Is Noncontact Normothermic Wound Therapy Cost Effective for the Treatment of Stages 3 and 4 Pressure Ulcers?
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Chronic pressure ulcers are significant health problems, especially for patients in long-term care facilities. Pressure ulcers reduce quality of life and may lead to infection, pain, and death. Estimates of the prevalence of pressure ulcers in nursing home patients range from 3 to 28 percent,1–3 with an annual incidence of 2 to 13 percent.4–6 Reducing the proportion of nursing home residents with pressure ulcers is receiving increasing public health attention and is one of the Healthy People 2010 Objectives.7
While prevention of pressure ulcers should be the primary goal, over the past decade, new adjunctive therapies have become available to treat pressure ulcers.8 These therapies include the use of electric energy,9 external negative pressure,10 low air-loss beds,11 various dressings,12 skin substitutes,13 and growth factors.14 Commonly, however, standard of care consists of cleansing the ulcer, using moisture-retentive dressings, providing a pressure-reducing surface, repositioning the patient, and debriding necrotic tissue.15
Another novel treatment is noncontact normothermic wound therapy (NNWT),* which is a semiocclusive, moisture-retentive wound cover that is warmed to 38 degrees C to deliver radiant heat, which maintains wound temperatures closer to normothermia. Increasing the temperature of wound tissues increases skin oxygen tension16–18 and increases oxygen delivery due to increased perfusion.19,20 These conditions encourage tissue healing21–24 and resistance to infection.25 NNWT also reduces the inhibitory effect of chronic wound fluid26 and stimulates cell proliferation in vitro.27 NNWT has been shown to accelerate healing of chronic venous stasis ulcers.28,29
From a Food and Drug Administration (FDA) regulatory perspective, NNWT can claim increased blood flow and increased oxygen at the wound site. As preliminary studies of wound healing efficacy with NNWT are now complete, the cost effectiveness of NNWT compared to standard care can be examined. The goal of this study was to develop a Markov model to estimate the incremental cost effectiveness of NNWT compared to that of the current standard of care from the societal perspective.
Cost-effectiveness analysis produces a ratio. The numerator takes into consideration the additional costs that one intervention imposes over another. The denominator considers the incremental improvement in health-related quality of life calculated as quality-adjusted life years (QALY).
Our base case focused on a 72-year-old continent man living in a nursing home with a two-month-old stage 3 pressure ulcer (no undermining) in the ischial area measuring 4cm x 4cm. This base case was chosen to be representative of a common clinical scenario. The base case represents our best estimate for each clinical variable. We completed a secondary economic analysis of stage 4 pressure ulcers.
Overview. We reviewed the literature to determine the rates of healing and complications associated with treatment of pressure ulcers, computed associated incremental costs, created a Markov model,30 assumed a societal perspective for the analysis as recommended by an expert panel,31 estimated quality of life for relevant health states, and performed a sensitivity analysis to evaluate the impact of changing key variables. A Markov model is built to simulate the progression of hypothetical patients through various health states related to their illness.
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