Wound Medicine 6 (2014) 11–14

Cost-minimization Analysis

Wound treatment costs comparing a bio-cellulose dressing with moistwound healing dressings and conventional dressings

Michael Schmitz a,*, Thomas Eberlein b, Anneke Andriessen c

a MCS Medical Consulting, Oberahr, Germanyb German Wound Academy, Hamburg, Germanyc Andriessen Consultants, Malden & UMC St. Radboud, Nijmegen, The Netherlands

A R T I C L E I N F O

Article history:

Received 17 July 2014

Accepted 28 July 2014

Available online 15 August 2014

Keywords:

Cost reduction

Traditional dressing

Moist wound healing dressing

Bio-cellulose dressing

A B S T R A C T

Aim: The aim of the present paper was to compare material and labour costs of a bio-cellulose dressing1

with traditional dressings (surgical pads, tulle grass, saline soaked gauze) and moist wound healing

dressings.

Methods: A prospective cohort study measured clinical efficacy, materials and labour costs when using

bio-cellulose dressing1 + film2 or bio-cellulose dressing1 + foam.3 60 patients with 73 complex wounds

of various aetiologies were treated for a period of 1 year, in an out-patient clinic setting in Frankfurt and

Neuwied, Germany and Bologna, Italy. The evaluated bio-cellulose dressing1 was combined with

polyhexamethylene biguanide for reduction of bacterial burden. The present study results were

compared to published data on complex wounds, treated with traditional dressings and moist wound

healing dressings, to calculate cost differences.

Results: For the traditional dressings, cost calculations are based on 7.0 dressing changes/week. For

moist wound healing dressings this was 3.0/week and for the bio-cellulose dressing 1.4/week. In

comparison to the treatment with traditional dressings wound treatment costs with moist wound

healing dressings were significantly lower. For calculation of a 3 months period, cost reduction for moist

wound healing dressings was 49.4%, for bio-cellulose dressing1 + foam3 61.9% and 73.7% for bio-cellulose

dressing1 + film.3

Conclusion: Moist wound healing dressings showed a cost reduction, compared to traditional dressings,

with a larger cost reduction shown for bio-cellulose dressing.1 These findings are to be confirmed by

randomized controlled studies.

� 2014 Elsevier GmbH. All rights reserved.

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Wound Medicine

jo ur n al ho mep ag e: www .e lsev ier . c om / loc ate /w nd m

1. Introduction

Complex wounds are an important source of morbidity topatients and generate high costs to hospitals and communityhealth care organizations [1,2]. Randomized controlled trials maynot always be the first choice to address the divergent variance incomplex wound issues. In practice, the best available researchevidence is to be reviewed and compared with current clinicalpractice [2–4]. This approach tries to offer objective input forclinical–medical decisions to be made, applying relevant scientific

Abbreviations: PHMB, polyhexamethylene biguanide; BD, bio-cellulose dressing;

MWH, moist wound healing dressings; TD, traditional dressings; NHP, Nottingham

Health Profile; WWS, Wurzburger Wundscore.

* Corresponding author. Tel.: +49 260281895.

E-mail addresses: michael.schmitz64@gmx.de (M. Schmitz), anneke.a@tiscali.nl

(A. Andriessen).

http://dx.doi.org/10.1016/j.wndm.2014.07.002

2213-9095/� 2014 Elsevier GmbH. All rights reserved.

data and ensuring appropriate utilization of resources [5].Evidence in this context is data on effectiveness of a treatmentor intervention, proven, comparing therapy with an appropriatecontrol [1,4]. Translational medicine is an emerging approach ofmedical practice and is considered a progression from evidencebased medicine [4]. This type of research looks specifically atimproving patient outcomes and sustainable solutions for real livesituations [6]. Refusal to adopt new technologies for woundtreatment may be based on the myth of high product cost and noton clinical evidence [6]. Posnett identified that there is a lack ofdata on the prevalence of wounds among European hospitals andthat more research is needed [2]. Especially there is a need for data

1 Suprasorb1 X + PHMB, Lohmann & Rauscher GmbH.2 Suprasorb1 F, Lohmann & Rauscher GmbH.3 Suprasorb1 P, Lohmann & Rauscher GmbH.

Fig. 1. Distribution of types of secondary dressings used during the study period.

Table 1Calculations of costs for traditional – and MWH dressings [10].

Material Units/

dressing

change

Traditional

wound

treatment

MWH

dressing

Gloves, non-sterile 1 0.18 s 0.18 sGloves, sterile 1 1.10 s 1.10 sKidney dish 1 0.13 s 0.13 sPadding 1 0.27 s 0.27 sES-gauze 10 cm �10 cm, sterile 3 � 2 0.81 s 0.81 sHand disinfectant 5 ml 0.15 s 0.15 sHydrogen peroxide solution 3% 50 ml 0.69 sWound therapeutics 5 g 2.50 sOintment applicator 1 0.05 sOintment gauze 1 1.60 sFixomull stretch 10 cm 20 cm 0.43 sSaline solution 0.9% Miniplasco 1 0.47 sMWH dressing ca. 10 cm � 10 cm 1 8.26 s

Total per dressing change 7.91 s 11.37 s

M. Schmitz et al. / Wound Medicine 6 (2014) 11–1412

on avoidable wounds and wound complications, such as infections.This information is needed to identify the true extent of costsassociated with wounds [2]. Sackett defined evidence-basedwound treatment as the integration of best research evidencewith clinical expertise and patient values [3]. Cost-effectivenessanalysis simultaneously identifies, calculates, and compares costsand outcomes of therapeutic approaches using clinical units asimpact measures [7–9]. These units include outcome, results orimpact of the interventions, including monetary components andeffectiveness [8].

German studies, Sellmer [10], Protz [11] and Wessig [12] havelooked at weekly costs of materials and staff, treating complexwounds with traditional dressings and moist wound healing(MWH) dressings. Due to more frequent dressing changesespecially the costs for staff were much higher [8]. Janben useda cost calculation method, comparing traditional dressings (TD)and MWH, calculating costs per week, in 100 patients withcomplex wounds [7]. In the present cohort study we implementedwound treatment with a bio-cellulose dressing1 (BD) that wasshown to be clinically effective [13].

2. Materials and methods

The aim of the present paper was to compare material and labourcosts of a bio-cellulose dressing1 with traditional dressings (surgicalpads, tulle grass, saline soaked gauze) and moist wound healingdressings (foams and alginates). Data were used from a prospectivecohort study which compared costs when using BD + PHMB1 withTD and MWH dressings in the treatment of complex wounds ofvarious aetiologies. During a 1 year period data were collected fromcentres in Frankfurt and Neuwied, Germany and Bologna, Italy. Thecohort study aimed to examine costs of BD1 and comparing it withTD and MWH dressings using effect variables [7] that may beexamined as part of everyday clinical routine, looking at: time towound healing, patient’ concordance, quality of life aspects(Nottingham Health Profile (NHP) and Wurzburger Wundscore(WWS)) [7]. The WWS looks at evolution of wound healing, relevantmedical status and quality of life issues. The cohort study includedN = 60 adult patients who consented. They had complex wounds,healing by secondary intention, with light, or moderate exudateproduction [14]. Excluded were patients with wounds healing byprimary intention, highly exuding wounds and clinically manifestinfected wounds. Patient information was collected on age, gender,wound type, clinical history, co-morbidities and medication.Participating unit staff was trained on dressing changes and wounddocumentation. Where appropriate the underlying disease wastreated and attention was paid to nutrition and nutritional status ofthe included patients. The cohort study employed BD1 as a primarydressing and depending on the exudate production, BD1 was coveredwith a foam,3 a film2 or an absorbent pad. Dressing changes tookplace when dressings were saturated or leakage occurred and wereat the discretion of the clinician.

Calculations were based on complex wounds, which weretreated with TD and MWH dressings, using the method asdescribed by Janben [7].

Effect variables: Relative measure of effects of the dressing wasdetermined using frequency of dressing change and absence ofdressing-related complications. Complications included skin-related issues (maceration), no signs of wound evolution and/orwound deterioration. Absence of complication was defined as theabsence of any unexpected event related to the use of thedressings, such as infection, maceration, and increase in pain,reported by the patient. For the effect variables, each wound wasconsidered one unique case, the study included 73 cases in N = 60patients. Total costs are calculated per day, per week, per monthand per 3 months (quarterly).

Statistical evaluation was performed applying IBM SPSS Statis-tics Standard, using where appropriate, the independent sample t-test. Tests were carried out at the 5% significance level, and 95%confidence interval.

3. Results

3.1. Cohort study

Patients from centres in Germany and Italy were selected asthere are similarities in their reimbursement system and coststructure. N = 60 patients (32 females and 28 males) with 73complex wounds of various aetiologies were included in theanalysis. Patients had a mean age of 73 years (49–89 years). Themajority of patients had venous leg ulcers (69%). Other woundtypes were diabetic foot ulcers (7%), pressure ulcers 6% and surgicalwounds healing by secondary intention (7%). The duration of thewounds was a mean of 7.7 months (0.1–24 months). There were nowound infections present at baseline. Dressing change interval wasa mean of 4.9 days. BD1 + foam3 was used in 45% of wounds,BD + film2 in 22%, BD1 + absorbent pads in 15% and BD1 + otherdressings in 18% of wounds. The study results obtained from thecohort study on costs of materials used, labour costs, woundhealing results and complications were compared to publisheddata from Germany [10–12] (Fig. 1).

3.2. Calculations

The calculations are based on Sellmer [10]. Table 1 shows costcalculations for dressing change materials, used with traditionaland MWH dressings. Table 2 shows cost calculations for traditionaldressings, MWH and BD,1 combining material costs and labourcosts. For the traditional dressings, cost calculations are based on7.0 dressing changes/week, for MWH this was 3.0/week and forBD1 this was 1.4/week. The authors used the price per unit, basedon the pharmacy retail price (Germany) (Table 3). In comparison totraditional dressings wound treatment costs with MWH were

Table 2Calculations of costs for dressing changes.

Day Week Month Quarter

Traditional wound treatment (7.0 dressing changes/week)

Material costs 7.91 s 55.37 s 221.48 s 664.44 sLabour costs 9.63 s 67.41 s 269.64 s 808.92 sOverall 17.54 s 122.78 s 491.12 s 1473.36 s

Modern wound treatment (3.0 dressing changes/week 3)

Material costs 11.37 34.11 s 136.44 409.32

Labour costs 9.63 s 28.09 s 112.36 337.08

Overall 21.00 s 62.20 s 248.80 s 746.40 s

Hydrobalance biocellulose wound dressing + PU-foam dressing (1.4 dressing changes/week)

Material costs 17.76 24.864 99.456 298.368

Labour costs 9.63 s 13.48 s 53.928 161.784

Overall 27.39 s 38.35 s 153.40 s 460.20 s

Hydrobalance biocellulose wound dressing + film dressing (1.4 dressing changes/week)

Material costs 13.46 s 18.85 s 75.40 s 226.20 sLabour costs 9.63 s 13.48 s 53.928 161.784

Overall 23.09 s 32.33 s 129.33 s 387.98 s

Fig. 2. Comparison of costs TD vs. MWH and BD.

€ 378,97

Cost savings 61,86%

Cost savings 73,67%

Q7

M. Schmitz et al. / Wound Medicine 6 (2014) 11–14 13

significantly lower. For a 3 months period cost reduction for MWHwas 49.4%, for BD1 + foam3 61.9% and for BD1 + film2 the costreduction was 73.7%. In comparison to traditional wounddressings, the longer intervals between BD1 dressing changes(4.9 days on average), reduced costs additionally. For BD1 + foam3

cost reduction was 61.9% and 73.7% for BD1 + film2 (Fig. 2). Whencompared to traditional and MWH dressings, for a three monthsperiod, costs savings with BD1 + film2 were 61.9% and 73.7% forBD1 + foam3 (Fig. 3).

4. Discussion

The need for pharmacoeconomical studies has increased formany reasons. Included are limited financial resources for existingand increasing demands and restrictions/regulations on clinicalpractice, obtaining a greater effectiveness in resource application[2]. Cost-effectiveness analysis is fundamental to clinical practicein general and wound care in particular. Time to healing the woundis one critical factor in the cost-effectiveness analysis, however the

Table 3Method of cost calculation according to Sellmer [10].

Ø frequency of dressing changes

with the different materials

Labour costs/

dressing change

Overall costs

BD: 1.4 per week/patient

MWM: 3.0 per week/patient

TD: 7.0 per week/patient

9.63 EUR (Material costs

+ personnel costs)

� dressing change

interval

frequency of dressing changes will impact on costs of materials andclinicians’ time [5,15]. MWH dressings are significantly moreexpensive per unit than traditional alternatives, but are suggestedto be more cost effective as they are associated with faster healingrates and fewer dressing changes [5,7,8].

The cohort study aimed to evaluate cost using effect variablesthat can easily be examined as part of clinical routine [5,7–9,16].The cost analysis that we used simultaneously identifies,calculates, and compares costs and outcomes of therapeuticapproaches using clinical units as impact measures [7,8,17,18]. Thevariables include average dressing change interval, costs ofmaterials used, clinicians’ time for dressing changes (labour),leakage and complications [7].

1,500 €1,000 €500 €0 €

BD + film

BD + foam

MWH

TD€ 1.473,36

€ 746,40

€ 561,99

Fig. 3. Costs savings per quarter when comparing TD vs. MWH and BD.

M. Schmitz et al. / Wound Medicine 6 (2014) 11–1414

Both doctors and nurses performed dressing changes, which iscommon practice in Germany and in Italy.

The cohort study results were compared with published data[10–12] on costs of the use of other MWH dressings, such as foamsand alginates. These dressings were currently in use in the centres,where the cohort study was conducted.

We propose that our cost calculations are in line withassumptions used in recently published data by Huljev [15] andRybak et al. [6].

5. Limitations

It is not feasible to draw a conclusion based on results comparedacross studies conducted in different settings at different times,with potentially different wound severity and complexity levels[16–18]. The retrospective comparison, using published data, therelatively small number of patients included in the cohort studyand the characteristics and homogeneity of the sample may haveinfluenced the final results. The cost calculation methods usedseems dated, however there have not been much changes inreimbursement approaches for both clinical practice and dressingmaterials over the past decade [10,12].

6. Conclusions

� The frequency of dressing changes is a key cost driver. Whenreducing the number of dressing changes, consequential there isa decrease in labour costs.� Advanced wound healing products and the bio-cellulose

dressing1 showed a cost reduction, when compared to traditionalgauze based dressings.� Randomized controlled trials on cost-effectiveness are required

to demonstrate true cost savings when using the bio-cellulosedressings.1

Conflict of interest

None declared.

Funding

The study has been supported by a scientific grant of Lohmann& Rauscher GmbH & Co. KG.

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