Cost‐effectiveness considerations for home health V.A.C.^® Therapy in the United States of America and its potential international application

Abstract

Vacuum‐assisted closure (V.A.C.^®) Therapy (KCI International, San Antonio, TX) has been widely used in hospital settings. However, use of V.A.C.^® Therapy in home health settings outside of the United States of America (USA) is often limited because of financial considerations. This review paper considers the published evidence on V.A.C. Therapy in home health settings from the USA and beyond and explores the potential economic implications of V.A.C. Therapy in home health settings.

Introduction

The management of chronic and surgical wounds represents a considerable and often unrecognised burden to health services. Wound management is a resource‐intensive discipline, requiring frequent consultations with health care professionals in a multiplicity of settings, including hospital, primary care and the home. The costs also include consumables, such as dressings. In addition to the burden to the health service, chronic wounds can affect a patient’s ability to lead a normal life, particularly in a working environment, which can lead to further societal losses.

The cost of managing wounds, particularly chronic wounds, is relatively well documented. Reddy et al. (1) estimated the total cost of managing pressure ulcers in the United States of America (USA) to be in excess of US$6 billion, with a cost per case between US$2000 and US$30 000. The International Diabetes Federation estimates that the cost of managing a diabetic foot ulcer is between US$7000 and US$10 000, although this can increase to as much as US$65 000 where complications resulting in amputation occur (2).

Xakellis and Frantz (3) highlight the differences that arise depending on the approach to management and the care setting. Hospital‐based care increases management costs sixfold compared with long‐term care settings. Despite this, the availability of many modern wound treatments, such as vacuum‐assisted closure (V.A.C.^®) Therapy (KCI International, San Antonio, TX), remains restricted to hospital settings outside of the USA. This has the potential to result in sub‐optimal management of wounds in home health settings and create inefficiencies in the use of scarce health care resources.

The potential role of V.A.C.^® therapy in home health settings

A number of studies have examined the use of V.A.C. Therapy in hospital settings in both chronic (4) and surgical (5) wounds and concluded that it has the potential to lead to cost savings compared with alternative dressing regimens. However, the increasing demand for home‐based care and the push by payers and health care planners to reduce the unnecessary burden on hospital beds means that there is significant scope for more widespread use of V.A.C. Therapy outside of hospital settings.

There are a number of potential benefits to managing patients in home health settings where this is possible, including

• • improved patient convenience and satisfaction;
• • reduced burden on scarce hospital resources (e.g. beds);
• • reduced patient management costs; and
• • reduced risk of contracting health‐care‐associated infections.

However, the adoption of V.A.C. Therapy in home health settings remains relatively limited outside of the USA. Restrictions on use are frequently the result of concerns over the cost of the therapy in home health settings (6).

This short paper considers some of the economic evidence on the use of V.A.C. Therapy in US home health settings and considers the potential for expanding use in such settings outside of the USA.

Evidence on V.A.C. therapy in home health settings in the USA

The use of V.A.C. Therapy to manage chronic wounds in home care settings is well established in the USA. A number of studies have reported the feasibility, effectiveness and cost‐effectiveness of V.A.C. Therapy in US home health settings.

Schwien et al. (7) conducted a retrospective analysis of the management of stage III and IV pressure ulcers in a home health setting. The study was intended to address both the clinical and the economic implications of using negative pressure wound therapy (NPWT) (V.A.C. Therapy) in home health care settings in the USA. Data were derived from the Outcome and Assessment Information Set (OASIS). OASIS contains a set of standardised assessments that must be completed by home health agencies over the course of a patient’s management.

A retrospective analysis of OASIS data identified a control group of 2288 patients with stage III or IV pressure ulcers treated with standard wound management protocols between 2002 and 2004. A matched cohort of 60 patients treated with V.A.C. Therapy was also identified from the database.

The analysis considered the rates of hospitalisation in each group. Hospitalisations were categorised as follows:

• • acute care hospitalisations (>24 hours) for any reason;
• • emergent care (emergency room visit, emergency home visit, emergency office/outpatient visit) hospitalisations for any reason;
• • acute care hospitalisation for wound infection, deteriorating wound status or new lesion /ulcer; and
• • emergent care for wound infection, deteriorating wound status or new lesion/ulcer.

The findings reveal that patients treated with V.A.C. Therapy in home care settings had significantly less hospitalisations (Table 1).

Table 1.

Hospitalisations in patients treated with V.A.C. Therapy^® versus standard wound care (7)

Type of hospitalisation	V.A.C. Therapy, n (%)	Control, n (%)	Difference (%)
Instances of hospitalisation	21 (35)	1,093 (48)	13 (P < 0·05)
Unplanned hospitalisations	21 (35)	937 (41)	6 (NS)
Hospitalisation for wound problems	3 (5)	310 (14)	9 (P < 0·01)
Emergent care episodes	14 (23)	771 (34)	11 (NS)
Emergent care episodes for wound problems	0 (0)	189 (8)	8 (P < 0·01)

NS, not significant.

Although there were fewer hospitalisations unrelated to wounds in the V.A.C. Therapy arm, the differences were not significant, which is not surprising if we assume that patients were managed identically other than for their wound care. However, rates of both unplanned wound‐related acute hospitalisations and emergent care episodes were lower in the V.A.C. Therapy arm. Indeed, there were no episodes of emergent care required for patients treated with NPWT.

The authors attempted to control this patient population for bias because of the observational nature of this study and relatively small sample of patients treated with V.A.C. Therapy. The fact that these findings are based on data derived from real‐world settings means that the findings should be reproducible in other home care environments.

A second study of chronic wounds by Philbeck et al. (8) considered the cost‐effectiveness of V.A.C. home health therapy in managing chronic wounds. The V.A.C. treatment data were analysed from Medicare qualified patients with pressure ulcers who had failed to respond to previous treatment. In total, 1032 patient records, reporting 1170 wounds were included in the study. Almost half (48%) were stage III or IV pressure ulcers. A number of other chronic wounds (diabetic, venous and dehisced post surgical excisions) were also included in the analysis. Analyses were stratified by multiple factors, including wound duration.

The study evaluated the rate of healing, as defined by the reduction in wound area. The analysis concluded that a wound of 22 cm² (approximately 4·7 × 4·7 cm) would heal in an average of 247 days costing US$23 465. The use of V.A.C. Therapy was predicted to reduce the healing time of the same wound to 97 days and reduce the costs of healing to US$14 546, a saving of almost US$9 000 per wound.

Adoption of V.A.C. therapy in home health settings outside of the USA

There is a paucity of evidence on the use of home health V.A.C. Therapy outside of the USA. Consensus guidelines on the use of V.A.C. Therapy in chronic, difficult to heal wounds in Canada emphasise the need to consider the position of V.A.C. Therapy in the continuum of care, rather than use in hospital or home care settings (9). The guidelines point out that the failure of V.A.C. Therapy following discharge from hospital is often because of inadequate health care professional training and education on how to use the system in the home care setting. These guidelines have subsequently influenced a provision in Canada where over 70 home care programmes are using V.A.C. Therapy (10). One such programme has reported the success rates of V.A.C. Therapy in home care settings, balancing some of the incremental acquisition costs of V.A.C. Therapy with reductions in nursing time and faster healing rates (11).

Data from the Netherlands on the use of V.A.C. Therapy to manage post‐surgical wounds following discharge from hospital has also been presented (12). The study reports the success of V.A.C. Therapy in achieving pre‐defined treatment goals in post‐surgical and trauma wounds following discharge from hospital. The pre‐defined treatment goal was deemed an appropriate endpoint for this analysis, rather than healing rates. This approach acknowledges that V.A.C. Therapy is often used to achieve objectives other than healing. For example, the most frequently cited treatment goal in the study was to improve granulation tissue prior to the use of alternative dressings or primary closure of the surgical wound. The findings suggest that V.A.C. Therapy allows for the safe and efficacious management of post‐surgical and trauma wounds in home care settings, with 74% of patients achieving their pre‐defined treatment goal. Patients with shorter wound duration (<6 months) were more likely to achieve their pre‐defined treatment goal (82% versus 33%), suggesting that positioning V.A.C. Therapy as a salvage Therapy for surgical wounds that fail to respond to initial treatment may not be the most effective use of this technology.

Conclusions

The use of V.A.C. Therapy outside of hospital settings has the potential to improve the efficiency of wound management. Increasing access to innovative wound care in home health settings can help reduce the reliance on hospital‐based care. This has the potential to reduce overall wound management costs and also ensure that scarce hospital resources, particularly hospital beds, are used efficiently.

Despite these potential benefits, V.A.C. Therapy adoption in home health settings remains subject to restrictions, particularly outside of the USA. Many patients currently commence V.A.C. Therapy in hospital settings and are then subsequently denied access following discharge, often on the grounds that V.A.C. Therapy is perceived to be more expensive than traditional dressings.

This approach can result in inefficiencies whereby patients are kept in hospital longer than necessary to access V.A.C. Therapy or else they are denied access to a therapy that could benefit them in home health settings. Payment and reimbursement mechanisms for V.A.C. Therapy should be reviewed to ensure that they consider potential health care system savings across the continuum as well as the individual patient needs including improved quality of life with faster healing.

Health care planners are urged to review the growing body of evidence on home health V.A.C. Therapy to ensure that appropriate access mechanisms are in place.