BMC Medicine
A systematic review of cost-effectiveness analyses of complex wound interventions reveals optimal treatments for specific wound types
Sharon E Straus3  Jeffrey S Hoch1  Jesmin Antony4  Geetha Sanmugalingham4  Paul A Khan4  Wanrudee Isaranuwatchai1  Elise Cogo4  Andrea C Tricco2 
[1]Institute of Health Policy, Management and Evaluation, University of Toronto, 155 College Street, Toronto M5T 3M7, ON, Canada
[2]Epidemiology Division, Dalla Lana School of Public Health, University of Toronto, 155 College Street, Toronto M5T 3M7, ON, Canada
[3]Department of Geriatric Medicine, University of Toronto, 200 Elizabeth Street, Suite RFE 3-805, Toronto M5G 2C4, ON, Canada
[4]Knowledge Translation Program, Li Ka Shing Knowledge Institute, St. Michael’s Hospital, 30 Bond Street, Toronto M5B 1W8, ON, Canada
关键词: Systematic review;    Skin ulcer;    Research design;    Cost-effectiveness analysis;    Cost-benefit analysis;    Complex wound;   
Others  :  1174832
DOI  :  10.1186/s12916-015-0326-3
 received in 2014-10-16, accepted in 2015-03-13, published in 13
【 摘 要 】


Complex wounds present a substantial economic burden on healthcare systems, costing billions of dollars annually in North America alone. The prevalence of complex wounds is a significant patient and societal healthcare concern and cost-effective wound care management remains unclear. This article summarizes the cost-effectiveness of interventions for complex wound care through a systematic review of the evidence base.


We searched multiple databases (MEDLINE, EMBASE, Cochrane Library) for cost-effectiveness studies that examined adults treated for complex wounds. Two reviewers independently screened the literature, abstracted data from full-text articles, and assessed methodological quality using the Drummond 10-item methodological quality tool. Incremental cost-effectiveness ratios were reported, or, if not reported, calculated and converted to United States Dollars for the year 2013.


Overall, 59 cost-effectiveness analyses were included; 71% (42 out of 59) of the included studies scored 8 or more points on the Drummond 10-item checklist tool. Based on these, 22 interventions were found to be more effective and less costly (i.e., dominant) compared to the study comparators: 9 for diabetic ulcers, 8 for venous ulcers, 3 for pressure ulcers, 1 for mixed venous and venous/arterial ulcers, and 1 for mixed complex wound types.


Our results can be used by decision-makers in maximizing the deployment of clinically effective and resource efficient wound care interventions. Our analysis also highlights specific treatments that are not cost-effective, thereby indicating areas of resource savings.

Please see related article: http://dx.doi.org/10.1186/s12916-015-0288-5 webcite

【 授权许可】

2015 Tricco et al.; licensee BioMed Central.

【 预 览 】
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【 参考文献 】
  • [1]Mustoe TA, O’Shaughnessy K, Kloeters O: Chronic wound pathogenesis and current treatment strategies: a unifying hypothesis. Plast Reconstr Surg 2006, 117:35S-41.
  • [2]Gottrup F: A specialized wound-healing center concept: importance of a multidisciplinary department structure and surgical treatment facilities in the treatment of chronic wounds. Am J Surg 2004, 187:38S-43.
  • [3]Sen CK, Gordillo GM, Roy S, Kirsner R, Lambert L, Hunt TK, et al.: Human skin wounds: a major and snowballing threat to public health and the economy. Wound Repair Regen 2009, 17:763-71.
  • [4]Swanson L: Solving stubborn-wound problem could save millions, team says. CMAJ 1999, 160:556.
  • [5]Miller PS: In economics as well as medicine prevention is better than cure. Age Ageing 2004, 33:217-8.
  • [6]Canadian Association of Wound Care. Best practice articles. http://cawc.net/index.php/resources/resources/clinical-practice/.
  • [7]Jull AB, Rodgers A, Walker N: Honey as a topical treatment for wounds. Cochrane Database Syst Rev 2008., 4Article ID CD005083
  • [8]Lazarus GS, Cooper DM, Knighton DR, Percoraro RE, Rodeheaver G, Robson MC: Definitions and guidelines for assessment of wounds and evaluation of healing. Wound Repair Regen 1994, 2:165-70.
  • [9]Werdin F, Tennenhaus M, Schaller HE, Rennekampff HO: Evidence-based management strategies for treatment of chronic wounds. Eplasty 2009, 9:e19.
  • [10]Global Industry Analysts. Advanced wound care: a global strategic business report. http://www.marketresearch.com/Global-Industry-Analysts-v1039/Advanced-Wound-Care-8102385/.
  • [11]Tricco A, Antony J, Vafaei A, Khan PA, Cogo E, Wilson C, et al. Seeking effective interventions to treat complex wounds: an overview of systematic reviews. BMC Med. 2015, DOI: 10.1186/s12916-015-0288-5.
  • [12]Sampson M, McGowan J, Cogo E, Grimshaw J, Moher D, Lefebvre C: An evidence-based practice guideline for the peer review of electronic search strategies. J Clin Epidemiol 2009, 62:944-52.
  • [13]Stone PW: Popping the (PICO) question in research and evidence-based practice. Appl Nurs Res 2002, 15:197-8.
  • [14]Newton D. Synthesi.SR. http://knowledgetranslation.ca/sysrev/login.php.
  • [15]Centers for Disease Control and Prevention. Public health economics and tools. http://www.cdc.gov/stltpublichealth/pheconomics/.
  • [16]Black WC: The CE, plane: a graphic representation of cost-effectiveness. Med Decis Making 1990, 10:212-4.
  • [17]Government of Ontario. Ontario guidelines for economic analysis of pharmaceutical products: interpretation of cost-effectiveness ratios. http://www.health.gov.on.ca/english/providers/pub/drugs/economic/econ_ratios.html.
  • [18]Drummond MF: Methods for the economic evaluation of health care programmes. 3rd edition. Oxford University Press, Oxford, New York; 2005.
  • [19]OECD. StatExtracts, PPPs and exchange rates. http://stats.oecd.org/Index.aspx?datasetcode=SNA_TABLE4.
  • [20]Economy Watch. Implied PPP conversion rate data for year 1997, all countries. http://www.economywatch.com/economic-statistics/economic-indicators/Implied_PPP_Conversion_Rate/1997/.
  • [21]US Bureau of Labor Statistics. Consumer price index – all urban consumers (current series). http://data.bls.gov/pdq/querytool.jsp?survey=cu.
  • [22]Augustin M, Siegel A, Heuser A, Vanscheidt W: Chronic leg ulcers: cost evaluation of two treatment strategies. J Dermatolog Treat 1999, 10:S21-5.
  • [23]DePalma RG, Kowallek D, Spence RK, Caprini JA, Nehler MR, Jensen J, et al.: Comparison of costs and healing rates of two forms of compression in treating venous ulcers. Vasc Surg 1999, 33:683-90.
  • [24]Glinski W, Chodynicka B, Roszkiewicz J, Bogdanowski T, Lecewicz-Torun B, Kaszuba A, et al.: The beneficial augmentative effect of micronised purified flavonoid fraction (MPFF) on the healing of leg ulcers: An open, multicentre, controlled, randomised study. Phlebology 1999, 14:151-7.
  • [25]Gordon L, Edwards H, Courtney M, Finlayson K, Shuter P, Lindsay E: A cost-effectiveness analysis of two community models of care for patients with venous leg ulcers. J Wound Care 2006, 15:348-53.
  • [26]Guest JF, Taylor RR, Vowden K, Vowden P: Relative cost-effectiveness of a skin protectant in managing venous leg ulcers in the UK. J Wound Care 2012, 21:389-94.
  • [27]Iglesias CP, Claxton K: Comprehensive decision-analytic model and Bayesian value-of-information analysis: pentoxifylline in the treatment of chronic venous leg ulcers. Pharmacoeconomics 2006, 24:465-78.
  • [28]Iglesias CP, Nelson EA, Cullum N, Torgerson DJ: VenUS I Collaborators: Economic analysis of VenUS I, a randomized trial of two bandages for treating venous leg ulcers. Br J Surg 2004, 91:1300-6.
  • [29]Jull A, Walker N, Parag V, Molan P, Rodgers A: Randomized clinical trial of honey‐impregnated dressings for venous leg ulcers. Br J Surg 2008, 95:175-82.
  • [30]Junger M, Arnold A, Zuder D, Stahl HW, Heising S: Local therapy and treatment costs of chronic, venous leg ulcers with electrical stimulation (Dermapulse): a prospective, placebo controlled, double blind trial. Wound Repair Regen 2008, 16:480-7.
  • [31]Kerstein MD, Gahtan V: Outcomes of venous ulcer care: results of a longitudinal study. Ostomy Wound Manage 2000, 46:22-6.
  • [32]Kikta MJ, Schuler JJ, Meyer JP, Durham JR, Eldrup-Jorgensen J, Schwarcz TH, et al.: A prospective, randomized trial of Unna’s boots versus hydroactive dressing in the treatment of venous stasis ulcers. J Vasc Surg 1988, 7:478-83.
  • [33]Michaels JA, Campbell WB, King BM, Macintyre J, Palfreyman SJ, Shackley P, et al.: A prospective randomised controlled trial and economic modelling of antimicrobial silver dressings versus non-adherent control dressings for venous leg ulcers: the VULCAN trial. Health Technol Assess 2009, 13:1-114.
  • [34]Morrell CJ, Walters SJ, Dixon S, Collins KA, Brereton LM, Peters J, et al.: Cost effectiveness of community leg ulcer clinics: randomised controlled trial. BMJ 1998, 316:1487-91.
  • [35]O’Brien JF, Grace PA, Perry IJ, Hannigan A, Clarke Moloney M, Burke PE: Randomized clinical trial and economic analysis of four-layer compression bandaging for venous ulcers. Br J Surg 2003, 90:794-8.
  • [36]Oien RF, Hakansson A, Ahnlide I, Bjellerup M, Hansen BU, Borgquist L: Pinch grafting in hospital and primary care: a cost analysis. J Wound Care 2001, 10:164-9.
  • [37]Sibbald RG, Torrance GW, Walker V, Attard C, MacNeil P: Cost-effectiveness of Apligraf in the treatment of venous leg ulcers. Ostomy Wound Manage 2001, 47:36-46.
  • [38]Taylor AD, Taylor RJ, Marcuson RW: Prospective comparison of healing rates and therapy costs for conventional and four-layer high-compression bandaging treatments of venous leg ulcers. Phlebology 1998, 13:20-4.
  • [39]Ukat A, Konig M, Vanscheidt W, Munter KC: Short-stretch versus multilayer compression for venous leg ulcers: a comparison of healing rates. J Wound Care 2003, 12:139-43.
  • [40]Watson JM, Kang’ombe AR, Soares MO, Chuang LH, Worthy G, Bland JM, et al.: VenUS III: a randomised controlled trial of therapeutic ultrasound in the management of venous leg ulcers. Health Technol Assess 2011, 15:1-192.
  • [41]Pham B, Harrison MB, Chen MH, Carley ME: Cost-effectiveness of compression technologies for evidence-informed leg ulcer care: results from the Canadian Bandaging Trial. BMC Health Serv Res 2012, 12:346-53. BioMed Central Full Text
  • [42]Schonfeld WH, Villa KF, Fastenau JM, Mazonson PD, Falanga V: An economic assessment of Apligraf (Graftskin) for the treatment of hard-to-heal venous leg ulcers. Wound Repair Regen 2000, 8:251-7.
  • [43]Simon DA, Freak L, Kinsella A, Walsh J, Lane C, Groarke L, et al.: Community leg ulcer clinics: a comparative study in two health authorities. BMJ 1996, 312:1648-51.
  • [44]Carr L, Phillips Z, Posnett J: Comparative cost-effectiveness of four-layer bandaging in the treatment of venous leg ulceration. J Wound Care 1999, 8:243-8.
  • [45]Guest JF, Nagy E, Sladkevicius E, Vowden P, Price P: Modelling the relative cost-effectiveness of amelogenin in non-healing venous leg ulcers. J Wound Care 2009, 18:216.
  • [46]Dumville JC, Worthy G, Soares MO, Bland JM, Cullum N, Dowson C, et al.: VenUS II: a randomised controlled trial of larval therapy in the management of leg ulcers. Health Technol Assess 2009, 13:1-182.
  • [47]Ohlsson P, Larsson K, Lindholm C, Moller M: A cost-effectiveness study of leg ulcer treatment in primary care. Comparison of saline-gauze and hydrocolloid treatment in a prospective, randomized study. Scand J Prim Health Care 1994, 14:295-9.
  • [48]Abidia A, Laden G, Kuhan G, Johnson BF, Wilkinson AR, Renwick PM, et al.: The role of hyperbaric oxygen therapy in ischaemic diabetic lower extremity ulcers: a double-blind randomised-controlled trial. Eur J Vasc Endovasc Surg 2003, 25:513-8.
  • [49]Apelqvist J, Ragnarson TG: Cavity foot ulcers in diabetic patients: a comparative study of cadexomer iodine ointment and standard treatment. An economic analysis alongside a clinical trial. Acta Derm Venereol 1996, 76:231-5.
  • [50]Edmonds M, Gough A, Solovera J, Standaert B: Filgrastim in the treatment of infected diabetic foot ulcers. Retrospective cost analysis of a phase II randomised clinical trial. Clin Drug Investig 1999, 17:275-86.
  • [51]Guo S, Counte MA, Gillespie KN, Schmitz H: Cost-effectiveness of adjunctive hyperbaric oxygen in the treatment of diabetic ulcers. Int J Technol Assess Health Care 2003, 19:731-7.
  • [52]Habacher W, Rakovac I, Gorzer E, Haas W, Gfrerer RJ, Wach P, et al.: A model to analyse costs and benefit of intensified diabetic foot care in Austria. Eur J Vasc Endovasc Surg 2007, 13:906-12.
  • [53]Horswell RL, Birke JA, Patout CA Jr: A staged management diabetes foot program versus standard care: a 1-year cost and utilization comparison in a state public hospital system. Arch Phys Med Rehabil 2003, 84:1743-6.
  • [54]Jansen JP, Kumar R, Carmeli Y: Accounting for the development of antibacterial resistance in the cost effectiveness of ertapenem versus piperacillintazobactam in the treatment of diabetic foot infections in the UK. Pharmacoeconomics 2009, 27:1045-56.
  • [55]Jeffcoate WJ, Price PE, Phillips CJ, Game FL, Mudge E, Davies S, et al.: Randomised controlled trial of the use of three dressing preparations in the management of chronic ulceration of the foot in diabetes. Health Technol Assess 2009, 13:1-86.
  • [56]McKinnon PS, Paladino JA, Grayson ML, Gibbons GW, Karchmer AW: Cost-effectiveness of ampicillin/sulbactam versus imipenem/cilastatin in the treatment of limb-threatening foot infections in diabetic patients. Clin Infect Dis 1997, 24:57-63.
  • [57]Persson U, Willis M, Odegaard K, Apelqvist J: The cost-effectiveness of treating diabetic lower extremity ulcers with becaplermin (Regranex): a core model with an application using Swedish cost data. Value Health 2000, 3:39-46.
  • [58]Piaggesi A, Macchiarini S, Rizzo L, Palumbo F, Tedeschi A, Nobili LA, et al.: An off-the-shelf instant contact casting device for the management of diabetic foot ulcers: a randomized prospective trial versus traditional fiberglass cast. Diabetes Care 2007, 30:586-90.
  • [59]Redekop WK, McDonnel J, Verboom P, Lovas K, Kalo Z: The cost-effectiveness of Apligraf treatment of diabetic foot ulcers. Pharmacoeconomics 2003, 21:1171-83.
  • [60]Allenet B, Paree F, Lebrun T, Carr L, Posnett J, Martinin J, et al.: Cost-effectiveness modelling of Dermagraft for the treatment of diabetic foot ulcers in the French context. Diabetes Metab 2000, 26:125-32.
  • [61]Ghatnekar O, Willis M, Persson U: Cost-effectiveness of treating deep diabetic foot ulcers with Promogram in four European countries. J Wound Care 2002, 11:70-4.
  • [62]Ghatnekar O, Persson U, Willis M, Odegaard K: Cost effectiveness of becaplermin in the treatment of diabetic foot ulcers in four European countries. Pharmacoeconomics 2001, 19:767-78.
  • [63]Hailey D, Jacobs P, Perry DC, Chuck A, Morrison A, Boudreau R: Adjunctive hyperbaric oxygen therapy for diabetic foot ulcer: an economic analysis. Canadian Agency for Drugs and Technologies in Health 2007, 75:1-19.
  • [64]Branom R, Rappl LM: Constant force technology versus low-air-loss therapy in the treatment of pressure ulcers. Ostomy Wound Manage 2001, 47:38-46.
  • [65]Burgos A, Gimenez J, Moreno E, Lamberto E, Utrera M, Urraca EM, et al.: Cost, efficacy, efficiency and tolerability of collagenase ointment versus hydrocolloid occlusive dressing in the treatment of pressure ulcers. A comparative, randomised, multicentre study. Clin Drug Investig 2000, 19:357-65.
  • [66]Chang KW, Alsagoff S, Ong KT, Sim PH: Pressure ulcers–randomised controlled trial comparing hydrocolloid and saline gauze dressings. Med J Malaysia 1998, 53:428-31.
  • [67]Chuangsuwanich A, Charnsanti O, Lohsiriwat V, Kangwanpoom C, Thong-In N: The efficacy of silver mesh dressing compared with silver sulfadiazine cream for the treatment of pressure ulcers. J Med Assoc Thai 2011, 94:559-65.
  • [68]Ferrell BA, Keeler E, Siu AL, Ahn SH, Osterweil D: Cost-effectiveness of low-air-loss beds for treatment of pressure ulcers. J Gerontol A Biol Sci Med Sci 1995, 50:M141-6.
  • [69]Foglia E, Restelli U, Napoletano AM, Coclite D, Porazzi E, Bonfanti M, et al.: Pressure ulcers management: an economic evaluation. J Prev Med Hyg 2012, 53:30-6.
  • [70]Graumlich JF, Blough LS, McLaughlin RG, Milbrandt JC, Calderon CL, Agha SA, et al.: Healing pressure ulcers with collagen or hydrocolloid: a randomized, controlled trial. J Am Geriatr Soc 2003, 51:147-54.
  • [71]Muller E, van Leen MW, Bergemann R: Economic evaluation of collagenase-containing ointment and hydrocolloid dressing in the treatment of pressure ulcers. Pharmacoeconomics 2001, 19:1209-16.
  • [72]Narayanan S, Van Vleet J, Strunk B, Ross RN, Gray M: Comparison of pressure ulcer treatments in long-term care facilities: clinical outcomes and impact on cost. J Wound Ostomy Continence Nurs 2005, 32:163-70.
  • [73]Payne WG, Posnett J, Alvarez O, Brown-Etris M, Jameson G, Wolcott R, et al.: A prospective, randomized clinical trial to assess the cost-effectiveness of a modern foam dressing versus a traditional saline gauze dressing in the treatment of stage II pressure ulcers. Ostomy Wound Manage 2009, 55:50-5.
  • [74]Robson MC, Hill DP, Smith PD, Wang X, Meyer-Siegler K, Ko F, et al.: Sequential cytokine therapy for pressure ulcers: clinical and mechanistic response. Ann Surg 2000, 231:600-11.
  • [75]Sanada H, Nakagami G, Mizokami Y, Minami Y, Yamamoto A, Oe M, et al.: Evaluating the effect of the new incentive system for high-risk pressure ulcer patients on wound healing and cost-effectiveness: a cohort study. Int J Nurs Stud 2010, 47:279-86.
  • [76]Xakellis GC, Chrischilles EA: Hydrocolloid versus saline-gauze dressings in treating pressure ulcers: a cost-effectiveness analysis. Arch Phys Med Rehabil 1992, 73:463-9.
  • [77]Sebern MD: Pressure ulcer management in home health care: efficacy and cost effectiveness of moisture vapor permeable dressing. Arch Phys Med Rehabil 1986, 67:726-9.
  • [78]Bale S, Hagelstein S, Banks V, Harding KG: Costs of dressings in the community. J Wound Care 1998, 7:327-30.
  • [79]Terry M, Halstead LS, O’Hare P, Gaskill C, Ho PS, Obecny J, et al.: Feasibility study of home care wound management using telemedicine. Adv Skin Wound Care 2009, 22:358-64.
  • [80]Vu T, Harris A, Duncan G, Sussman G: Cost-effectiveness of multidisciplinary wound care in nursing homes: a pseudo-randomized pragmatic cluster trial. Fam Pract 2007, 24:372-9.
  • [81]Sebern MD: Cost and efficacy of pressure ulcer management in a metropolitan visiting nurse association. Decubitus 1989, 2:58-9.
  • [82]Chuck AW, Hailey D, Jacobs P, Perry DC: Cost-effectiveness and budget impact of adjunctive hyperbaric oxygen therapy for diabetic foot ulcers. Int J Technol Assess Health Care 2008, 24:178-83.
  • [83]Iglesias C, Nelson EA, Cullum NA, Torgerson DJ, VenUS Team. VenUS I: a randomised controlled trial of two types of bandage for treating venous leg ulcers. Health Technol Assess. 2004;8:iii. 1-105.
  • [84]International Conference on Harmonisation (ICH) of Technical Requirements for the Registration of Pharmaceuticals for Human Use. Guidance E9: Statistical Principles for Clinical Trials. Rockville, MD: ICH; 1998.
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