February 22, 2024 | Net Health

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The Cost of Chronic Wounds

Chronic Wounds: A Look at the human and financial toll

Over the past few years, in an effort to promote better outcomes for patients, healthcare providers, payers, researchers, and regulators have started paying more attention to a once-overlooked area of healthcare: chronic wounds. Chronic wounds encompass injuries such as burns and surgical site infections, as well as pressure injuries (bedsores), hospital-acquired pressure injuries (known by the acronym HAPIs), and diabetic ulcers.

The advent of value-based care initiatives and heavy penalties for HAPIs are leading to changes in wound care. Not only do these injuries cause pain for the individual, but they also add to a hospital’s costs, are a cause for readmissions, and can lead to additional infections and even death. Dedicated clinicians and innovators bringing promising technologies, products, and services to the market are starting to move the dial in managing costs and improving outcomes.

Technological advancements in wound care have created new options for treating chronic wounds, and electronic records and AI-assisted treatment allow for better monitoring and decision-making.

The impetus for further adoption of new technologies may lie in an honest exploration of the cost of chronic wounds – economic, societal, and personal. This summary, developed by Net Health and TissueAnalytics, provides additional insights and a framework for discussing the value of adopting new technologies, tools, and best practices to combat chronic injuries.

Pressure injuries

Pressure injuries (PIs), commonly known as bedsores, occur when excessive pressure over a prolonged period is placed on an extremity. People over age 70, those with mobility limitations, and anyone with underlying health concerns are more vulnerable to pressure injuries.

The most common location for a pressure injury is the sacrum, but they also develop on the hips, heels, back of the head, and elbows—all places where the bone is close to the surface of the skin and can restrict the blood supply resulting in a breakdown of the skin.

There are four stages of pressure injuries, measured by the amount of deterioration of the skin, fat, muscle, or bone in the most severe cases.

Chronic wounds such as PIs can occur in a hospital, long-term care, or home care setting. As early as 2010, research indicated that while not all PIs are preventable, the vast majority could be avoided.[1]

However, rates of incidence are not falling. Due to the continuous increase in the number of diabetic, obese, and elderly patients, the number of PIs medical facilities see and treat is expected to keep rising.[2]

  • More than 2.5 million people are estimated to develop a pressure injury each year in the United States[3]
  • Nearly 60,000 people die each year as a direct result of pressure injuries.
  • Pressure injuries cost the United States healthcare system between $9.1 and $11.9 billion annually.
  • Treating an individual with a pressure injury can add $20,000-$151,000 to their cost of care per injury.[4]

Prevention of chronic wounds like PIs starts with engaging the hospital or treatment facility staff to understand what PIs are and what precautions need to be taken to avoid them. The Agency for Healthcare Research and Quality (AHRQ) developed a toolkit for providers in acute care settings on how to prevent pressure injuries and saw anywhere from a 50% to 100% decrease in PIs at the hospitals that implemented this program.[5] The training included plans for educating leadership about the cost of PIs and implementing best practices for preventing pressure injuries.

Most facilities use the Braden Scale[6] or the Norton Scale[7] to evaluate a patient’s risk factors for developing a PI. These assessments help develop a treatment plan based on the patient’s risk factors and mobility limitations to heal or prevent additional PIs. Treatment of pressure injuries can include traditional dressing material or material embedded with wound-healing substances such as silver, magnesium, honey, or polycaprolactone gelatin.

Chinese herbal medicine, nonsteroidal anti-inflammatory drugs (NSAIDs), topical corticosteroids, and debridement practices may all play a role in healing pressure injuries.[8] With proper and continuous treatment, acute pressure injuries can move through the four phases of healing within about four weeks.[9]

HAPIs

HAPIs are Hospital-Acquired Pressure Injuries that develop while in a hospital setting. Patients at risk include the elderly, those with mobility restrictions, and those with cardiovascular disease, diabetes, incontinence, and other chronic conditions. Five to 15% of hospital patients experience HAPIs, with the highest rates seen in long-term care settings.[10] Rates of hospital-acquired conditions rose as much as 60% during the COVID-19 pandemic.[11]

HAPIs and other hospital-acquired conditions add to medical care costs, increase the time spent in the hospital, and significantly affect health outcomes. Additionally, Medicare and Medicaid do not reimburse for costs associated with HAPI treatment, eating away at the facility’s bottom line. HAPIs are the second most common hospital lawsuit claim, with an average settlement cost of $250,000.

  • Each year, HAPIs impact 2.5 million patients and cause more than 60,000 deaths.[12]
  • It costs an average of $11,000 to treat each HAPI.[13]
  • The US spends $26.8 billion annually caring for patients with HAPIs.
  • There are four stages of pressure ulcers. Stages three and four are considered “never events” that are serious but preventable and must be reported with financial penalties for the hospital.[14] Nearly 80% of hospitals are penalized for HAPI events.

An average, medium-sized hospital will experience in excess of 600 HAPIs each year resulting in an average of 146 readmissions and costs of more than $10 million. Even a small reduction in this number can result in big savings.[15]

Education is essential for preventing HAPIs. Staff should routinely monitor patients for signs of skin irritation, reposition those who move infrequently to redistribute pressure, and support patients’ nutrition. It is estimated that 50% of hospital patients are malnourished. This directly affects the body’s ability to heal from any injury, particularly PIs. A dietician can assess nutritional needs and create a diet plan that promotes healing.[16]

As technology advances, artificial intelligence is being used to create prediction models of which patients are most at risk for HAPIs. This information will assist healthcare providers make better decisions about treatment and apply preventative measures for individual patients.[17] Wearable devices are preferred by some hospitals to monitor for repositioning and to increase turn compliance.[18]

Diabetic ulcers

People with diabetes are at high risk for diabetic foot ulcers due to poor circulation, high blood sugar (hyperglycemia), and nerve damage. A key concern for foot ulcers is that, left untreated or improperly treated, they often lead to below-the-knee (BTK) amputations. In fact, ulcers are a factor in 85% of lower limb amputations despite the use of antibiotics to combat infection. Unfortunately, the surgery is still not a guarantee of better medical outcomes. Of those who have a BTK amputation, 19% will have an additional amputation within one year, and 37% will within five years.[19]

Low-income and underserved regions suffered the most tragic consequences from diabetic ulcers. Black Americans are twice as likely to have undiagnosed diabetes and are three times as likely to lose a limb to amputation as white Americans. Another study in California found that the lowest income neighborhoods had ten times the rate of amputation as the wealthiest neighborhoods.[20]

  • There are 463 million people living with diabetes, and they have a 34% lifetime risk of developing a diabetic foot ulcer.[21]
  • An estimated 12.2% of the population will be living with diabetes by 2040.[22]
  • Diabetic ulcers cost $9-13 billion over and above the standard cost of managing diabetes.[23]
  • Every three and a half minutes, a limb is amputated in the US due to complications of diabetes.[24]

As the rates of diagnosis of diabetes continue to rise, hospitals, clinics, and nursing homes will need to develop better and more effective techniques for treating complications. Diabetic ulcers are notoriously difficult to heal because blood, particularly infection-fighting white blood cells, is slowed by the presence of excess sugar. Because the body struggles to heal itself, even small cuts and scrapes can cause lasting health problems.

Prevention and early treatment are essential for those with diabetes. Patients who develop diabetic ulcers have a 30% mortality rate in the next five years and a 70% mortality rate if they endure a major amputation.[25] Treating diabetic foot ulcers requires a comprehensive approach, including carefully monitoring glucose levels and a variety of wound care management techniques. Debridement, dressing that allows for a moist environment, shifting pressure away from the wound, and oxygen therapy are common treatments with positive outcomes.[26]

Surgical infections

Surgical site infections (SSI) occur when a break in the skin following surgery becomes infected. SSIs can develop in the skin, muscles, tissue, or organs, and remain a common and costly complication of any surgery. Because SSIs can lead to sepsis, a serious blood infection, they must receive proper interventions and treatments. The majority of SSIs occur within 30 days of surgery and affect 300,000 Americans every year. A history of smoking, poorly controlled glucose levels, obesity, and undergoing surgery that lasts longer than 180 minutes are all factors that increase the risk of developing a surgical infection.[27] SSIs are the leading cause of readmission, and approximately 3% of patients who develop an SSI will die from it.

  • Between two and five percent of surgeries result in an SSI.[28]
  • Surgical infections increase hospital stays by an average of 9.7 days and admission costs by an average of $20,000.[29]
  • Up to 60% of SSIs are preventable by following evidence-based practices.[30]

Surgical site infections can be particularly difficult to monitor because the length of stay following surgery has been declining. Doctors and nurses in the acute care setting are not the only ones who will see or treat SSIs. Patients need to monitor their own health, and clinics, rehabilitation centers, and home health aids can help to track signs of infection. Antibiotics and antimicrobials can be used after surgery to help prevent infection.[31]

Once a surgical site infection has begun, it needs to be treated to prevent further damage. The puss discharge can be tested to reveal the type of bacteria in the infection. Targeted treatments can be delivered based on this information.

Burns

Burns can be one of the more challenging chronic wounds to treat. They affect young and old and are caused by cold, heat, radiation, chemical or electric sources. Burns are the leading cause of accidental death and injury in the US, particularly for children. One-third of people who suffer from burns are under the age of 15, and children under two are twice as likely as any other age group to be treated for a burn injury. Treatment has improved greatly, and 96% of people who are burned will survive, but many will have life-long disfigurement and disability.[32]

  • 450,000 people receive burn treatment in US hospitals each year.
  • Burn hospitalizations cost $1 billion annually, which is equivalent to 1% of hospital costs.[33]
  • Mortality rates for burns increase with age.[34]

Treatment of burns varies widely based on the location and severity of the injury. Burns to sensitive areas such as the face, eyes, hands, and joints are considered more severe and should be treated in a dedicated burn center. Full-thickness or third-degree burns usually require surgery and skin grafting.[35] For most patients, this should be done quickly—in one study, the rate of mortality dropped from 45% to just 9% when grafting was done within three days of the burn injury.[36]

There are two main types of skin grafting. Applying healthy skin to chronic wounds is skin replacement. Skin substitution employs the use of biomaterial or engineered tissue to regrow healthy skin. Skin substitution has evolved rapidly in recent years with the advent of 3D printing, tissue engineering, the production of materials like nylon and silicone, and tissue analytics.

Chronic wounds impact nursing homes

Skilled Nursing Facilities (SNF) and Long-Term Care facilities (LTC) provide both personal and health related services around the clock. These patients can no longer care for themselves in their homes and require hands-on daily assistance.

  • More than 1.3 million older Americans or 2.3% of those over 65, live in SNFs.[37]
  • More than 60% of Long-Term Care patients use Medicaid as their payment method, but the number of CMS-certified facilities decreased by 4% between 2015 and 2023.
  • New rules were proposed in 2023 to establish a minimum staffing standard for SNFs.[38]
  • Between 2015 and 2023, the average number of deficiencies per nursing home increased from 6.8 to 8.9, and the percentage of facilities reporting serious deficiencies increased from 17% to 26%.[39]

Recent research indicates that the rate of pressure ulcer prevalence in nursing homes is 8.5%. Factors that make SNF patients more susceptible to chronic would are that residents rely on staff for mobility assistance and that up to one-third of nursing home residents also have diabetes.[40] Of those who have ulcers, 19.4% have more than one location affected.[41] These avoidable injuries cost $9-$11 billion per year to treat in the United States.[42]

The AHRQ has developed a tool kit for acute treatment centers that has been shown to reduce the number of pressure injuries by 10%. Their recommendations include a care bundle that brings together all the professionals providing services to the patient to ensure they are monitoring areas for concern and quickly responding with effective methods of prevention and treatment for chronic wounds.

Patients should be assessed for temperature, color, moisture, turgor, and skin integrity. Documentation is essential for clear communication between all nurses, doctors, therapists, and assistants, and electronic medical records will help keep notes organized and action items a priority for early treatment.[43]

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