Making the case for cost-effective wound management Professor Keith Harding, Cardiff University, UK
Making the case for cost-effective wound management Clinicians who treat patients with wounds need access to resources that deliver the best and most appropriate treatments However, tension exists between resource availability and demand Increasing cost of healthcare Constrained healthcare budgets Choices and sacrifices Aging population... increasing prevalence and incidence of wounds
Types of wounds 1 Acute wounds Chronic wounds Traumatic wounds Total wounds 300+ million 20 million 100+ million 400+ million Surgical wounds Lacerations Skin grafts Cosmetic Pressure ulcers Leg ulcers Diabetic ulcers Burns Trauma Increasing Public health Tolerance
Cost estimates 1 Traditional Advanced dressings Actives Total spend $2.1 billion $3.2 billion $0.7 billion $70+ billion Gauze Absorbents Moist wound dressings NPWT Active Dressings Biologicals Surgery Biologicals Dressings Bandages Adjuncts Beds Care time Pharma
How do you measure success to secure funding? Wounds healed? Wound-free days? Decrease in pain, odour or exudate? Eradication of infection? Increase in patients quality of life? Changes in patients /caregivers experiences? Improved cost-effectiveness? Unrealistic to use complete healing as primary outcome measure more appropriate to adopt broader-based approach 2
Challenges to cost-effective wound management 3,4 Need to understand true costs of wound care to defend services 3 How can we demonstrate that a health intervention offers value for money for the patient benefits it provides? Health economics can help using data on efficacy, effectiveness and cost 4 However, in wound management there is: lack of consistency in cost/resource-usage data collection and in best practice application limited data on clinical efficacy and effectiveness
New international consensus 4 Document aims to help clinicians, budget-holders, payors, etc to: understand what is meant by 'cost-effective wound management' appreciate the different types of economic analysis used in healthcare interpret information on the cost and cost-effectiveness of wound care modalities and protocols set up systems to collect the data for analysis make an appropriate case for cost-effective wound management
What is cost-effectiveness? 4 A cost-effective intervention provides clinical benefits at a reasonable cost, and the benefits provided exceed those that would be gained if the resources were used elsewhere Being cost-effective is sometimes equated with being inexpensive or cost-saving, but often this is not the case Terminology can be confusing and may have multiple meanings in everyday language require clear definitions to avoid misinterpretation
Types of economic analysis 4 Assessing the cost-effectiveness of a health intervention is about examining the balance between cost and benefit Type Cost or burden of illness Cost-minimisation Cost-effectiveness* Cost-utility Cost-benefit Cost-consequences Comments *Sometimes also known as a cost-benefit study Determines how much a particular disease costs individuals, the healthcare system, the economy and society Does not indicate value for money Measures the costs of treatments with identical outcomes Measures the costs of achieving a defined unit of outcomes, eg cost per wound healed, amputation avoided or life-year gained Measures costs in terms of survival and quality of life Measures both costs and benefits in monetary terms, eg cost per QALY Quantifies all outcomes and relates them to the costs for each of a range of alternative courses of action
What are costs? 4 Direct and indirect costs which to include depends on the perspective of the analysis Direct costs Diagnostic tests Primary and secondary dressings, tape, cleansers, bandages, support stockings, medication and other materials costs Clinician time (eg nursing and medical) Hospital/clinic overheads (eg administration services, building costs, heating, lighting, cleaning, etc) Costs of transporting the patient to the health service Indirect costs Loss of income by patients and/or their carers due to reduced time at or ability to work Costs due to reduced ability to undertake domestic responsibilities, eg cleaning or caring for others Welfare, social security or disability payments by government or insurance company
Costs 4 Direct costs are easier to collect, but may not fully represent the economic impact of a wound or its treatment To aid comparisons, economic analyses of wound care interventions should specify amounts for each resource analysed, eg number of hours of clinician time and number of dressings used, in addition to the monetary costs and the date and source of the valuation for each
Outcome measures 4 Should be appropriate for the condition and intervention being studied, and ideally should be meaningful to patients Outcome measures used to compare different interventions should have the same units The wide variety of outcome measures used in wound management research hinders comparisons of interventions and progress We urgently need to develop patient-centred outcomes and international agreement on which outcome measures should be used
Interpreting cost studies 4 Requires care studies are very variable in approach and quality The cheapest intervention is not necessarily the most cost-effective Some agencies use QALY thresholds, eg NICE in the UK ( 20,000 30,000/QALY)
Data collection 4 We need to develop consistency in what data we collect Using data collected as part of routine clinical contact provides opportunities for accumulating data Know what you are measuring and why Develop uniform collection methods Involve a statistician and/or health economist Consider health-related and patient-related QOL Consider starting on a small scale, then scale up to involve more centres to allow larger amounts of data to be collected over a wider area
What do we know? 4 There is limited information on cost and costeffectiveness for wound management What information is available varies considerably by country In general, cost analyses of wound management produce underestimates because measurement and valuation of all costs in monetary terms is not usually possible It is clear that cost-effective wound management will include treatment of the underlying cause and treatment of the wound itself
Myths about cost-effectiveness 4 Myth: Cost-effective means cheaper or costsaving Myth: An intervention is either cost-effective or not cost-effective Myth: Evidence of cost-effectiveness is sparser and more difficult to acquire than in other areas of healthcare Myth: Analysis of cost-effectiveness is too difficult and time-consuming to undertake Myth: A favourable cost-effectiveness analysis will in itself gain the intervention funding or reimbursement and adoption into clinical practice, and is the only parameter of interest to payors
Making the case 4 Identify and engage with key stakeholders and understand their different perspectives. Consider providing information to answer: What is the scale of the problem? What is the target group of the intervention? What is the evidence base? Are there examples from the real world? How long is the intervention required? What is the payment/reimbursement? Is the intervention affordable? What are the costs and how cost-effective is the intervention? What are the benefits to staff/organisation/healthcare setting or system? How will the new intervention fit into the current system? What education/training costs and additional resources are needed? What are the risks?
Making the case 4 Keep your argument short and straightforward; avoid technical language Use your clinical expertise to provide stakeholders with a deeper knowledge of wound management Demonstrate what good wound management can achieve use simple measures such as clinical photographs Educate stakeholders to look at the big picture cost savings in one area may increase resource usage elsewhere Your data are powerful develop your argument carefully and be aware of any unintended consequences Remember: you are the catalyst for improving patient care
Challenges: wound infection Wound infection is a common complication At least 5% of patients develop an SSI after a surgical procedure 5 Around 50% of chronic wounds may be infected 6 Determining wounds that are infected is often difficult No diagnostic tools Need to use other ways of identifying wound infection
Challenges: identifying infection
Challenges: identifying infection
Challenges: clinical evidence base The routine use of antibiotics is not justified for colonised or infected wounds 7 Need to identify patients who may benefit from treatment with a topical antimicrobial such as silver 8 BUT there is an absence of high-level evidence 9 Need to THINK, REFLECT and EVALUATE
Making a case for silver Silver dressings play an integral role in the topical management of wound bioburden 10 Judicious use of silver is central to ensuring sustainability of these products BUT misunderstanding can lead to misuse International consensus documents have highlighted the need to use antimicrobial dressings appropriately to help manage wound infections 7,11
Principles for appropriate use 10,11 Follow a best-practice approach to determine the need for a silver dressing do not use if no clinical signs of infection Choose the most appropriate silver dressing to meet a patient s needs Read manufacturer s instructions for use Know how long to use the silver dressing for
The two-week challenge 11 The 2012 silver consensus group suggested that the first two weeks of treatment with a silver dressing can be seen as a challenge period during which the efficacy of the silver dressing can be assessed Ongoing assessment and re-evaluation will provide guidance on the need to continue, alter or discontinue the use of a silver dressing
Effect of two-week challenge The two-week challenge can lead to: Timely interventions to control infection Avoidance of repeating treatments that don t work Better outcomes Reduction in cost of silver dressings 12 Remember cost-effectiveness is not determined by direct cost alone. Consider ease of use, wear time, nursing visits and efficacy of dressing in reducing wound bioburden
Conclusion Chronic wounds represent a large and growing burden for patients and healthcare providers 1 3 It is important that we use limited resources effectively the right product, on the right wound, at the right time, for the right patient 4 Timely and appropriate use of topical antimicrobial agents and dressings, such as silver, is important to meet clinical and patient needs 10,11 Implementation of effective treatment protocols can lead to better utilisation of resources and improved cost-efficiency 4
References 1. Harding K, Queen D. A 25-Year Wound Care Journey within the Evolution of Wound Care. Adv Skin & Wound Care 2012; 25(2):66 70 2. Grey D, Leaper D, Harding K, Editorial BMJ 24 April 2009 3. Harding D, Posnett J, Vowden K. A new methodology for costing wound care. Int Wound J 2013; 10:623 9. 4. International consensus. Making the case for cost-effective wound care. An expert working group consensus. London: Wounds International, 2013. Available from http://www.woundsinternational.com/clinical-guidelines/international-consensus-making-the-casefor-cost-effective-wound-management 5. National Institute for Health and Clinical Excellence (2008) Quick reference guide: surgical site infection. London: NICE. Available from http://www.nice.org.uk/nicemedia/live/11743/42381/42381.pdf 6. Reddy M, Gill SS, Wu K et al. Does this patient have an infection of a chronic wound? JAMA 2012;307(6):605 11 7. World Union of Wound Healing Societies (WUWHS). Principles of best practice: Wound infection in clinical practice. An international consensus. London: MEP Ltd, 2008. Available from http://www.woundsinternational.com/clinical-guidelines/wound-infection-in-clinical-practice-aninternational-consensus 8. Best Practice Statement: The use of topical antimicrobial agents in wound management. Wounds UK 2013. Available from http://www.wounds-uk.com/best-practice-statements/best-practice-statementthe-use-of-topical-antimicrobial-agents-in-wound-management 9. Beam JW. Topical silver for infected wounds. J Athl Train 2009; 44(5): 531 3. 10. Moore Z. How to...top tips on when to use silver dressings. Wounds Int 2013; 4(1). 11. International consensus. Appropriate use of silver dressings in wounds. An expert working group consensus. London: Wounds International, 2012. Available from http://www.woundsinternational.com/clinical-guidelines/international-consensus-appropriate-use-ofsilver-dressings-in-wounds 12. Searle R, Bielby A. Dressing strategies for the management of infected wounds in community wound care: impacts and implications. Poster presented at Wounds UK, Harrogate Nov 2010.