The real cost of treating venous ulcers in a contemporary vascular practice

Background: Venous leg ulcers (VLUs) are a prevalent and morbid disease that consumes considerable health care resources. Estimates place the total costs for treatment of VLU at 1% of health care budgets in many industrialized countries: Unfortunately, there is little contemporary information on the total cost of treating VLU in the United States, particularly in a wound center staffed by vascular specialists. The purpose of this study was to define the actual cost of treating VLU and to identify factors influencing costs. Methods: A cohort of 84 patients with active VLU (Clinical, Etiologic, Anatomic, and Pathologic class 6 disease) who were treated in a wound center by five vascular surgeons with a minimum follow-up of 6 months (median, 368 days; range, 336-483 days) was retrospectively studied. Actual costs (not charges) were obtained for outpatient and inpatient facility, visiting nurse services, and our physician practice group to yield true cost. The proportion of healed VLUs and time to complete healing were determined to calculate time to healing as well as ulcer-free intervals. Calculations of cost/ulcer-free days and cost to complete healing for the entire follow-up period were carried out as well as univariate analysis of factors affecting cost. Results: The mean total cost of treating VLU during this follow-up period was $15,732. A total of 50 patients (60%) healed their VLUs without recurrence in a mean time of 122 days (range, 6-379 days) at a cost of $10,563 (range, $430-$50,967). This translated to $86/day of treatment to heal an ulcer, resulting in a cost of $42/ulcer-free day. In comparison, the total cost was threefold higher at $33,907 (range, $390-$132,730) for the patients (n = 17; 20%) who did not heal their VLUs. Significant contributing factors included outpatient facility fees ($10,332) and visiting nurse services ($11,365) related to extended treatment of the open VLU. Patients who had a recurrence of their VLU (n = 17; 20%) during the follow-up period had a total cost of $12,760. Inpatient admission for wound-related issues increased total cost to $33,629. Nearly two thirds of admissions were for treatment of cellulitis with intravenous antibiotics. VLUs treated with surgical intervention did not significantly increase total cost ($12,304 vs $19,503; P>.05) but significantly reduced recurrence rates (34% vs 5%). There were three outliers who experienced complications after treatment of outflow obstruction that dramatically increased the total cost to $71,526. Conclusions: This economic analysis demonstrates the high true costs associated with modern treatment of VLU by aggressive medical and surgical techniques. Inpatient and outpatient facility fees, physician fees, and visiting nurse payments all contribute to the cumulative tally that results in these staggering direct costs for treatment of VLUs. The daily cost of treatment that accrues for the ongoing care of VLU patients until they are healed provides an economic rationale for initiatives that advance approaches seeking to provide more rapid wound healing. Our analysis also highlights the significant costs associated with treatment of infections and complications encountered in aggressive surgical interventions for patients with extensive chronic central venous occlusive disease. More aggressive early outpatient treatment of infections and refined criteria for selection of outflow stenting candidates may reduce total cost by preventing complications while improving outcomes.