A chronic wound is one that has failed to proceed through an orderly and timely reparative process to produce sustained anatomic and functional integrity. It may persist from 4 weeks to more than 3 months, and may be caused by trauma, diabetes, vascular disease, infection, pressure, or radiation.1 Approximately 2% of all hospitalized patients worldwide have a chronic wound, and older adult patients are at highest risk, because aging impairs the healing process.2,3 As many as 70% of these wounds recur, and 34% are accompanied by infection.,4
Chronic wounds continue to be of international and local concern and are an indicator of healthcare quality that generates substantial morbidity and considerable healthcare cost.5 These wounds are prevalent in China, accompanying the rapid increase in population aging and attendant shift to a chronic disease burden. The distribution and clinical characteristics of these wounds vary as a result of China’s large size and imbalance in economic development among regions, which come with unique challenges for healing. However, systematic studies on the prevalence of chronic wounds and the influence of age-associated changes in chronic wounds at a national and population level are lacking.6 A further challenge is the heterogeneity of existing studies, which make comparisons difficult.7
Therefore, further analysis of the distribution of causes and trends in chronic wounds across different areas of China is necessary. Epidemiologic study of chronic wounds is required to establish their main risk factors and understand the influence of regional, seasonal, and demographic differences. Accordingly, researchers conducted this retrospective study to gain more insight into the magnitude of the problem of chronic wounds and to analyze the demographics, etiology, related health economic problems, and clinical characteristics of patients and wounds during hospital stays. Identifying the risk factors for chronic wounds and correlations among those risk factors could help plan and provide hospital-based wound management and prevention in China and other developing countries, avoiding unnecessary medical disputes and adverse outcomes.8
The authors investigated hospitalized patients with difficult-to-heal wounds in a tertiary hospital in Dalian, North China, over 5 years. This was a descriptive retrospective case-control study that reviewed the health record database for inpatients between January 1, 2014, and December 31, 2018.
Classification of chronic wounds was based on the patient’s history and clinical assessment. The inclusion criteria for the case group were (1) an inpatient hospital stay longer than 24 hours and (2) a chronic wound subject to one or more diagnostic or treatment methods specific to a cutaneous ulcer for at least 4 weeks. Patients who had surgery that did not involve an incision on the skin surface (eg, tonsillectomy, dilation, and curettage) were excluded, as were patients without a skin wound or with a wound that could not be identified as a chronic wound. Using random number sampling, all inpatients without chronic wounds were included in the control group; participants were matched according to the same exclusion criteria as the case group in the corresponding year. To investigate risk factors, a comparison group of patients without wounds was randomly selected from the same source as the case group.
According to Chinese law, a retrospective study based on a health record database does not require ethics committee approval. The entire study followed the ethical principles of the Declaration of Helsinki.
Data entry was carried out by two wound healing specialists to ensure accuracy. Names and other information not relevant to the study were removed from the data. The following variables were collected: sex, age, marital status, occupation, season and route of admission, length of inpatient stay, readmissions, diagnosis, specialty unit, treatment funding (self-supporting or medical insurance), patient discharge outcome, and hospitalization expenses. Patients were divided into four age groups: 20 years or younger, 21 to 40 years, 41 to 60 years, and 61 years and older.
The following additional clinical variables were collected: wound cause, date of occurrence, rehospitalizations, and outcome. Wound causes were classified as diabetic, pressure ulcer, surgery, vascular, trauma, infection, and other. Patients were considered to have a wound infection when a field record explicitly referring to skin, wound, or bone infection or a microbiology investigation was present. The possible outcomes for each wound were healed, improvement, death, unhealed, and other (ie, outcome could not be obtained because of transfer or other reason).
The study was designed to analyze patient demographics, wound etiologies, wound types, types of therapy, and funding. Sample sizes were based on the recommended requirements for precision in a complex survey design. Data were analyzed using SAS 9.4 (SAS Institute Inc, Cary, North Carolina). Descriptive statistics were used for sample characteristics. Frequencies were reported for categorical variables (sex, age group, season, occupation, and so on), and mean and SD were used for normally distributed quantitative variables (age, length of stay, rehospitalizations, and so on). Case and control group comparisons were explored using a χ2 test for categorical variables and a two-tailed Student t or Wilcoxon rank-sum test for normally distributed quantitative variables. The correlation between potential risk factors and main outcome was analyzed using multiple logistic regression to eliminate the influence of confounders. P = .05 was considered significant. A rough odds ratio was calculated using univariate logistic regression, and an adjusted odds ratio was used to demonstrate the effect of multiple impact factors. R2 was used to interpret and predict the model.
A total of 1,977 cases with chronic wounds and 1,979 controls without chronic wounds were included in the final analysis. The total prevalence of chronic wounds over the study period was 16.8 per 1,000 hospital inpatients, and prevalence rose significantly during the 5 years, reaching a peak of 26.4 wounds per 1,000 patients in 2017 (Figure 1). Among the case participants, 62.87% were male, and the mean age of all patients was 68.18 ± 18.10 years. Most participants were older than 60 years (72.23%)(Table 1).
Of all wound patients, 79.21% were employed. Diabetic wounds, vascular wounds, and pressure ulcers were the major etiologies among nonworking patients; wounds related to infection, vascular ulcers, and surgical wounds were prevalent among manual workers.
The participants were grouped using hospitalization date to determine the admission season: 24.48% of patients were admitted in spring, 25.75% in summer, 25.95% in autumn, and 23.82% in winter. The majority of patients with diabetic ulcers were admitted to the hospital in summer and autumn (27.79% and 26.04%, respectively), those with vascular ulcers were mainly admitted in autumn (28.53%), pressure ulcers in autumn and winter (27.19% and 30.70%, respectively), infectious and traumatic wounds in summer (27.78% and 28.26%, respectively), and surgical wounds in winter (28.24%).
The main specialties to which patients were admitted were orthopedic surgery (16.34%), dermatology (13.05%), traditional Chinese medicine (9.46%), endocrinology (9.26%), and otorhinolaryngology (6.98%). The major cause of chronic wounds among traditional Chinese medicine and endocrinology patients was diabetes; infection in orthopedics and dermatology; arterial ulcers in endocrinology; vascular ulcers in neurology; and pressure ulcers and surgical and traumatic wounds were prevalent among orthopedic patients.
Overall, study authors found that infection caused 42.60% of the wounds in this study; diabetic ulcers, 21.90%; vascular ulcers, 18.64%; pressure ulcers, 5.46%; surgery, 4.07%; trauma, 2.20%; and 5.13% of wounds were from other causes (Figure 2). Chronic wounds with multiple causes developed in 18.19% of patients. Interestingly, the disease spectrum of these wounds changed across the study period. The proportion of ulcers attributable to infection, diabetes, vascular causes, and pressure gradually increased year after year, but trauma-related wounds decreased. Patients with diabetic ulcers accounted for 10.28% of total cases in 2014 and 36.11% in 2017; patients with pressure ulcers peaked in 2016 (35.09%) but fluctuated over the next 2 years (Table 2 and Figure 3). However, the proportion of surgical ulcers over the 5 years did not fluctuate (P = .1723).
Diabetic wounds occurred in nearly a fifth of all patients, and the highest ratios of vascular wounds occurred in patients older than 60 years (92.54%; P <.05). Chronic wounds following infection or surgery occurred at all age groups but peaked in those older than 60 years. Patients with pressure ulcers were mainly older than 60 years, but approximately one quarter of these wounds occurred in patients aged 41 to 60 years. A larger percentage of 21- to 40-year-old patients had chronic wounds caused by infection, trauma, and surgical factors.
Multiple logistic analysis revealed that sex, age, occupation, and season were all significantly correlated with the occurrence of chronic wounds. The risk of chronic wounds was 1.72 times higher in men than in women. Compared with those younger than 20 years, the risk of a chronic wound was 9.462 times higher in 21- to 40-year-olds, 14.865 times higher in those aged 41 to 60 years, and 27.6 times higher in those older than 60 years. Unemployed patients were 12.344 times more likely to have a chronic wound than those who were employed. Compared with workers in sedentary occupations, unemployed patients were more likely to develop a chronic wound (adjusted odds ratio, 2.442), the unemployed were 2.44 times more likely, and students were 2.229 times more likely. Compared with patients with wounds admitted in spring, patients were 1.508 times more likely to be admitted in autumn, but equally as likely to be admitted in summer and winter (Table 3).
Outcomes and Economic Burden
In terms of patient discharge outcomes, 2.58% of the patients with wounds survived with unhealed wounds, and 3.34% died during their stay. Approximately 40% of patients with wounds from infection or surgery or vascular wounds were completely healed at discharge. Twenty-three percent of patients with pressure ulcers died, along with 3.53% of patients with surgical ulcers, 2.92% with infections, and 2.41% with diabetic ulcers.
The total cost of treating chronic wounds in the hospital increased from RMB 3.68 million (US $526,000) in 2014 to RMB 8.90 million (US $1,271,000) in 2017, representing 1.23% and 3.18% of total healthcare expenditures for each year, respectively. The medical insurance system covered expenses for most of the patients with chronic wounds (87.20%); however, more than 10% of diabetic, infection, pressure, and surgical ulcer patients paid for their own treatment.
The mean cost of a hospital inpatient stay was RMB 14,326.64 (US $2,046.58). In terms of expenditures, expenses for medication and nursing were higher for patients with wounds than for the matched control group (P > .0001). Surgical ulcers were the most expensive wound type, with an average expense of RMB 23,128.29 (US $3,303.90) per patient, followed by pressure ulcers (RMB 20,618.81/US $2,945.42) and diabetic ulcers (RMB 15,790.56/US $2,255.70). Pressure, surgical, and diabetic ulcers had the highest costs for medicine, whereas nursing costs were highest for surgical and infected wounds.
The median length of inpatient stay was 13 days (maximum, 266 days), and patients with wounds had an average of 10 readmissions (maximum, 92 readmissions). Patients with surgical ulcers had the longest inpatient stays (mean, >20 days); patients with traumatic wounds, diabetic ulcers, and vascular ulcers had more frequent stays (mean readmissions, >10).
These authors investigated trends in prevalence of chronic wounds with various causes and analyzed their etiologies, economic factors, and risk factors such as sex, occupation, admission season, and length of inpatient stay. Authors found the prevalence of inpatient chronic wounds increased year over year during the study period. Further, the prevalence of chronic wounds was higher in the study region compared with other regions of China.9 One systematic epidemiologic survey conducted in China in 1998 noted a chronic wound prevalence of 1.70%, mainly in trauma and younger patients.10 The incidence of diabetes and cardiovascular disease has increased in China over the last 2 decades, and these conditions play a major role in the development of chronic wounds.11
Given the prevalence of drug-resistant bacteria and hospital-acquired infection, the problem of infectious ulcers has been acknowledged in previous studies.4,12 However, the present study included a more diverse sample that reflected various trends in the characteristics of hospitalized chronic wounds during the last 5 years. Chronic wounds caused by medical and nonmedical injury have decreased in recent years, but the proportion of secondary wounds has increased. For example, in this study, the number of patients with pressure ulcers increased during the last 5 years alongside an increase in the duration of treatment.
The Chinese population is aging, and this is reflected in the prevalence and incidence of chronic wounds.13 Older adults with chronic disease and sedentary behaviors have a higher risk of developing nonhealing wounds.7 There is an increase in the prevalence of chronic wounds that accompany aging as a result of impaired healing, slow blood flow, and insufficient blood supply to the limbs. A lack of physical activity and reduced circulation in older surgical patients mean that pressure ulcers may easily occur and recur.14
Because men are at higher risk of type 2 diabetes, vascular disease, and accidental injury, the prevalence of chronic wounds in men is higher than in women, which is borne out by the data from this study.15 The results of this study are comparable to reports on pressure ulcers in the US inpatient population: male sex and older age increase risk.16 For unemployed and sedentary patients, encouraging exercise and promoting circulation may help prevent pressure and vascular ulcers.17 That said, improved management of all chronic wound risk factors would certainly influence wound healing and prevention.
Management of surgical wounds is problematic for an increasing number of patients.18 Younger and younger patients are presenting with infectious and surgical ulcers given the expansion of surgical indications, especially in plastic surgery. In European hospitals, the overall rate of surgical site infection (SSI) ranges between 3% and 4% of patients undergoing surgery. Depending on the nature of the surgery, SSI incidence ranges between 1% and 10%.19 As populations age, future SSI incidence is expected to rise sharply, with a doubling of the SSI rate among older adults.20 Factors such as conditions for surgery, physician skill, instrument disinfection, and operation specifications all influence SSI.21 Any insufficient infection control in hospitals necessitates health departments to reflect deeply and work to increase prevention and control of medical infection.22
Recent studies have found that chronic wounds and their associated symptoms have a negative impact on the quality of life of the individual across the physical, psychological, spiritual, and social domains.23 Of all wound-related symptoms, odor is cited by patients and professionals as the most distressing, contributing to a restricted lifestyle, social isolation, depression, and feelings of guilt and repulsion.24 Prolonged hospital stays and the associated costs also result in patients and their families carrying a significant physical and economic burden while coping with the psychological impact of the wound.25 In older adults with chronic wounds and those approaching the end of life, wound management is a major challenge. The aim of treatment in older adults and patients who are dying may be primarily palliative;26 this approach may also have economic benefits. The present study revealed that increased durations of hospital stay and readmissions for treating chronic wounds could lead to an increased cost of RMB 2,033 (US $290.42) over the average hospital stay, particularly in nursing expenses and medication costs. The highest costs were incurred for pressure ulcers, surgical wounds, infected wounds, and vascular ulcers.
The increasing cost of caring for chronic wounds within the Chinese healthcare system is a great challenge for the national economy. On the one hand, preventing chronic wounds through spending on reasonable control measures and improving the treatment and care of such wounds through related research and technological innovation are necessary. On the other hand, restrictions from medical insurance, such as in the rate of reimbursement and the length of hospital stay permitted, may have influenced these results, which is an important problem. Taking into full consideration the adjustments required by medical insurers in managing pressure ulcers, SSIs, and vascular ulcers, there is benefit in promoting optimal distribution of national health resources and health service efficiency.
It is of particular interest that patients with chronic wounds who accessed hospital services were more likely to do so in autumn; this season accounted for 26% of all chronic wound admissions and 1.508 times the rate of admissions compared with spring. Examining the influence of the season is important, because climate change may affect wound healing by influencing the skin’s microenvironment.27
Trauma-related and infectious ulcers occurred mostly in the summer, and vascular and pressure ulcers in autumn. Individuals with vascular disease may be subject to insufficient hemoperfusion of the skin, developing wounds in late autumn and early winter because of skin damage associated with added clothing and sedentary behavior. Another plausible explanation for these seasonal trends is that bacteria associated with sweating and heat in summer influence poor wound healing.28 Wound prevention efforts based on climate should be considered.
These results showed that patients with chronic wounds had higher mortality and more incomplete healing than the control group. Although most patients with chronic wounds experienced improvement during treatment in hospital, complete healing was difficult to achieve. Patients with wounds that fail to heal may have a single infection, multiple infections, or drug-resistant infections, which may lead to amputation or death.29 A prospective observational study revealed that the development of a foot ulcer (affecting a quarter of patients with diabetes over their lifetime) was associated with recurrence (9.60%), amputation (17.40%), and death (15.10%).30,31 In another study of patients with pressure ulcers, 66% of patients died by the end of the median follow-up period (12 weeks).16 These data reinforce how chronic wounds can be difficult to heal and require lengthy treatment, as well as result in significant complications such as amputation and mortality. Therefore, general health recommendations for living with a wound must be considered, such as promoting physical activity, to prevent ischemia and infection.
These data were obtained from a single site and generalization of the results may be limited. Despite the small size of this study, the results confirm that wound management is a major but largely unrecognized problem for community healthcare providers. Further research on the prevalence of chronic wounds and their risk factors in various regions of China will assist in informing targeted health education for patients. Health screening and improving awareness among high-risk populations would assist in preventing the appearance of chronic wounds.
This study investigated patients with chronic wounds over 5 years, and prevalence increased year after year. Chronic wounds were mainly secondary to infectious, diabetic, and arterial etiologies. Males, older adults, the unemployed, and retired patients were more likely to develop chronic wounds, and patients with chronic wounds were more likely to be admitted to the hospital in autumn.
With the continuous aging of the Chinese population, chronic wound management is expected to become an increasing problem. Prevention and treatment should be tailored for the characteristics of the patients and region. Characterizing chronic wounds has received recent attention, especially in relation to older adult inpatients, but the challenge of reducing lengths of stay and readmissions remains. Palliative care should be administered for chronic wounds where appropriate, minimizing the risk of complications and reducing cost. Further research and improvements in treatment are required. Finally, the economic burden of chronic wounds needs to be addressed through expansion of medical insurance, optimizing treatment, and improved allocation of health resources.
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