Inpatient management of diabetic foot problems: summary of NICE guidanceBMJ 2011; 342 doi: https://doi.org/10.1136/bmj.d1280 (Published 23 March 2011) Cite this as: BMJ 2011;342:d1280
All rapid responses
What does wound failure cost the patient and the healthcare system?
This question is raised by NICE Clinical Guidelines 119 on Diabetic Foot
Problems,(1) which Tan and colleagues summarized.(2) We agree on the value
of a multidisciplinary approach to diabetic foot wound management.(3)
However, we are concerned that guidance to "use wound dressings with the
lowest acquisition cost"(1,2) may contribute to longer wound healing
durations, affecting patient quality of life and increasing costs over
Two large randomized controlled trials (RCTs) compared Negative
Pressure Wound Therapy with V.A.C. Therapy (NPWT) to advanced moist wound
therapy (eg, alginates, hydrogels) in patients with diabetic foot
amputation wounds(4) and ulcers.(5) In both RCTs,(4,5) significantly more
NPWT patients achieved complete wound closure in significantly shorter
times compared to Control, and fewer NPWT patients required secondary
amputations (significantly fewer in the Blume RCT). NOTE: NICE
Guidelines(1) referenced the Williams Letter to the Editor rather than
Armstrong and Lavery's Lancet article.(4)
NICE Guidelines comment that, because NPWT has been reported to
reduce amputations, a health economic evaluation should be done.(1) In
2008, Apelqvist et al(6) published their economic analysis of inpatient
resource utilization based on the Armstrong and Lavery RCT's diabetic foot
wound data.(4) Apelqvist and colleagues reported that NPWT patients had
lower average direct cost per patient treated for 8 or more weeks,
independent of clinical outcome ($27,270 USD vs. $36,096 USD) and lower
average total cost to achieve healing ($25,954 USD, n=43 vs.$38,806 USD,
Xie's recent systematic review concluded that there is sufficient evidence
to justify NPWT's "use in the treatment of diabetes-associated chronic leg
wounds."(7) While NPWT may not be appropriate for every diabetic foot
wound, we believe that limiting NPWT to "rescue" therapy discounts the
human and financial costs of failing to heal a wound.
(1) Diabetic foot problems: Inpatient management of diabetic foot
problems. London: National Institute for Health and Clinical Excellence;
2011 Mar 1. Report No.: NICE Clinical Guideline 119.
(2) Tan T, Shaw EJ, Siddiqui F, Kandaswamy P, Barry PW, Baker M. Inpatient
management of diabetic foot problems: summary of NICE guidance. Br Med J
2011 March 23;342:d1280.
(3) Sumpio BE, Driver VR, Gibbons GW et al. A multidisciplinary approach
to limb preservation: The role of V.A.C. therapy. Wounds 2009 September
1;21(9 Suppl 2):1-19.
(4) Armstrong DG, Lavery LA, Diabetic Foot Study Consortium. Negative
pressure wound therapy after partial diabetic foot amputation: a
multicentre, randomised controlled trial. Lancet 2005 November
(5) Blume PA. Comparison of Negative Pressure Wound Therapy Using Vacuum-
Assisted Closure With Advanced Moist Wound Therapy in the Treatment of
Diabetic Foot Ulcers: a Multicenter Randomized Controlled Trial: Response
to Hemkens and Waltering. Diabetes Care 2008 October 1;31(10):e77.
(6) Apelqvist J, Armstrong DG, Lavery LA, Boulton AJ. Resource utilization
and economic costs of care based on a randomized trial of vacuum-assisted
closure therapy in the treatment of diabetic foot wounds. Am J Surg 2008
(7) Xie X, McGregor M, Dendukuri N. The clinical effectiveness of negative
pressure wound therapy: a systematic review. J Wound Care 2010 November
Competing interests: All authors are employees of Kinetic Concepts, Inc. and own stock in the company.