Abstract
Background: Studies that have previously validated the use of incisional negative pressure wound therapy (iNPWT) after body contouring procedures (BCP) have provided limited data regarding associated health care utilization and cost. We matched 2 cohorts of patients after BCP with and without iNPWT and compared utilization of health care resources and post-operative clinical outcomes. Methods: Adult patients who underwent abdominoplasty and/or panniculectomy between 2015 and 2020 by a single surgeon were identified. Patients were propensity score matched by body mass index (BMI), gender, smoking history, diabetes mellitus, hypertension, and incision type. Primary outcomes included time to final drain removal, outpatient visits, homecare visits, emergency department visits, and cost. Secondary outcomes included surgical site occurrences (SSO), surgical site infections, reoperations, and revisions. Results: One hundred sixty-six patients were eligible, and 40 were matched (20 with iNPWT and 20 without iNPWT) with a median age of 47 years and BMI of 32 kg/m2. There were no differences in demographics or intraoperative details (all P > .05). No significant differences were found between the cohorts in terms of health care utilization measures or clinical outcomes (all P > .05). Direct cost was significantly greater in the iNPWT cohort (P = .0498). Inpatient length of stay and procedure time were independently associated with increased cost on multivariate analysis (all P < .0001). Conclusion: Consensus guidelines recommend the use of iNPWT in high-risk patients, including abdominal BCP. Our results show that iNPWT is associated with equivalent health care utilization and clinical outcomes, with increased cost. Additional randomized controlled trials are needed to further elucidate the cost utility of this technique in this patient population.
Keywords: negative pressure wound therapy, body contouring, cost, post-operative outcomes
Résumé
Contexte: Les études qui ont validé antérieurement l’utilisation de la thérapie par pression négative des incisions chirurgicales (iNPWT) après une procédure de remodelage corporel (BCP) n’ont fourni que des données limitées sur l’utilisation et le coût des soins de santé associés. Nous avons apparié deux cohortes de patients après BCP avec ou sans iNPWT et nous avons comparé l’utilisation des ressources de soins de santé ainsi que les résultats cliniques postopératoires. Méthodes: Les patients adultes qui ont subi une abdominoplastie et/ou une panniculectomie effectuée(s) par un seul chirurgien entre 2015 et 2020 ont été identifiés. Les patients ont été appariés avec un score de propension par indice de masse corporelle (IMC), sexe, antécédent de tabagisme, diabète, hypertension et type d’incision. Les critères d’évaluation principaux étaient, notamment, le délai de retrait du dernier drain, les visites au service de consultations externes, les visites au département des urgences et le coût. Les critères de jugement secondaires ont inclus les survenues du site opératoire (SSO), les infections du site opératoire (SSI), les réinterventions et les révisions. Résultats: Il y a eu un total de 166 patients admissibles et 40 ont été appariés (20 avec iNPWT et 20 sans); leur âge médian était de 47 ans et leur IMC de 32 kg/m2. Il n’y a pas eu de différence entre les groupes pour les données démographiques ou les détails peropératoires (P > 0,05 pour tous). Aucune différence significative n’a été trouvée entre les cohortes pour ce qui concerne les mesures d’utilisation des ressources de santé ou les résultats cliniques (P > 0,05 pour tous). Le coût direct a été significativement plus élevé dans la cohorte iNPWT (P = 0,0498). La durée de séjour des patients hospitalisés et la durée de la procédure ont été associées de manière indépendante à une augmentation du coût dans une analyse multifactorielle (P < 0,0001 pour toutes). Conclusion: Les lignes directrices de consensus préconisent l’utilisation de l’iNPWT pour les patients à risque élevé, y compris en cas de remodelage corporel abdominal. Nos résultats montrent que l’iNPWT est associée à un recours équivalent aux soins de santé et à des résultats cliniques identiques, pour un coût plus élevé. Des essais contrôlés à répartition aléatoire supplémentaires sont nécessaires pour préciser le rapport coût/utilité de cette technique dans cette population de patients.
Introduction
As the number of obese individuals across the United States has increased, 1 so has the number of patients pursuing panniculectomy and/or abdominoplasty after bariatric surgery and massive weight loss. Although panniculectomy is considered a reconstructive procedure aimed to restore function by removing excess abdominal tissue and laxity from the pannus and lower abdomen, abdominoplasty is considered a cosmetic procedure aimed at restoring abdominal contour through greater undermining and tightening of the muscles of the abdominal wall. After massive weight loss, many patients have one or both of these procedures, often in combination with liposuction. Although abdominal body contouring procedures (BCP) can significantly improve patient body image and quality of life, 2 they are associated with higher rates of complications than other reconstructive surgeries with reported incidences varying from 30% to 60%. 3 -7 The search for perioperative strategies to reduce the complication profile in these popular reconstructive surgeries is ongoing.
Traditionally, abdominal incisions are closed primarily using sutures, staples, and/or various adhesive materials. However, the use of commercially available incisional negative pressure wound therapy (iNPWT) devices has more recently been employed for patients with at least one comorbidity that puts them at risk for developing a surgical site infection (SSI), including high tension incisions, incisions with extensive undermining, traumatized soft tissue, and post-bariatric abdominoplasty incisions, among others. 8,9 Several studies have validated the use of iNPWT in abdominal BCP patients, reporting reductions in post-operative complication rates such as infection, wound dehiscence, and seroma formation. 10,11 However, larger meta-analyses examining the specific incidences of seroma, hematoma, reoperation, and readmission in patients undergoing complex abdominal wall surgery demonstrated no significant differences between the iNPWT and standard groups. 12,13 Furthermore, compared to traditional methods of post-operative wound care, the use of iNPWT in BCP patients may require additional homecare and post-operative clinic visits, which can result in increased burden to the patient and health care system. 14,15
In this study, we analyze 2 matched patient cohorts after abdominal BCPs managed with and without iNPWT, and compare clinical outcomes, utilization of health care resources, and overall cost. We hypothesized that iNPWT would lead to shortened drain times and improved clinical outcomes, but overall increased utilization of health care resources. 16
Methods
Study Design and Patient Selection
All adult patients (>18 years old) who underwent abdominal BCPs (abdominoplasty and/or panniculectomy) between September 15, 2015, and September 15, 2020, by a single surgeon (J.P.F.) were identified by retrospective review. The following data were extracted from the electronic medical record (EMR): age, gender, race, insurance type, insurance approval status, body mass index (BMI, kg/m2), comorbidities (diabetes mellitus [DM], smoking history, chronic obstructive pulmonary disease, peripheral vascular disease [PVD], hypertension [HTN]), preoperative steroid use, immunosuppression, history of bariatric surgery, and history of BCPs. Operative characteristics extracted from the EMR included: type of BCP, concomitant procedures, procedure length in minutes, American Society of Anesthesiologists classification (ASA), incision type (eg, transverse vs fleur-de-lis), surgical closure techniques, use of iNPWT, number of drains, and length of stay (LOS). “Complex hernia repair” was considered any ventral hernia that required operative placement of mesh and/or component separation, and all other repairs were considered “simple hernia repair.” For the purposes of this study, iNPWT was considered any negative pressure wound dressing placed over a closed incision. 17
The following post-operative clinical outcomes were extracted up to 12 months after the index procedure: surgical site occurrences (SSO; including delayed wound healing necessitating change in management, dehiscence, hematoma, and seroma), SSI, complications requiring readmission, complications requiring reoperation in the operating room, and revision procedures. Health care utilization data were also gathered, including days of iNPWT use, timing of drain removal, number of homecare visits, office visits, and emergency department (ED) visits. In the senior authors practice, drains remain for at least 5 to 7 days and are removed sequentially when output is serosanguinous and less than 50 cc daily for 3 consecutive days. Cost data of the index hospital encounter were acquired from the hospital finance office using Hospital Account Records and rounded to the nearest hundred for ease of interpretation. Cost data included direct cost, indirect cost, total procedure cost, and total hospital charges. Direct cost comprised of expected hospital expenses to deliver the health care procedure, such as mediations, operating room cost, and surgical cost. Indirect cost comprised of additional costs that are less easily traced directly to the procedure, such as lighting, administrative assistance, and patient transport. Total cost is direct cost plus the indirect cost. A hospital charge is a total dollar amount charged to the patient, as noted on a medical bill before insurance reimbursement. 18 The hospital charge is often greater than the total cost, due to potential negotiations and individual payment contracts with various commercial insurers. Two cohorts were created based on use of iNPWT, and matched using a propensity score method based on BMI, gender, history of smoking, DM, HTN, and incision type. Using our original hypothesis, a sample size analysis was conducted to a power of 0.8. Data were collected and managed using Research Electronic Data Capture (REDCap), a secure web-based platform designed to support data capture for research studies. 19
Descriptive statistics were used to report counts and frequencies for categorical data, and medians and interquartile ranges (IQRs) for continuous data, as appropriate. Post-operative outcomes, including health care cost data, were compared using χ2 tests for categorical variables and Wilcoxon rank-sum tests for continuous variables. A multivariate linear regression was conducted to further assess overall and direct costs, including relevant variables such as iNPWT use, length of index procedure, LOS, and number of drains. Statistical significance was set at P ≤ .05, and all analyses were performed using STATA/IC 16.0 (StataCorp LLC).
Results
Demographics and Study Population
A total of 166 patients met eligibility criteria and were included in the propensity score match. Forty patients were matched, including 20 patients who received iNPWT and 20 who did not. The 2 cohorts were equivalent in the following demographics: female sex (P = .29), age (P = .65), insurance approval (P = .57), BMI (P = .73), history of DM (P > 0.99), history of smoking (P = .71), history of PVD (P > .99), and history of HTN (P = .52, Table 1). History of bariatric surgery and previous BCP was also equivalent between the 2 cohorts (both P > .05).
Table 1.
Demographics.
| n (%) | Traditional | iNPWT | P value |
|---|---|---|---|
| Number of patients | 20 | 20 | |
| Sex, female | 16 (80.0%) | 13 (65.0%) | .29 |
| Age, years, median (IQR) | 50 (38-57) | 44 (36-57) | .65 |
| BMI, kg/m2, median (IQR) | 32 (31-41) | 33 (30-48) | .73 |
| Race | .11 | ||
| Black | 10 (50.0%) | 5 (25.0%) | |
| White | 7 (35.0%) | 12 (60.0%) | |
| Asian | 2 (10.0%) | 0 (0.0%) | |
| Other | 1 (5.00%) | 3 (15.0%) | |
| Insurance type | .32 | ||
| Private | 12 (60.0%) | 12 (60.0%) | |
| Public | 8 (40.0%) | 6 (30.0%) | |
| HMO | 0 (0.0%) | 2 (10.0%) | |
| Insurance approval | 13 (65.0%) | 14 (70.0%) | .57 |
| DM | 4 (20.0%) | 4 (20.0%) | >.99 |
| Ever smoker | 5 (25.0%) | 4 (20.0%) | .71 |
| COPD | 1 (5.00%) | 0 (0.0%) | .31 |
| PVD | 1 (5.00%) | 1 (5.00%) | >.99 |
| HTN | 13 (65.0%) | 11 (55.0%) | .52 |
| Previous bariatric surgery | 6 (30.0%) | 9 (45.0%) | .33 |
| Previous body contouring | 18 (90.0%) | 19 (95.0%) | .55 |
Abbreviations: BMI, body mass index; COPD, chronic obstructive pulmonary disease; DM, diabetes mellitus; HMO, health maintenance organization; HTN, hypertension; IQR, interquartile range; iNPWT, incisional negative pressure wound therapy; PVD, peripheral vascular disease.
Operative Characteristics
All patients underwent abdominoplasty, panniculectomy, or both. There were no differences in index procedure type between the 2 cohorts (all P > .05, Table 2). A total of 77.5% of patients underwent concomitant procedures, namely ventral hernia repair and/or liposuction, and there were no differences in these procedures between the cohorts (all P > .05). The 2 cohorts were equivalent in terms of median procedure length, ASA class, incision type, Scarpa’s fascia closure, dermal closure, and number of drains placed (all P > .05). There was no statistical difference in post-operative LOS between cohorts (1 day iNPWT vs 0 days traditional, P = .49).
Table 2.
Operative Details.
| n (%) | Traditional | iNPWT | P value |
|---|---|---|---|
| Procedure | |||
| Abdominoplasty | 2 (10.0%) | 5 (25.0%) | .21 |
| Panniculectomy | 17 (85.0%) | 14 (70.0%) | .26 |
| Abdominoplasty and panniculectomy | 1 (5.00%) | 1 (5.00%) | >.99 |
| Concomitant procedures | |||
| Simple hernia repair | 4 (20.0%) | 9 (45.0%) | .09 |
| Complex hernia repair | 4 (20.0%) | 5 (25.0%) | .71 |
| Liposuction | 4 (20.0%) | 5 (25.0%) | .71 |
| Procedure length, minutes, median (IQR) | 75 (56-122) | 104 (83-117) | .15 |
| ASA classification | .35 | ||
| 1 | 2 (10.0%) | 0 (0.0%) | |
| 2 | 11 (55.0%) | 12 (60.0%) | |
| 3 | 7 (35.0%) | 8 (40.0%) | |
| Incision type | .49 | ||
| Transverse | 13 (65.0%) | 15 (75.0%) | |
| Fleur De Lis | 7 (35.0%) | 5 (25.0%) | |
| Scarpa’s layer closure | 0.32 | ||
| Running suture | 3 (15.0%) | 1 (5.00%) | |
| Interrupted suture | 16 (80.0%) | 19 (95.0%) | |
| Both | 1 (5.00%) | 0 (0.0%) | |
| Dermal closure | |||
| Running suture | 1 (5.00%) | 0 (0.0%) | .31 |
| Interrupted suture | 16 (80.0%) | 18 (90.0%) | .38 |
| Both | 2 (10.0%) | 0 (0.0%) | .15 |
| Stapler (Insorb®) only | 1 (5.00%) | 2 (10.0%) | .55 |
| Subcutaneous closure | |||
| Running suture | 20 (100.0%) | 20 (100.0%) | >.99 |
| Interrupted suture | 3 (15.0%) | 1 (5.00%) | .292 |
| LOS, days, median (IQR) | 0 (0-4) | 1 (0-3) | .49 |
Abbreviations: ASA, American Society of Anesthesiologists; IQR, interquartile range; iNPWT, incisional negative pressure wound therapy; LOS, length of stay.
Health Care Utilization and Post-Operative Outcomes
Analysis revealed no significant differences in terms of health care utilization between the 2 cohorts, including days to final drain removal (25 iNPWT vs 19 traditional, P = .28), median number of homecare visits (9 iNPWT vs 15 traditional, P = .60), median outpatient clinic visits (6 iNPWT vs 6 traditional, P = .59), and median number of ED visits (0 iNPWT vs 0 traditional, P = .86). In terms of clinical outcomes, the 2 cohorts were equivalent in SSOs (40.0% iNPWT vs 35.0% traditional, P = .74), SSIs (15.0% for both cohorts, P > .99), readmissions (20.0% iNPWT vs 10% traditional, P = .38), and reoperations (10.0% iNPWT vs 5.00% traditional, P = .55). Length of follow-up was equivalent between the 2 cohorts (12 months for both, P = .11, Table 3).
Table 3.
Post-Operative Care and Outcomes.
| Outcomes | Traditional | iNPWT | P value |
|---|---|---|---|
| Days of iNPWT, median (IQR) | NA | 7 (5-8) | NA |
| Number of drains, median (IQR) | 2 (2-3) | 3 (2-3) | .80 |
| Days to final drain removal | 19 (12-30) | 25 (13-34) | .28 |
| Homecare, median (IQR) | 6 (30.0%) | 8 (40.0%) | .51 |
| # Homecare visits | 15 (6-33) | 9 (7-14) | .60 |
| # Office visits, median (IQR) | 6 (5-8) | 6 (4-6) | .59 |
| # ED visits, median (IQR) | 0 (0-0) | 0 (0 -1) | .86 |
| Clinical outcomes, n (%) | |||
| SSO | 5 (25.0%) | 8 (40.0%) | .31 |
| Delayed healing | 2 (10.0%) | 3 (15.0%) | .63 |
| Dehiscence | 0 (0.0%) | 0 (0.0%) | >.99 |
| Hematoma | 1 (5.00%) | 1 (5.00%) | >.99 |
| Seroma | 1 (5.00%) | 4 (20.0%) | .15 |
| SSI | 3 (15.0%) | 4 (20.0%) | 0.68 |
| Complication requiring readmission | 2 (10.0%) | 4 (20.0%) | .38 |
| Complication requiring OR reoperation | 1 (5.00%) | 1 (5.00%) | >.99 |
| Revision procedure | 1 (5.00%) | 1 (5.00%) | >.99 |
| Follow-up, months, median (IQR) | 12 (12-12) | 12 (11.3-12) | .11 |
Abbreviations: ED, emergency department; IQR, interquartile range; iNPWT, incisional negative pressure wound therapy; SSI, surgical site infection; SSO, surgical site occurrences.
Lastly, cost analysis revealed significant differences between the 2 cohorts (Figure 1). Although total cost did not reach statistical significance (USD$15 400 iNPWT vs $8300 traditional, P = .064), iNPWT patients had an increased direct cost ($9700 iNPWT vs $4100 traditional, P = .0498), and total hospital charges to insurance ($84 000 iNPWT vs $50 000 traditional, P = .027). Multivariate linear regression revealed that iNPWT and number of drains were not independently associated with increased total cost, direct cost, or charges (all P > .05, Table 4). However, procedure length and LOS were each independently associated with increased total cost, direct cost, indirect cost, and overall hospital charges (all P < .001).
Figure 1.
Cost analysis, USD.
Table 4.
Linear Regression.
| Variables | Coefficient | 95% CI | P value |
|---|---|---|---|
| Total costs | |||
| iNPWT | 559 | [−1588 to 2705] | .60 |
| Procedure length | 83.5 | [60 to 107] | <0.001 |
| LOS | 2236 | [1635 to 2837] | <.001 |
| Number of drains | 1,013 | [−359 to 2386] | .14 |
| Direct costs | |||
| iNPWT | 502 | [−1427 to 2431] | .60 |
| Procedure length | 44.5 | [23 to 66] | <.001 |
| LOS | 1,890 | [1350 to 2429] | <.001 |
| Number of drains | 872 | [−361 to 2105] | .16 |
| Indirect costs | |||
| iNPWT | 56.8 | [−833 to 946] | .90 |
| Procedure length | 39.1 | [29 to 49] | <.001 |
| LOS | 346 | [97 to 595] | <.001 |
| Number of drains | 141 | [−427 to 709] | .37 |
| Overall hospital charges | |||
| iNPWT | 7,306 | [−2751 to 17 364] | .15 |
| Procedure length | 339 | [229 to 449] | <.001 |
| LOS | 12 404 | [9590 to 15 219] | <.001 |
| Number of drains | 3666 | [−2761 to 10 094] | .26 |
Abbreviations: iNPWT, incisional negative pressure wound therapy; LOS, length of stay.
Discussion
iNPWT has been proposed as a strategy to help mitigate complications from SSO in high-risk patients. 20 However, optimal management in these cases is still debated both clinically and in the literature. 12,21,22 Although some studies have reported positive outcomes with the use of iNPWT in high-risk patients, such as those undergoing abdominal BCP, 16,23 -25 few explore the implications of its use on the health care system. 14,15 With continued increases in the number of obese patients with comorbidities in the United States, 26 effective techniques to optimize wound healing in this patient population are critical. Our study demonstrated via matched analysis that when iNPWT is compared to wound closure without the use of iNPWT, there are equivalent post-operative outcomes, health care utilization, and total cost.
The iNPWT consensus guidelines have recommended the use of iNPWT for a variety of high-risk surgical wounds, including post-bariatric abdominoplasty, high-tension incisions, and wounds with potential contamination. 8 This guideline also recommends using iNPWT on patients with health factors that put them at greater risk for complications, such as DM, obesity, and active tobacco use, as well as intra-operative risk factors such as extensive undermining and prolonged operative time. 8 Recent literature has supported this guideline, demonstrating beneficial post-operative clinical and aesthetic results after iNPWT use in patients after burns, panniculectomies, and reduction mammoplasties. 27 -30 Shiroky et al’s recent systematic review and meta-analysis demonstrated a nearly 40% risk reduction in SSIs with use of iNPWT compared with conventional dressings. 25 However, responses to this publication highlight the notable lack of cost analysis in their conclusions. 31 Abesamis et al examined iNPWT in 19 abdominoplasty patients and reported a 70% reduction of post-operative fluid drainage and shortened time to drain removal by approximately 5 days. 16 Altogether, current literature on abdominal BCP has positive clinical and aesthetic outcomes after iNPWT use 29 but lacks associated cost analysis. 32 Our results strengthen the current literature to provide an additional perspective of post-operative wound management and demonstrate that, while iNPWT is not directly associated with increased cost, there are potential repercussions to its use that ought to be considered.
Prior studies would lead us to expect favourable clinical outcomes overall in the iNPWT cohort. With respect to our original hypothesis, we believed that iNPWT would also significantly shorten time to drain removal. 16,33 Interestingly, patients with iNPWT did not experience less adverse post-operative events than their matched counterparts who did not have iNPWT used. Although this may be due to small sample size, we attribute this to patient-related and intra-operative factors that cannot be accounted for in a propensity-matched analysis. Patients who receive iNPWT are typically more clinically complicated than patients without iNPWT. Although the rigorous matching process helps to eliminate key confounding factors between the 2 cohorts, such as BMI and other co-morbid conditions, 34,35 the true burden of disease and inherent complexity of patients who receive iNPWT cannot be fully captured or equilibrated in a match. Ultimately, there are additional perioperative and intraoperative factors that cannot be easily extracted in a retrospective fashion, and the decision to place an iNPWT is multifactorial. For example, the need for extensive intra-operative undermining and overall poor tissue quality play a large role in determining post-operative wound management with the goal of minimizing complications. Additionally, some patients may require substantial tissue removal and contouring, while others require much more conservative measures. This clinical gestalt in the operating room is a key determinant of post-operative incisional management. Although the match does aid in balancing the complication risk profiles of the 2 cohorts, underlying clinical complexity remains. Patients who had iNPWT placed in this cohort also had on average one additional drain and 6 additional days before final drain removal. This suggests that there was a greater degree of complexity in these patients warranting additional drains to be placed and more conservative drain removal. Although this difference did not reach statistical significance, the presence of an extra drain for longer post-operative periods signals that this cohort required considerable post-operative monitoring to accomplish similar outcomes. This speaks to the multifaceted nature of risk stratification that is often difficult to capture in entirety.
Health care utilization analysis revealed striking differences between the 2 cohorts, with the total cost of each case an average of $7000 more expensive for iNPWT patients. However, multivariate sub-analysis further revealed that this increased cost is independently associated with LOS and length of index procedure rather than the presence of iNPWT. The authors believe that there is an underlying relationship between post-operative wound management, LOS, and inpatient health care utilization. Certainly, the presence of iNPWT may allow us to achieve acceptable clinical outcomes in patients with heightened risk profiles. Negative pressure extracts fluid from the wound to reduce wound edema, optimizes tissue approximation by reduction of lateral strain, and shields the incision from infection. 36 On the other hand, these dressings take longer to apply in the operating room, require heightened post-operative monitoring by clinical staff, and may result in increased LOS. With approximately 21 000 BCPs billed to insurance in 2019 alone, 37 our results suggest that overuse of iNPWT could create a large monetary deficit for the health care system. As such, iNPWT must be used judiciously, especially in this complex patient population. Future randomized controlled trials are indicated to elucidate the full cost burden and clinical utility of iNPWT.
Our study is not without limitations. Predominantly, the retrospective nature and rigorous matching process resulted in a relatively small sample size. Propensity-score matching is not commonly used in plastic surgery literature and has distinct advantages and setbacks. Propensity score method utilizes logistic regression to establish cohorts that are balanced in terms of covariates that could introduce bias to the results. Each participant is assigned a propensity score based on a set list of criteria, and then matched 1:1 to another participant. Although this is effective for smaller retrospective studies to mimic randomization when it is not otherwise possible, latent characteristics are not accounted for, and therefore, bias may remain. This, in addition to the single surgeon design, may limit the generalizability of our study population to other patients. However, these processes were necessary to maximally reduce confounding factors, and our study is one of the largest matched analyses of this patient cohort. Additionally, our study did not include detailed perioperative data due to the retrospective study design. These supplementary specifics, such as specific drain output data and intraoperative surgical nuances, would help bolster the overall classification of the patients in each cohort. Lastly, our study was limited to inpatient costs and did not include long-term costs of readmissions and reoperations. This information would be useful in the future for determining the comprehensive cost utility of iNPWT. Nevertheless, this was outside the scope of our study and the results presented here contribute important considerations regarding the implications of iNPWT on health care utilization and hospital costs.
Conclusion
In one of the largest matched studies comparing iNPWT to traditional dressings in abdominal BCPs, we demonstrate that iNPWT is associated with equivalent clinical outcomes and health care utilization, with increased cost. Although we agree with the consensus guidelines regarding the use of iNPWT in high-risk populations, the risk–benefit ratio, including the burden on the health care system, must be carefully considered on an individual basis.
Footnotes
Authors’ Note: This study was approved by the University of Pennsylvania Institutional Review Board (protocol #834489). This article does not contain any studies with human or animal subjects.
The author(s) declared potential conflicts of interest with respect to the research, authorship, and/or publication of this article: Dr. Fischer is a consultant for Integra, Gore, and Becton Dickinson.
Funding: The author(s) received no financial support for the research, authorship, and/or publication of this article.
ORCID iD: Martin P. Morris, MBE https://orcid.org/0000-0002-4552-1411
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