Cost-Utility Analysis of Negative Pressure Wound Therapy Compared With Traditional Wound Care in the Treatment of Diabetic Foot Ulcers in Iran

Vahid Alipour, PhD; Aziz Rezapour, PhD; Mehdi Ebrahimi, MD; Jalal Arabloo, PhD


Wounds. 2021;33(2):50-56. 

In This Article

Abstract and Introduction


Introduction: Negative pressure wound therapy (NPWT; also known as vacuum-assisted wound closure) has emerged as a promising option that may result in better health outcomes.

Objective: This study analyzed the cost-utility of NPWT compared with traditional wound care (TWC) for the treatment of patients with diabetic foot ulcers in Iran from the perspective of health care providers.

Materials and Methods: This economic evaluation study was conducted in 2016 to estimate the incremental cost effectiveness ratio of NPWT compared with TWC. The Markov model was applied, incorporating the 7 health states of uninfected, infected, infected post-amputation, healed, healed post-amputation, amputation, and death for a 1-year time period and monthly cycles (12 cycles). Quality-adjusted life years (QALYs) were calculated from utility weights of each diagnosis, which were derived from the published literature. Costs for each diagnosis were estimated monthly and separately based on inpatient and outpatient care. The analysis of cost-effectiveness and sensitivity for uncertain parameters was carried out using TreeAge Pro 2011 software.

Results: A total of 200 patient records (NPWT = 100; TWC = 100) were analyzed in this study. The results indicated that annual cost per patient for NPWT and TWC strategies were $5165 ± $3258 and $9833 ± $5861, respectively. In addition, mean effectiveness per patient per year for NPWT and TWC strategies were 8.9026 ± 1.7622 and 8.7974 ± 1.855 QALYs, respectively. When treatment with NPWT was compared with TWC using the incremental cost-effectiveness ratio of -$44 370 per QALY, NPWT was shown as a more cost-effective treatment strategy than TWC.

Conclusions: The results of the study show that NPWT is less costly and more effective compared with TWC. In addition, NPWT reduces the number of amputations and increases the number of healed wounds, decreasing patients' and payers' costs. The sensitivity analysis of parameters proved the robustness of the Markov model.


According to the fourth round of the periodic National Survey of Risk Factors for Non-communicable Diseases project in 2011 (SuRFNCD-2011), 4.5 million adults in Iran had diabetes, which is expected to reach 9.2 million by 2030.[1] In 2009, total costs of type 2 diabetes in Iran were estimated at $3.78 billion, including $2 billion direct (ie, medical and non-medical) costs and $1.78 billion indirect costs. Most treatment costs for patients with diabetes are related to complications of this disease,[2] with lower limb ulcers, including foot ulcers, being the most common complications of diabetes.[3] Diabetic foot ulcers (DFUs) are the main reason for hospitalization and amputation;[4] worldwide, approximately 15% of patients with diabetes also have DFUs.[3] Managing diabetic ulcers is a complicated process, and the ulcers may take months or years to heal.[5] Care and treatment of DFUs have significant clinical and economic challenges for both patients and health care systems.[6] On average, ulcer treatment costs were estimated to be about $13 179 per each episode. With increasing level of severity, the cost ranged between $1892 (level 1) and $27 721 (levels 4 and 5). Inpatient hospital expenditures are the most expensive treatments for DFU.[7] Clinical factors such as ulcer depth and surface, the healing rate, severity of infection, and ischemia can affect the cost of treatment as well. If the advantage of healing is negligible in comparison to treatment damage, the last treatment option is amputation. In cases of re-infection, re-amputation will occur, which would increase the cost burden imposed on the community.[8]

The global DFU prevalence rate is 6.3% (95% confidence interval [CI], 5.4%–7.3%), and the DFU prevalence rate in Asia is reported as 5.5%.[9] Prevention of this complication can relieve direct and indirect cost burdens on society. Notably, the prevalence rate of DFU was estimated to be 6.4% in Iran.[10] Based on the results of a study conducted in Iran, of the total costs of diabetes complications, 10.7% were related to DFU (US $107.1 million).[2]

The use of treatment strategies that are both cost effective and clinically effective is one of the main goals of DFU management. Currently, a wide range of dressings are used in DFU treatment, including traditional wound dressing, wet wound dressing, foam and alginate dressing, hydrogels, and hydrocolloids.[11]

Wound dressing is recommended as one of the best practices for wound management in patients with DFU;[12] however, some clinical evidence on the effectiveness of these dressings in DFU treatment is still unclear. In many studies, there were no significant improvements in the wound healing process using dressing treatment.[13]

Negative pressure wound therapy (NPWT; also known as vacuum-assisted wound closure) is a relatively innovative strategy in ulcer treatment. In this technique, the negative pressure imposed into the wound enhances the wound healing process and facilitates the discharge of secretions.[14] The decrease in wound healing time, wound depth and surface, and number of amputations are known benefits of NPWT.[15] Clinical efficacy of NPWT can lead to the reduction of resource usage and consequently to decreased treatment cost for patients and health care providers. Therefore, NPWT technology can be a cost-effective alternative for both wound care recipients and health care providers. The results of economic evaluation studies showed that, in contrast to patients undergoing advanced wound treatment, patients treated with NPWT have both more quality-adjusted life years (QALY) and better wound healing with lower costs.[5,16]

Cost-utility analysis examines technical and allocative efficiencies and incorporates some changes in the quantity of life (mortality) and changes in the quality of life (morbidity) into a single unit of QALYs. This economic evaluation method compares the incremental cost of a particular treatment to the incremental health gains expressed in QALYs. In this case, the incremental cost-utility ratio (ICER) is usually expressed as the incremental cost to gain an extra QALY. Moreover, it provides a context to make judgments on the value for money in a given intervention usage. The ICER is the ratio between the differences in costs and benefits of 2 interventions.[17]

Numerous studies have been conducted on the cost-effectiveness of NPWT compared with conventional dressings. The results of these studies showed that NPWT has been more cost-effective than standard dressings and other comparators.[16,18,19]

Negative pressure wound therapy has emerged as a promising option that may result in better health outcomes. Despite the efficacy of NPWT compared with traditional wound dressing treatment, there is little research conducted on the cost-effectiveness of this technology to date, especially in economically developing countries, and the evidence is not strong enough to support this method's cost-effectiveness. The purpose of this study was to analyze the cost-utility of NPWT compared with traditional wound care (TWC) for the treatment of patients with DFU in Iran from the perspective of health care providers.