofen foam with local sustained release of low‐dose ibuprofen was observed in this study. It was generally found that women reported less pain intensity than men, and pain intensity decreased with increasing age. In addition, pain intensity increased with initial pain intensity and increasing wound size. This study has demonstrated that the ibuprofen‐foam dressing provided pain relief and reduced pain intensity without compromising healing or other safety parameters.

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.

Amelogenin, an extracellular matrix protein, in the treatment of venous leg ulcers and other hard-to-heal wounds: Experimental and clinical evidence

Amelogenins are extracellular matrix proteins that, under physiological conditions, self-assemble into globular aggregates up to micron-sizes. Studies with periodontal fibroblasts indicate that attachment to these structures increases the endogenous secretion of multiple growth factors and cell proliferation. Pre-clinical and clinical studies indicate that cutaneous wounds benefit from treatment with amelogenins. A randomized controlled trial (RCT) involving patients with hard-to-heal venous leg ulcers (VLUs) (ie, ulcers with a surface area ≥10 cm2 and duration of ≥6 months) showed that the application of amelogenin (Xelma®, Molnlycke Health Care, Gothenburg, Sweden) as an adjunct treatment to compression results in significant reduction in ulcer size, improvement in the state of ulcers, reduced pain, and a larger proportion of ulcers with low levels of exudate, compared with treatment with compression alone. Amelogenin therapy was also shown to be safe to use in that there were no significant differences in adverse events noted between patients treated with amelogenin plus compression and those treated with compression alone. Case study evaluations indicate that the benefits of amelogenin therapy demonstrated in the RCT are being repeated in “real life” situations and that amelogenin therapy may also have a role to play in the treatment of other wound types such as diabetic foot ulcers.

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.