socio-economic impact on wound management—a pilot study at a tertiary care indian hospital
TRANSCRIPT
Wound Medicine 2–3 (2013) 3–5
Socio-economic impact on wound management—A pilot study at aTertiary care Indian Hospital
Maneesh Paul-Satyaseela, Althaf Chinna Hussain, Varghese Philip 1,*
St. Martha’s Hospital, #5, Nrupatunga Road, Bangalore 560001, Karnataka, India
A R T I C L E I N F O
Article history:
Received 13 September 2013
Accepted 11 October 2013
Available online 17 October 2013
Keywords:
Wound management
India
Cost
Socio-economic
A B S T R A C T
Although evaluating health is an important factor in managing the patients, there are other factors such
as monthly income, number of dependents, cost of sickness, etc. all of which contribute to the socio-
economic status of an individual, which impact the type of care sought and the type of healthcare
facilities they go to. St. Martha’s Hospital, Bangalore, India, is a tertiary hospital where patients come
from mostly the middle and lower socio-economic population. The present two month pilot study was
carried out to document the impact of socioeconomic status in the current practice of wound
management at the hospital. We observed that the patients from lower documented economic status did
not come for repeat visits for regular wound management unlike the comparatively better economic
status patients. Since the actual cost to manage the wound was not significantly high, this non-managing
tendency could be attributed to the other additional costs such as attendant, travel, incidentals, etc.
Hence we conclude that there is clear impact of the socio-economic status of the patients in wound-
management; and it is imperative to develop a right approach in wound management in order to reduce
the economic burden on the patients while lowering the morbidity and mortality related to wounds.
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1. Introduction
Generally, while evaluating health, some of the importantfactors are often missed such as monthly income, number ofdependents, cost of sickness, associated costs, etc. all of whichdetermine the socio-economic status of an individual, which inturn impacts the management of their illness. For bettermanagement of patients, understanding their socio-economicstatus is important especially for those requiring long-term follow-up such as wound-patients. In addition to these patient-specificfactors, wound assessment is a vital factor which impacts thewound management. Practitioners and Nurses caring for patientswith wounds need to ensure they have the essential skills to makean objective assessment of wounds, to plan, implement andevaluate care on an individual basis [1,2].
One could easily generalize the type of patients who visit thehospital, e.g., a government hospital may have predominantly poor
Abbreviations: DFU, diabetic foot ulcer; DM, diabetes mellitus; INR, Indian rupees;
CDC, Centre for Disease Control, USA; WHO, World Health Organization.
* Corresponding author.
E-mail addresses: [email protected] (M. Paul-Satyaseela),
[email protected] (A.C. Hussain), [email protected] (V. Philip).1 Principal Investigator.
2213-9095/$ – see front matter � 2013 Elsevier GmbH. All rights reserved.
http://dx.doi.org/10.1016/j.wndm.2013.10.003
patients while a private hospital may have patients from middlesocio-economic strata. While there are multiple options availableto the patients from the better economic status, there are verylimited options available to the poorer patients. In such a scenario,adopting a more cost-effective approach would bring down thetotal cost of wound management. Apart from factoring patients’socio-economic status, the skill of the caring-staff is essential tocustomize their wound-management which ultimately affects theoutcome [1]. St. Martha’s Hospital, Bangalore, India, is a tertiaryhospital where patients come from across the socio-economicstrata. In this present two month pilot study we evaluated theimpact of socioeconomic status on care of patients with woundsand the overall wound management approach. Based on theoutcome, it is proposed to evolve future strategies to improvewound care management.
2. Materials and methods
All patients who presented with wounds were included in thestudy. Patients’ consent was taken and those patients agreeingto participate were included to answer the questionnaire (seeSupplementary material). This study did not alter the care forthe patient in any manner since the goal of the study was tounderstand the cost of wound care as currently practiced.
Table 1Distribution of wounds and the number of patients.
No. of patients No. of wounds Total wounds
42 3 2 1
15 repeat visits 1 � 3v (3W) 1 � 3v (2W) 1 � 4v (1 W) 6
1 � 5v (3W) 2 � 3v (2 W) 5
9 � 2v (9 W) 9
27 single visits 0 4 � 1v (8W) 23 � 1 (23 W) 31
51 wounds
W: wound and v: visits.
M. Paul-Satyaseela et al. / Wound Medicine 2–3 (2013) 3–54
3. Results
Wound data from a total of 42 patients were documented whichincluded 15 patients coming for repeat visits (Table 1). Of the 15, 3patients had multiple wounds while the rest 12 patients had singlewound each. Among the 27 single visit patients, 4 had two woundseach and the remaining 23 patients had single wounds. Thus the totalnumber of wounds documented was 51 wounds from 42 patients.
We documented the pre-existing conditions of the patients(Fig. 1) and observed that majority of the patients were diabetic(36%) and those who had injury (33%) followed by patients withpressure ulcers (18%), with varicose 10%, and one patient (3%) hadarterial condition. The predominant co-morbidity observed washypertension (n = 15) and one patient had a history of stroke.
A cross-section of the wounds of the repeat visit patients wasfurther evaluated to estimate the extent of wound healing withthe current practice of wound management by measuring thewound outline. We observed that the number of patients in whomthe wounds worsened was comparatively higher than the healedones (cross-pattern bars [n = 8] versus square-pattern bars[n = 6]). These patients would continue to visit the hospital untilthe resolution of the wound is completed.
From the socio-economic perspective, the patients who made asingle visit to the hospital spent INR 210/- (2.5s at 1s = 82 Indian
14
1
4
13
7
151050
Diabetes
Vascular
Vari cose
Injury
Pressure
Fig. 1. No. of pre-existing conditions reported.
0.00
100.00
200.00
300.00
400.00
500.00
600.00
p1w1p1w2p2w1p2w2w10w9w8w7w6w5w4w3w2w1
Fig. 2. No. of status of wounds of patients coming for repeat visits. Legend: Black:
size at first visit, cross-pattern bars/square-pattern bars: size on last visit (cross-
pattern indicates worsening and square-pattern indicates healing); w: wound and
p: patient.
rupees) to INR 230/- (2.8s) for their visit for wound care excludingthe medication. Among these patients, the number of lost workingdays averaged to 15 in a month during the study; in addition to alsohaving 3–4 dependents. Among the repeat visit patients, thenumber of lost working days averaged two months with aspending of INR 270/- (3.2s) to INR 300/- (3.6s) per visit tothe hospital. All the patients who came for single visit were inearning a monthly income less than INR 5000/- (60.9s) whilethose that came for repeat visits earned a monthly income betweenINR 5000/- (60.9s) to INR 20,000/- (243.9s) (Fig. 2).
4. Discussion
Quality of life (QOL) and Health related QOL has been defined byWHO which makes it possible to demonstrate scientifically theimpact of QOL on health. Similarly CDC’s Mission is to promotehealth and QOL by preventing, and controlling disease, injury anddisability [3]. In light with these approaches, we observed thatpatients, irrespective of if they came for a single or repeat visit, theirinitial clinical presentation or their pre-existing conditions were notdifferent; but the manner in which they managed their wound wasdifferent indicating the impact of their socio-economic status. Forthis, we assessed the core healthy days of a person through questionson: (1) self-rated health, (2) number of recent days when physicalhealth was not good, (3) number of recent activity limitation daysbecause of poor physical health, and (4) financial status [3]. Weobserved that most of the patients who came for repeat visitsgenerally had better financial status than the patients who came fora single visit, though there was not much difference between thegroups on the number of lost working days. This observation maypoint to the probable financial reason as to why the single visitpatients do not come to the hospital for follow-up. The lowerincome-group patients may not have had the ability to afford aspending of more than INR 210/- (2.5s) to INR 230/- (2.8s). Theother reason could be that because of the financial difficulty, they arelooking for a quick cure of the wound and when the wound is nothealed with one visit, they would go to another hospital or clinic orresort to traditional medicine in search of a quick cure. Where-in theactual wound dressing costs not more than INR 50/- (0.6s) per visit,the incidental charges were a heavy burden on these patients. Thiscost is significantly less than the cost reported (INR 147/- = 1.79s) inan extensive study conducted by Chatterjee and Laxminarayan [4].This observation indicates that the patients’ economic status is oneof the major drivers in their decision on the way they choose tomanage their wound.
5. Conclusion
Based on these observations, we conclude that there is asubstantial impact of the socio-economic status of the patients inhow they manage wounds and consequently on its healing. Lowersocio-economic populations try to manage their wounds withtraditional methods or with irregular visits to clinics and hence are atrisk of worsening of the wound, which potentially can lead to
M. Paul-Satyaseela et al. / Wound Medicine 2–3 (2013) 3–5 5
amputation. Hence we further propose to extend this study toexplore modified/improved wound management approach such asusing the Modern wound management [5,6], Multi-disciplinaryapproach [7], etc. so that the time to healing of the wound issignificantly reduced and consequently total cost of wound-management is reduced.
Acknowledgements
We acknowledge C.S. Rajan, Boggaram-Giridhar, Arunkumar N.of the department of Surgery at St. Martha’s Hospital for theirsupport while collecting the data; and Thomas Wild, WoundConsulting for overall guidance in the project.
Appendix A. Supplementary data
Supplementary data associated with this article can be found, in
the online version, at doi:10.1016/j.wndm.2013.10.003.
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