Improved wound management at lower cost: a sensible goal for Australia

Abstract

Chronic wounds cost the Australian health system at least US$2·85 billion per year. Wound care services in Australia involve a complex mix of treatment options, health care sectors and funding mechanisms. It is clear that implementation of evidence‐based wound care coincides with large health improvements and cost savings, yet the majority of Australians with chronic wounds do not receive evidence‐based treatment. High initial treatment costs, inadequate reimbursement, poor financial incentives to invest in optimal care and limitations in clinical skills are major barriers to the adoption of evidence‐based wound care. Enhanced education and appropriate financial incentives in primary care will improve uptake of evidence‐based practice. Secondary‐level wound specialty clinics to fill referral gaps in the community, boosted by appropriate credentialing, will improve access to specialist care. In order to secure funding for better services in a competitive environment, evidence of cost‐effectiveness is required. Future effort to generate evidence on the cost‐effectiveness of wound management interventions should provide evidence that decision makers find easy to interpret. If this happens, and it will require a large effort of health services research, it could be used to inform future policy and decision‐making activities, reduce health care costs and improve patient outcomes.

Introduction

Chronic wounds are an under‐recognized issue in Australian health care and under‐considered in terms of both research and public policy. There are limited Australian data on the prevalence of chronic wounds, particularly in the community, but a recent systematic review 1 suggests pressure injuries are the most common wound type comprising 84% of the estimated 420 000 cases of chronic wounds in hospital and residential care settings, followed by venous leg ulcers (VLUs) (12%), diabetic foot ulcers (3%) and arterial insufficiency ulcers (1%) (Figure 1) 2. This distribution is supported by a state‐wide prevalence survey in Western Australia 3.

Figure 1.

Distribution of chronic wounds in Australian hospitals and residential care settings. Source: Graves et al. 2. Chronic wounds are defined as those that have failed to proceed through an orderly and timely reparative process to produce anatomic and functional integrity or that have proceeded through the repair process without forming a sustained anatomic and functional result 118.

Chronic wounds reduce quality of life and working capacity and increase social isolation 4. It is clear that implementation of evidence‐based practice 5, 6, 7, 8, 9, 10, 11, 12 coincides with large health improvements and cost savings 8, 10, 13, 14, yet a significant gap exists in the use of evidence‐based practice in Australia 10, 15, 16, 17, 18. Underscoring this gap is Australia's failure to successfully implement national evidence‐based recommendations for the management of diabetes‐related foot ulcers 18, 19. Australia's national diabetes‐related amputation rates have increased by 30% over the last 15 years to be the second highest in the developed world 20, 21, 22. Furthermore, this lack of evidence‐based care is felt more acutely among Indigenous Australians where age standardised diabetes‐related amputation rates are up to 38 times higher 23, 24.

In addition to the impact on quality of life, chronic wounds impose substantial costs to the health care system and patients. Graves and Zheng estimated the direct health care costs of chronic wounds in Australia at US$2·85 billion a year which equates to approximately 2% of the national health care budget 2. These direct health care costs include costs in hospitals and residential care settings but do not include general practice and community nursing costs, indirect costs of lost productivity, the intangible costs of pain and suffering and travel and other costs of consumables to individual patients. It has been estimated that patients 60 years and older with a VLU pay AU$27·5 million in out‐of‐pocket costs for consumables per year 14.

Comparable high costs have been reported in other well‐resourced countries. The overall cost of chronic wounds to the UK health system was estimated at £2·3–3·1 billion per year (at 2005–2006 prices) or around 3% of the total National Health Service (NHS) budget 25, 26. A more recent report demonstrated 5·5% of total health expenditure in Wales is now spent on chronic wounds alone 27. In the USA, chronic wound treatment costs were between US$6 and 15 billion per year 28 with approximately 2 million work days lost annually 4, 29. In Denmark, the cost of wound care is expected to increase by 30% over a decade because of demographic and lifestyle changes 30. Similar trends are expected in Australia because of our ageing population and associated increases in the prevalence of chronic diseases.

Despite increasing costs and the impact on quality of life, chronic wounds remain an under‐recognised public health issue, and wound care receives little attention and investment compared to other chronic conditions. In this review, we investigate the reasons for this phenomenon by examining the case for improved wound care in Australia. We explore current funding and barriers to the implementation of evidence‐based wound care. We also preview the social and economic benefits to be gained from improving health service coordination and funding. Lastly, we make recommendations regarding appropriate incentives for optimal wound care and identify critical gaps in the current research evidence.

Health service pathways for chronic wounds

Wound management in Australia is extremely complex and diverse. It takes place along a continuum from the primary to the acute care sector. The transition between sectors is not adequately coordinated which impacts patient outcomes and costs (Figure 2).

Figure 2.

Wound Management Services in Australia. ¹Wounds diagnosed by a health care professional would be managed by a range of community‐based services. These services vary by their knowledge skills and ability to heal chronic wounds. For example, a patient could be seen by his/her general practitioner (GP), not be offered evidence‐based care and bounced around between community care services and GP visits for long periods of time incurring high costs and suffering poor quality of life. ²In addition to GPs, wounds can be treated by medical specialists (on referral) such as dermatologists or vascular surgeons, nurses, allied health professionals and Aboriginal health workers. Treatment can also be provided in specialised hospital‐based outpatient wound clinics (upon referral from medical practitioner). There are also specialist wound clinics led by nurse practitioners and podiatrists (in the community as well as private) 10, 97, 119. In addition, unregulated health care workers have been known to provide wound care in aged care facilities. These services include patient out‐of‐pocket payments for services, products and devices. ³A wound not diagnosed might be self‐managed for some time until the patient seeks care from a range of community‐based services² and might then continue with self‐management. ⁴All chronic wounds, self‐managed or other, are at risk of infection, which could lead to admissions to acute hospitals⁵ and, in some cases, amputation or even mortality⁶. After discharge from hospital, these chronic wounds are again managed by community service providers², and patients may then be re‐admitted to hospital with complications. ⁷Wounds managed by community service providers could be healed after some time and then might recur, incurring further interactions with community‐based services.

Primary care is at the forefront of wound management with general practitioners (GPs) involved in the care of around 80–90% of patients with a leg ulcer 10, 14. Application of wound dressings is the second most frequent procedure in general practice 31 and wound management the most frequent task undertaken by general practice nurses 32. Community nurses are also important in providing home‐based and centre‐based care 10, 14, 33, 34, 35. Allied health professionals, such as podiatrists, have also been found to manage up to five diabetes patients with foot ulcers on average each week depending on the health care sector 18. However, wound management most often involves a multitude of un‐coordinated health care providers and treatment arrangements (Figure 2). The most frequent combinations include: GP care in isolation (42%); GP and allied health professional teams (13%); GP and medical specialists (12%); and GP, medical specialist and community nursing teams (16%) 10.

Self‐management of wounds is also common, and this can lead to hospital admission for serious recurrent complications due to inappropriate treatment, which compounds pressure on public hospitals. In turn, early discharge from hospital, before the wounds are healed, also puts pressure on the primary health care system. The apparent diffusion of responsibility among the range of health care providers leads to poor continuity of evidence‐based treatment and preventative care along the health service continuum 10.

How wound care is funded at present

Different funding, reimbursement arrangements and cost structures apply to different health care providers. Patient out‐of‐pocket payments for wound care also vary depending on these arrangements and structures.

In Australia, hospital‐based care, residential aged care and community care programs are funded by federal and jurisdictional governments. Consultations at public hospital outpatient wound clinics are typically free and often also cover the cost of consumables. Community nursing services include the costs of consumables in some jurisdictions but not in others 14 and are generally funded by non‐government, not‐for‐profit organisations with reimbursement through Commonwealth Home and Community Care Program Services.

Medicare, Australia's universal health insurance scheme, funded by the Commonwealth Government, reimburses health care provided by GPs, medical specialists and nurse practitioners outside hospital as per the Medicare Benefits Schedule (MBS) 36. Some patients are charged the base level consultation rebate with no extra cost, while some patients are charged an additional fee depending on the individual GP or medical specialist. However, the cost of consumables such as dressings are not subsidised under the Pharmaceutical Benefits Scheme (PBS) 37 or the MBS (except for veterans who have served in the Australian Defence Force). GPs often charge patients for medical consumables, or patients purchase these at retail pharmacies or through commercial distributors.

Patients using private sector allied health professional services including podiatrists may be reimbursed for up to five allied health consultations per year through the MBS if there was an appropriate referral from a GP. However, the full costs of consultations in excess of five per year are incurred solely by patients. Furthermore, the cost of consumables is not subsidised for all allied health professional services. Some patients with private health insurance may be able to claim a proportion of costs incurred, such as a portion of the consultation fees, compression hosiery and topical negative pressure wound therapy devices for a limited time period and only if initially funded through the acute care system prior to discharge.

Since the removal of MBS item 10996 – wound care service provided by a practice nurse – there are no wound‐specific MBS items. Health care professionals use a range of MBS items for wound care episodes and claim these as fees for service (Table 1). They are then paid as a percentage of items billed. In an audit of current wound management in general practices in the Sunshine Coast, Queensland, the total costs of wound care in most cases was greater than the total income, resulting in a net loss to the general practice 38.

Table 1.

MBS items used for reimbursement of wound management services in Australia

	MBS item	Summarised notes (please refer to MBS online for the full description of the item)	Fees in AUD based on MBS, July 2014 update*
Standard services	3	Professional attendance by a GP for an obvious problem characterised by the straightforward nature of the task that requires a short patient history and, if required, limited examination and management	$16·95
	23	Professional attendance by a GP lasting less than 20 minutes	$37·05
	36	Professional attendance by a GP lasting at least 20 minutes	$71·70
	44	Professional attendance by a GP lasting at least 40 minutes	$105·55
	11610	ABPI – for new patients with chronic wound as part of a vascular assessment – measurement of ankle brachial indices and arterial waveform analysis	$63·75
	82200	Nurse practitioner straightforward attendance	$9·60
	82205	If nurse practitioner in attendance for <20 minutes based on bulk billing For the GP and NP to claim item numbers on the same day, the NP would need to ‘escalate’ care needs of patient to the GP	$20·95
	82210	If nurse practitioner in attendance for at least 20 minutes based on bulk billing For the GP and NP to claim item numbers on the same day, the NP would need to ‘escalate’ care needs of patient to the GP	$39·75
	82215	If nurse practitioner in attendance at least 40 minutes For the GP and NP to claim item numbers on the same day, the NP would need to ‘escalate’ care needs of patient to the GP	$58·55
	10996	Wound care service provided by a practice nurse (this item has now been removed)	$11·80
	104	Specialist, referred consultation – surgery or hospital (e.g. vascular surgeon) (initial)	$85·55
	105	Subsequent specialist consultation	$43·00
	110	Consultant physician, referred consultation – surgery or hospital [professional attendance at consulting rooms or hospital by a consultant physician in the practice of his or her specialty (other than in psychiatry) where the patient is referred to him or her by a referring practitioner] – initial attendance in a single course of treatment	Fee: $150·90 Benefit: 75% = $113·20 85% = $128·30
	116	Consultant physician attendance – each attendance subsequent to the first in a single course of treatment	Fee: $75·50 Benefit: 75% = $56·65 85% = $64·20
	132	Consultant physician (other than in psychiatry) referred patient treatment and management plan – surgery or hospital (at least 45 minutes)	Fee: $263·90 Benefit: 75% = $197·95 85% = $224·35
	141	Consultant Physician or Specialist in Geriatric Medicine, Referred Patient, Initial Comprehensive Assessment and Management – Surgery or Hospital (more than 60 minutes)	Fee: $452·65 Benefit: 75% = $339·5 85% = $384·80
Additional bulk billing payment	10990	Service is provided to a person who is under the age of 16 or is a Commonwealth concession card holder, and the service is bulk‐billed. Can be used in conjunction with more than one item number	Fee: $7·20 Benefit: 85% = $6·15
	10991	Service is provided to a person who is under the age of 16 or is a Commonwealth concession card holder, and the service is bulk‐billed and provided at a listed practice location. Can be used in conjunction with more than one item number	Fee: $10·85 Benefit: 85% = $9·25
Other possible services†	721	Preparation of a GPMP Chronic Disease Management service for a patient who has at least one medical condition that has been (or is likely to be) present for at least 6 months or is terminal	$144·25
	723	Coordinate development of TCA Chronic Disease Management service as in GPMP, where patient requires ongoing care from at least three collaborating health care providers, each of whom provides a different kind of treatment or service to the patient and at least one of whom is a medical practitioner	$114·30
	732 × 2 (one for GPMP and TCA)	Review of GPMP or coordination or review of TCA If 2 × 732 are claimed, must indicate they were rendered at different times	$72·05 × 2
	10997	Service provided to a person with a chronic disease by a practice nurse or an Aboriginal and Torres Strait Islander health practitioner if the person has a GPMP, TCA or multidisciplinary care plan in place	$12·00
	701	Health assessment <30 minutes	$59·35
	703	Health assessment 30–45 minutes	$137·90
	705	Health assessment ≥ 60 minutes	$190·30
	30071	Diagnostic biopsy of skin	$52·20
	900	Domiciliary Medication Management Review	$154·80
	30023	Debridement of soft tissue, traumatic, deep or extensively contaminated wound; debridement under general anaesthesia or regional or field nerve block, including suturing of that wound when performed	Fee: $326·05 Benefit: 75% = $244·55 85% = $277·15
	729	Contribution by a medical practitioner (including a general practitioner but not including a specialist or consultant physician) to a multidisciplinary care plan prepared by another provider or to a review of a multidisciplinary care plan prepared by another provider	$70·40
	735	Attendance by a medical practitioner (including a general practitioner but not including a specialist or consultant physician), as a member of a case conference team, to organise and coordinate a case conference in a RACF or a community case conference or a discharge case conference	Fee: $70·65 Benefit: 75% = $53·00
	747	Attendance by a medical practitioner (including a general practitioner but not including a specialist or consultant physician), as a member of a case conference team, to participate in a case conference in a RACF or a community case conference or a discharge case conference	Fee: $51·90 Benefit: 75% = $38·95
		People in telehealth‐eligible areas of Australia have access to specialist video consultations under Medicare (please see MBS online website). The Tier 2 Compendium 120 stipulates inclusions and exclusions for telehealth reimbursements

AUD, Australian Dollars; GP, general practitioner; GPMP, General Practitioner Management Plan; MBS, Medicare Benefits Schedule; NP, nurse practitioner; RACF, Residential Aged Care Facility; TCA, Team Care Arrangement.

^*Fees subject to change. There is a difference in MBS for the scheduled fee which is the amount MBS considers reasonable for that service item and the benefit (either 75% or 85% of that of scheduled fee) which the medical practitioner can claim if they bulk bill. In some cases, they are the same amount.

^†Despite no direct funding for a wound procedure, there are specific MBS item numbers for chronic disease management plans that could be used to identify patients at risk and enhance the whole care approach for patients with chronic wounds including referrals to allied health professionals. The chronic disease MBS item numbers (721/723), requiring the use of the practice nurse, are under‐utilised in wound management and have the potential to make a considerable difference, especially in prevention.

It has been argued that, although practice nurses may provide a more cost‐effective option for delivering wound care, this recent federal government policy change (removal of MBS item 10996) may have diminished their role in wound care 38. The recently introduced Practice Nurse Incentive Program (PNIP), administered by Medicare, consolidated funding under several previously available MBS practice nurse items into a single payment to eligible practices. The benefit for MBS item 10996 was only $11·80 while incentive payments of up to $125 000 per year are now available to practices through the PNIP 39, which could enhance the role of practice nurses in wound care. However, how the nurses are assigned depends on the individual practice, and there could be incentives to use them for tasks that generate more income for the practice such as health assessments and chronic disease management, which have specific MBS item numbers. It will be interesting to determine whether the PNIP has enhanced wound management practice when the program is fully evaluated in 2015.

Barriers to implementation of evidence‐based wound care

High costs and inadequate reimbursement

The lack of reimbursement associated with contemporary wound management products means that patients with chronic wounds outside aged care facilities and the acute hospital system incur high personal out‐of‐pocket costs 40. There is clear evidence that compression therapy is the most effective treatment for VLUs 12, yet compression bandages and hosiery are not subsidised under the MBS or the PBS. Several evidence‐based recommendations from the National Health and Medical Research Council (NHMRC) diabetes foot guidelines 8 are also not funded by the MBS 22. Of particular note is the lack of any MBS or PBS rebate for recommendations with the highest possible supporting research evidence (Level 1 Evidence), such as offloading plantar pressure using an irremovable prefabricated cast in those with a diabetes‐related foot ulcer 8, 41. Furthermore, as aforementioned, rebatable allied health consultations (including podiatry) are capped at five per year 36 resulting in an inability for patients to afford ongoing wound care from the recommended multidisciplinary foot team 8.

Poor incentives to invest in evidence‐based practice

With no wound‐specific MBS item numbers, and the inability to access reimbursement for clinician time and consumables through the MBS, there are no financial or time‐saving incentives for general practices to become actively involved in evidence‐based wound care 42. As evidence‐based wound assessment and management can be particularly time consuming, consultations are based on the presenting problem with little opportunity for preventive measures.

There are also poor incentives to invest in evidence‐based wound care in the primary sector when the cost savings are disbursed in the acute sector. The use of less expensive dressings at the commencement of treatment has been shown to increase overall costs to the health system in the long run because of the increased risk of complications requiring hospitalisation 43. However, GPs controlling their own budgets may find it difficult to invest in more expensive evidence‐based wound products that reduce risk of hospitalisation because they do not want to pay for benefits accrued elsewhere in the health system.

Difficulties in accessing wound care expertise and lack of equitable access

There is a general lack of access to expert wound advice for all Australians. Secondary tier clinics in the community are few, and tertiary clinics are often confined to major cities and towns. As most chronic wounds are linked to chronic diseases such as diabetes and vascular disease with disproportionately higher prevalence, morbidity and mortality among Indigenous Australians 44, the lack of equitable access to services and consumables means Indigenous and rural populations are most affected.

The burden of chronic wounds is high in remote and rural areas of Australia 42, 45. In the Northern Territory, where the majority of the Indigenous population resides, there are few GPs 46. Health centres providing primary health care to the majority of the Indigenous population in these areas are overwhelmed 47. There are also transport issues for Indigenous Australians having to travel to receive hospital care including high costs and separation from families 48.

Poor education and training in evidence‐based practice

Lack of confidence and lack of skilled health care professionals proficient in evidence‐based practice 42, 49, 50 is another important barrier. The lack of knowledge, skill and confidence to manage wounds efficiently 16, 50, 51, 52, 53, 54 is because of minimal teaching in medical, nursing and allied health schools as well as minimal postgraduate education in evidence‐based practice, especially compression therapy. This is likely attributed to limited syllabus space and the misguided perception that chronic wounds have less severe consequences than other chronic conditions.

There is a clear need for more wound management education and training for primary health care workers around implementation of evidence‐based practice, utilising wound investigations appropriately and understanding wound management products 50. There is also a lack of specialised support for primary providers and patients because of a lack of knowledge of specialised clinics and providers and no credentialing system to recognise this specialisation. As only specialists can bill for telehealth on MBS, this also poses difficulties for other wound experts, such as GPs, nurse practitioners and podiatrists.

Other major barriers

Other major barriers to the adoption of best practice treatment include constraints associated with multiple health care providers, poor communication, poor co‐ordination across health sectors and confusion among patients as to whom to access for treatment 10, 55 as well as limited processes for secure sharing of medical records 42.

Financial burden of delayed wound healing and complications

As a result of this poor implementation of evidence‐based wound care, chronic wounds have extended healing times, high recurrence rates, require frequent assessment and treatment from a health care professional and often result in hospitalisation through infections and other complications 10, 56. This places a significant burden of largely avoidable costs on the health care system.

Time to heal, frequency of dressing changes, consultation time and infections are all important drivers of the cost of wound care 26, 43, 57, 58, 59, 60, 61. In the UK, although nursing costs account for a high proportion of total costs (33–41%) 62, the most important component of overall cost is the cost of hospitalisation as a result of wound complications, accounting for almost half the total costs of wound care to the NHS 62.

Given that estimated hospital costs per bed‐day in Australia are between AU$699 and 840 depending on location and hospital size 63, chronic wound complications are expensive to treat. For pressure injuries, the median excess length of hospital stay has been estimated at 4·3 days 64. Hospital admission stays for diabetic foot ulcers and amputations involve 13 and 26 bed‐days 45, respectively, and diabetic foot ulcers need, on average, 18 GP visits per year 65. As a result, amputations and foot ulcers are the second and third most expensive diabetes complications to treat after renal failure 22.

Social and economic benefits to be gained from improving health service coordination and funding of wound care

Investing in improved wound management with the right financial incentives will save costs overall and improve patient outcomes, quality of life and social functioning. It is important to note that interventions to improve wound outcomes are expensive and predicted savings must be balanced against the cost increases 2. There is now a wealth of health economic studies mostly concerned with basic wound care, advanced therapies, or product‐oriented interventions, assessing devices, drugs or dressings. Cost‐effectiveness studies on guideline‐based interventions, however, are few 66, but those that exist strongly support the benefits of evidence‐based wound care, collaborative multidisciplinary teams and education for reducing healing times, lowering recurrence and decreasing the rate at which health services are accessed. This leads to a reduction in primary health care costs associated with GPs and nurses, costs to individual patients and hospital and residential care costs from wound complications.

In Sweden, repeated questionnaires sent out to community nurses demonstrated that continuous education, establishment of a wound healing centre and recommendations from a multidisciplinary wound care team reduced annual costs of wound care by SEK 6·96 million in the study area from 1994 to 2005 67. Similarly, in the province of Ontario, Canada, best practice care for VLUs in community settings resulted in savings of CA$4000 per patient per year compared with standard care 68.

In Australia, Graves and colleagues showed cost savings of AU$76·99 (SD $14·27) per patient each week when evidence‐based wound care was adopted in dedicated specialist clinics in Queensland. If 10 000 individuals received evidence‐based practice for an average of 12 weeks, this would translate to cost savings of about AU$9·2 million for the duration of 12 weeks 13. Also in Queensland, a Leg Club Model for chronic VLU management resulted in cost savings compared with traditional community home nursing, largely as a result of shorter time to heal and the kind support provided by the community 69. In Melbourne, a standardised wound treatment protocol by a trained multidisciplinary team was found to be cost‐effective when compared with usual care in aged care facilities 70. Cost‐effective interventions for specific wound types are discussed below.

Venous leg ulcers

Compression therapy is recommended by clinical practice guidelines and is an effective 71, 72 and cost‐effective intervention 14, 73, 74 for the treatment and prevention of VLU. In Australia, estimated annual cost savings of AU$166 million could be generated if all eligible patients with VLUs were treated with compression therapy. In addition, older adults were anticipated to reduce out‐of‐pocket costs for ongoing wound related consumables annually by AU$10·5 million with compression therapy 14.

Diabetic foot ulcers

In the Kimberley region of Western Australia (WA), which has a high Indigenous population, improved diabetic foot ulcer healing and lower amputation rates were observed in patients who received remote expert wound consultation via telemedicine as compared with normal care with cost savings of AU$191 935 after a year 75.

In the Netherlands, adopting international standards to prevent and treat diabetic foot ulcers versus current Dutch care was found to be cost‐effective with reductions in diabetic foot ulcers and lower extremity amputations 76. Similarly, in Sweden, the additional prevention costs associated with funding and implementing evidence‐based practice to manage diabetes foot‐related complications was found to be offset by reduced costs associated with a 25% reduction in incidence of foot ulcers and amputations 77. Assuming similar scenarios in Australia, a 24–90% reduction range in amputation, with the implementation of evidence‐based guidelines, has been estimated to result in respective overall savings of AU$220–400 million per year 22. Considering that 40% reductions in state‐wide diabetes foot‐related hospitalisation and amputation rates have been achieved in both Queensland and WA following the implementation of evidence‐based practice, any national reduction seems very achievable 24, 78.

Pressure injuries

Several strategies have been shown to be effective in reducing the incidence and costs associated with pressure injuries. In the UK, a cost‐effectiveness analysis of alternating pressure mattresses compared with an alternating pressure overlay demonstrated that mattresses were associated with an 80% probability of being cost‐saving 79. Mattress replacement was cost‐effective for the treatment of both deep and superficial pressure injuries albeit with a high degree of uncertainty 80.

Repositioning has also been shown to be an effective strategy to prevent pressure injuries 81, 82. In the UK, frequent repositioning was found to reduce the incidence of pressure injuries and was cost‐saving 83.

In Australia, nutrition support was found to be a cost‐effective intervention for the prevention of pressure injuries in high risk patients 84. Economic modelling predicted that a mean of 2896 (SD 632) cases of pressure injury could have been avoided and 12 397 (SD 4491) bed‐days could have been released through an intensive nutrition support intervention in Queensland public hospitals resulting in overall cost saving of AU$5·4 million 84.

Interestingly, two Canadian studies in long‐term care facilities found certain prevention strategies such as alternate foam mattresses to replace standard mattresses; adding 4‐hourly turning/ repositioning; pressure redistribution; and foam cleansing for residents at high risk of developing pressure injuries to be cost‐effective, but nutritional supplementation was not 85, 86.

Using evidence‐based prevention methods in long‐term care settings in the Netherlands, the incidence of pressure injuries dropped from 15% to 4·5% over the course of a year 87. In Japan, a government incentive targeting increased employment of skilled nurses to prevent and manage pressure injuries lowered prevalence to 3·6% and reduced health care costs by ¥1·8 billion per year 88.

The WoundsWest program in WA demonstrated a 14·9% reduction in the number of patients with hospital‐acquired pressure injuries from 2008 to 2009, although prevalence then increased from 6·3% in 2009 to 7·4% in 2011 3. The Australian Department of Health (DOH) funded a project under the Encouraging Better Practice in Aged Care program to develop and trial a model to facilitate increased uptake of evidence‐based prevention and management of wounds in the residential aged care setting. The Champions for Skin Integrity model was trialled in seven aged care facilities and resulted in decreased point prevalence of pressure injuries (including all stages), from 24% prior to the program to 10% 6 months after commencing the program 89. Recently, in a tertiary hospital in Brisbane, Australia, nurse‐led initiatives including ongoing education and a multidisciplinary team approach led to a reduction in hospital‐acquired prevalence from 13·7% in 2002 to 4·0% in 2012 90.

Skin tears

The application of moisturiser twice a day to the extremities of aged care residents in WA has been found to halve the number of skin tears. If adopted in all aged care facilities, hospitals and communities across Australia, this intervention to prevent skin tears would not only result in improved quality of life but also significantly reduce health care costs 91.

Recommendations to achieve better social and economic outcomes

These recommendations are summarised in Table 2.

Table 2.

Summary of recommendations

	Recommendations
	Raise awareness of the significance of chronic wounds
1	Chronic wounds should be one of Australia's National Health Priority Areas
	Changes to policy and funding structures
2	Co‐ordinate high‐level investment in wound care and policy development to improve affordability and support access to health professionals and multidisciplinary teams
3	Incentivise cost‐effective evidence‐based wound care and prevention within MBS
4	List evidence‐based wound products and services on MBS/PBS
	Improved education and training to increase uptake of evidence‐based guidelines
5	Include wound management education in undergraduate medical, nursing and allied health training programs
6	Encourage wound management education where appropriate to postgraduate medical, nursing and allied health professionals, especially for those working in primary care
7	Establish an institute of wound healing to develop coordinated wound management education including accredited best practice online wound education programs delivered as continuing professional development
8	Promote patient education for improved self‐management of wounds
	Improved health service co‐ordination and improved access to wound care
9	Launch a public health campaign to promote early intervention and referral to specialist wound management to improve wound healing and prevention
10	Develop innovative models of health service delivery that involve multidisciplinary teams
11	Encourage general practices to use the PNIP to enhance the use of the practice nurse in wound management
12	Encourage general practice to use the Medicare‐funded care planning for chronic disease to enhance the multidisciplinary approach to wound management and prevention
13	Encourage regulatory bodies such as the RACGP to promote evidence‐based wound management in primary care through avenues such as accreditation processes, ongoing education programs and adaptations to their own guidelines
14	Improve continuity of wound care with the sharing of secure electronic information on wounds
15	Establish a telehealth initiative that links tertiary and primary services and the Personally Controlled Electronic Health Records, with adequate IT and clinical support and secure electronic sharing of patient data, to facilitate evidence‐based wound practice, particularly in rural and remote areas
16	Recognition by government of chronic wounds as a specific chronic condition and wound management as a health care specialty available to appropriately credentialed health practitioners
17	Incorporate wound ‘specialty’ consultations from medical, nursing or allied health within the existing MBS telehealth items
18	Ensure initiatives to ‘close the gap’ in inequities in wound outcomes for Indigenous Australians are central to national wound care policy development
	National standards and financial penalties
19	Introduce incentive system rather than penalty system for pressure injury management
	Data and research for evaluation
20	Fund research into the barriers and enablers of translating wound care evidence into clinical practice
21	Conduct a national wound prevalence survey that clearly identifies the magnitude of the problem in the tertiary, primary, community and residential aged care sectors
22	Establish a national wound registry linked to international wound registries as a tool for enabling evidence‐based wound management research, analysis and evaluation
23	Generate evidence on the cost‐effectiveness of evidence‐based wound management interventions

IT, Information Technology; MBS, Medicare Benefits Schedule; PBS, Pharmaceutical Benefits Scheme; PNIP, Practice Nurse Incentive Program; RACGP, Royal Australian College of General Practitioners.

Raise awareness of the significance of chronic wounds

We need to raise awareness of the relationship between chronic wounds and the Australian National Health Priority Areas and also establish the chronic wound as a specific chronic disease in its own right. This has the potential to gather support from research funders and policy makers and deliver health benefits to people living with chronic wounds 92.

Improved education and training to increase uptake of evidence‐based guidelines

Foremost, we need to build knowledge and skills capacity in health care providers to improve wound management outcomes overall. Where innovative wound management training has been implemented in Australia, it has resulted in improvements in evidence‐based knowledge and skills amongst health care providers 93, 94, 95, 96. One such foot ulcer training program reported significant long‐term retention of improved knowledge, skill and competence 94, which was identified as a factor in improving regional evidence‐based clinical practice 97 and contributed to reductions in state‐wide diabetes‐related amputation rates 78.

A recent education and training needs analysis, identified staff working in primary health care and residential aged care facilities as having the highest need 50. Wound management should be part of routine training for health care professionals and incorporated into the national curriculum for all Australian medical, nursing and allied health schools. Ongoing comprehensive and accessible wound management education would also be valuable for all health care providers. In addition to formal courses, a range of education modes should be available to meet the needs of all levels of health care providers and unregulated workers especially in the aged care or remote setting, such as developed by the Champions for Skin Integrity Program 89.

There are also a number of supporting professional bodies and organisations such as the Australian College of Nursing, the Australian College of Midwives, the Australian Nursing and Midwifery Council, community nursing organisations such as the Royal District Nursing Service, the Australian Health Practitioner Regulation Agency, the Australian Medical Association, the Royal Australian College of General Practitioners, the Rural Doctors Association of Australia, the Australian College of Rural and Remote Medicine accredited by the Australian Medical Council, the Australian Primary Health Care Nurses Association and the Australasian Podiatry Council whose collaboration is essential to facilitate changes in wound care education, assessment and certification. Health care professionals often rely on continuing professional development to upskill. However, with so many competing chronic diseases, wound care is not high on the agenda, and there is a need to replicate models that have proven to be effective for other chronic diseases, particularly mental health, where, in order to access certain MBS items, GPs need to first complete a range of accredited activities 98.

In addition, we need recognition of wound care as a clinical specialty with national accreditation of wound clinics and health care professionals using the appropriate regulatory processes and professional bodies listed above, but also including the DOH, the Australian Wound Management Association (AWMA) and WoundsWest, soon to be renamed the Wound Healing Institute of Australia (WHIA). The use of highly trained wound specialists has been fundamental to the successful implementation of evidence‐based care in health services 10, 49, 99.

Furthermore, education and training of patients and carers will improve self‐management, preventative measures and the implementation of published evidence‐based guidelines and pathways in clinical practice leading to improved patient outcomes 54. Completion of a standardised education program was found to impart successful self‐management strategies among participants looking to prevent VLU recurrence 100.

Improved health service co‐ordination and improved access to wound care

There is a need to implement standard models of multidisciplinary wound care teams across the country and to promote wound management in primary health care as a priority. The answer to many of the challenges of providing efficient wound management lies with primary care. Enhancing education, skills and financial incentives in primary care can prevent wounds and reduce hospitalisations; primary care has the potential to reduce the incidence of VLUs by 50% in 10 years 54.

Both static and mobile wound management clinics are needed. Secondary level wound specialty clinics run by appropriately trained health care providers could fill referral gaps in the community, provide education and training in wound management and encourage the implementation of evidence‐based wound management.

The Wound Management Innovation Cooperative Research Centre (WMI CRC), in collaboration with Medicare Locals and GP practices, has initiated a program to establish community‐based Cooperative Wound Clinics in the primary health care setting. This initiative has the potential to optimise best practice wound care in primary health care.

Mobile wound clinics can deliver wound management expertise to support residential aged care facilities and peripheral hospitals. The Mobile Wound Care Program in the Gippsland region Victoria 101 resulted in significant decreases in wound‐healing time and costs of treatment over 3 years of implementation. The participating organisations also benefitted with regard to skills development 102.

Implementation of the Champions for Skin Integrity program has also been shown to enable residential aged care facilities to increase the uptake of evidence‐based wound care and staff knowledge and to significantly decrease the prevalence and severity of wounds 89.

Telemedicine may be particularly well‐suited to wound care as patients with chronic wounds often need multiple consultations and are usually older patients with various comorbidities and may be unable to travel 103. Telemedicine formats may include digital imaging options for wound assessment and algorithms for treatment decisions, which enhance clinical and learning outcomes 104, 105, 106, 107.

While telemedicine refers specifically to remote clinical services, telehealth also encompasses education and training of health care providers. Wound care was identified as a telehealth priority among health staff in rural WA 108. The WoundsWest Advisory Service has been deployed in all WA country health services 109 and other non‐WA Aboriginal medical services to impart evidence‐based wound care advice to health care professionals in remote and rural areas 110. This service was found to be beneficial for both patients and health care professionals in wound prevention and management 110.

Shared electronic wound records linked to the Personally Controlled Electronic Health Records are also deemed essential to improve co‐ordination of wound care along the continuum of health care providers; however, this is yet to become a nationwide option 42.

Changes to policy and funding structures

In the UK, dressings and bandages are included in the drug tariff and are available for prescribing on the NHS 111. In Australia, however, current Medicare subsidy arrangements do not encourage evidence‐based wound management. For many, the lack of access to affordable products could be perceived to compromise care decisions, and changes in policy are needed to ensure a sustainable funding model for product and service delivery. A subsidy should be implemented through MBS for the full cost of evidence‐based wound care, including products and increased access to nurse practitioners and allied health services 19, 22. In particular, care and cost advantages could result from funding of preventive wound care programs for treating high risk individuals.

We envisage that AWMA (soon to be renamed Wounds Australia) in collaboration with the WMI CRC and the professional bodies mentioned above would be instrumental in seeking the support of the Australian Federal Government to fund and implement a national wound service and product supply scheme to ensure equitable access to best practice care. The first step would be to develop an evidence‐based wound product listing to ensure careful and economical use of high‐quality products and secondly, to ensure that MBS reimbursement is linked to services and products. An example of a similar successful submission is that of the National Dystrophic Epidermolysis Bullosa Research Association (DebRA) of Australia. DebRA played a key role in the National Epidermolysis Bullosa Dressing Scheme allowing ongoing access to dressings for all eligible patients in Australia 112.

In addition, we need to incentivise cost‐effective evidence‐based wound care. A financial clinical incentive payment was reported to be one of several important factors that led to the proliferation of evidence‐based secondary care of diabetes foot‐related ulcers and subsequent amputation reduction in a large Australian study 78.

National standards and financial penalties

The prevalence of hospital‐acquired pressure injuries is high 3, 113, 114, 115, and the National Safety and Quality Health Service Standards 116 have been introduced to reduce this burden. All hospitals have to report on their strategies for preventing and managing pressure injuries.

Queensland Health has also imposed financial penalties for certain stages of pressure injuries ($30 000 for stage 3; $50 000 for stage 4) classified as adverse events. An incentive system rather than a penalty system, however, may be more effective and cost‐effective for the management of pressure injuries. This is supported by data from Japan where a change in governmental regulation from a penalty system to an incentive system has been extremely successful and shown to be cost‐effective leading to significant reductions in pressure injuries and faster healing 88.

Data and research for evaluation

With increasing health care costs and the demand for higher efficiency, there is an urgent need for objective evidence on the costs and benefits of evidence‐based wound management, whilst taking into account the need for greater health equity, transparency of decision making and stakeholder acceptability in Australia. As wound care is not recognised as a discrete health care field, securing funding for wound management is particularly challenging. We need to demonstrate that wound management provides good value for money in light of competing chronic diseases. Although clinical practice guidelines in chronic wound care are flourishing, large gaps exist in assessing their cost‐effectiveness. We need well‐conducted cost‐effectiveness studies to guide decision makers regarding evidence‐based interventions for chronic wounds 66.

The WMI CRC has endeavoured to overcome this discrepancy in its support of rigorous and much needed studies. It proposes to establish an Australian National Wound Registry, following the model developed for the Welsh Wound Registry. This comprehensive electronic data collection system will provide an opportunity for identifying the national scope of the wound burden and benchmarking healing and cost outcomes. This real‐world data collected in real time is ideally suited for conducting cost‐effectiveness analyses 117.

Future efforts to generate evidence on the cost‐effectiveness of wound management interventions should provide evidence that decision makers find easy to interpret. If this happens, and it will require a large effort of health services research, it could be used to inform future policy and decision‐making activities, reduce health care costs and improve patient outcomes. Economic modelling to reveal the social and economic benefits of optimal wound services, in particular, is essential to support recommended changes to the current funding and reimbursement structures and promote investment in strategies to address chronic wounds at commonwealth, state and local government levels.

Conclusion

Inappropriate, un‐coordinated services, limited knowledge and skills, outdated methods, lack of access to specialist wound management practitioners and inadequate subsidy arrangements contribute to high costs and poor wound‐healing outcomes in Australia. This creates pressure on personal finances and health care resources. Increased uptake of evidence‐based practice is unlikely until the fundamental issues of education of health care providers and reimbursement of wound services and products are resolved. Evidence for cost‐effective wound prevention and treatment should be the highest priority, especially in light of our ageing population.

Conflict of interest

The Wound Management Innovation Cooperative Research Centre (WMI CRC) receives funding from the Australian Government, Curtin University of Technology, Queensland University of Technology, Smith & Nephew Proprietary Limited, Southern Cross University, University of South Australia, Australian Wound Management Association Inc., Blue Care, the Department of Health South Australia, the Department of Health Victoria, Ego Pharmaceuticals Pty Ltd, Metropolitan Health Service/Wounds West, Queensland Health, Royal District Nursing Service Limited, Royal Melbourne Institute of Technology, Silver Chain Group, and South East Queensland Hyperbaric Pty Ltd. The funding source played no role in study design; in the collection, analysis and interpretation of data; in the writing of the report; or in the decision to submit the article for publication. All authors declare no conflicts of interest.