Innovative new medical devices could revolutionise the way wounds are treated – but the NHS is still using a cost-per-unit approach to procurement. Paul Trueman, VP market access at Smith & Nephew, argues a performance-based strategy would cut costs in the long-term.
Broken Piggy Bank
Last year Lord Hunt, former Chief Executive of the NHS Confederation, drew attention to the substantial costs and outdated practices related to managing wound care.1 An estimated £5.3bn is spent on treating wounds by the NHS every year, which exceeds the costs of obesity treatment.2 A recent study, led by Professor Julian Guest, found that the average CCG spends in excess of £40m managing wounds every year3. With the prevalence of acute, chronic, and other unspecified wounds increasing at a rate of 9–13% per annum, this figure is predicted to increase year on year. 3 Against this background, Lord Hunt has called for innovation and a clear leadership strategy to save costs, but also improve clinical outcomes and quality of life.
Clinically sub-optimal and labour-intensive wound management methods have become embedded within many healthcare providers, which are now struggling to reduce the financial burden of wound care. “Healing takes far too long, diagnosis is not good enough, and inadequate commissioning of services by CCGs compounds the problem,” explained Baroness Margaret Wheeler. 1
Professor Guest described how wound care delivery appears to be “patchy and disparate”3 at best and promotes a major rethink on the issue, including a greater focus on prevention and active management with the intent of healing wounds.4
Factors driving the cost of wound care are well established. Caroline Dowsett, tissue viability nurse at the East London Foundation Trust said: “Healing time, frequency of dressing change and incidence of complications are the three main cost drivers.”5 Appropriate use of innovative and clinically proven wound management technologies can help to alleviate some of these pressures.
An estimated two million people are living with a chronic wound across Europe and an estimated 15% of all chronic wounds remain unresolved after a year of treatment6. This falls well below best practice when there is technology designed to improve healing rates, overall cost, and prevent or reduce complications readily available, but not adopted because of the current procurement strategy based on cost-per-unit.
Procurement practice relating to wound care often adopts a narrow, cost-per-unit focus which promotes dressing selection based on cost rather than patient need. Whilst this may reduce the supply cost, it may have an adverse effect on the total cost of care, if it results in sub-optimal treatment choices. Adopting a total cost of care approach to procurement is likely to result in more appropriate use of advanced treatment options with proven effectiveness where these can deliver better outcomes and reduce the frequency of nurse visits and expensive complications. There is a growing body of evidence to support the use of ‘care pathways’ incorporating criteria for the use of innovative wound technologies that have been shown to deliver improved outcomes at lower total treatment costs.5
Take, for example, surgical site complications; infections and dehiscence (re-opening of the wound) often occur post-discharge and create a significant burden on community nursing services.7 A study has suggested that around 40% of wounds treated by community nursing are acute, such as surgical, wounds.3 Where complications occur, this results in extended treatment costs and excess morbidity for patients8. Evidence indicates that many of these complications could be avoided through improved management of the surgical wound in the immediate post-operative period.9,10 Studies of PICO, a single-use negative pressure wound therapy device, illustrate a potential 50% reduction in surgical site complications.10 Despite this, adoption of this pioneering, single-use negative pressure wound therapy device remains limited, largely due to concerns over the unit cost compared to standard care. The fact that it has been shown to deliver improved outcomes and reduce the total costs of care may not be adequately taken into account in the procurement process.
Infections are a common recurring theme of longer-term chronic wounds too, extending the duration of the wound and increasing the potential risk of hospitalisation.5,11 Detection of infection largely relies on clinical judgement. Given that the majority of wounds are treated by non-specialist nurses (as opposed to dedicated tissue viability nurses) there can be inconsistencies in judgement. Innovative technologies, such as MolecuLight i:X, a handheld device that measures the surface area of a wound and visualises the presence and distribution of fluorescent bacteria, can contribute to earlier and more consistent detection of wounds at risk of infection.12,13 More accurate detection of infection may lead to more appropriate use of antimicrobial dressings, which at present are often restricted from use in community nursing settings due to concerns over their cost and inappropriate use. Furthermore, accurate diagnosis can also contribute to improved stewardship of antimicrobials and antibiotics thereby reducing concerns about resistance.It has been estimated that there are 400,000 pressure ulcers per annum in the UK, at an estimated cost to the NHS of £1.8-2.6bn.2,4 Standard care with regards prevention requires considerable nursing input, in the form of active monitoring and regular re-positioning of patients. Recent evidence has indicated that implementing a multi-layer silicone adhesive foam dressing in pressure ulcer prevention, as part of a pressure ulcer prevention protocol, is an effective strategy.14
Such dressings are a relatively inexpensive intervention and require only modest nurse training, meaning that they can easily be integrated into existing workflows. Despite this, a number of wound care formularies continue to limit the use of such dressings for prevention.
These examples illustrate how the narrow cost per unit focus of procurement may restrict access to innovative treatments and increase the total costs of wound care. Focusing on the need to find the lowest priced intervention reduces the clinician’s access to more advanced therapies, even where evidence exists to show that they can deliver improved outcomes and efficiency. Care pathways and protocols that provide clear guidance on the appropriate use of advanced technologies offer real potential to improve outcomes and reduce the costs of wound management.
As Baroness Jolly, Liberal Democrat Lords spokesperson for health, said, “There are many voices and players in this discussion: the clinicians, the commissioners, industry, those who are trying to improve performance and save money by rationalising systems and processes, and of course the patients too.” 1 All of these stakeholders have the common interest of delivering improved outcomes and cost effective wound care, incorporating the appropriate use of innovative technology. With an ageing population and ever-increasing demands on community nurses, it is vital that a national strategy is put in place to address the burden of wound care. Procurement practices need to embrace the potential of technology to disrupt the inefficiencies of current practice and enable sustainable care pathways that reduce the burdens on patients and the NHS.
References
1. Lords House, “NHS: Wound Care,” London, 22 November 2017.
2. J. Guest, N. Ayoub and T. McIlwraith, “Health economic burden that wounds impose on the National Health Service in the UK,” BMJ Open, vol. 5, no. 12, 2015.
3. J. Guest, K. Vowden and P. Vowden, “The health economic burden that acute and chronic wounds impose on an average clinical commissioning group/health board in the UK.,” Journal of Wound Care, vol. 26, no. 6, 2017.
4. J. Guest, N. Ayoub and T. McIlwraith, “Health economic burden that different wound types impose on the UK's National Health Service,” International Wound Journal, vol. 14, no. 2, 2016.
5. C. Dowsett, J. Hampton, D. Myers and T. Styche, “Use of PICO to improve clinical and economic outcomes in hard-to-heal wounds,” Wounds International, vol. 8, no. 2, 2017.
6. C. Lindholm and R. Searle , “Wound management for the 21st century: combining effectiveness and efficiency.,” International Wound Journal, vol. Jul, no. 13, 2016.
7. Woelber, E., Schrick, E. J., Gessner, B. D., & Evans, H. L. (2016). Proportion of surgical site infections occurring after hospital discharge: a systematic review. Surgical infections, 17(5), 510-519.
8. Stephen-Haynes, J., Bielby, A., & Searle, R. (2011). Putting patients first: reducing the human and economic costs of wounds. Wounds UK, 7(3), 47-55.
9. Hyldig, N., Birke‐Sorensen, H., Kruse, M., Vinter, C., Joergensen, J. S., Sorensen, J. A., ... & Bille, C. (2016). Meta‐analysis of negative‐pressure wound therapy for closed surgical incisions. British Journal of Surgery, 103(5), 477-486.
10. V. Strugala, “Scientific and medical affairs PICO evidence summary,” Surgical Infections, November 2016. 11. World Union of Wound Healing Societies. (2008). Wound infection in clinical practice. An international consensus. International Wound Journal, 5(Suppl 3), 1-11.
12. MolecuLight Inc., “MolecuLight i:X User Manual”.
13. R. DaCosta, “Point-of-care autofluorescence imaging for real-time sampling and treatment guidance of bioburden in chronic wounds: first-in-human results.,” PLoS ONE, vol. 19, no. 10, 2015.
14. Forni C, D’Alessandro F, Gallerani P, et al. Effectiveness of using a new poly-urethane foam multi-layer dressing in the sacral area to prevent the onset of pressure ulcer in the elderly with hip fractures: A pragmatic randomised con-trolled trial. Int Wound J. 2018;1–8.
