Is My Wound Dressing Better Than Yours?

  Have you ever been asked why you chose one wound care product over another? I have. As we carefully consider why to use one product instead of a similar one for each of our patients, we are doing a comparative effectiveness evaluation. We should do these evaluations to find the best treatments for our patients.

A recent manuscript published in this journal compared 2 silver dressings in the treatment of diabetic mice.¹ It is a good thing when clinicians do comparative effectiveness evaluations, but it can be a problem when someone with subtle ulterior motives does them.

  Because of the escalating cost of health care, Medicare inaugurated the Agency for Healthcare Research and Quality to sponsor the development of systematic reviews to be used “in whole or in part, as the basis for development of clinical practice guidelines and other quality enhancement tools, or as a basis for reimbursement and coverage policies.”² Yes, these “reviews” are supposed to be used for the improvement of the quality of medical practice, but the ugly bit about using the information for determining insurance coverage or reimbursement is there. I was recently involved in a review of the treatment of chronic venous ulcers,² in which nearly every dressing, bandage, treatment, and operation used to treat venous ulcers was evaluated with the available “evidence of its effectiveness to heal,” usually randomized controlled trials. Of the more than 10,000 articles that were found, only 60 were considered appropriate to include in the review. At the end of the review, the findings were that “advanced wound dressings had no impact on wound healing when compared with compression therapy alone, with the exception of cellular skin equivalents.”² After looking at all those products and treatments, compression therapy and cellular skin equivalents were the only 2 that had any effect on healing of the venous ulcers! Really? Personally, I found the results misleading at best.

  My review of the manuscript found several key issues. The first is that in wound care there are very few randomized controlled trials of most treatments. They have been done for advanced therapies but for most products that are only considered dressings, they have not been done, nor have they been required. I would suggest that the mere fact the data is nonexistent does not make the product or treatment ineffective. We just need to acquire more data.

  A second problem seems to be a lack of regard for the process of wound healing. As every wound care clinician knows, a wound heals by progressing through a series of defined steps in an orderly fashion. In the chronic, hard to heal wound, these steps can be disrupted by a number of abnormalities and conditions including infection, damaged tissue in the wound, and even the patient’s genetics, just to name a few possibilities. Most of the products used in the treatment of a chronic venous ulcer are designed to address only one or, at most, a few of the problems with the nonhealing wound. I am not aware of any single product that can correct all the problems of the chronic wound and allow the wound to heal. Even the compression bandaging and cellular skin equivalents would not be successful if it were not for many of the so-called “ineffective products” preparing the wound bed before their use. I have said many times that I could line up 100 patients matched as closely as possible with the same wound and treat them exactly the same way. At the end of the treatment, there would be 100 different outcomes, because patients respond to treatments in individual ways. One size treatment does not fit all. This has been brought home to me by one of my recurrent venous ulcer patients. Through the years, he has been treated with just about every treatment available for his venous ulcer! There is only one product that, when used in combination with compression therapy, stimulates his wound to heal. Even when he has a recurrence of his ulcer, this is the only treatment that works for him. This is a treatment that works well for many other patients, but for him, it is the only successful treatment. What if the product were no longer available since it is considered “ineffective” in healing a chronic venous ulcer?

  Patient compliance, a major issue in wound healing, was not considered in the evaluation of the products. It is unfair to say a treatment does not work if the patient fails to use it as intended. It is well known that patients do not like compression bandaging. One study showed that only 49% of the patients wore their compression and, when patients were questioned closely, the incidence was closer to only 20%.³ It would hardly be fair to say compression bandaging is a failure if 80% of patients fail to use it appropriately. It doesn’t seem reasonable to hold providers responsible for the results of treatment when there are many factors, including the patient’s behavior, which can alter the outcomes.^4,5

  Comparative effectiveness research and evaluations are here to stay and can have a place in the treatment of patients in wound care. It is important for us to know which treatments work best for our patients, but it should be up to the provider to choose those for each patient. I am afraid all of us will have to stand and voice our opinion on this issue. As providers, we always must represent the welfare of our patients. “Americans do not favor allowing the government to use comparative effectiveness research information to limit their options for care.”⁶