Cost-Effectiveness of Wound Care A concept analysis *Koukab A. Al-Gharibi,1 Sajana Sharstha,2 Maria A. Al-Faras2 Sultan Qaboos University Med J, November 2018, Vol. 18, Iss. 4, pp. e433–439, Epub. 28 Mar 19 Submitted 29 Apr 18 Revision Req. 13 Jun 18; Revision Recd. 9 Jul 18 Accepted 2 Aug 18 1College of Nursing, Sultan Qaboos University, Muscat, Oman; 2College of Nursing & Health Professions, Valparaiso University, Valparaiso, Indiana, USA *Corresponding Author’s e-mail: kawkab@squ.edu.om doi: 10.18295/squmj.2018.18.04.002 Chronic or difficult-to-he al skin wounds—such as diabetic leg ulcers, burns or pressure ulcers—impose an economic burden on the affected patient and healthcare system due to the increased costs associated with wound care, such as additional hospital/clinic visits, dressing changes, nursing care and hospital stays.1,2 Unfortunately, due to the increasing ageing population worldwide and the high prevalence of chronic diseases among the elderly, it is estimated that the number of patients with chronic wounds will continue to rise.3 In addition, the growing prevalence of antibiotic resistance and comorbidities such as diabetes mellitus, obesity, venous hypertension and peripheral vascular disease also increases the cost of wound care.2,4 Moreover, optimal wound care often requires changes in practice, including the implementation of advanced technologies.5–8 This review aimed to analyse the concept of cost-effectiveness in wound care in terms of the financial impact of wound care on patients, medical staff and healthcare instit- utions. These findings may serve as a guide to future researchers studying the benefits of cost-saving wound care measures. Methods The concept of cost-effectiveness was analysed using Walker and Avant’s method.9 A literature search for articles related to cost-effectiveness was performed of the Cumulative Index to Nursing and Allied Health Literature® (EBSCO Information Services, Ipswich, Massachusetts, USA), MEDLINE® (National Library of Medicine, Bethesda, Maryland, USA) and Nursing & Allied Health® (ProQuest LLC, Ann Arbor, Michigan, review فعالية التكلفة يف العناية باجلروح حتليل املفهوم كوكب عبداهلل الغريبي، �شاجانا �شريا�شثا، ماريا ارورا الفرا�س abstract: This review aimed to analyse the concept of cost-effectiveness within the context of chronic wound care using Walker and Avant’s approach. The Cumulative Index to Nursing and Allied Health Literature® (EBSCO Information Services, Ipswich, Massachusetts, USA), MEDLINE® (National Library of Medicine, Bethesda, Mary- land, USA) and Nursing & Allied Health® (ProQuest LLC, Ann Arbor, Michigan, USA) databases were searched using a combination of keywords. A total of 18 peer-reviewed articles were identified. In wound care, defining attributes for the concept of cost-effectiveness encompassed treatments which were both effective and economical. Four antecedents were identified, including the type of wound, care setting, type of dressing and patient-related characteristics. The consequences of cost-effective wound care were patient prognosis, quality of life, the economic burden on the patient and healthcare system and cost-savings. These findings will hopefully help to standardise cost-effectiveness terminology among nursing professionals in various healthcare settings. Keywords: Cost Effectiveness; Wounds and Injuries; Healthcare Costs; Nursing; Concept Formation. امللخ�ص: هدفت هذه املراجعة إىل حتليل مفهوم الفعالية من حيث التكلفة يف سياق الرعاية الصحية للجروح املزمنة باستخدام طريقة "ووكر" و "أفانت"، مت البحث يف قواعد البيانات باستخدام جمموعة من الكلمات الرئيسية يف حمركات البحث مثل املؤشر الرتاكمي للمنشورات العلمية املتعلقة بالتمريض واملهن الوطنية )املكتبة MEDLINE® و األمريكية( املتحدة الواليات يف ماساتشوستس ايبسويتش، املعلومات، خلدمات ،EBSCO( املساندة® الصحية للطب، بيثيسدا ، مرييالند يف الواليات املتحدة األمريكية( والتمريض و املهن الصحية املساندة® )ProQuest LLC، آن اربور، ميتشجني يف الواليات املتحدة األمريكية(. وقد مت حتديد 18 جمموعة من البحوث العلمية يف جمال العناية باجلروح، ويف هذه الدراسة مت تعريف السمات ملفهوم فعالية التكلفةواليت تشمل العالجات اليت كانت فعالة واقتصادية يف الوقت نفسه، ومت حتديد أربع ميزات سابقة، وهي نوع اجلرح، وإعدادات الرعاية، ونوع التضميد ومسات متعلقة باملريض، كانت النتائج املرتتبة على رعاية اجلروح فعالة من حيث التكلفة تشمل االستجابة للعالج، ونوعية احلياة، والعبء االقتصادي على املريض ونظام الرعاية الصحية والرتشيد يف التكاليف املستخدمة. تسعى نتائج هذه الدراسة إىل أن تساعد يف توحيد مصطلحات فعالية التكلفة بني املتخصصني يف التمريض يف خمتلف إعدادات الرعاية الصحية. الكلمات املفتاحية: الفعالية من حيث التكلفة؛ اجلروح واإلصابات؛ تكلفة الرعاية الصحية؛ التمريض؛ تشكيل مفهوم. Cost-Effectiveness of Wound Care A concept analysis e434 | SQU Medical Journal, November 2018, Volume 18, Issue 4 USA) databases. Subsequently, the search was narrowed down using more specific keywords either alone or in combination, including “cost-effectiveness”, “economical”, “profitable”, “cheap”, “cost-saving”, “cost-analysis”, “nursing”, “wound care”, “wound management”, “dressing change” and “wound dressing”. However, the term “cost-effectiveness” was consistently used throughout the search process in order to maintain the focus of the analysis. Finally, all scholarly English-language articles published between 2011–2016 were identified in order to gather recent research findings related to cost-effectiveness in nursing. Initially, 64,618 articles were identified using the term “cost-effectiveness” and related keywords; this was subsequently narrowed down to 17,445 articles with the inclusion of the term “nursing” and 2,175 articles when combined with wound care-related keywords. However, 1,771 articles were excluded as they did not meet the inclusion criteria with regards to the year or language of publication or because they were not published in scholarly peer-reviewed journals. Although the term “cost analysis” was interchangeably used with “cost- effectiveness” in some articles, such results were excluded to maintain the focus on cost-effectiveness. Articles with general information, commentaries, speeches/lectures, biographies and instructional materials/guidelines were also excluded. Finally, the remaining 32 articles were screened to ensure their relevance to cost-effectiveness in wound care, resulting in 18 articles which were included in the final analysis [Table 1].1,2,5–8,10–21 Use of Concept In nursing literature, the concept of cost-effectiveness was used mainly in relation to the cost and frequency of wound dressing changes, the duration of wound healing, the size of the wound and the use of other treatments or medications. Wound dressing results in both direct healthcare costs (encompassing both hospital and nursing costs), the cost of the actual dressing itself and the costs associated with applying the dressing or treating any systemic infections. Direct healthcare costs include the salaries of the nurses, various hospital costs, the time needed for the nurses to care for the patients, the time and costs related to home visits, if necessary, as well as visits to the primary care provider and follow-up visits.6,13–16 In addition, the rate of wound healing also has an effect on costs in relation to the size and duration of the wound as it progresses.11 Moreover, the use of other medications and treatments also contributes to the total cost of wound care, such as analgaesics, anxiolytic medications and topical/systemic antibiotics to treat underlying infections and prevent downstream inter- ventions.7,10,17 Defining Attributes Attributes denote the key characteristics of the concept being analysed.9 Overall, two defining attributes—effect- iveness and economy—were identified for the concept of cost-effectiveness in wound care. For the first attribute, it is imperative that treatment modalities are effective, as evidenced via rapid wound healing and a decrease in wound size. For the second, the total cost of wound care, including both direct and indirect healthcare costs, should not be more expensive than comparable treatments available on the market while still meeting treatment needs. The concept of cost-effectiveness is sometimes conflated with cost-saving, cost comparisons, cost analyses, cost-benefit ratios or being cost-conscious. However, these terms should not be used interchangeably. In the researchers’ opinion, cost-saving is a consequence of cost-effective measures rather than a synonym of cost- effectiveness. For example, even if a particular wound care product is cost-saving, it cannot be considered cost-effective if the treatment outcome is suboptimal. Furthermore, if a wound is not treated properly to begin with, various complications might arise requiring further treatment or surgical interventions such as wound debridement. e f f e c t i v e n e s s Rapid healing is a hallmark of effective treatment. Several studies reported faster wound healing times and smaller wound sizes with the use of newer, more cost-effective wound dressing technologies.5,7,12 Jemec et al. found that the use of silver dressings resulted in wound closure occurring approximately three weeks earlier among patients with chronic leg ulcers compared to those treated with non-silver dressings.19 Although the initial cost of silver dressings was higher than that of non-silver dressings during the first four weeks of treatment, the average total treatment cost per patient was lower due to the shorter healing time.19 Hämmerle et al. also found that patients with venous leg ulcers treated with octenidine gel had significantly faster healing rates and decreased wound sizes compared to those treated with modern wound dressings.11 Brown et al. compared treatment costs in relation to healing rates and changes in wound size among paediatric burn victims.1 Wounds treated with single-use negative pressure wound therapy (NPWT) resulted in a marked decrease in wound size, with an average reduction in size of 21% per week. As such, the expense of NPWT was offset by the reduction in wound size, as this form of treatment resulted in wound healing occurring after two weeks compared Koukab A. Al-Gharibi, Sajana Sharstha and Maria A. Al-Faras Review | e435 Ta bl e 1: C on ce pt a na ly si s of c os t- eff ec ti ve ne ss in w ou nd c ar e1 ,2 ,5 – 8, 10 – 21 A ut ho r an d ye ar o f pu bl ic at io n T yp e of a rt ic le T re at m en t T yp e of w ou n d Fi n di n gs P os si bl e at tr ib ut es A nt ho ny 6 ( 20 15 ) M et a- an al ys is N PW T V ar io us • N PW T r eq ui re s a sh or te r tr ea tm en t d ur at io n an d fe w er d re ss in g ch an ge s. • N PW T is e ffe ct iv e in d iff er en t s et tin gs . • C os t o f t re at m en t • Sa fe ty o f t re at m en t • Effi ci en cy o f t re at m en t • Si ze o f w ou nd • D ur at io n of tr ea tm en t A ug us tin e t a l.7 (2 01 6) C om pa ra tiv e st ud y H yd ro ac tiv e dr es si ng c on ta in in g a na no -o lig os ac ch ar id e fa ct or ve rs us a n eu tr al fo am d re ss in g V as cu la r le g ul ce rs • Th e hy dr oa ct iv e dr es si ng w as m or e eff ec tiv e in r ed uc in g th e w ou nd a re a co m pa re d to th e ne ut ra l f oa m d re ss in g. • Effi ci en cy o f t re at m en t • Ty pe o f d re ss in g • Si ze o f w ou nd Br ow n et a l.1 (2 01 5) R C T N on ph ar m ac ol og ic al D IT T O in te rv en tio n ve rs us s ta nd ar d w ou nd c ar e Pa ed ia tr ic b ur ns • O n av er ag e, th e D IT T O in te rv en tio n re su lte d in lo w er d ir ec t h ea lth ca re co st s, d ir ec t n on -h ea lth ca re c os ts a nd o ve ra ll co st s pe r ch ild . • W ou nd s tr ea te d w ith th e D IT T O in te rv en tio n re -e pi th el ia lis ed a n av er ag e of th re e da ys fa st er . • C os t o f t re at m en t • Effi ci en cy o f t re at m en t • Ty pe o f t re at m en t • R at e of w ou nd c lo su re Br ow ni ng 10 (2 01 4) R ev ie w V ar io us V ar io us • Th e to ta l c os t o f t re at m en t i s de pe nd en t o n th e co st o f s pe ci al is ed m ed ic al st aff a nd th e nu m be r of d re ss in g ch an ge s re qu ir ed p er w ee k. • Th e co st o f t re at m en t f or in fe ct io n is d ep en de nt o n th e nu m be r of tr ea tm en ts r eq ui re d an d th e ne ed fo r su rg ic al d eb ri de m en t. • C os t o f t re at m en t • D ur at io n of tr ea tm en t • N um be r of d re ss in g ch an ge s • O cc ur re nc e of c om pl ic at io ns B ut ch er e t a l.1 3 ( 20 14 ) R ev ie w V ar io us C hr on ic w ou nd s • Th e to ta l c os t o f c ar e de pe nd s on th e fr eq ue nc y of in te rv en tio ns a nd dr es si ng c ha ng es a nd c os ts a ss oc ia te d w ith s ta ff tim e an d re so ur ce s. • O th er c os ts in cl ud e di sp os ab le it em s su ch a s dr es si ng p ac ks , p ai n re lie f m ea su re s, in pa tie nt /o ut pa tie nt h os pi ta l c os ts a nd n ur si ng ti m e. • Ph ar m ac eu tic al in te rv en tio ns s uc h as a na lg ae si cs a nd a nx io ly tic m ed ic at io ns al so c on tr ib ut e to c os ts . • C os t o f t re at m en t • D ur at io n of tr ea tm en t • N um be r of d re ss in g ch an ge s C ar te r2 (2 01 4) R ev ie w V ar io us C hr on ic w ou nd s • O ne s tu dy o f d ia be tic fo ot u lc er s de m on st ra te d th at IG C in c on ju nc tio n w ith op tim al fo ot c ar e w as m or e co st -e ffe ct iv e co m pa re d to s ta nd ar d ca re . • C os t o f t re at m en t • C os t o f p re ve nt at iv e ca re Ev an s1 7 ( 20 14 ) R ev ie w V ar io us V ar io us • So ft s ili co ne w ou nd c on ta ct d re ss in gs h av e a w id e ra ng e of w ou nd c ar e ap pl ic at io ns . • Su ch d re ss in gs a re m or e co st -e ffe ct iv e in a c om m un ity s et tin g as o ne s in gl e pr od uc t c an b e us ed fo r a va ri et y of d iff er en t t yp es o f w ou nd s. • R at e of h ea lin g • Eff ec tiv en es s of tr ea tm en t • V er sa til ity o f t re at m en t G ill ig an e t a l.2 0 (2 01 5) R et ro sp ec tiv e st ud y B ec ap le rm in g el p lu s G W C v er su s G W C a lo ne D ia be tic fo ot u lc er s • B ec ap le rm in g el p lu s G W C r es ul te d in b et te r ou tc om es a t l ow er c os ts co m pa re d to G W C a lo ne . • D ur at io n of tr ea tm en t • R at e of w ou nd c lo su re • C os t o f t re at m en t H äm m er le e t a l.1 1 (2 01 4) R C T O ct en id in e- ba se d w ou nd g el ve rs us m od er n dr es si ng s C hr on ic v en ou s le g ul ce rs • O ct en id in e ge l r es ul te d in a g re at er r ed uc tio n in w ou nd s iz e an d fa st er he al in g ra te s co m pa re d to m od er n dr es si ng s. • Th e ov er al l c os t o f t re at m en t w ith o ct en id in e ge l w as lo w er . • C os t o f t re at m en t • Sa fe ty o f t re at m en t • Effi ca cy o f t re at m en t • Si ze o f w ou nd • In ci de nc e of lo ca l i nf ec tio ns • R at e of h ea lin g (g ra nu la tio n tis su e an d bi ob ur de n) Cost-Effectiveness of Wound Care A concept analysis e436 | SQU Medical Journal, November 2018, Volume 18, Issue 4 Ta bl e 1 (c on td .): C on ce pt a na ly si s of c os t- eff ec ti ve ne ss in w ou nd c ar e1 ,2 ,5 – 8, 10 – 21 A ut ho r an d ye ar o f pu bl ic at io n T yp e of a rt ic le T re at m en t T yp e of w ou n d Fi n di n gs P os si bl e at tr ib ut es H am pt on 5 ( 20 15 ) C oh or t s tu dy N PW T v er su s st an da rd c ar e H ar d- to -h ea l l eg ul ce rs o r pr es su re ul ce rs • Th e av er ag e w ee kl y re du ct io n in w ou nd s iz e w as 2 1% w ith N PW T. • A lth ou gh th e w ee kl y co st o f N PW T w as e xp en si ve , t he to ta l c os t w as lo w er co m pa re d to s ta nd ar d ca re d ue to th e sh or te ne d tr ea tm en t d ur at io n. • R at e of h ea lin g • Si ze o f w ou nd • C os t o f t re at m en t • D ur at io n of tr ea tm en t Je m ec e t a l.1 9 ( 20 14 ) C om pa ra tiv e st ud y Si lv er d re ss in gs v er su s no n- si lv er dr es si ng s H ar d- to -h ea l ch ro ni c ve no us le g ul ce rs • Pa tie nt s tr ea te d w ith s ilv er d re ss in gs h ad fa st er r at es o f w ou nd c lo su re co m pa re d to th os e tr ea te d w ith n on -s ilv er d re ss in gs . • Si lv er d re ss in g tr ea tm en t r es ul te d in a c os t- sa vi ng o f £ 14 1. 57 c om pa re d to no n- si lv er d re ss in gs . • R at e of h ea lin g • C os t o f t re at m en t Li m a et a l.1 4 ( 20 16 ) D es cr ip tiv e st ud y V ar io us Pr es su re u lc er s • H yd ro co llo id d re ss in gs w er e th e m os t c os t- eff ec tiv e ty pe o f d re ss in g. • R at e of h ea lin g • Ty pe o f t re at m en t • C os t o f t re at m en t • D ur at io n of tr ea tm en t M au no ur y et a l.2 1 (2 01 5) R C T A nt im ic ro bi al c hl or he xi di ne gl uc on at e- co nt ai ni ng se cu re m en t d re ss in gs v er su s no n- an tim ic ro bi al tr an sp ar en t dr es si ng s IC U v en ou s/ ar te ri al c at he te r in se rt io n si te s • Th e ch lo rh ex id in e dr es si ng w as b et te r in te rm s of in fe ct io n pr ev en tio n co m pa re d to th e no n- an tim ic ro bi al d re ss in g. • C os t o f t re at m en t • Eff ec tiv en es s of tr ea tm en t • R at e of h ea lin g • C os t o f t re at m en t • D ur at io n of tr ea tm en t • In ci de nc e of in fe ct io n O th m an 18 (2 01 2) R ev ie w N PW T C hr on ic w ou nd s • N PW T r ed uc es th e co st o f c hr on ic w ou nd c ar e m an ag em en t a nd in cr ea se s Q O L du e to fa st er w ou nd h ea lin g ra te s. • C os t o f t re at m en t • D ur at io n of tr ea tm en t • R at e of h ea lin g Ph am e t a l.1 5 ( 20 12 ) R C T 4L B ve rs us S SB c om pr es si on te ch ni qu es V en ou s le g ul ce rs • B ot h 4L B an d SS B co m pr es si on te ch ni qu es w er e eff ec tiv e an d ha d co m pa ra bl e co st -e ffe ct iv en es s w he n us ed b y tr ai ne d re gi st er ed n ur se s. • R at e of h ea lin g • Eff ec tiv en es s of tr ea tm en t • C os t o f t re at m en t • D ur at io n of tr ea tm en t Si bb al d et a l.8 (2 01 5) C M E ar tic le / va lid at io n st ud y N on co nt ac t i nf ra re d sk in th er m om et er s Pa tie nt s at h ig h ri sk o f d ev el op in g di ab et ic fo ot u lc er s • N on co nt ac t i nf ra re d sk in th er m om et er s w er e ea sy to u se a nd a va ila bl e at a co ns id er ab ly lo w er c os t c om pa re d to c on ta ct in fr ar ed th er m om et er s. • D ue to it s ea se o f u se a nd a va ila bi lit y, th is to ol c ou ld b e us ed o n a da ily b as is at h om e. • C os t o f t re at m en t • Eff ec tiv en es s of tr ea tm en t • C os t o f p re ve nt at iv e ca re • Eff ec tiv en es s of p re ve nt at iv e ca re T ri cc o et a l.1 2 ( 20 15 ) R ev ie w V ar io us c om pl ex w ou nd in te rv en tio ns C hr on ic h ar d- to - he al w ou nd s an d pr es su re u lc er s • A to ta l o f 2 2 co m pl ex w ou nd in te rv en tio ns w er e id en tifi ed to b e eff ec tiv e an d le ss e xp en si ve c om pa re d to o th er m et ho ds . • R at e of h ea lin g • C os t o f t re at m en t • Ty pe o f t re at m en t • D ur at io n of tr ea tm en t W hi tlo ck e t a l.1 6 (2 01 4) C ro ss -s ec tio na l st ud y V ar io us C hr on ic w ou nd s an d ul ce rs • O nl y ha lf of th e ge ne ra l p ra ct iti on er s’ tim e w as c ov er ed b y pa tie nt b ill in g. • In m os t c as es , t he to ta l c os t w as g re at er th an th e to ta l i nc om e, r es ul tin g in a ne t l os s to th e pr ac tic e. • C os t o f t re at m en t N PW T = n eg at iv e p re ss ur e w ou nd th er ap y; R C T = ra nd om is ed co nt ro lle d tr ia l; D IT T O = co m pu te ri se d m ul tim od al p ro ce du ra l p re pa ra tio n an d di st ra ct io n; IG C = in te ns iv e g ly ca em ic co nt ro l; G W C = g oo d w ou nd c ar e; IC U = in te ns iv e ca re u ni t; Q O L = qu al ity o f l ife ; 4 LB = fo ur -l ay er b an da ge ; S SB = sh or t- st re tc h ba nd ag e; C M E = co nt in ui ng m ed ic al e du ca tio n. Koukab A. Al-Gharibi, Sajana Sharstha and Maria A. Al-Faras Review | e437 to an average of 3.2 weeks of treatment with standard care.1 Similar findings were reported in a recent meta-analysis; although the initial cost of NPWT was higher during treatment, the overall cost was reduced due to the lower costs incurred for personnel-related expenses and the shorter duration of treatment.6 Augustin et al. explored the cost-effectiveness of treating vascular leg ulcers using UrgoStart® (Urgo Ltd., Loughborough, UK), a hydroactive dressing containing a nano-oligosaccharide factor, and UrgoCell Contact® (Urgo Ltd.), a neutral foam dressing.7 According to an economic model, the hydroactive dressing was less expensive than the neutral foam dressing after eight weeks of treatment (USD $849.86 versus $1,335.51). In addition, the hydroactive dressing resulted in a ≥40% reduction in wound size, with greater healing observed over a shorter treatment period.7 Gilligan et al. investigated the expected cost of treatment per week and the number of weeks needed for wound closure using becaplermin gel and good wound care (GWC) versus GWC alone among patients with diabetic foot ulcers.20 As with NPWT, although treatment with becaplermin gel and GWC was initially more expensive compared to GWC alone, the former treatment method resulted in accelerated wound closure and lowered the risk of amputation, thus reducing overall long-term costs.20 e c o n o m y A treatment is considered cost-effective only if it is economical in terms of both time and money. As mentioned earlier, the duration of treatment is often directly linked with costs as the shorter the duration of treatment, the less expensive the total costs of treatment.11,19 However, apart from increasing the rate of wound healing, a treatment may also be economical in that it reduces the number of wound dressing changes needed or decreases the time required to apply the dressing. In a cohort study, both the frequency of dressing changes and the time required to change dressings was reduced using NPWT in comparison to standard treatment.5 m o d e l c a s e A 60-year-old man developed a diabetic foot ulcer after wearing a new pair of shoes for one week. He had initially been diagnosed with diabetes mellitus five years previously. The surface area of the wound was 10 cm2 at baseline prior to starting treatment. After six months of standard wound care, the surface area of the wound had decreased to 7 cm2. The cost of each standard dressing was USD $24, with the dressing changed every other day. As a result, the total cost of treatment was USD $3,456 over a six-month period. Subsequently, the patient’s primary care provider advised changing treatment methods from standard dressings to becaplermin gel due to poor wound healing. After three months, the wound size had decreased to 3 cm2. The becaplermin gel dressing was re-applied three times a week at a cost of USD $30 each time. In total, the cost over three months of treatment was USD $1,040. This case highlights the two defining attributes of cost-effectiveness.9 Treatment with becaplermin dressing gel was more effective compared to standard wound care, as evidenced by the rapid wound healing and the greater decrease in wound size over a shorter period of time (a 4 cm2 decrease over three months versus a 3 cm2 decrease over six months). Moreover, although the cost per dressing change of becaplermin gel was higher than standard wound care, it was more economical in the long term (USD $1,040 versus USD $3,456). Antecedents Antecedents refer to the factors, events or incidents that must arise or be present prior to the occurrence of the concept.9 Four antecedents were identified in the concept of cost-effectiveness in wound care, including the type of wound, the setting at which the wound care takes place, the type of dressing/treatment used and patient-related characteristics. In terms of wound type, injuries and wounds may be classified as either acute or chronic (e.g. pressure ulcers, venous/arterial leg ulcers, diabetic ulcers and burns). This will therefore have an impact on duration of care and treatment costs. Generally, chronic wounds are more expensive and difficult to treat than acute wounds.2,6 However, certain treatments for acute wounds might be less cost- effective, particularly when used only for short periods of time.5 Wound care can take place in a variety of settings which will affect cost of treatment, such as in a hospital, outpatient department, home-care facility or an ambulatory clinic. For instance, the cost of treatment might be higher in a hospital setting in contrast to an outpatient setting.8 The type of dressing or treatment utilised will also have an impact on cost-effectiveness. Common treatments include beca- plermin gel, infrared thermometry, bandages, hydro- active/neutral foam dressings, antimicrobial dressings and NPWT.5,7,8,20,21 Finally, certain patient-related characteristics will affect care costs, such as age and the presence of comorbidities such as diabetes mellitus or other conditions affecting health such as decreased immunity or immobility.2–4 Cost-Effectiveness of Wound Care A concept analysis e438 | SQU Medical Journal, November 2018, Volume 18, Issue 4 Consequences Consequences are the events or outcomes that arise as a result of the occurrence of the concept.9 In terms of the concept of cost-effectiveness in wound care, four consequences were identified: patient prognosis, economic burden, quality of life (QOL) and cost-savings. As cost-effective wound dressings result in more rapid wound healing and reduce the risk of complications such as infection, the prognosis of the patient is improved.10 Additionally, as cost- effective treatments are more affordable and result in desired outcomes within shorter periods of time, the economic burden of wound care on the part of the patients and, ultimately, the healthcare system is reduced. Moreover, the patient’s QOL is significantly improved as a result of the more rapid recovery and reduced costs associated with the use of cost-effective treatments.18 Finally, there are obvious cost-savings that come with the use of wound dressings which are cost-effective. Empirical Referents Empirical referents indicate actual factors or events that, by virtue of their presence, demonstrate the occurrence of the concept.9 The empirical referents for the concept analysis of cost-effectiveness in wound care were divided into observable referents and measurable referents. Observable referents are factors associated with wound healing, such as photographs which showcase observable changes in wound healing after the application of dressings.11 Measurable referents include measuring the size of the wound throughout its progression and estimating the total cost of wound dressings. The following formulae may be used to calculate wound size:11 where r is the radius of the wound, L is the length of the wound and WMin and WMax are the minimum and maximum widths of the wound, respectively. Equation 1 is used mainly to calculate the size of circular wounds, while Equation 2 is used for wounds of other shapes. Implications Clinicians and managers should have a better understanding of the effect that clinical decision- making has on financial budgets and how the concept of cost-effectiveness can benefit various stakeholders, including both patients and healthcare facilities. As a result, clinicians should consider ways to reduce costs of care while maintaining optimal clinical outcomes. This will allow nurses and clinicians to support patients and their families in choosing effective treatments with a reduced economic burden and fewer financial constraints. Conclusion Nurses and clinicians should promote cost-effect- iveness in wound care in terms of both efficacy and economy, by considering healing rates and patient prognosis while maintaining low treatment costs in light of the duration of treatment. Further research is recommended to investigate nurses’ perceptions of cost-effective wound care. References 1. Brown NJ, David M, Cuttle L, Kimble RM, Rodger S, Higashi H. Cost-effectiveness of a nonpharmacological intervention in pediatric burn care. Value Health 2015; 18:631–7. https://doi. org/10.1016/j.jval.2015.04.011. 2. Carter MJ. Economic evaluations of guideline-based or strategic interventions for the prevention or treatment of chronic wounds. Appl Health Econ Health Policy 2014; 12:373–89. https://doi.org/10.1007/s40258-014-0094-9. 3. Gist S, Tio-Matos I, Falzgraf S, Cameron S, Beebe M. Wound care in the geriatric client. Clin Interv Aging 2009; 4:269–87. https://doi.org/10.2147/CIA.S4726. 4. 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. https://doi.org/10.1111/j.1524-475X.2009.00543.x. 5. Hampton J. Providing cost-effective treatment of hard-to- heal wounds in the community through use of NPWT. Br J Community Nurs 2015; 20:S116–20. https://doi.org/10.12968/ bjcn.2015.20.sup6.S14. 6. Anthony H. Efficiency and cost effectiveness of negative pressure wound therapy. Nurs Stand 2015; 30:64–70. https:// doi.org/10.7748/ns.30.8.64.s50. 7. Augustin M, Herberger K, Kroeger K, Muenter KC, Goepel L, Rychlik R. Cost-effectiveness of treating vascular leg ulcers with UrgoStart(®) and UrgoCell(®) Contact. Int Wound J 2016; 13:82–7. https://doi.org/10.1111/iwj.12238. 8. Sibbald RG, Mufti A, Armstrong DG. Infrared skin ther- mometry: An underutilized cost-effective tool for routine wound care practice and patient high-risk diabetic foot self- monitoring. Adv Skin Wound Care 2015; 28:37–44. https://doi. org/10.1097/01.ASW.0000458991.58947.6b. 9. Walker LO, Avant KC. Strategies for Theory Construction in Nursing, 5th ed. London, UK: Pearson, 2010. Pp. 160–8. 10. Browning P. The cost-effectiveness of wound dressings. Br J Healthc Manag 2014; 20:462–6. https://doi.org/10.12968/ bjhc.2014.20.10.462. 11. Hämmerle G, Strohal R. Efficacy and cost-effectiveness of octenidine wound gel in the treatment of chronic venous leg ulcers in comparison to modern wound dressings. Int Wound J 2016; 13:182–8. https://doi.org/10.1111/iwj.12250. Mean wound area = L × (WMin + WMax) 2 [Equation 2] Wound area = r2 × π [Equation 1] Koukab A. Al-Gharibi, Sajana Sharstha and Maria A. Al-Faras Review | e439 12. Tricco AC, Cogo E, Isaranuwatchai W, Khan PA, Sanmugalingham G, Antony J, et al. A systematic review of cost-effectiveness analyses of complex wound interventions reveals optimal treatments for specific wound types. BMC Med 2015; 13:90. https://doi.org/10.1186/s12916-015-0326-3. 13. Butcher M, White R. Factors affecting cost-effectiveness in wound care decision making. Nurs Stand 2014; 28:51–8. https://doi.org/10.7748/ns2014.04.28.35.51.e7671. 14. Lima AF, Castilho V, Baptista CM, Rogenski NM, Rogenski KE. Direct cost of dressings for pressure ulcers in hospitalized patients. Rev Bras Enferm 2016; 69:290–7. https://doi. org/10.1590/0034-7167.2016690212i. 15. Pham B, Harrison MB, Chen MH, Carley ME; Canadian Bandaging Trial Group. Cost-effectiveness of compression technologies for evidence-informed leg ulcer care: Results from the Canadian Bandaging Trial. BMC Health Serv Res 2012; 12:346. https://doi.org/10.1186/1472-6963-12-346. 16. Whitlock E, Morcom J, Spurling G, Janamian T, Ryan S. Wound care costs in general practice: A cross-sectional study. Aust Fam Physician 2014; 43:143–6. 17. Evans J. A solution to cost-effective wound management in the community. J Community Nurs 2014; 28:46–51. 18. Othman D. Negative pressure wound therapy literature review of efficacy, cost effectiveness, and impact on patients’ quality of life in chronic wound management and its implementation in the United Kingdom. Plast Surg Int 2012; 2012:374398. https://doi. org/10.1155/2012/374398. 19. Jemec GB, Kerihuel JC, Ousey K, Lauemøller SL, Leaper DJ. Cost-effective use of silver dressings for the treatment of hard- to-heal chronic venous leg ulcers. PLoS One 2014; 9:e100582. https://doi.org/10.1371/journal.pone.0100582. 20. Gilligan AM, Waycaster CR, Motley TA. Cost-effectiveness of becaplermin gel on wound healing of diabetic foot ulcers. Wound Repair Regen 2015; 23:353–60. https://doi.org/10.1111/ wrr.12285. 21. Maunoury F, Motrunich A, Palka-Santini M, Bernatchez SF, Ruckly S, Timsit JF. Cost-effectiveness analysis of a transparent antimicrobial dressing for managing central venous and arterial catheters in intensive care units. PLoS One 2015; 10:e0130439. https://doi.org/10.1371/journal.pone.0130439.