Cost-effectiveness Resources

Lower limb ulceration continues to be a common cause of suffering and its management places a significant burden on the NHS, with venous leg ulcers (VLUs) being the most common hard-to-heal wound in the UK. It is estimated that over one million patients in the UK have lower limb ulceration, of which 560,000 were categorised as VLUs at a cost of over £3 billion each year. Although self and shared care in chronic disease  management is not new, historically wound care and specifically lower limb management has been undertaken solely by healthcare professionals. This article outlines the results of implementing a lower limb wound pathway (Wounds UK, 2016), and a lower limb self-care delivery model measuring clinical outcomes and the impact on workforce pressures through limiting face-to-face healthcare professional contact up to one appointment every six weeks, when capacity and capability criteria are met. A suitability assessment was conducted and, when appropriate, patients were
managed using a self-care delivery model. Patient data were collected, anonymised and independently analysed, comparing time to healing against data on file from a previous audit using the lower limb wound pathway (Wounds UK, 2016). This highlighted VLUs in 84 of the 95 patients selected for the self-care model had healed by week 24 and a
further 10 patients had healed by week 42, with only one remaining patient reaching 42 weeks without healing. These results support the hypothesis that when suitable, patients with a VLU can self-care and deliver clinical effectiveness without compromise.

Debridement is the removal of non-viable tissue from the wound bed and surrounding skin and is an important part of wound healing and wound bed preparation. Devitalised tissue, such as necrosis, slough and hyperkeratosis, interfere with the process of wound
healing. When a wound fails to progress, there is a need to assess the wound bed and surrounding tissue and promote an optimum environment that encourages the formation of healthy granulation tissue (Young, 2014). Recent advances in debridement techniques
using monofilament fibre technology can be practised by nonspecialist nurses and used safely and effectively in a patient’s home. In a recent audit, a dataset of 486 patients who had been newly prescribed a monofilament fibre debridement pad was obtained to
validate clinical effectiveness and cost efficiency. The total cost of wound care prescribing fell by 14% or £101,723 in the six months after the intervention compared with the six months before. The average monthly expenditure per patient fell from £244 before the intervention to £209 after (Burnett et al, 2021). This evidence reinforces the National Institute for Health and Care Excellence (NICE) recommendations for use of monofilament fibre debridement in the community, based on evidence of its effectiveness and estimated cost savings (NICE, 2019).

The management of exudate in acute and chronic wounds is a common issue for community nurses, with too much exudate resulting in issues with infection and the breakdown of periwound skin; while too little moisture risks the wound bed becoming too dry. Nurses need to find the most cost-effective and clinically proven treatment regimen when treating wounds that produce different levels of exudate, minimising dressing changes and patient discomfort. While it can be difficult to make a choice about which dressing to use because of the vast array on offer, it is important to match the dressing to the wound and use the most appropriate dressing for the levels of exudate being produced. Similarly, using a more responsive approach to wound management — adapting treatment as the wound changes — will result in a more cost-effective approach. Advancis Medical have a range of wound management dressings that are suitable for different wound types and can handle varying levels of exudate. This allows nurses to use a step-up, step-down approach to the management of exudate as the most cost-effective dressing regimen.

In the current economic climate it is important that clinical quality and cost-effectiveness is maintained and community nurses must be confident that they are selecting dressings which provide multiple treatment outcomes. This can include exudate management, reducing trauma and pain at dressing change, extended wear time, and protection of the periwound area. Similarly, there has been a recent rise in the incidence of skin tears, particularly within care homes and in the elderly population, and this requires a dressing that can both protect vulnerable skin and prevent the entry of contaminants and bacteria into the wound bed. Community nurses need a dressing that can perform all of these roles and this article examines Advazorb® Border (Advancis Medical), a dressing specifically designed to manage exudate, prevent pain, trauma and skin stripping on removal, and protect the periwound skin. Crucially, in clinical practice Advazorb Border has been shown to manage skin tears appropriately while staying in place longer and the author discusses clinical evidence that shows how the dressing provides cost-effective wound management and long-term savings within clinical practice.

For community nurses faced with expanding case-loads and patients who are now being discharged earlier into the community, the sheer range of conditions they come across means that cost-effective and practical, clinically-effective solutions are at a premium. This is particularly true in wound care, where nurses in the community need products that can be used on a variety of wound types that are also cost-effective. This article looks at the range of wound care knowledge needed by generalist nurses, before focusing on one dressing in particular, Silflex® (Advancis Medical, Nottinghamshire). With its all-round versatility, Silflex provides a balance of usability and cost-effectiveness.

In chronic wound management the potential for healing increases following effective debridement. Indeed, it has been suggested that debridement’s effect on chronic wound healing is similar in impact to the relief of pressure in preventing pressure ulceration. Debridement can be performed using a number of methods, but larval debridement has recognised benefits, including the breakdown of necrotic tissue; removal of microbes; wound cleansing; and breakdown of biofilm. The reduction of malodour in the wound can also help increase patients’ self-esteem and overall wellbeing. This article looks at the use of larval therapy in a community setting, which can be particularly cost-effective as rapid debridement swiftly reduces the bacterial load, helping to lessen the potential for hospital admission.

Pressure ulcers are a significant problem in both the acute sector and the community, where nurses can spend a great deal of their time dealing with what is a painful and debilitating condition. As government policy encourages more care to be delivered in patients’ homes, finding solutions to pressure damage that aid healing and improve patients’ quality of life, as well as being cost-effective, is paramount. This article examines the background to pressure damage, as well as looking at its effect on community nurses’ workload. In particular, it focuses on the heel as a common site of pressure damage.

Lorraine Grothier, Clinical Nurse Specialist (Tissue Viability), Tissue Viability Service, Provide, delivering NHS and local authority services

With government reforms increasingly bringing care into patients’ homes, community nurses will inevitably encounter more and more people who have a stoma. Stomas essentially involve the maintenance of a permanently open breach of the skin, therefore, the site requires expert skin care as it is vulnerable to stripping and break down. This article looks at the use of silicone-based adhesive removers, which improve quality of life and can also reduce healthcare costs as they prevent the escalation of peristomal skin dysfunction. These products also help to prevent costly ongoing treatment for the effects of stripping on sensitive peristomal skin.

Jackie Stephen-Haynes, Professor and Consultant Nurse in Tissue Viability, Birmingham City University and Worcestershire Health and Care NHS Trust