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Cost-effective Alternative for Negative-pressure Wound Therapy

Kim, Jeff J., MD*; Franczyk, Mieczyslawa, PT, PhD; Gottlieb, Lawrence J., MD, FACS*; Song, David H., MD, MBA, FACS*

Plastic and Reconstructive Surgery – Global Open: February 2017 - Volume 5 - Issue 2 - p e1211
doi: 10.1097/GOX.0000000000001211
Special Topic
Open
United States

Background: Current predominantly used equipments for negative-pressure wound therapy (NPWT) are expensive. In current healthcare climate continually emphasizing cost containment, importance in developing more cost-effective alternatives cannot be understated. Previously, therapeutically equivalent methods of providing NPWT was demonstrated using just low-cost, universally available supplies, coined Gauze-SUCtion (GSUC). Here, we examine long-term potential financial savings of utilizing GSUC over commercialized products.

Methods: A retrospective cost analysis was performed at the University of Chicago Medical Center between 1999 and 2014. All NPWT was provided via either GSUC or commercialized vacuum-assisted closure (VAC, KCI) device. Sum of all material component costs were reviewed to determine theoretical average daily cost. For the VAC group, recorded institutional spend to KCI was also reviewed to determine actual daily cost. In the GSUC group, this figure was extrapolated using similar ratios. Labor costs for each method were determined using analysis from prior study. Patient demographics, etiology, wound location, and treatment length were also reviewed.

Results: Total of 35,871 days of NPWT was provided during the 15-year span. Theoretical average cost of VAC was $94.01/d versus $3.61/d for GSUC, whereas actual average was $111.18/d versus $4.26/d. Average labor cost was $20.11/dressing change versus $12.32. Combined, total cost of VAC therapy was estimated at $119,224 per every 1,000 days of therapy versus $9,188 for the GSUC.

Conclusions: There is clear and significant cost savings from utilization of GSUC method of NPWT. Furthermore, the added advantage of being able to provide NPWT from universally accessible materials cannot be overstated.

From the *Section of Plastic and Reconstructive Surgery, Department of Surgery, University of Chicago Medicine and Biological Sciences, Chicago, Ill.; and Department of Therapy Services, University of Chicago Medical Center, Chicago, Ill.

Received for publication May 25, 2016; accepted December 2, 2016.

Disclosure: The authors have no financial interest to declare in relation to the content of this article. The Article Processing Charge was paid for by the authors.

Jeff J. Kim, MD, Section of Plastic and Reconstructive Surgery, Department of Surgery, University of Chicago Medicine and Biological Sciences, 5841 S. Maryland Ave., Rm J641, MC 6035, Chicago, IL 60637, E-mail: jeff.kim@uchospitals.edu

This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially without permission from the journal.

Wound care is a common medical problem that poses a significant financial burden to our healthcare system. In 2012, US health care spending reached $2.8 trillion, with hospital care spending reaching up to $882.3 billion. Wound care management accounts for almost 4% of that total health system cost from current estimates, with total global wound management market projected to be worth over $18.5 billion by 2021.1

The increasing cost of medical technology is a significant contributor to higher health care spending. The implementation of new medical technology across the board accounts for between 38% and 65% of health care spending increases.2,3 The wound care market is no exception. Although various segments of its market have been reported to grow at widely variable rates, highest sales growth has been in biological growth factors and therapies integrating new and evolving technology.1–3

Negative-pressure wound therapy (NPWT) is an example of evolving integration of technology for wound management.4–7 The application of a suction pump device for the treatment of suppurative wounds was first described in the 1980s by several authors from the former Soviet Union in a series of articles now known as the “Kremlin papers.”6,8–11 In the early 1990s, Western European surgeons adopted negative-pressure (more accurately, subatmospheric) wound therapy for the treatment of open wounds,12,13 and by 1997, the technique was introduced in the United States and commercialized as the vacuum-assisted closure device (VAC; KCI, San Antonio, Tex.).14,15 Efficacy of NPWT leading to reduction in wound size and promotion of wound healing is well documented in literature.7,16–18 In the inpatient setting, NPWT can reduce the need and complexity of surgical therapy in some situations and improve the clinical outcome of operations in others.17,19–23 It can also help expedite patients’ transition to outpatient settings more quickly as many types of chronic and acute wounds can be managed at home with NPWT.24–26 Overall, patients benefit from quality of life improvement from decreased need for painful dressing changes, faster healing time, and an earlier return to normal function.

In 2013, the global NPWT device market was valued at 1.5 billion dollars with steady continued expected growth.2,3 This has led to an expansion of commercially available NPWT devices trying to capture this market in recent years. However, with that said, these commercialized equipments typically used for NPWT continues to be costly, at times, prohibitively so. This financial burden can limit the use of NPWT in settings and situations where budgets are constrained, particularly in public hospitals and for patients who are underinsured or uninsured (not to mention in developing countries globally). From health care providers’ stand point, our interest to come up with more cost-effective alternatives is obvious; such efforts can ultimately translate to increased availability/accessibility of therapies for patient in various settings. Furthermore, for such issues as prevalent as wound care management, they can also have significant financial impact on hospitals and the health care system as a whole.

In the previous studies, we have looked at an alternative method of providing NPWT using low-cost, universally available medical supplies called Gauze-SUCtion (GSUC) therapy and demonstrated therapeutically equal or greater efficacy to commercialized product as the VAC.16,18,19,27–29 In this study, we review strictly from a financial stand point a 15-year experience and present the potential cost impact at an institutional level when comparing the use of GSUC against commercialized system like the VAC.

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METHODS

A retrospective chart review approved by the University of Chicago Medical Center (UCMC) Institutional Review Board was performed on all patients treated with NPWT between July 1, 1999, and June 30, 2014 at the UCMC. All patients were treated with either the vacuum-assisted closure device (VAC; KCI) or wall suction applied to a sealed gauze dressing (GSUC) therapy. Of note, the use of GSUC was first initiated on July 1, 2006, whereas the use of VAC was discontinued all together after June 30, 2011. During the span of this 15-year review, the primary authors maintained a database of number of days of each therapy utilized across all patients receiving NPWT.

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Objectives

The primary objective was to compare daily average cost of VAC and GSUC therapy and total incurred institutional cost annually. Cost of each therapy was broken down into cost of equipment/materials and cost of labor for dressing application. Cost of equipment/materials was analyzed by both the average sum of all component costs and average daily cost calculated from actual recorded annual institutional spend on these materials.

Secondary objective was to analyze basic demographic information and wound characteristics, including age, sex, wound etiology, and wound location.

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Calculating Costs

Equipment/Materials

For the VAC group, equipment/material cost consisted of (1) portable vacuum machine rental per day, (2) cost of suction canister, and (3) cost of sponge/adhesive dressing packages that came in 3 different sizes (depending on the size of the wound).

For the GSUC, equipment/material cost consisted of (1) wall suction canister, (2) Kerlix gauzes, (3) red rubber catheters, and (4) Ioban/occlusive tapes.

Average cost of each component was reviewed through hospital billing records. For the VAC group, all available records of institutional payment to KCI between 1999 and 2011 were also reviewed.

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Labor

Labor costs for both therapies were determined by average time required for dressing application/changes in minutes, prorated to average physical therapist’s hourly salary between 1999 and 2014.

For both therapies, dressing changes were performed on average of every 2 to 3 days, as recommended by VAC therapy guidelines. Methods entailing specifics of statistical comparison including the use of Wilcoxon rank-sum test for average time/dressing change have been described in our previous prospective study by our group. All dressings were performed by a single wound care physical therapist. The study was performed on 45 patients for the GSUC arm and 42 patients for the VAC arm and time of dressing changes were rounded to the nearest 5-minute intervals.18 No new analyses regarding per dressing change labor cost have been performed for this study. Annual total labor cost for each therapy was extrapolated using per dressing change cost multiplied by the total number of days of therapy provided (divided by 2.5) each year.

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RESULTS

Primary Outcomes

Vacuum-assisted closure device (VAC, KCI) was utilized in 2,132 patients for a total of 20,363 days for average of 9.55 days/patient (range, 2–40 days) and GSUC was utilized in 1,895 patients for a total of 15,508 days for average of 8.18 days/patient (range, 2–39 days; Table 1).

Table 1.

Table 1.

The theoretical average daily material cost calculated from the sum of component costs was estimated to be $94.01/d for of VAC group and $3.61/d for GSUC group (Table 2).

Table 2.

Table 2.

Recorded total institutional material cost for VAC therapy between 1999 and 2011 (use of VAC discontinued completely after July 2011) was ~$2.2 million. Table 3 shows annual total material cost, number of patients treated, and total days of NPWT provided through VAC and also shows actual daily material cost of therapy and per patient cost calculated for each year. Because of missing dressing cost between July 1999 and June 2001 and limited the use of VAC between July 2007 and June 2011, only data between July 2001 and June 2007 were used to calculate the annual averages. During this 6-year span, average actual daily material of therapy was estimated to be $111.18. This represents 118.26% of the theoretical daily material cost calculated from the sum of components mentioned earlier ($94.01).

Table 3.

Table 3.

Because GSUC therapy utilized materials all available from routine hospital supply, there is no available annual or otherwise cumulative documented cost specific to GSUC. But by using the same theoretical-to-actual cost ratio determined from VAC group (assuming same rate of waste/efficiency), we extrapolated average actual daily material cost of GSUC therapy to be $4.26.

By using this figure, total extrapolated institutional material cost of GSUC therapy between 2006 and 2014 was ~$66,000. Table 4 shows total number of patients treated, total days of therapy, and extrapolated total material cost of GSUC annually. Because of the limited use of GSUC in the initial years (July 2006 to June 2008), only data between July 2008 and June 2014 were used to calculate the annual averages. During this 6-year span, extrapolated average annual cost of GSUC therapy to the institution was $10,788.45, with average of ~2532.5 days of therapy provided.

Table 4.

Table 4.

In terms of labor cost per dressing change, analysis from previous study was used demonstrating average time spent on dressing to be 31 minutes for cost of $20.11 per dressing change for VAC group and 19 minutes for cost of $12.32 per dressing change for GSUC group (Table 5).18

Table 5.

Table 5.

By using the total number of days of therapy provided (divided by 2.5, since dressings were changed every 2–3 days on average) by each method per year, we extrapolated average annual labor cost of applying each system to be $19,598.20 for the VAC and $12,480.16 for the GSUC (Table 6).

Table 6.

Table 6.

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Secondary Outcomes

Negative-pressure therapy was performed for 35,871 days on 4,027 patients (2,058 men, 1,616 women, and 353 children younger than 18 years) between July 1999 and June 2014. Total mean age was 51.66 years (range, 4 month to 93 years). Mean age of patients treated with VAC was 49.98 years and 53.37 for GSUC, P = 0.62 (Table 7). Etiologies and locations of wounds for each method are summarized in Tables 8 and 9.

Table 7.

Table 7.

Table 8.

Table 8.

Table 9.

Table 9.

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DISCUSSION

The significance of placing emphasis on technological advancement in medicine in expanding the range of more effective treatment options can be seldom overstated. However, in the current health care climate with continually increasing emphasis on cost containment, it is also important to be mindful that sometimes these advancements can place undue pressure in foregoing lower cost options for perhaps more sophisticated, yet more costly products and services, even without good evidence for increased benefit. They can also overshadow and hinder motivations for developing alternative and innovative applications of already available technology and equipments that may be more cost-effective.

Treatment of both acute and chronic wounds is a good example of difficult and costly management driving continued development and utilization of advanced technology. The efficacy and the many benefits of NPWT in wound management are well documented, yet current costs of utilizing commercialized products like the VAC can be prohibitive to universal access. An alternative method of providing NPWT using just simple, sealed gauze dressings was developed at the UCMC – coined GSUC therapy – and has been utilized since 2006. GSUC was initially developed to provide temporary replacement therapy when VAC supplies were not readily available around the hospital. Given the ease and convenience of application from the use of virtually universally available supplies in any health care facilities, its use expanded naturally at our institution. Eventually, several prospective and randomized studies were performed to formally compare the efficacy of this method to the VAC system, which demonstrated therapeutic equivalence.18,19,27 In a prospective randomized trial of 87 patients from 2006 to 2008, Dorafshar et al (July 2012) demonstrated therapeutically equal efficacy of GSUC dressings when compared to that of commercialized VAC. Outcomes were primarily compared in respect to changes in wound surface area and volume over time. They also demonstrated improved ease of application and while only self-reported, suggested less painful dressing changes for the patient with decreased amounts of analgesics required during dressing changes. Study comprised patients with acute wounds resulting from trauma, dehiscence, or surgery.18 In a supplemental analysis, Dorafshar et al27 also demonstrates similar analysis for equivalent efficacy of treating infected wounds in selected acute settings as well. Furthermore, Nguyen et al in Wounds 2013 compared the efficacy of use of GSUC against VAC in securing split thickness skin graft with NPWT in prospective randomized controlled trial in 157 wounds. STSG take was evaluated on postoperative day 4 or 5, and size of skin graft and any nonadherent areas were measured and recorded. Comparative results were demonstrated with 96.12% in the GSUC group and 96.21% in the VAC arm.19 Given the simple, inexpensive component materials used for the method, these studies also demonstrated great potential for cost savings even just on a per diem, per therapy basis. With that, the next natural progression was to review the long-term cost savings at an institutional level, as we have done here.

Before June 2006, UCMC strictly utilized the commercialized vacuum-assisted closure device (VAC, KCI) for all patients being treated with NPWT. GSUC was developed around 2006 with limited utilization between July 2006 and June 2008. Its use subsequently continued to expand, largely replacing the VAC system by 2008, with limited continued use of VAC in the next subsequent years only as a part of comparative studies. By July 2011, with our studies demonstrating equal or better efficacy with cost saving implications, VAC use was completely discontinued in the institution.

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Cost Analysis

Two approaches were used in analyzing the material cost of VAC therapy. First, theoretical per daily cost was calculated from the sum of all its average component costs, which was determined to be $94.01. Significant portion of that cost—$66.37 (77.9%)—was accounted by the daily rental cost of the portable suction unit. In the second approach, actual per daily cost was calculated using recorded annual hospital spending to KCI for all VAC-related materials, divided by the number of days of VAC therapy provided at the institution that year. Of note, only data from 2001 to 2007 were used, as years 1999 and 2000 had incomplete cost records, whereas data after year 2007 were decided not to be used as the low-volume use of VAC at our institution after 2007 would likely skew the average daily cost higher than seen during high-volume years. The average actual per daily cost between 2001 and 2007 was calculated to be $111.18, which represents 118.26% of the theoretical per daily cost from above. The difference is likely explained by wastes and other expected and reasonable inefficiencies (eg, from error in application or unused dressing supplies paid for in bulks) seen in real practice. Average annual material cost of VAC therapy to the institution during this time span was estimated to be $299,956.02, with average of 2,698 days of therapy provided each year.

For the GSUC therapy, material costs were similarly analyzed. Theoretical per daily cost was likewise calculated using sum of all its average component costs, which was determined to be $3.61. However, in terms of calculating actual per daily cost, no records of actual hospital spending specifically on GSUC therapy were available (as all supplies were taken from standard supply stocks). Thus, instead we assumed similar waste/inefficiency rate as with the VAC and extrapolated an actual per daily cost of GSUC to be $4.26 (using the same theoretical-to-actual ratio of 118.26% with the VAC). By using this extrapolated actual per daily cost, we further extrapolated an average actual annual material cost of GSUC therapy to the institution to be $10,788.45, with average of 2,532.5 days of therapy provided each year. This represents almost 30-fold decrease in cost compare to the VAC system.

In terms of labor cost, analysis was directly taken from our previous study. All dressings were performed by a single wound care physical therapist. The study was performed on 45 patients for the GSUC arm and 42 patients for the VAC arm, and time of dressing changes was rounded to the nearest 5-minute intervals. There were no statistical difference between average initial wound surface area and volume between the 2 groups, as well as basic demographics and anatomic distributions of the wounds. The analysis demonstrated statistically significant average time difference for dressing application for the 2 therapies, 31 minutes for the VAC versus 19 minutes for GSUC.18

This resulted in calculated labor cost per dressing of $20.11 for the VAC versus $12.32 for GSUC, using $38.91/hr as the average hourly salary of the physical therapist. By using total number of days of NPWT provided by each method each year, we were able to extrapolate average annual labor cost of each system to be $19,598.20 for the VAC and $12,480.16 for the GSUC. The difference in application time in previous study was largely attributed to the longer time it took to cut the sponge into the correct shape and orientation in oddly shaped wounds for the VAC, compared to merely unrolling layers of rolled gauze into the area. Certainly, there is a learning curve to applying the GSUC dressings, but no assumed difference from learning curve in applying VAC dressings.

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Limitations

Retrospective nature of the study and limited actual spending data on GSUC are the major limitations of this review. Furthermore, calculated and extrapolated figures are all estimates at best, including question of whether GSUC dressing application truly does take less time than the VAC, not to mention differences in learning curve that would be required to proficiently and efficiently perform GSUC versus VAC dressings. However, regardless of whatever minute inaccuracies in the details of our figures, there may be are of almost moot significance given the overall magnitude of cost difference. Near 30-fold decrease in just the material cost alone makes our overall conclusion undeniable.

Between 1999 and 2007, the peak years of VAC use in this study, the UCMC as an institution spent anywhere between $200,000 and $370,000 annually on material cost of VAC system alone, totaling over $2.2 million dollars in the 8 years. Meanwhile during the latter half of the study, during peak GSUC use (2007–2014), the institution is likely to have incurred at the most, an estimate of extra $8,000-$15,000 annually for a total of ~$66,000 on routine supplies in the 8 years. Combined with differences in labor cost, we estimate savings of about ~$110,000 for every 1,000 days of therapy provided (Table 10).

Table 10.

Table 10.

However, with all this said, the main limitation to GSUC therapy is portability. In an outpatient/home setting where supplies and equipments need to be packaged and delivered in a very portable way, VAC and other commercial services/devices that can provide NPWT in such a way still makes sense. However, our results and message of this study was specifically regarding providing NPWT in a facility/hospital setting with at least minimal infrastructure such as wall suction and basic dressing supplies readily available. In such settings, these authors believe that significantly greater cost of commercialized devices—as demonstrated in this study—without increased therapeutic efficacy is not well justified.

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CONCLUSIONS

NPWT is an integral part of current wound care management. Although innovation and progress of technology is paramount to continued development and advancement of medical therapies, it is also important to be mindful of developing more cost-effective approaches to currently utilized therapies. This 15-year review of NPWT use at a single institution demonstrates clear and significant cost savings from utilization of our gauze suction method over commercialized products like the VAC (KCI). We estimate about $110,000 in institutional saving for every 1,000 days of therapy provided. Furthermore, being able to provide NPWT just from using easily accessible and almost universally available medical supplies is an added advantage of GSUC that cannot be overstated. Combined with our previous studies demonstrating equal or greater therapeutic efficacy compared to commercial products like the VAC, we advocate for wider spread investigation and utilization of similar methods at other institutions.

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REFERENCES

1. National Health Expenditures 2012 Highlights. Available at: www.cms.gov. Accessed May 1, 2015.
2. Office of Inspector General. Available at: http://oig.hhs.gov. Accessed May 1, 2015.
4. Davydov IuA, Larichev AB, Abramov AIu, et al. [Concept of clinico-biological control of the wound process in the treatment of suppurative wounds using vacuum therapy]. Vestn Khir Im I I Grek. 1991;146:132–136.
5. Usupov YN, Yepifanov MV. Active wound drainage. Vestn Khir. 1987:42–45.
6. Davydov IuA, Larichev AB, Men’kov KG. [Bacteriologic and cytologic evaluation of vacuum therapy of suppurative wounds]. Vestn Khir Im I I Grek. 1988;141:48–52.
7. Morykwas MJ, Argenta LC. Nonsurgical modalities to enhance healing and care of soft tissue wounds. J South Orthop Assoc. 1997;6:279–288.
8. Davydov IuA, Malafeeva EV, Smirnov AP, et al. Vacuum therapy in the treatment of suppurative lactation mastitis [in Russian]. Vestn Khir Im I I Grek. 1986;137:66–70.
9. Kostiuchenok BM, Karlov VA, Gerasimov MV, et al. Vacuum treatment of suppurative wounds [in Russian]. Sov Med. 1984:108–110.
10. Kostiuchenok BM, Kolker II, Karlov VA, et al. [Vacuum treatment in the surgical management of suppurative wounds]. Vestn Khir Im I I Grek. 1986;137:18–21.
11. Lusupov IuN, Epifanov MV. Active drainage of a wound [in Russian]. Vestn Khir Im I I Grek. 1987;138:42–46.
12. Fleischmann W, Strecker W, Bombelli M, et al. [Vacuum sealing as treatment of soft tissue damage in open fractures]. Unfallchirurg 1993;96:488–492.
13. Fleischmann W, Russ M, Marquardt C. [Closure of defect wounds by combined vacuum sealing with instrumental skin expansion]. Unfallchirurg 1996;99:970–974.
14. Morykwas MJ, Argenta LC, Shelton-Brown EI, et al. Vacuum-assisted closure: a new method for wound control and treatment: animal studies and basic foundation. Ann Plast Surg. 1997;38:553–562.
15. Argenta LC, Morykwas MJ. Vacuum-assisted closure: a new method for wound control and treatment: clinical experience. Ann Plast Surg. 1997;38:563–576; discussion 577.
16. Chariker ME, Jeter KF, Tintle TE, et al. Effective management of incisional and cutaneous fistulae with closed suction drainage. Contemp Surg. 1989;34:59–63.
17. Molnar JA, DeFranzo AJ, Marks MW. Single-stage approach to skin grafting the exposed skull. Plast Reconstr Surg. 2000;105:174–177.
18. Dorafshar AH, Franczyk M, Gottlieb LJ, et al. A prospective randomized trial comparing subatmospheric wound therapy with a sealed gauze dressing and the standard vacuum-assisted closure device. Ann Plast Surg. 2012;69:79–84.
19. Nguyen TQ, Franczyk M, Lee JC, et al. Prospective randomized controlled trial comparing two methods of securing skin grafts using negative pressure wound therapy: vacuum-assisted closure and gauze suction. J Burn Care Res. 2015;36:324–328.
20. Song DH, Wu LC, Lohman RF, et al. Vacuum assisted closure for the treatment of sternal wounds: the bridge between débridement and definitive closure. Plast Reconstr Surg. 2003;111:92–97.
21. Agarwal JP, Ogilvie M, Wu LC, et al. Vacuum-assisted closure for sternal wounds: a first-line therapeutic management approach. Plast Reconstr Surg. 2005;116:1035–1040; discussion 1041.
22. Gill NA, Hameed A, Sajjad Y, et al. “Homemade” negative pressure wound therapy: treatment of complex wounds under challenging conditions. Wounds. 2011;23:84–92.
23. Chariker ME, Gerstle TL, Morrison CS. An algorithmic approach to the use of gauze-based negative-pressure wound therapy as a bridge to closure in pediatric extremity trauma. Plast Reconstr Surg. 2009;123:1510–1520.
24. Philbeck TE Jr, Whittington KT, Millsap MH, et al. The clinical and cost effectiveness of externally applied negative pressure wound therapy in the treatment of wounds in home healthcare Medicare patients. Ostomy Wound Manage. 1999;45:41–50.
25. McCallon SK, Knight CA, Valiulus JP, et al. Vacuum-assisted closure versus saline-moistened gauze in the healing of postoperative diabetic foot wounds. Ostomy Wound Manage. 2000;46:28–32, 34.
26. Lavery LA, Boulton AJ, Niezgoda JA, et al. A comparison of diabetic foot ulcer outcomes using negative pressure wound therapy versus historical standard of care. Int Wound J. 2007;4:103–113.
27. Dorafshar AH, Franczyk M, Karian L, et al. A prospective randomized trial comparing subatmospheric wound therapy with a sealed gauze dressing and the standard vacuum-assisted closure device: a supplementary subgroup analysis of infected wounds. Wounds 2013;25:121–130.
28. Borgquist O, Gustafson L, Ingemansson R, et al. Tissue ingrowth into foam but not into gauze during negative pressure wound therapy. Wounds 2009;21:302–309.
29. Campbell PE, Smith GS, Smith JM. Retrospective clinical evaluation of gauze-based negative pressure wound therapy. Int Wound J. 2008;5:280–286.
Copyright © 2017 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of The American Society of Plastic Surgeons.