Unexpected economics of ulcer care protocols.

Abstract: The cost of managing chronic ulcers, both venous leg and decubiti (sacral pressure), was reviewed using 36 randomized, controlled studies with a focus on saline, hydrocolloid, and a human skin construct. When one includes the labor intensiveness of dressing changes three to four times per day, the application of hydrocolloid dressing becomes the most cost-effective.

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The world of long-term care (LTC) is changing. As the elderly population grows at an unprecedented rate, increasing numbers of people are dependent on LTC facilities and health care professionals for their health and comfort. (1) Unfortunately, the increasing numbers of people who need LTC do not necessarily coincide with a similar increase in funding for such care. (1) Pressure and venous ulcers are common in LTC facilities, where resident health care problems are a daily and expensive certainty. In the present economic environment, efforts to lower health care costs, both for patients and for providers, are of growing importance. (2-7)

According to a 2001 meta-analysis of multiple clinical studies, considering only the cost of the products required when assessing the impact of care procedures can be misleading, especially in the instance of ulcer treatment protocols. (8) This analysis produced a "snapshot" of wound-care practices that provides a perspective of these protocols that would not be available from a single study. The results of the meta-analysis illustrate that the best quality care, although apparently more costly at the outset, is less expensive than the protocol of care that appears initially to be the most economical.

Methods

For this analysis, the Lewin Group, an independent study group based in Falls Church, VA, reviewed the literature on the basis of data from 36 randomized, controlled clinical studies conducted between 1984 and 1999. These studies involved both acute and LTC patients. A panel of wound-care experts--a vascular surgeon, a dermatologist, a family medicine practitioner, and a geriatric nurse practitioner--validated the study's findings. Wound-care protocols in the studies followed Agency for Health Care Policy and Research (currently known as the Agency for Healthcare Research and Quality) guideline recommendations. The studies were varied by wound type (pressure or venous ulcer) and dressing type (gauze, hydrocolloid, or human skin construct). (9) (10) The cost of wound management was tracked, including average time to heal, wear time of wound-management products, and complication management costs. (11), (12) Costs were calculated using data from the 2000 Drug Topics RedBook and 2000 Medicare Durable Medical Equipment Fee Schedule (dressings); 2000 Medicare Physician Fee Schedule (physician fees); and the March 1996 National Sample Survey of Registered Nurses, with monetary values inflated to 2000 equivalents (nursing costs).

Results

Four treatment protocols were analyzed to determine the cost of pressure ulcer care: saline gauze (Protocol G), hydrocolloid C (Protocol C [Comfeel, Coloplast, Humlebaek, Denmark]), hydrocolloid D (Protocol D [DuoDERM, E.R. Squibb & Sons, L.L.C., Princeton, NJ]), and a human skin construct (Apligraf, Novartis Pharmaceuticals Corp., East Hanover, NJ). In addition to the costs of wound dressings, many different factors were used to determine the final cost of ulcer wound management during a 12-week period. (13-15) Supportive care, including pressure relief, nutritional support, and incontinence management, is necessary for all pressure ulcers, whereas vascular assessment is required for venous ulcers. (16), (17) Physician/nursing visits and dressing changes affect costs for both ulcer types, and debridement and infection treatment were included in many instances. At least 12 weeks are required to heal 50% of ulcers, with more time needed for deep and/or large wounds.

Discussion

Saline gauze is the least expensive ulcer dressing ($93 for gauze versus approximately $265 for hydrocolloid versus $7,021 for human skin construct). However, total treatment cost for 12 weeks of pressure ulcer care was much lower with the initially more expensive Protocols C and D, because ulcers treated with hydrocolloid require far fewer dressing changes and heal faster (and have considerably lower associated nursing costs) than those treated with gauze. The use of human skin construct represents a product cost but not a labor cost. (18), (19)

In fact, the price difference for the dressings pales in comparison with gauze versus hydrocolloid nursing costs over 12 weeks ($996 for gauze versus $152 to $170 for hydrocolloid, and $7,021 for human skin construct). (2), (14) With doctor visit charges being equal for both types of dressing, the overall cost of saline gauze Protocol G averages far more than that of Protocols C and D human skin construct in pressure ulcer care.

Likewise, the initial cost of (saline) Protocol G materials (an average of $112) for venous ulcer treatment appears to indicate that treatment with gauze is the most economical. Protocol D (hydrocolloid) materials cost an average of approximately $225, and human skin construct (Protocol A [Apligraf]), begins at more than $6,000 for materials. (7), (18), (19) However, nursing costs for (saline) Protocol G average approximately $560, whereas Protocol D (hydrocolloid) nursing averages less than $230. Although Protocol A (Apligraf) is significantly more expensive than Protocols G and D; interestingly, associated nursing costs ($138) are significantly lower.

Conclusion

In view of these findings, LTC personnel should not rely solely on the initial cost of materials when making decisions regarding ulcer treatment protocols. The apparently costlier hydrocolloid ulcer treatment is significantly less expensive than saline gauze treatment. As more residents rely on LTC facilities for their health and comfort, caregivers and facilities need to be informed regarding all elements that contribute to the cost of ulcer treatment protocol.

Key Points

* Supportive care, including pressure relief, nutritional support, and incontinence management is necessary for all (pressure) ulcers; vascular assessment is required for all venous ulcers.

* The true cost of wound care is measured by the cost of dressings and the cost of labor (number of visits, length of visit).

* Alternatives in ulcer (venous, pressure) care include saline, hydrocolloid (Comfeel, DuoDERM), and human skin construct.

* At least 12 weeks are required to achieve 50% healing of wound (10 X 10 cm) when using hydrocolloid dressings plus appropriate care.

Acknowledgement

I thank Gae O. Decker-Garrad for editorial assistance.

Accepted May 21, 2003.

Copyright [c] 2004 by The Southern Medical Association 0038-4348/04/9702-0135

References

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(13.) Brandeis GH, Ooi WL, Hossain M, et al. A longitudinal study of risk factors associated with the formation of pressure ulcers in nursing homes. J Am Geriatr Soc 1994;42:388-393.

(14.) Einarson TR. Pharmacoeconomic applications of meta-analysis for single groups using antifungal onychomycosis lacquers as an example. Clin Ther 1997;19:538-539, 559-569.

(15.) Kerstein MD, Gahtan V. Outcomes of venous ulcer care: Results of a longitudinal study. Ostomy Wound Manage 2000;46:22-26, 28-29.

(16.) Langemo DK, Olson B, Hunter S, et al. Incidence and prediction of pressure ulcers in five patient care setting. Decubitus 1991;4:25-26, 28, 30 passim.

(17.) Lyon RT, Veith FJ, Bolton L, et al. Clinical benchmark for healing of chronic venous ulcers: Venous Ulcer Study Collaborators. Am J Surg 1998;176:172-175.

(18.) Thomas DR, Goode PS, LaMaster K, et al. Acemannan hydrogel dressing versus saline dressing for pressure ulcers: A randomized, controlled trial. Adv Wound Care 1998;11:273-276.

(19.) Wood CR, Margolis DJ. The cost of treating venous ulcers to complete healing using an occlusive dressing and a compression bandage. Wounds 1992;4:138-141.

Morris D. Kerstein, MD

From the Veterans Affairs Medical and Regional Office Center, Wilmington, DE, and the Jefferson Medical College of Thomas Jefferson University, Philadelphia, PA.

This article is adapted from Kerstein MD, Gemmen E, van Rijswijk L, et al. Cost and cost effectiveness of venous and pressure protocols of care. Dis Manage Health Outcomes 2001;9:651-663.

Reprint requests to Morris D. Kerstein, MD, 1214 Valley Road, Villanova, PA 19085-2124. Email: [e-mail]