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A systematic review of cost-effectiveness analyses of complex wound interventions reveals optimal treatments for specific wound types

  • Andrea C Tricco1, 2,
  • Elise Cogo1,
  • Wanrudee Isaranuwatchai1, 3,
  • Paul A Khan1,
  • Geetha Sanmugalingham1,
  • Jesmin Antony1,
  • Jeffrey S Hoch1, 3 and
  • Sharon E Straus1, 4Email author
BMC Medicine201513:90

https://doi.org/10.1186/s12916-015-0326-3

Received: 16 October 2014

Accepted: 13 March 2015

Published: 22 April 2015

Abstract

Background

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.

Methods

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.

Results

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.

Conclusions

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

Keywords

Complex woundCost-benefit analysisCost-effectiveness analysisResearch designSkin ulcerSystematic review

Background

Complex wounds are those that do not heal after a period of 3 months or more [1]. These types of wounds are a significant burden on the healthcare system and result in patient and caregiver stress, economic loss, and decreased quality of life. At least 1% of individuals living in high economy countries will experience a complex wound in their lifetime [2], and over 6.5 million individuals have a complex wound in the United States alone [3]. Moreover, these types of wounds have a significant economic impact. For example, $10 billion United States dollars (USD) per year in North America is spent managing complex wounds [4], and 4% of the annual National Health Service expenditure in the United Kingdom is spent on care for patients with pressure ulcers [5].

There are three main categories of complex wounds: i) wounds resulting from chronic disease (e.g., venous insufficiency, diabetes), ii) pressure ulcers, and iii) non-healing surgical wounds [6-8]. Treatment is targeted to the type of wound. Managing complex wounds resulting from disease usually involves improving the underlying disease; for example, optimizing diabetes control for patients with diabetes [9]. A clinical assessment and history of mobility and neurological disability is often necessary to treat patients with pressure ulcers [9]. Considerations for managing surgical wound infections include previous antibiotic treatment and immune response [3].

It is estimated that the global wound care market will reach over $22 billion USD annually by 2020 [10]. Due to the burgeoning costs from the management of patients requiring complex wound care, policymakers are interested in finding cost-effective treatments. However, the cost-effectiveness of all interventions available to treat complex wounds is currently unclear. As such, we sought to elucidate cost-effective treatment strategies for complex wounds through a systematic review of cost-effectiveness analyses.

Methods

Protocol

The systematic review question was posed by members of the Toronto Central Local Health Integrated Network. In collaboration with the Toronto Central Local Health Integrated Network, our research team prepared a draft protocol that was revised to incorporate feedback from systematic review methodologists, policymakers, and clinicians with expertise in wound care (Additional file 1). Our protocol also included conducting a related project comprising an overview of systematic reviews for treating complex wounds, and these results are available in a separate publication [11].

Information sources and search strategy

On October 26, 2012, an experienced librarian conducted comprehensive literature searches in the following electronic databases from inception onwards: MEDLINE, EMBASE, and the Cochrane Library. The literature search was limited to adult patients and economic studies. The Peer Review of Electronic Search Strategies (PRESS) checklist [12] was used by another expert librarian to peer review the literature search. The search was revised, as necessary, and the final MEDLINE search is presented in Additional file 2. Full literature searches for the other databases are available upon request. The reference lists of the included studies were searched to identify additional relevant studies.

Eligibility criteria

Inclusion criteria were defined using the ‘Patients, interventions, comparators, outcomes, study designs, timeframe’ (PICOST) framework [13], as follows:

Patients

Adults aged 18 years and older experiencing complex wounds. Complex wounds included those due to chronic disease (such as diabetic foot ulcers or venous leg ulcers), pressure ulcers (such as decubitus ulcers or bed sores), and non-healing surgical wounds.

Interventions

All complex wound care interventions were included, as identified from our overview of systematic reviews [11] and outlined in Additional file 3.

Comparators

All comparators were eligible for inclusion, including any of the eligible interventions in comparison with each other or versus no treatment or placebo or usual care.

Outcomes

Cost-effectiveness (i.e., both incremental cost and incremental effectiveness) was included, where effectiveness was measured by at least one of the following outcomes: quality-adjusted life-years (QALYs), wounds healed, ulcer-free/healing time, wound size reduction/improvement, or hospitalizations (number/length of stay).

Study designs

Economic evaluations were included in which the incremental cost-effectiveness ratios (ICERs) were reported or could be derived.

Timeframe

We did not limit inclusion to year of publication.

Other limitations

We limited cost-effectiveness analyses to those based on a study with a control group, and where the data were from direct comparisons (versus a review using indirect data). Both published and unpublished studies were eligible for inclusion. Although we focused inclusion on those studies written in English, we contacted the authors of potentially relevant non-English studies to obtain the English translation.

Screening process for study selection

The team pilot-tested the pre-defined eligibility criteria using a random sample of 50 included titles and abstracts. After 90% agreement was reached, each title and abstract was screened by two team members, independently, using our Synthesi.SR tool [14]. Discrepancies were resolved by discussion or the involvement of a third reviewer. The same process was followed for screening full-text articles that were identified as being potentially relevant after screening their titles and abstracts.

Data abstraction and data collection process

The team pilot-tested data abstraction forms using a random sample of five included cost-effectiveness analyses. Subsequently, two investigators independently read each article and abstracted relevant data. Differences in abstraction were resolved by discussion or the involvement of a third reviewer. Data items included study characteristics (e.g., type of economic evaluation, time horizon, treatment interventions examined, study comparators), patient characteristics (e.g., clinical population, wound type), and cost-effectiveness results (e.g., ICERs, cost per QALY, cost per wound healed). The perspective of the economic evaluation was categorized as: patient, public payer, provider, healthcare system, or society [15].

Cost-effectiveness studies can have four possible overall results, which are often represented graphically in quadrants on a cost-effectiveness plane [16]. The possibilities for the intervention versus a comparator are: 1) more effective and less costly, which we noted as ‘dominant’; 2) more effective and more costly; 3) less effective and less costly; and 4) less effective and more costly, which we noted as ‘dominated’. The first possibility is considered to be cost-effective; whereas possibility 4 is not cost-effective. Situations 2 and 3 requires judgment by the decision-maker to interpret [17], and in such cases, the decision is often dependent on the decision-maker’s willingness to pay. For interventions that were found to be more effective yet more costly (i.e., situation 2) or less effective and less costly (situation 3), ICERs were reported or derived from both the differences in cost (i.e., incremental cost) and effectiveness (i.e., incremental effectiveness) between the study’s intervention and comparator groups using the formula:

(Cost of the intervention – Cost of the comparator) ÷ (Effectiveness of the intervention – Effectiveness of the comparator)

To assess key variables influencing the cost-effectiveness results, sensitivity analyses, level of uncertainty in the cost and benefit estimates, and incremental variabilities (i.e., the variability of the incremental cost and the variability of the incremental effectiveness), were reported.

Authors of the included cost-effectiveness analyses were contacted for data verification, as necessary. Further, multiple studies reporting the same economic data were sorted into the major publication (e.g., most recent paper or largest sample size) and companion report. Our results focus on the major publications and the companion reports were used to provide supplementary material.

Methodological quality appraisal

The methodological quality of the cost-effectiveness analyses was appraised using a 10-item tool developed by Drummond et al. (Additional file 4) [18]. The items on this tool include the appraisal of question definition, description of competing alternatives, effectiveness of the intervention, consideration of all relevant costs, measurement of costs, valuation of costs and consequences, cost adjustment/discounting, incremental analysis, uncertainty/sensitivity analysis, and discussion of study results. The Drummond score can range from 0 to 10. Each included cost-effectiveness analysis was appraised by two team members and conflicts were resolved by discussion or the involvement of a third reviewer.

Synthesis

Since the purpose of this systematic review was to summarize the cost-effectiveness of interventions for complex wound care, the results are reported descriptively. The costing data from all studies were converted to 2013 USD to increase the comparability of the economic results across cost-effectiveness studies. This process entailed first converting the currencies into USD using purchasing power parities for the particular year of the data [19,20], and then adjusting these for inflation to the year 2013 (rounded to the nearest dollar) using the consumer price index for medical care in the United States [21].

Results

Literature search and screening

The literature search identified 422 potentially relevant full-text articles after screening 6,200 titles and abstracts (Figure 1). There were 59 included cost-effectiveness analyses that fulfilled our eligibility criteria and were included [22-80], plus an additional three companion reports [81-83].
Figure 1

Study flow diagram.

Study and patient characteristics

The cost-effectiveness analyses evaluated interventions to treat venous ulcers (41%), diabetic ulcers (27%), and pressure ulcers (24%) (Table 1). The studies were published between 1988 and 2012. Most of the papers were conducted in the United Kingdom (29%) and United States (27%). Almost half (49%) reported private or mixed (private and public) funding sources of the studies, while one-third (34%) did not report a source of funding.
Table 1

Summary characteristics of all cost-effectiveness analyses (CEAs)

Characteristic

No. of CEAs (n = 59)

Percentage of CEAs

Original year of values

  

  1982–1996

15

25.4

  1997–2000

19

32.2

  2001–2005

10

16.9

  2006–2010

15

25.4

Year of publication

  

  1988–1996

7

11.9

  1997–2001

21

35.6

  2002–2006

12

20.3

  2007–2012

19

32.2

Country of conduct

  

  Europe (17 from the UK)

34

57.6

  North America (16 from USA)

19

32.2

  Asia

3

5.1

  Australia and New Zealand

3

5.1

Perspective

  

  Public payer

17

28.8

  Society

8

13.6

  Provider

6

10.2

  Health care system

1

1.7

  Not reported

27

45.8

Efficacy study design

  

  RCT

44

74.6

  Observational

9

15.3

  Systematic review of RCT

4

6.8

  Systematic reviewa

1

1.7

  Pseudo-RCT

1

1.7

Sample size b

  

  10–30

4

6.8

  31–50

11

18.6

  51–100

12

20.3

  101–150

5

8.5

  151–200

3

5.1

  201–400

16

27.1

  >400

8

13.6

Patient age c (years)

  

  50–59

5

8.5

  60–69

20

33.9

  70–79

18

30.5

  80–89

8

13.6

  Not reported

8

13.6

Timeframe

  

  ≤12 weeks

28

47.5

  13–24 weeks

9

15.3

  >24 weeks

22

37.3

Funding source d

  

  Private

23

39.0

  Public

10

16.9

  Mixed

6

10.2

  Not reported

20

33.9

Type of wound

  

  Venous ulcers

24

40.7

  Diabetic ulcers

16

27.1

  Pressure ulcers

14

23.7

  Mixed wounds

3

5.1

  Mixed venous and venous/arterial ulcers

2

3.4

Unit of effectiveness

  

  Additional wound healed

26

44.1

  QALY gained

10

16.9

  Ulcer-free time (day/week/month) gained

9

15.3

  Percentage additional reduction of ulcer (area/volume/volume per week)

8

13.6

  Increase in healing rate

2

3.4

  Reduction in DESIGN score

1

1.7

  Patient-year gained

1

1.7

  Hospital-free day gained

1

1.7

  Foot-related hospitalization avoided

1

1.7

Interventions e

  

  Dressings

17

24.3

  Bandage

12

17.1

  Biologics

8

11.4

  Topical Tx

8

11.4

  Wound care programs

7

10.0

  Devices

5

7.1

  Skin replacement Tx

4

5.7

  Oral Tx

3

4.3

  Support surfaces

2

2.9

  Stockings

1

1.4

  Surgery

1

1.4

  Wound cleansing

1

1.4

  Unspecified

1

1.4

Comparators e

  

  Dressings

17

24.3

  Bandage

8

11.4

  No Tx

6

8.6

  Biologics

4

5.7

  Stockings

2

2.9

  Support surfaces

2

2.9

  Topical Tx

2

2.9

  Wound care programs

2

2.9

  Devices

1

1.4

  Surgery

1

1.4

  Usual care/Unspecified

25

35.7

QALY, Quality-adjusted life-year; RCT, Randomized clinical trial; Tx, Therapy/treatment.

a Not specified if the included studies were RCTs.

b For studies based on a review, this refers to the total sample size of the combined studies that the data were estimated from.

c Age here refers to mean age or the age used in the model.

d Mixed here indicates both private and public funding.

e Numbers do not add up to 59 as some studies contributed data to more than one category.

While the majority of studies based effectiveness on a (single) randomized clinical trial (75%), only a few based effectiveness on a systematic review (9%) and 15% were based on observational studies (Tables 2, 3, 4, 5 and 6). Almost half (46%) of the economic studies included a sample size of 10 to 100 patients and the rest had a sample of >100 patients. In addition, 48% were conducted in a timeframe of 12 weeks or less, while the other studies had a duration of >12 weeks follow-up. Across the 59 economic studies, 9 different units of effectiveness were used, with the most common ones being healed wound (44%) and QALY (17%). Regarding the perspective of the cost-effectiveness analysis, almost half (46%) did not report this explicitly and 29% reported using the public payer perspective.
Table 2

Characteristics of each cost-effectiveness analysis (CEA) for venous ulcers (n = 24)

CEA (Original year of values)

Country (Original currency)

Perspective

Efficacy study design

Sample size

Population

Timeframe

Funding source a

Augustin 1999 (1989) [22]

Germany (DM)

Not reported

RCT

25

Mean 61 yrs; venous insufficiency

24 wks

Not reported

DePalma 1999 (1998) [23]

USA (US$)

Not reported

RCT

38

Mean 61 yrs; venous insufficiency

max. 12 wks

Private

Glinski 1999 (1998) [24]

Poland (PLN)

Public payer

RCT

140

Mean 65 yrs; venous insufficiency

24 wks

Not reported

Gordon 2006 (2005) [25]

Australia (AU$)

Society

RCT

56

Most >71 yrs; venous insufficiency

24 wks

Not reported

Guest 2012 (2010) [26]

UK (£)

Public payer

Observational

510

Mean 80 yrs; venous insufficiency

24 wks

Private

Iglesias 2006 (2004) [27]

UK (£)

Public payer

SR of RCTs

434

66 yrs; venous insufficiency

52 wks

Public

Iglesias 2004 (2001) [28]

UK (£)

Public payer

RCT

387

Mean 71 yrs; venous insufficiency

52 wks

Public

Jull 2008 (2005) [29]

New Zealand (NZ$)

Public payer

RCT

368

Mean 68 yrs; venous insufficiency

12 wks

Mixed

Junger 2008 (2007) [30]

Germany (DM)

Not reported

RCT

39

Mean 67 yrs; venous insufficiency

17 wks

Private

Kerstein 2000 (1995) [31]

USA (US$)

Not reported

Observational

81

Mean 65 yrs; venous insufficiency

3 yrs

Not reported

Kikta 1988 (1987) [32]

USA (US$)

Not reported

RCT

87

Venous insufficiency; (ages NR)

24 wks

Not reported

Michaels 2009 (2007) [33]

UK(£)

Public payer

RCT

213

Mean 71 yrs; venous insufficiency

12 wks

Public

Morrell 1998 (1995) [34]

UK (£)

Public payer

RCT

233

Mean 74 yrs; venous insufficiency

52 wks

Public

O’Brien 2003 (2000) [35]

Ireland (€)

Public payer

RCT

200

Mean 72 yrs; venous insufficiency

12 wks

Private

Oien 2001 (1997) [36]

Sweden (£)

Not reported

Observational

68

Mean 76 yrs; venous insufficiency

12 wks

Not reported

Sibbald 2001 (1997) [37]

Canada (CAN$)

Society

RCT

293

Elderly; venous insufficiency

13 wks

Private

Taylor 1998 (1987) [38]

UK (£)

Not reported

RCT

36

Mean 75 yrs; venous insufficiency

12 wks

Private

Ukat 2003 (2002) [39]

Germany (€)

Not reported

RCT

89

Mean 69 yrs; venous insufficiency

12 wks

Private

Watson 2011 (2007) [40]

UK (£)

Public payer

RCT

337

Mean 69 yrs; venous insufficiency

52 wks

Public

Pham 2012 (2009) [41]

Canada (CAN$)

Society

RCT

424

Mean 65 yrs; venous insufficiency; most fully mobile

max. 52 wks

Public

Schonfeld 2000 (1996) [42]

USA(US$)

Public payer

RCT

240

Mean 60 yrs; venous insufficiency

52 wks

Private

Simon 1996 (1993) [43]

UK (£)

Not reported

Observational

901

Venous insufficiency; (ages not reported)

13 wks

Mixed

Carr 1999 (1998) [44]

UK (£)

Public payer

RCT

233

Mean 73 yrs; venous insufficiency

52 wks

Private

Guest 2009 (2007) [45]

UK (£)

Public payer

RCT

83

Mean 71 yrs; venous insufficiency

52 wks

Private

RCT, Randomized clinical trial; SR, Systematic review; wks, Weeks; yrs, Years.

a Mixed here indicates both private and public funding.

Table 3

Characteristics of each cost-effectiveness analysis (CEA) for venous and venous/arterial ulcers (n = 2)

CEA (Original year of values)

Country (Original currency)

Perspective

Efficacy study design

Sample size

Population

Timeframe

Funding source

Dumville 2009 (2006) [46]

UK (£)

Public payer

RCT

267

Mean 74 yrs; venous insufficiency

52 wks

Not reported

Ohlsson 1994 (1993) [47]

Sweden (SEK)

Not reported

RCT

30

Median 76 yrs; venous insufficiency; most female

6 wks

Not reported

RCT, Randomized clinical trial; WKS, Weeks; Yrs, Years.

Table 4

Characteristics of each cost-effectiveness analysis (CEA) for diabetic ulcers (n = 16)

CEA (Original year of values)

Country (Original currency)

Perspective

Efficacy study design

Sample size

Population

Timeframe

Funding source a

Abidia 2003 (2000) [48]

UK (£)

Not reported

RCT

18

Mean 71 yrs; diabetes

52 wks

Not reported

Apelqvist 1996 (1993) [49]

Sweden (SEK)

Society

RCT

41

Included >40 yrs; diabetes

12 wks

Mixed

Edmonds 1999 (1996) [50]

UK (£)

Provider

RCT

40

Mean 66 yrs; diabetes; foot infections

2 wks

Private

Guo 2003 (2001) [51]

USA (US$)

Society

SRb

126

60 yrs; diabetes

12 yrs

Not reported

Habacher 2007 (2001) [52]

Austria (€)

Society

Observational

119

Mean 65 yrs; diabetes

15 yrs

Not reported

Horswell 2003 (1999) [53]

USA (US$)

Not reported

Observational

214

Mean 54 yrs; diabetes; mostly African-Americans

52 wks

Not reported

Jansen 2009 (2006) [54]

UK (£)

Public payer

RCT

402

Mean 58 yrs; diabetes

approx. 4 wks

Private

Jeffcoate 2009 (2007) [55]

UK (£)

Public payer

RCT

317

Mean 60 yrs; diabetes

24 wks

Public

McKinnon 1997 (1994) [56]

USA (US$)

Provider

RCT

90

Mean 60 yrs; diabetes; limb-threatening foot infections

3 wks

Private

Persson 2000 (1999) [57]

Sweden (US$)

Not reported

SR of RCTs

500

Median 60 yrs; diabetes

52 wks

Private

Piaggesi 2007 (2006) [58]

Italy (€)

Not reported

RCT

40

Mean 60 yrs; diabetes

12 wks

Private

Redekop 2003 (1999) [59]

The Nether-lands (€)

Society

RCT

208

Elderly; diabetes

52 wks

Private

Allenet 2000 (1998) [60]

France (FF)

Society

RCT

235

Diabetes; (ages not reported)

52 wks

Not reported

Ghatnekar 2002 (2000) [61]

France (€)

Not reported

RCT

157

Diabetes; (ages not reported)

52 wks

Private

Ghatnekar 2001 (1999) [62]

UK(US$)

Public payer

SR of RCTs

449

Diabetes; (ages not reported)

52 wks

Private

Hailey 2007 (2004) [63]

Canada (CAN$)

Public payer

SR of RCTs

305

65 yrs; diabetes

12 yrs

Public

RCT, Randomized clinical trial; SR, Systematic review; wks, Weeks; yrs, Years.

a Mixed here indicates both private and public funding.

b Not specified if the included studies were RCTs or not (but states they were prospective controlled clinical studies).

Table 5

Characteristics of each cost-effectiveness analysis (CEA) for pressure ulcers (n = 14)

CEA (Original year of values)

Country (Original currency)

Perspective

Efficacy study design

Sample size

Population

Timeframe

Funding source a

Branom 2001 (2000) [64]

USA (US$)

Not reported

RCT

20

Mean 72 yrs; bedridden

max. 8 wks

Not reported

Burgos 2000 (1998) [65]

Spain (Pta)

Not reported

RCT

37

Mean 80 yrs

12 wks

Private

Chang 1998 (1997) [66]

Malaysia (RM)

Not reported

RCT

34

Mean 58 yrs

max. 8 wks

Private

Chuangsu-wanich 2011 (2010) [67]

Thailand (US$)

Not reported

RCT

45

Mean 66 yrs

8 wks

Not reported

Ferrell 1995 (1992) [68]

USA (US$)

Provider

RCT

84

Mean 81 yrs; mostly Caucasians; most fecal incontinence

52 wks

Mixed

Foglia 2012 (2010) [69]

Italy (€)

Provider

Observational

362

Most >80 yrs

4.3 wks

Not reported

Graumlich 2003 (2001) [70]

USA (US$)

Not reported

RCT

65

Mean 83 yrs

8 wks

Public

Muller 2001 (1998) [71]

The Netherlands (NLG)

Provider

RCT

24

Mean 73 yrs; all females

12 wks

Private

Narayanan 2005 (2004) [72]

USA (US$)

Not reported

Observational

976

Most ≥80 yrs; mostly Caucasians

approx. 22 wks

 

Payne 2009 (2007) [73]

USA (US$)

Provider

RCT

36

Mean 73 yrs

4 wks

Private

Robson 2000 (1999) [74]

USA (US$)

Not reported

RCT

61

Mean 50 yrs; mostly Caucasians

5 wks

Mixed

Sanada 2010 (2007) [75]

Japan (Yen)

Not reported

Observational

105

Mean 75 yrs

3 wks

Not reported

Xakellis 1992 (1990) [76]

USA (US$)

Not reported

RCT

39

Mean 80 yrs

1.4 wks

Mixed

Seberrn 1986 (1985) [77]

USA (US$)

Not reported

RCT

77

Mean 74 yrs

8 wks

Not reported

RCT, Randomized clinical trial; SR, Systematic review; wks, Weeks; yrs, Years.

a Mixed here indicates both private and public funding.

Table 6

Characteristics of each cost-effectiveness analysis (CEA) for mixed wound types (n = 3)

CEA (Original year of values)

Country (Original currency)

Perspective

Efficacy study design

Sample size

Population

Timeframe

Funding source

Bale 1998 (1994) [78]

UK (£)

Not reported

RCT

100

Mean 76 yrs

max. 8 wks

Private

Terry 2009 (2008) [79]

USA (US$)

Not reported

RCT

160

Mean 58 yrs

6 wks

Public

Vu 2007 (2000) [80]

Australia (AU$)

Health care system

Pseudo-RCT

342

Mean 83 yrs

20 wks

Public

RCT, Randomized clinical trial; wks, Weeks; Yrs, Year.

Methodological quality appraisal

Approximately 71% (42 out of 59) of the cost-effectiveness analyses had a score of 8 or higher out of a total possible score of 10 (Additional file 5, Figure 2). Using the Drummond 10-item tool [18], the key methodological shortcoming across the cost-effectiveness analyses was that only 51% (30 out of 59) had established the ‘effectiveness’ of the intervention using data from efficacy studies (i.e., systematic reviews, randomized clinical trials or observational studies) that had sufficiently large sample sizes according to the International Conference on Harmonisation guidelines for establishing efficacy [84]. Consistent methodological strengths across the cost-effectiveness analyses included a clear research question, costs and consequences measured in appropriate physical units, credibly valued costs and consequences, and discounted costs (when applicable).
Figure 2

Drummond methodological quality summary results (n = 59). Items: 1. Well-defined question. 2. Competing alternatives well described. 3. Effectiveness established. 4. All important and relevant costs and consequences identified. 5. Measurement accurately performed. 6. Valuation credibility. 7. Discounting. 8. Incremental analysis performed. 9. Allowance made for uncertainty. 10. Discussion.

Cost-effectiveness results

Due to the large number of cost-effectiveness studies included and the numerous results, we have focused on dominant results in the text. However, all of the cost-effectiveness results are presented in Tables 7, 8, 9, 10 and 11 and the sensitivity analyses, level of uncertainty, and incremental variabilities are outlined in Additional file 6.
Table 7

Cost-effectiveness analysis (CEA) outcomes for venous ulcers (n = 24)

CEA (Original year of values)

Treatment vs. Comparator

ICER summary/estimate [2013 US$]

Unit of effectiveness

Incremental cost [2013 US$]

Incremental effectiveness

Augustin 1999 (1989) [22]

Hydrocolloid dressing vs. Vaseline gauze dressing

Dominant

Ulcer-free week gained

−3,362

1.3

DePalma 1999 (1998) [23]

Thera-boot vs. Unna’s boot

Dominant

Ulcer-free week gained

−601

1.71

Glinski 1999 (1998) [24]

Micronized purified flavonoid fraction + SC vs. SC alone

Dominanta

Additional wound healed

−714

0.19

Gordon 2006 (2005) [25]

Community leg club vs. community home nursing

488a

Additional wound healed

Not reported

Not reported

Guest 2012b (2010) [26]

NSBF vs. DBC

18a

Percent additional reduction of ulcer area

146

8

Guest 2012b (2010) [26]

NSBF vs. no skin protectant

1a

Percent additional reduction of ulcer area

17

22

Guest 2012b (2010) [26]

DBC vs. no skin protectant

Dominanta

Percent additional reduction of ulcer area

−129

14

Iglesias 2006 (2004) [27]

Pentoxifylline plus compression vs. placebo plus compression

Dominanta

QALY gained

−213

0.01

Iglesias 2004 (2001) [28]

Four-layer bandage vs. short-stretch bandage

Dominanta

QALY gained

−566

0.02

Jull 2008 (2005) [29]

Manuka honey dressing vs. UC

Dominanta,c

Additional wound healed

−48

0.06

Junger 2008 (2007) [30]

Low-frequency pulsed current (Dermapulse) vs. placebo

More costly & more effectived

Percent additional reduction of ulcer area

Not reported

Not reported

Kerstein 2000b (1995) [31]

Hydrocolloid dressing plus compression hosiery vs. Unna’s boot

Dominant

Additional wound healed

−6,748

0.18

Kerstein 2000b (1995) [31]

Unna’s boot vs. saline gauze plus compression hosiery

More costly & more effectived

Additional wound healed

Not reported

Not reported

Kikta 1988 (1987) [32]

Unna’s boot vs. hydrocolloid (DuoDERM)

Dominanta

Additional wound healed

−209

0.32

Michaels 2009 (2007) [33]

Antimicrobial silver-donating dressings vs. low-adherent dressings

917,298a

QALY gained

183

0.0002

Morrell 1998 (1995) [34]

Community leg ulcer clinics using four-layer compression bandaging vs. home nursing UC

7a

Ulcer-free week gained

44

5.9

O’Brien 2003 (2000) [35]

Four-layer bandage vs. UC

Dominanta

Increase in healing rate

−42

0.2

Oien 2001 (1997) [36]

Pinch grafting in primary care vs. pinch grafting in hospital

Cost saving & same effectiveness

Additional wound healed

−14,075

0

Sibbald 2001 (1997) [37]

Skin substitute (Apligraf) plus four-layer bandage vs. four-layer bandage only

6095a

Additional wound healed

457

0.075

Taylor 1998 (1987) [38]

Four-layer high-compression bandaging vs. UC

Dominanta

Additional wound healed

−659

0.095

Ukat 2003 (2002) [39]

Multilayer elastic bandaging (Profore) vs. short-stretch bandaging

Dominanta

Additional wound healed

−1,198

0.08

Watson 2011 (2007) [40]

Ultrasound plus SC vs. SC alone

Dominateda

QALY gained

371

−0.009

Pham 2012 (2009) [41]

Four-layer bandaging vs. short-stretch bandaging

43,918a

QALY gained

395

0.009

Schonfeld 2000 (1996) [42]

Apligraf (Graftskin) vs. Unna’s Boot

Dominanta

Ulcer-free month gained

−13,883

2.85

Simon 1996 (1993) [43]

Community leg ulcer clinic vs. UC clinic

Dominant

Additional wound healed

−1,826

0.22

Carr 1999 (1998) [44]

Four-layer compression bandaging (Profore) vs. UC

Dominanta

Additional wound healed

−1,289

0.13

Guest 2009 (2007) [45]

Amelogenin plus compression therapy vs. compression therapy only

Dominanta

QALY gained

−835

0.054

DBC, Durable barrier cream; ICER, Incremental cost-effectiveness ratio; NSBF, No sting barrier film; QALY, Quality-adjusted life-year; SC, Standard care; UC, Usual care; US$, United States dollars.

a Denotes the higher quality studies (Drummond score ≥8).

b Multiple comparisons are reported.

c ICER was mostly due to an extra 3 patients hospitalized in control group… “probably due to random variation”. If remove these costs, the dominance is reversed in favor of UC.

d Unable to calculate specific ICER for these 2 studies because the data was not reported for all treatment arms or presented in a figure only but the overall result (more costly & more effective) was reported.

Table 8

Cost-effectiveness analysis (CEA) outcomes for venous and venous/arterial ulcers (n = 2)

CEA (Original year of values)

Treatment vs. Comparator

ICER summary/estimate [2013 US$]

Unit of effectiveness

Incremental cost [2013 US$]

Incremental effectiveness

Dumville 2009 (2006) [46]

larval therapy vs. hydrogel

17,757a

QALY gained

195

0.011

Ohlsson 1994 (1993) [47]

hydrocolloid (DuoDERM) dressing vs. saline gauze

Dominanta

Additional wound healed

−588

0.357

ICER, Incremental cost-effectiveness ratio; QALY, Quality-adjusted life-year; US$, United States dollars.

a Denotes the higher quality studies (Drummond score ≥8).

Table 9

Cost-effectiveness analysis (CEA) outcomes for diabetic ulcers (n = 16)

CEA (Original year of values)

Treatment vs. Comparator

ICER summary/estimate [2013 US$]

Unit of effectiveness

Incremental cost [2013 US$]

Incremental effectiveness

Abidia 2003 (2000) [48]

HBOT vs. control

Dominant

Additional wound healed

−7,596

0.625

Apelqvist 1996 (1993) [49]

Cadexomer iodine ointment vs. standard treatment

Dominanta

Additional wound healed

−119

0.183

Edmonds 1999 (1996) [50]

Filgrastim vs. placebo

Dominanta,b

Hospital-free day gained

−7,738

7.5

Guo 2003 (2001) [51]

HBOT + SC vs. SC alone

3508a

QALY gained

2,137

0.609

Habacher 2007 (2001) [52]

Intensified treatment vs. SC

Dominanta

Patient-year gained

−7,625

2.97

Horswell 2003 (1999) [53]

Staged management diabetes foot program vs. SC

Dominanta

Foot-related hospitalization avoided

−7,848

0.41

Jansen 2009 (2006) [54]

Ertapenem vs. Piperacillin/Tazobactam

Dominanta

Lifetime QALY gained

−822

0.12

Jeffcoate 2009c (2007) [55]

Hydrocolloid (Aquacel) vs. antiseptic (Inadine)

1449a

Additional wound healed

14

0.01

Jeffcoate 2009c (2007) [55]

Antiseptic (Inadine) vs. non-adherent dressing

1590a

Additional wound healed

80

0.05

McKinnon 1997 (1994) [56]

Ampicillin/sulbactam vs. imipenem/cilastatin

Dominanta

Hospitalization day avoided

−5,891

3.5

Persson 2000 (1999) [57]

Becaplermin plus GWC (unspecified) vs. GWC alone

Dominanta

Ulcer-free month gained

−628

0.81

Piaggesi 2007 (2006) [58]

Total contact casting vs. Optima Diab device

8,578

Additional wound healed

858

0.1

Redekop 2003 (1999) [59]

Apligraf (skin substitute) + GWCd vs. GWC alone

Dominanta

Ulcer-free month gained

−1,223

1.53

Allenet 2000 (1998) [60]

Dermagraft (human dermal replacement) vs. SC

70,961a

Additional wound healed

12,652

0.178

Ghatnekar 2002 (2000) [61]

Promogran dressing plus GWCe vs. GWC alone

Dominanta

Additional wound healed

−294

0.042

Ghatnekar 2001 (1999) [62]

Becaplermin gel (containing recombinant human platelet-derived growth factor) plus GWCf vs. GWC alone

Dominanta

Ulcer-free month gained

−794

0.81

Hailey 2007 (2004) [63]

HBOT + SC vs. SC alone

Dominant

QALY gained

−9,337

0.63

GWC, Good wound care; HBOT, Hyperbaric oxygen therapy; ICER, Incremental cost-effectiveness ratio; QALY, Quality-adjusted life-year; SC, Standard care; US$, United States dollars.

a Denotes the higher quality studies (Drummond score ≥8).

b “Patient selection may have occurred during the in-hospital stay where more control patients experienced a bad vascular condition requiring the more costly interventions”.

c Multiple comparisons are reported.

d GWC, “the best wound care available and consists mainly of offloading, debridement, and moist dressings”.

e GWC, “sharp debridement (if necessary) and wound cleansing. In the GWC alone arm, the primary dressing was saline-soaked gauze and the secondary gauze and tape”.

f GWC, “sharp debridement to remove callus, fibrin and necrotic tissue; moist saline dressing changes every 12 hours; systematic control of infection, if present; glucose control; and offloading of pressure”.

Table 10

Cost-effectiveness analysis (CEA) outcomes for pressure ulcers (n = 14)

CEA (Original year of values)

Treatment vs. Comparator

ICER summary/estimate [2013 US$]

Unit of effectiveness

Incremental cost [2013 US$]

Incremental effectiveness

Branom 2001 (2000) [64]

Constant Force Technology mattress vs. low-air-loss mattress

Dominant

Percent additional reduction in wound volume per week

−1,435

0.04

Burgos 2000 (1998) [65]

Collagenase ointment vs. hydrocolloid (Varihesive) dressing

1,278

Percent additional reduction of ulcer area

20,825

16.3

Chang 1998 (1997) [66]

Hydrocolloid (DuoDERM CGF) vs. saline gauze

3

Percent additional reduction of ulcer area

121

43

Chuangsu-wanich 2011 (2010) [67]

Silver mesh dressing vs. silver sulfadiazine cream

Dominant

Increase in healing rate

−1,695

11.89

Ferrell 1995 (1992) [68]

Low-air-loss bed vs. conventional foam mattress

58a

Ulcer-free day gained

Not reported

Not reported

Foglia 2012 (2010) [69]

Advanced dressings vs. simple dressings

Dominanta

Percent additional reduction of ulcer area

−132

6

Graumlich 2003 (2001) [70]

Collagen (Medifil) vs. hydrocolloid (DuoDERM)

63,147a

Additional wound healed

632

0.01

Muller 2001 (1998) [71]

Collagenase-containing ointment (Novuxol) vs. hydrocolloid (DuoDERM) dressing

Dominanta

Additional wound healed

−149

0.281

Narayanan 2005b (2004) [72]

Initial wound stage 1: BCT (balsam Peru + hydrogenated castor oil + trypsin ointment) only vs. BCT + Others (BCT plus Other treatments)

Dominant

Additional wound healed

−5

0.106

Narayanan 2005b (2004) [72]

Initial wound stage 1: BCT + Others vs. Others

Dominant

Additional wound healed

−10

0.263

Narayanan 2005b (2004) [72]

Initial wound stage 2: BCT only vs. Others

Dominant

Additional wound healed

−6

0.16

Narayanan 2005b (2004) [72]

Initial wound stage 2: BCT only vs. BCT + Others

Dominant

Additional wound healed

−7

0.159

Narayanan 2005b (2004) [72]

Initial wound stage 2: BCT + Others vs. Others

226,208

Additional wound healed

226

0.001

Payne 2009 (2007) [73]

Polyurethane foam dressing (Allevyn Thin) vs. saline gauze

Dominant

Additional wound healed

−564

0.181

Robson 2000b (1999) [74]

Sequential GM-CSF and bFGF vs. bFGF only

Dominant

Percent additional reduction of ulcer volume

1,357

−0.07

Robson 2000b (1999) [74]

Sequential GM-CSF and bFGF vs. GM-CSF only

Dominant

Percent additional reduction of ulcer volume

−848

1

Robson 2000b (1999) [74]

Placebo vs. sequential GM-CSF and bFGF

735

Percent additional reduction of ulcer volume

2,205

3

Sanada 2010 (2007) [75]

New incentive system vs. non-introduced control

Dominant

reduction in DESIGN score

−16

4.1

Xakellis 1992 (1990) [76]

Hydrocolloid (DuoDERM) vs. gauze

Dominanta

ulcer-free day gained

−25

2

Sebern 1986b (1985) [77]

Grade II PrU: MVP vs. gauze

Dominanta

percent additional reduction of ulcer area

−1,925

48

Sebern 1986b (1985) [77]

Grade III PrU: MVP vs. gauze

9a

percent additional reduction of ulcer area

217

23

BCT, Balsam Peru plus hydrogenated castor oil plus trypsin ointment; bFGF, Basic fibroblast growth factor; GM-CSF, Granulocyte-macrophage/colony-stimulating factor; ICER, Incremental cost-effectiveness ratio; MVP, Moisture vapor permeable dressing; PrU, Pressure ulcer; QALY, Quality-adjusted life-year; US$, United States dollars.

a Denotes the higher quality studies (Drummond score ≥8).

b Multiple comparisons are reported.

Table 11

Cost-effectiveness analysis (CEA) outcomes for mixed wound types (n = 3)

CEA (Original year of values)

Treatment vs. Comparator

ICER summary/estimate [2013 US$]

Unit of effectiveness

Incremental cost [2013 US$]

Incremental effectiveness

Bale 1998 (1994) [78]

Hydrocellular (Allevyn) dressing vs. hydrocolloid (Granuflex) dressing

26

Additional wound healed

3

0.13

Terry 2009 (2008) [79]

Telemedicine plus WCS consults vs. WCS consults only

Dominateda

Additional wound healed

2,085

−0.249

Vu 2007 (2000) [80]

Multidisciplinary wound care team vs. UC

Dominantb

Additional wound healed

−346

0.092

ICER, Incremental cost-effectiveness ratio; UC, Usual care; US$, United States dollars; WCS, Wound care specialist.

a “Disproportionate distribution, by chance, in group A [telemedicine plus WCS consults] of large non-healing surgical wounds and large, numerous pressure ulcers”.

b Denotes the higher quality study (Drummond score ≥8).

Venous ulcers

Twenty-four cost-effectiveness analyses examined interventions for venous ulcers (Table 7) [22-45,83]. Sixteen studies found the interventions were dominant (i.e., more effective and less costly) [22-24,26-29,31,32,35,38,42-45], and 12 of these were studies with a Drummond score ≥8 [24,26-29,32,35,38,39,42,44,45]. These included Apligraf (Graftskin) vs. Unna’s Boot [42], Unna’s boot vs. hydrocolloid (DuoDERM) [32], micronized purified flavonoid fraction plus usual care vs. usual care alone [24], durable barrier cream vs. no skin protectant [26], pentoxifylline plus compression vs. placebo plus compression [27], Manuka honey dressing vs. usual care [29], amelogenin plus compression therapy vs. compression therapy only [45], and four-layer compression bandaging vs. usual care [35,38,44]. Although four-layer compression bandaging vs. short-stretch compression bandaging was found to be dominant in two studies [28,39]], this intervention was more effective and more costly in another economic evaluation [41].

Dominant interventions from four studies scoring <8 on the Drummond tool [22,23,31,43] included hydrocolloid dressing vs. Vaseline gauze dressing [22], hydrocolloid dressing plus compression hosiery vs. Unna’s boot [31], Thera-boot vs. Unna’s boot [23], and community leg ulcer clinic vs. usual care clinic [43].

Mixed venous and venous/arterial ulcers

Two cost-effectiveness analyses evaluated interventions for mixed venous and venous/arterial ulcers (Table 8) [46,47]. Only one study found an intervention to be dominant (and had a Drummond score ≥8); hydrocolloid (DuoDERM) dressing was dominant compared to saline gauze [47].

Diabetic ulcers

Sixteen cost-effectiveness analyses examined interventions for diabetic ulcers (Table 9) [48-63]. Twelve studies found the interventions were dominant [48-50,52-54,56,57,59,61-63], and 10 of these were studies with a Drummond score ≥8 [49,50,52-54,56,57,59,61,62]. These included becaplermin gel (containing recombinant human platelet-derived growth factor) plus good wound care (GWC) vs. GWC alone (note: the various GWC definitions used are outlined in Table 9) [57,62], cadexomer iodine ointment vs. usual care [49], filgrastim vs. placebo [50], intensified treatment vs. usual care [52], staged management diabetes foot program vs. usual care [53], ertapenem vs. piperacillin/tazobactam [54], ampicillin/sulbactam vs. imipenem/cilastatin [56], Apligraf (skin substitute) plus GWC vs. GWC alone [59], and promogran dressing plus GWC vs. GWC alone [61]. Hyperbaric oxygen therapy plus usual care vs. usual care alone was found to be dominant in one study [63], yet was more effective and more costly in another economic evaluation [51].

Dominant interventions from studies scoring <8 on the Drummond tool included hyperbaric oxygen therapy vs. control [48], and hyperbaric oxygen therapy plus standard care vs. standard care alone [63].

Pressure ulcers

Fourteen cost-effectiveness analyses evaluated pressure ulcer interventions (Table 10) [64-77]. Ten studies found the interventions were dominant [64,67,69,71-77], and four of these were studies with a Drummond score ≥8 [69,71,76,77]. These included moisture vapor permeable dressing vs. gauze [for grade II pressure ulcers] [77], advanced dressings vs. simple dressings [69], and hydrocolloid (DuoDERM) vs. gauze [76]. Collagenase-containing ointment (Novuxol) vs. hydrocolloid (DuoDERM) dressing was found to be dominant in one study [71], while collagen (Medifil) vs. hydrocolloid (DuoDERM) was more effective and more costly in another cost-effectiveness analysis [70].

The following interventions were dominant in six studies with a Drummond score <8: constant force technology mattress vs. low-air-loss mattress [64], silver mesh dressing vs. silver sulfadiazine cream [67], balsam Peru plus hydrogenated castor oil plus trypsin ointment vs. balsam Peru plus hydrogenated castor oil plus trypsin ointment plus other treatment (unspecified) for stage 1 and 2 wounds [72], balsam Peru plus hydrogenated castor oil plus trypsin ointment plus other treatment (unspecified) vs. other treatment (unspecified) for stage 1 wounds [72], balsam Peru plus hydrogenated castor oil plus trypsin ointment vs. other treatment (unspecified) for stage 2 wounds [72], polyurethane foam dressing vs. saline gauze [73], sequential granulocyte-macrophage/colony-stimulating factor and basic fibroblast growth factor vs. basic fibroblast growth factor alone [74], sequential granulocyte-macrophage/colony-stimulating factor and basic fibroblast growth factor vs. granulocyte-macrophage/colony-stimulating factor alone [74], and new hospital incentive system vs. non-introduced control [75].

Mixed wound types

Three cost-effectiveness analyses evaluated mixed complex wound types (Table 11) [78-80]. One study with a Drummond score ≥8 found that a multidisciplinary wound care team was dominant compared to usual care [80].

Discussion

We conducted a comprehensive systematic review to summarize the cost-effectiveness of interventions for complex wound care including data from 59 cost-effectiveness analyses. These economic studies examined numerous interventions and comparators and used different outcomes to assess effectiveness. In a few situations, the intervention considered in one cost-effectiveness analysis comprised the comparator in another cost-effectiveness analysis. Therefore, cost-effectiveness results are presented as comparisons of one treatment option relative to another.

Based on evidence from 42 cost-effectiveness studies with a Drummond score ≥8, 22 intervention comparisons were dominant (Additional file 7). For venous ulcers, these were four-layer compression bandaging vs. usual care, skin replacement vs. Unna’s Boot, Unna’s boot vs. hydrocolloid, micronized purified flavonoid fraction plus usual care vs. usual care, durable barrier cream vs. no skin protectant, pentoxifylline plus compression vs. placebo plus compression, Manuka honey dressing vs. usual care, and amelogenin plus compression therapy vs. compression therapy only. For mixed venous and venous/arterial ulcers, only hydrocolloid dressing vs. saline gauze was dominant according to high quality cost-effectiveness analyses. For diabetic ulcers, cadexomer iodine ointment vs. usual care, filgrastim vs. placebo, intensified treatment vs. usual care, staged management diabetes foot program vs. usual care, ertapenem vs. piperacillin/tazobactam, ampicillin/sulbactam vs. imipenem/cilastatin, skin replacement plus GWC vs. GWC alone, promogran dressing plus GWC vs. GWC alone, and becaplermin gel (containing recombinant human platelet-derived growth factor) plus GWC vs. GWC alone were dominant. For pressure ulcers, moisture vapor permeable dressing vs. gauze, advanced dressings vs. simple dressings, and hydrocolloid vs. gauze were dominant. Finally, for mixed wound types, multidisciplinary wound care team was dominant vs. usual care.

Our results highlight a need for a future network meta-analysis given the numerous interventions and comparators available. Network meta-analysis is a statistical technique that can be used to combine direct evidence of effectiveness from head-to-head studies and indirect evidence of the relative benefits of interventions versus a common comparator (usually placebo). This powerful statistical approach can also be used to select the best treatment option available from a ranking of all treatments. An attractive property of network meta-analysis is that it allows researchers and health economists the opportunity to use the ranking analysis to generate a de novo cost-effectiveness analysis more efficiently. Another potential future study is to conduct a systematic review of clinical practice guidelines on complex wounds, and compare the interventions recommended in these with those found to be cost-effective in our review.

The major methodological quality limitation found in the included cost-effectiveness analyses was that the majority did not adequately establish the effectiveness of the wound care intervention using data from systematic reviews, randomized clinical trials, or observational studies that had sufficiently large sample sizes. Moreover, many of the included economic studies did not report on uncertainty of the cost-effectiveness estimates, incremental variabilities, or sensitivity analyses, thereby further limiting the utility of those results. Further, many of the cost-effectiveness analyses did not assess long-term cost-effectiveness, and the choice of timeframe for an economic evaluation might significantly affect the cost-effectiveness results. Given the chronic nature of many types of wounds, economic modeling of a longer time horizon would provide a clearer picture in many circumstances. As an example, an intervention might be more effective yet more costly in the first 2 months of usage but it might be cost saving over a 1 year or longer timeframe due to overall fewer additional interventions required. Furthermore, most of the cost-effectiveness studies did not include information on patient-reported quality of life, which is a major limitation of this literature.

The majority of the included economic studies were from European countries and 16 were from the United States. When trying to apply the cost-effectiveness results to a country-specific context, several factors need to be assessed such as the perspective of the economic evaluation (e.g., public payer, healthcare provider), the type of healthcare system (e.g., publicly-funded healthcare), the local practice of medicine, and local costs.

There are a few limitations related to our systematic review process worth noting. Due to resource constraints, we only included studies written in English. However, we contacted authors of non-English studies to obtain the English translations. In addition, although we contacted authors to share their unpublished data, only published literature was identified for inclusion. Finally, due to the numerous number of cost-effectiveness analyses included, we focused reporting on those with dominant results and a score ≥8 on the Drummond tool in the main text. We note that this is an arbitrary cut-off, and there is not an agreed upon method to provide a summary score on this tool. However, all of our results for all studies are presented in the tables and appendices despite dominance and score on the Drummond tool.

Conclusions

We conducted a comprehensive systematic review of cost-effectiveness studies for interventions to treat adult patients with complex wounds. Our results can be used by decision-makers to assist in maximizing the deployment of clinically effective and resource efficient wound care interventions. Our analysis also highlights specific treatments that are not cost-effective, thus indicating areas for potential improvements in efficiency. A network meta-analysis and de novo cost-effectiveness analysis will likely bring additional clarity to the field, as some of the findings were conflicting.

Abbreviations

GWC: 

Good wound care

ICER: 

Incremental cost-effectiveness ratio

QALY: 

Quality-adjusted life-year

USD: 

United States dollar

Declarations

Acknowledgements

We thank the Toronto Central Local Health Integrated Network (TC LHIN) for their generous funding. ACT is funded by Canadian Institutes for Health Research/Drug Safety and Effectiveness Network (CIHR/DSEN) New Investigator Award in Knowledge Synthesis. SES is funded by a CIHR Tier 1 Research Chair in Knowledge Translation. We thank Dr. James Mahoney and Chris Shumway from the TC LHIN who provided invaluable feedback on our original report. We thank Laure Perrier for conducting the literature searches, and Afshin Vafaei, Alana Harrington, Charlotte Wilson, and John Ivory for screening articles. We also thank Inthuja Selvaratnam and Wasifa Zarin for formatting the report and references, and Judy Tran for obtaining the full-text articles.

Authors’ Affiliations

(1)
Knowledge Translation Program, Li Ka Shing Knowledge Institute, St. Michael’s Hospital
(2)
Epidemiology Division, Dalla Lana School of Public Health, University of Toronto
(3)
Institute of Health Policy, Management and Evaluation, University of Toronto
(4)
Department of Geriatric Medicine, University of Toronto

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