The Ostomy Files: Stomal Complications: At What Price?
Most people who undergo ostomy surgery experience some type of complication during the time they live with a stoma. Each complication carries with it not only management issues but also emotional, psychological, and financial problems that can negatively impact the individual's ability to earn a living or to pay for the treatment, additional supplies, and management of the complication.
Any one or a combination of these factors may negatively impact the patient's overall sense of well being. To overlook or diminish the price paid by the patient in lost wages, pain and suffering, and decreased quality of life would be remiss. The purpose here, however, is to more clearly illustrate the cost to our healthcare system for peristomal problems that could be prevented, in some instances, through heightened education both for ostomy patients and the professionals who care for them.
Most of the data regarding ostomy care, peristomal complications, and related costs remain elusive, although some studies are beginning to emerge.1,2 A survey conducted by the United Ostomy Association (UOA) in 2000 found that skin problems were the most common reason patients consulted a WOC nurse.3 Other authors4 reviewed the literature to find 15% to 28% of patients with ileostomies experience peristomal skin breakdown. In a literature review, Colwell and colleagues5 reported rates of peristomal skin problems that ranged between 18% and 55%, depending on stoma type. If these rates were extended to include the entire American ostomy population (450,000), they could represent between 81,000 and 247,500 patients, the majority of whom are Medicare beneficiaries.
Because annual WOC nurse visits are not standard practice for most people with a stoma and the services of a WOC nurse often are unavailable, many ostomy-related problems go untreated until they become so severe they require re-hospitalization. This makes Medicare the primary payer for care in the most expensive care setting in our healthcare delivery system. In addition, the bill for the hospital stay is not the total bill. Add to this the cost for physicians' services (eg, colorectal surgeons, urologists, dermatologists, radiologists, and pathologists) and the out-of-pocket expenses paid by the patient (ie, copayments, 100% payment for non-covered services, and the like). Table 1 suggests the possible financial impact of peristomal skin complications.
Although it might seem to be an "extravagance" or a "nice to have, but not a need to have," an ostomy product's advanced technology can have an enormous impact on clinical as well as financial outcomes. We, as clinicians, may honestly believe that we are being fiscally responsible to our patient by selecting the lowest priced product. But are we really? For example, the cause of irritant dermatitis may simply be that the stomal aperture in the pouching system is the wrong size or shape. Or that the patient has some physical limitations that interfere with optimal self-care, that a less expensive skin barrier erodes too quickly, or the patient needs some degree of convexity. Add to these possibilities the trial-and-error practice of fitting ostomy pouching systems and the price of ostomy supplies escalates at the same time the complications exacerbate. Even when we believe we are being economically responsible to our patients by finding the cheapest product, we may in fact be laying the groundwork for more expensive treatment scenarios.
A UOA survey2 found that the average time since respondents had seen a WOC nurse was 7.21 years and that the average number of WOC nurse visits during the last 5 years was 1.78. Recent findings in Europe1 suggest that patient quality of life will improve more if patients have access to specialist care (ie, a WOC nurse) for 3 to 6 months following surgery. Patient education is a controllable factor that may help reduce the number of skin and stoma complications that are costing hospitals, our healthcare delivery system, and the patients themselves valuable healthcare dollars. Wound ostomy continence nurses must integrate financial considerations into their clinical care and petition insurers to pay for WOC nursing services not only as cost-effective care, but also as preventive and cost-saving care.
The Agency for Healthcare Research and Quality (AHRQ) has established an initiative to promote the regular delivery of accepted preventive services in the primary care setting called Putting Prevention into Practice (PPIP). Its publication, A Step-by-Step Guide to Delivering Clinical Preventive Services, is designed to be used by physicians, nurses, health educators, and office staff in public health clinics, community health centers, private practices, and other settings. Although this program is not directed at ostomy care (a rather small patient population when compared to heart disease or diabetes), aspects of the program could be adapted by the ostomy community (UOA, WOCN, manufacturers, and distributors) to establish a program of preventive care for ostomy patients. A continuum-wide program of clinical preventive services for ostomy care quite possibly would not only help improve outcomes and quality of life for the patient, but also help decrease overall costs.
Gwen B. Turnbull, RN, BS, author of The Ostomy Files, is a healthcare consultant specializing in public and private healthcare reimbursement as well as the development of professional and consumer educational and marketing tools.
1. Marquis R, Marrel A, Jambon B. Quality of life in patients with stomas: the Montreux study.Ostomy/Wound Management. 2003;49(2):48-55.
2. Ratliff CR, Donovan AM. Frequency of peristomal complications. Ostomy/Wound Management. 2001;47(8):26-29.
3. Cooke CR. Access for People with a Stoma to Enterostomal Therapy Nurses (ET Nurses). Data on file. United Ostomy Association, Inc. 19772 MacArthur Blvd., Suite 200, Irvine, CA 92612-2405. September 28, 2000.
4. Turnbull GB, Erwin-Toth P. Ostomy care: foundation for teaching and practice. Ostomy/Wound Management. 1999;45(Suppl 1A):23S-30S.
5. Colwell J, Goldberg M, Carmel J. The state of the standard diversion. JWOCN. 2001;28(1):6-17.
6. Agency for Healthcare Research and Quality. Putting Prevention into Practice: A Step-by-Step Guide to Delivering Clinical Preventive Services: A System Approach. Available at: www.ahrq.gov/ppip/manual. Accessed February 19, 2003.
