INSIDE THE CURRENT ISSUE

July 2008

What Works

Saving healthcare dollars while saving limbs

by Penny E. Campbell, PT, CWS, FACCWS, DAPWCA

How can we afford it? This is a
question we seem to be asking about
every aspect of our lives these days. With the rising cost of food, clothing, gas, education and especially healthcare, is there an answer or end in sight? I would like to share a healthcare cost
that is close to my heart both personally and professionally.

The challenge

My 71-year-old grandmother is a strong woman, to say the least. She has endured multiple complicating diagnoses that make overcoming the smallest deficit nearly impossible. She has been an insulin-dependent diabetic for several years. In addition, she has battled breast cancer, colon cancer, congestive heart failure, coronary artery disease, peripheral neuropathy and glaucoma as a result of her diabetes. Three years ago she developed some vascular changes that led to gangrenous ulcerations in one of her lower extremities. She lost her extremity to a below-the-knee amputation. During rehabilitation, she suffered severe pain while being fitted for her prosthetic. Getting back to her normal life seemed out of reach. After the initial amputation, there were color changes in the surviving limb. She had deep reddened discoloration in her foot with increased pain. Within a month of her initial amputation, she lost her other leg to another below-the-knee amputation.

This is a very sad story with great loss. Luckily, I have a very strong grandmother who has a will to live longer. I am happy to say she lives alone, cooks for herself, performs most activities of daily living and even quilts—making some of the loveliest quilts I’ve ever seen. Although she receives some assistance from my mother for shopping and cleaning, she is a remarkably independent lady.

Besides family, my other passion is my job. I am a physical therapist specializing in wound care. I have worked in this industry for nearly 11 years. I have had the opportunity to work with many wound types and different wound treatments. In doing so, I have found negative pressure wound therapy (NPWT) to be highly effective in promoting wound healing. This treatment has been around for centuries and uses low pressure "suction" from a vacuum source.

In the mid 1990s, Mark Chariker, MD and Katherine Jeter, EdD, developed a technique utilizing gauze, a drain catheter and occlusive film connecting to a vacuum device.¹ The technique has resurfaced in the past 5 years and is now available from Smith & Nephew Inc. (St. Petersburg, FL). This NPWT system recommends continuous negative pressure with default settings of 60-80 mm Hg.

The experience

How does this relate to my grandmother? Well, let’s take a look at the cost, on average, of her amputations versus the cost of NPWT for a diabetes-related surgical amputation in a patient with similar complications.

The author and her grandmother

According to the article "Diabetic Foot: Evaluation and Management" in the Southern Medical Journal, Green et al revealed some astounding information.2 They stated that:

• 15% of people with diabetes have an ulcer in their lifetime

• Today, annual cost of diabetic foot ulcers (DFUs) is $5 billion direct cost and $400 million indirect cost

• 70% of diabetics with foot ulcers have no follow-up care

• Diabetes is the leading cause of lower-limb amputations at 57,000/year or 150/day

• Today, ulcer, amputation, prosthesis and rehab cost is $20,000 – $60,000/person

• 50% of these amputations can be prevented

How can we do better as healthcare providers, family members and human beings? Knowledge is power. Education can take us further. Now, let’s look at the cost of treating a diabetic ulcer with gauze-based NPWT versus the cost of an amputation.

Case Study: A 76-year-old diabetic male with an open wound created by a right "great" toe amputation.

Comorbidities Included: Type II diabetes, hypertension, congestive heart failure, chronic obstructive pulmonary disease and, most detrimentally, noncompliance with NPWT related to dementia. The patient would disconnect himself from the therapy for several hours a day (most of the time 3-6 hours a day). The disconnection of the therapy resulted in maceration of the wound edges, slowing progress.

Treatment: NPWT at 80 mm Hg using the Chariker-Jeter moistened gauze dressing technique. Dressings were changed 2 times per week.

Outcome: Beginning measurements: 2.0 x 4.5 x 2.3 cm

Ending measurements: 1.5 x 1.1 x 0.4 cm

96.8% wound resolution in 72 days (10.3 weeks). This translates to a 9.4% volume reduction per week. The physician was pleased with the progress and NPWT discontinued. Patient was soon discharged home.

Direct cost: Daily rental cost of therapy device: $40/day = $2880

Disposable cost: dressing kits @ 2/week (37.50) = $772.50

Canister kits @ 1/week (28.50) = $293.55

Total cost of device rental and consumables = $3946.05

The reported cost of NPWT is direct cost only. This does not include such things as nursing time, medications related to the wound, and the cost of the patient’s non-compliance. The savings are still economically significant, but equally or more importantly are the clinical and emotional significance.

The results

This case study was supplied by Bethany Health and Rehab Center in Nashville, TN, a facility with extensive experience with gauze-based NPWT. The benefits of Smith & Nephew NPWT include more than simply direct clinical results. "I enjoy working with the Smith & Nephew NPWT system because it is less painful for my patients compared to my experience with other systems. The Chariker-Jeter technique is also easy to use, which makes it easy to train my nurses," explains Jennifer Hope, director of wound care at Bethany Health and Rehab Center.

The estimated cost savings compared to my grandmother’s double amputation is about $32,000 to $112,000. This is an incredible amount of money that could be used for patient education and prevention programs. Dwight Osten, an administrator at Bethany believes that making NPWT more cost-effective has allowed his facility to treat more involved wounds than they have in the past, helping to establish the rehab facility’s specialization in wound care. "The cost of NPWT in our facility has decreased directly, but we’ve also seen indirect cost savings through less use of pain medications and nursing costs associated with administering the medications."

The clinical benefits of NPWT, which possibly saved the limb in the above case, include increasing localized circulation, decreasing bacterial load and edema, increasing wound contraction and stimulating granulation tissue formation.3,4 Smith & Nephew NPWT systems offer enhanced patient comfort, ease of use and cost savings.

• The Smith & Nephew NPWT system is associated with less pain due to lower negative pressures of 40 to 80 mm Hg versus 125 mm Hg. The system also uses non-adherent, antimicrobial gauze on the wound bed that limits pain upon dressing removal and prevents in-growth into the dressing

• The wound can be easily dressed using the ostomy paste, included in the Smith & Nephew Wound Sealing Kit, around the wound to assist with maintaining a sealed system.

• The most significant advantage is related to cost savings. The Smith & Nephew system has been shown to be more cost effective than the most common NPWT.

As stated in the case above, the patient was very noncompliant with the therapy. He would disconnect the dressing for hours at a time. Compared to the immediate need for replacement with foam dressing, Smith & Nephew NPWT systems utilize antimicrobial gauze that protects against bacterial colonization in the dressing for up to 72 hours. Ultimately the dressing could be without suction for up to 72 hours and not require changing. Without active suction it would simply become a saline moistened gauze dressing. In the above case, this would translate into at least a 2x/day dressing change with foam-based NPWT systems or inability to utilize NPWT at all due to noncompliance. The difference in the NPWT system utilized could have been the difference in saving the limb.

Reducing the number of amputations related to diabetes in the US translates
to millions of dollars in savings that could be spent on diabetes prevention programs, patient education and advanced therapies such as NPWT. As an industry, family member, caregiver and, most importantly, a human being,
shouldn’t we do more?

Penny E. Campbell, PT, CWS, FACCWS, DAPWCA is a Smith & Nephew-Advanced Wound Care Division medical education manager-NPWT.

References

1. Chariker ME, Jeter KF, Tintle TE, Bottsford JE. Effective management of incisional and cutaneous fistulae with closed suction wound drainage. Contemp Surg. 1989;34:59-63.

2. Green MF, Aliabadi Z, Green BT. Diabetic foot: evaluation and management. South Med J. 2002;95:95-101.

3. Campbell PE. Surgical wound case studies with the versatile 1 wound vacuum system for negative pressure wound therapy. J Wound Ostomy Continence Nurs. 2006;33:176-185.

4. McCord SS, Naik-Mathuria BJ, Murphy KM, et al. Negative pressure therapy is effective to manage a variety of wounds in infants and children. Wound Repair Regen. 2007;15:296-301.