JOURNAL ANALYSIS

Cost-Effective Use of Silver Dressings for the Treatment of Hard-to-Heal Chronic

Venous Leg Ulcers

Written by:
Irfan Fauzi

J210134002

BACHELOR OF NURSING
HEALTH SCIENCE FACULTY
MUHAMMADIYAH UNIVERSITY OF SURAKARTA
2015

CHAPTER I
ANALYSIS
A. Title
Cost-Effective Use of Silver Dressings for the Treatment of Hard-to-Heal
Chronic Venous Leg Ulcers.
B. Writers
Gregor B. E. Jemec,Jean Charles Kerihuel, Karen Ousey, Sanne Lise
Lauemller, David John Leaper from Department of Dermatology, Health Sciences
Faculty, Roskilde Hospital, University of Copenhagen, Copenhagen, Denmark,
Vertical, Paris, France, School of Human and Health Sciences, University of
Huddersfield, Huddersfield, United Kingdom, Coloplast A/S, Humlebaek, Denmark.
C. Published
On June 19, 2014
D. Background
The most common causes of lower extremity ulcers are venous hypertension,
arterial disease, neuropathy (usually due to diabetes), pressure injury and ischaemia.
Venous leg ulceration is a debilitating, chronic condition that affects people of all
ages. Venous ulceration is generally considered to result from venous occlusion,
incompetent calf muscle pump function or venous valvular failure that give rise to
venous hypertension. Venous hypertension accounts for nearly 80% of all leg ulcers.
Venous ulceration is strongly related to risk factors such as family history of, or
previous surgery for varicose veins; venous disease; phlebitis; DVT; congestive
cardiac failure; obesity; immobility and previous leg injury.Venous leg ulcers
represent the most common chronic wound problem seen in general practice and are
commonly managed by practice nurse (The Australian Wound Management
Association, and The New Zealand Wound Care Society, 2011)
These ulcers will take months to heal despite appropiate treatment, including
efficient venous compression bandage system and have 12 month recurrence rates
between 18% and 28%. Ulcer size and ulcer duration are clearly identified risk factor
for a poor healing prognosis. Venous Leg Ulcers (VLUs) are also frequently painful,
malodorous, often with moderate to high exudate, and have a significant negative
impact on patients quality of life.
E. Aims

The aims of the current study was to analysis of journal about using the silver
dressing for the treatment of hard-to-heal chronic venous leg ulcers can estimate the
cost of effectiveness benefit could be helpful for healthcare decision makers in
evaluating economic aspects of treatment with silver-releasing dressings.

CHAPTER II
THEORY
A. Definition of VLUs
A venous leg ulcers (VLUs) is an open skin lesion that usually occurs on the
medial side of the lower leg between the ankle and the knees as a result of chronic
venous insufficiency (CVI) and ambulatory venous hypertensio, and that shows little
progress towards healing within 4-6 weeks of initial occurence (Harding K, 2015).
Venous leg ulcers (VLUs also known as varicose or statis ulcers) pose
significant challenges to patient and healthcare system; they are frequent, costly to
manage, recurring, and may persist for month or years.

A skin ulcer happens when an area of skin breaks down to reveal the
underlying flesh. Venous leg ulcers are the most common type of skin ulcer. They
mainly occur just above the ankle. They usually affect older people and are more
common in women. It affects about 1 in 1,000 people in the UK at some stage in their
lives. It gets more common as you get older and 20 in 1,000 people become affected
by the time they are in their 80s. Venous leg ulcers can be painless but some are
painful. Without treatment, an ulcer may become larger and cause problems in the leg.
Skin inflammation (dermatitis) sometimes develops around a venous ulcer.
Non-venous skin ulcers are less common. For example, a skin ulcer may be
caused by poor circulation due to narrowed arteries in the leg, problems with nerves
that supply the skin, or other problems. The treatment for non-venous ulcers is
different to that of venous ulcers.
VLUs are the most common type of chronic lower limb wound (Table 1) and
are due to disease or disrupted function of the veins, known as chronic venous
insufficiency (CVI). In clinical practice, an understanding of the likely history and
characteristics of lower limbcwounds will aid in distinguishing VLUs and leg ulcers
that may have a venous component fromcother types of lower limb wound (Table 2).

B. Etiology of VLUs
VLUs are due to increased pressure within the veins of the lower limb caused
by chronic venous insufficiency (CVI). This most commonly occurs as a result of
damage to the valves in leg veins as in varicose veins or as a result of venous
thrombosis.
Venous valves prevent blood that is going up the leg towards the heart from
flowing backwards (Figure 2). Blood flow towards the heart is assisted by the muscles

of the lower leg (the calf muscle pump). Damaged valves allow blood to flow towards
the ankle, which increases distal venous pressure during standing and walking
(ambulatory venous hypertension). Raised venous pressure may cause swelling and
oedema of the leg, and increased fragility of blood capillaries and the skin, and an
increased risk of leg ulceration.

The root of the problem is increased pressure of blood in the veins of the
lower leg. This causes fluid to ooze out of the veins beneath the skin. This causes
swelling, thickening and damage to the skin. The damaged skin may eventually break
down to form an ulcer.
The increased pressure of blood in the leg veins is due to blood collecting in
the smaller veins next to the skin. The blood tends to collect and pool because the
valves in the larger veins become damaged by a previous blood clot (thrombosis) in
the vein or varicose veins. Gravity causes blood to flow back through the damaged
valves and pool in the lower veins.

C. Silver Dressings
The topical antimicrobial agent silver has been used for hundreds of years in
wound care. For example, silver has been used to prevent or manage infection in its
solid elemental form (e.g silver wire placed in wounds), as solutions of silver salts
used to cleanse wounds (e.g silver nitrate solution), and more recently as creams or
ointments containing a silver antibiotic compound (silver sulfadiazine (SSD) cream)
(International Consensus, 2012).
In recent years, a wide range of wound dressings that contain elemental silver
or a silverreleasing compound have been developed. These dressings have overcome
some of the problems associated with the first silver preparations. They are easier to
apply, may provide sustained availability of silver, may need less frequent dressing
changes, and may provide additional benefits such as management of excessive
exudate, maintenance of a moist wound environment, or facilitation of autolytic
debridement.
The use of silver dressings in wound care has recently been faced with
considerable challenges. These include a perceived lack of efficacy and cost
effectiveness, and questions about safety. In some healthcare settings, these
challenges have led to restrictions in the availability or complete withdrawal of silver

dressings. This has left some clinicians in the frustrating position of not being able to
use silver dressings for patients who may find them beneficial.
Differentiating between the many silver dressings that are available can be
perplexing because of the variety of antimicrobial testing methods and clinical
endpoints used in studies, and the complexity of comparing the data derived.
In practice, the factors most likel to influence choice of a silver dressing are:

Availability and familiarity

The additional needs of the patienr and the wound, e.g level of exudate
production and condition of the wound bed.

Whether a secondary dressing is required

Patient preference

The duration of silver availability may also be important. In general, silver dressings
are intended to provide sustained delivery of silver over several days, so reducing the
need for frequent dressing changes. If dressing changes are planned to take place once
weekly, use of a dressing that is known to continue releasing silver for seven days
would be advisable.

D. Cost Effectiveness
Many misperception that Silver dressings are too expensive; the assessment of
the cost effectiveness of wound treatments is not straightforward. The total cost of
wound care involves many direct and indirect cost, and some costs are difficult to
measure, e.g reduces productivity at work or in the home, reduced quality of life, and
social isolation. Several silver dressing studies have demonstrated beneficial effects
on overall cost of wound management and on quality of life parameters.
Thorough assessment of the cost effectiveness of a healthcare intervention is
complicated and considers many factors, including resource use, quality of life issues

and economic parameters such as ability to work and ideally should be conducted
separately from clinical trials.
A number of studies have found that silver dressings are associated with
factors that may be beneficial in terms of cost effectiveness, e.g:

Reduced time to wound healing

shorter hospital stays

Reduced dressing change frequency

Reduced need for pain medication during dressing change

Fewer MRSA bacteremias resulting from MRSA-infected wounds

A formal cost-effectiveness analysis of silver dressings is needed and awaited.

However, a retrospective study of hospital costs for burns in paediatric patients found
that total charges and direct costs were significantly lower for patients treated with a
silver Hydro fiber dressing than for those treated with SSD (p<0.05 for both).
Similarly, another RCT found that treatment of burns patients with a silver Hydrofiber
dressing cost significantly less than did treatment with SSD.
In practice, healthcare reimbursement is compartmentalised and costs of
clinician time are kept separate from resource costs. This means that even if a dressing
is shown to save money overall by reducing time to healing, hospital stay or nursing
time, controllers of dressing budgets may choose to restrict reimbursement to simple
low cost dressings.

CHAPTER III
JOURNAL
A. PICO Analysis
the content of journals used Person, Intervention, Comparison, and Outcome
(PICO)
1. Person
The data set was based on four RCTs conducted on 685 patients where the same
active silver dressing was compared with non-silver dressings with respect to
relative reduction in ulcer area at four weeks.
a. Inclusion
All patients had venous or mixed aetiology legs ulcers that exhibited delayed
healing.
b. Exclusion
1) As clinical signs of infection (pain, odor, increased exudate)
2) Patient with a realtive ulcer area reduction more than 40% at 4 weeks.
3) The ulcers were defined as hard-to-heal VLUs
2. Intervention

a. Patients who responded to the four weeks treatment were assumed to have
continued treatment with a non-silver treatment until their ulcer was healed.
Time to wound healing was estimated by linear extrapolation of the ulcer areas
at baseline and at four weeks for each patient in the data set.
b. Patients who did not respond after four weeks treatment were assumed to have
been referred to a wound specialist for wound assessment and development of
a treatment plan. The healing time for these ulcers was assumed to be the same
whether the patient was started on the silver treatment or the non-silver
treatment, and set equal to the estimated healing time in patients with
improved ulcers at four weeks in the silver treatment.
3. Comparison
Treatment wth silver dressings for an initial four weeks compared with
treatment with non silver dressings.
4. Outcome
a. Clinical Outcomes
The estimated healing time for the VLUs treated with silver dressings was
shorter than the healing time for the non-silver treatment group with an
average of 10.1 weeks compared with 12.8 weeks, respectively
b. Economic Results
The use of a four week silver treatment was considered to be cost saving
because of a shorter time to healing, and fewer patients requiring referral to
specialist care. The initial four weeks treatment in primary care was estimated
to be more expensive for the group treated with silver (623.52) compared
with non-silver treatment (533.60).
B. Research Procedure
1. Method
A decision tree was constructed to evaluate the cost-effectiveness of treatment
with silver compared with non-silver dressing for four weeks in a primary care
setting. During the initial four week periods each patient was deemed to have one
of three possible outcomes; complete healing (healed ulcer), the ulcer may have
decreased in size (healing ulcer), be unchanged or enlarged (no improvement).

2. Result
Based on a health economic model, where clinical data was sourced from a
recently published meta-analysis, it has been shown that when patients with hardto-heal VLUs are allocated to an initial four weeks treatment using silver
dressings there can be associated cost savings (141.57) compared with patients
who are treated with non-silver dressings. In addition, patients treated with silver
dressings had wound closure approximately 3 weeks before those patients treated
with non-silver dressings. Thus, use of silver dressings improves healing time in
hard-to-heal VLUs and can lead to overall cost-savings. These results can be used
to guide healthcare decision makers in evaluating the economic aspects of
treatment with silver dressings in hard-to-heal VLUs.

REFERENCES

Harding K, e. a., 2015. Simplifying Venous Leg Ulcer Management. Consensus

recommendations. London: Wounds International Enterprise House.
International Consensus, 2012. Appropiate use of silver dressings in wound. An expect
working group consensus. London: Wound International.
NHS Scotland, 2010. Management of chronic venous leg ulcers. A national clinical
guideline. Scotland: Scottish Intercollegiate Guidelines Network.
The Australian Wound Management Association, and The New Zealand Wound Care Society,
2011. Australian and New Zealand Clinical Practice Guideline for Prevention and
Management of Venous Leg Ulcers. Cambridge: Cambridge Publishing.