Cost Effectiveness of Vacuum-Assisted Closure and Its Modi�cations� A �evie�

Negative topical pressure, the general category to which the trademarked VAC therapy belongs, is not a new concept in wound therapy. It is also called subatmospheric pressure therapy, vacuum sealing, vacuum-assisted closure therapy, vacuum pack therapy, and sealing aspirative therapy. e VAC therapy system is trademarked by Kinetic Concepts, Inc., or KCI. It was �rst reported in 1997. e aim of the procedure is to use negative pressure to create suction, which drains the wound of exudate (i.e., �uid, cells, and cellular waste that has escaped from blood vessels and seeped into tissue) and in�uences the shape and growth of the surface tissues in a way that helps healing. Negative-pressure therapy for the closure of wounds accelerates secondary wound healing. High cost is still a hindrance in its use in developing nations. Many modi�cations were tried, but their efficacy is yet to be proved. In reality, this method is quite cost effective. It is only the lack of understanding and adequate setup which makes this method hard to use. e main objective of this paper is to focus on the cost effectiveness of VAC and its modi�cations. We want to emphasize the importance of homemade NPT and the use of simple suction devices.


Introduction
Chronic wound management represents a considerable burden on health services and requires considerable manpower, frequent specialist consultation, and adjunct therapies.e negative pressure wound therapy (NPWT) is an important adjunct, which offers an important option for the advanced management of many wound types [1][2][3].Currently NPWT has become an established method of wound management.Most of reports used the foam-based NPWT system using commercially available devices (e.g., KCI's VAC).ese are affordable and easily available in developed nations.But in developing countries, where the proportion of poor patients is very high, it is still beyond the reach of the needy patients.Some tried to reduce cost using other cheaper suction devices.Taking inspiration from such efforts, we are also trying one of the cheaper options for the betterment of patients and our observations were satisfactory.us, the importance of such methods is highlighted to enhance more research in this �eld so that the prolonged misery of chronic as well as acute wounds can be shortened in minimal cost.
e �rst description of the NPWT in a series of patients was given by Fleischmann et al. in 1993 [26].e efficacy of NPWT was initially described by Morykwas et al. and Morykwas [27,28].ere is a substantial literature on NPWT including reports of both comparative and noncomparative clinical studies, case studies, economic analyses, literature reviews, and technology assessments.Most studies demonstrate the superior or at least the same efficacy as compared to the conventional wounds management.But due to heterogeneity in types, sites and duration of wounds the results cannot be generalized.Aer a thorough literature search, we concluded that NPWT is efficacious and cost effective method of wound management not only in chronic but also for acute wounds (Table 1).(2) Braakenburg et al., [8] Hydrocolloids, alginate, acetic acid, and sodium hypochlorite NPWT had faster healing and greater wound size reduction and lesser time investment (   and   ,   , resp.).Total costs were in favour of the dressings group, however, insigni�cant (  ) [8].Although NPWT instruments and dressings are more expensive, their longer application on wounds and less-frequent changing will reduce the total cost and the labour power and positively impacting on productivity.
(3) Vuerstaek et al., [17] Conventional wound care Quicker healing, faster wound preparation for graing, and reduced costs with NPWT (  ,   ,   , resp.); the major part of this cost difference was due to higher personnel costs and longer hospital stay in the dressings group caused by the slower healing.Both groups showed signi�cant increase in patients� QoL and decrease in pain scores.
(4) Lavery et al., [18] Wet-to-moist therapy TNP improved successful wound treatment outcome for diabetic foot ulcers and might reduce resource utilization (5) Apelqvist et al., [19] Wet guage dressing NPWT resulted in lower resource utilization and a greater proportion of patients obtaining wound healing at a lower overall cost of care (6) Mody et al., [20] Wet gauze dressing Inexpensive materials can be utilized for TNP wound closure in a developing country.
(7) Flack et al., [21] Traditional and advanced dressings V.A.C. therapy was more effective and less expensive for patients with Type 1 and Type 2 diabetes (8) Perez et al., [22] Wet dressings Although costlier, the HM-VAC should be considered in underdeveloped countries as the healing is signi�cantly faster. (c)

S. no. Study Trials included Inferences
(1) Vikatmaa et al., [23] 14 RCTs NPWT was at least as effective and in some cases more effective than the control treatment.NPWT to be a safe treatment, and serious adverse events have been rarely reported.
(2) Ubbink et al., [24] 13 RCTs NPWT is efficient in treating wounds with improved clinical outcomes and should stimulate the healthcare system to provide such services and prevent it being obstructed by �nancial constraints.
(3) Birke-Sorensen et al., [25] Systematic review ere is relatively weak evidence on which to base recommendations for any one NPWT treatment variable over another.ere is a requirement of developing an international consensus for NPWT recommendations and treatment variables.

Literature Search of Manually Powered Negative Pressure Devices
No doubt, manually powered vacuum devices are much more cheaper than commercially available devices.e devices using normal suction apparatus are also cheaper but cannot be used in community setting.Although more systemic studies are required to prove effectiveness of these manually powered devices such as vacuum drains, but there is no doubt that these are much cheaper, easy to handle and any body  can operate them aer minimal training.us, they are very suitable to be used at home, avoiding hospital stay and in cases of mass casualties.
To the best of our knowledge, there are limited studies on dressings with manually operated vacuum devices.Singh et al. performed NPWT using Romovac or similar 18 fr drain.Seven patients with complex wounds were treated with alternate vacuum suction dressing.e dressing was applied 24 hours aer surgical debridement of necrotic tissue (Figure 1).Aer few modi�cations, they obtained gratifying results.Speci�c results were no given.ey described it to be a simple and e�ective method of NPWT which should bene�t the larger population where the standard equipment is not available [29].
Mody et al. used a bellows which generated 75 mmHg negative pressure and has to be compressed every 8 hours (Figure 2).ey applied it on 24 patients with 26 wounds.ey described it to be safe and feasible for use in low resource settings.It costs only $3 and light, weighing only half a pound.e clinical efficacy and efficaciousness would be studied in subsequent trials [30].
rough this paper the necessity of more re�nement in cheaper NPWT is emphasized.In sequence we are also using the same kind of device as described by Singh et al.We are F 3: NPWT using simple vacuum drain on a post cholecystectomy SSI.
using poly urethane foam dressing, aer twice autoclaving, opposite covering and constant suction by Romovac or JP drains for 48 hours (Figure 3).We applied this dressing on 4 cases of postoperative surgical site infections and obtained very motivating results.One of our infected mesh repair healed within 30 days without removing the mesh.
We observe the following advantages of such kinds of device: e difficulties faced are a follows: (i) cannot be applied on highly uneven body surfaces (ii) proper occlusion is difficult to maintain in warm conditions due to sweating (iii) drain require �xation.
Due to the fewer number of cases, the efficacy cannot be commented.But the results were highly satisfactory in such that kind of government set where most of the patients are poor and funding is limited preventing the use of commercial devices.We suggest further studies to settle down the matter of efficacy and to develop proper guidelines.

Conclusion
NPWT is oen perceived to be more expensive than advanced wound care.However, this perception may be based more on unit price considerations than on a comparison of the total treatment cost.Wider use of NPWT in wound management is a potential way to save money, providing at least the same quality of care as conventional methods.A large number of studies within a very short time of NPWT evolution have provoked national and international committees to develop NPWT wound care guidelines.is should encourage the government to conduct studies to validate these results with implemented local evaluations and audits to support widespread adoption of NPWT in national wound care.All patients should be assessed on an individual basis and have equality impact and risk assessments to ensure that every patient has the opportunity to bene�t from NPWT, which is a valuable addition, if used appropriately to speci�c patients' case and health care provider experience.NPWT has evolved from large devices to smaller, more portable devices, which can allow a smoother transition from hospital to community.Evidence on the cost effectiveness of TNP is necessarily limited, because of the lack of robust clinical effectiveness evidence.It was con�ned to only few types of wounds and usually related to only one manufacturer's product.

F 1 :
Singh et al. 's NPWT using constant suction with Romovac drain for 24 hours.

F 2 :
Mody et al. 's NPWT device on traumatic foot wound.Occlusive dressing with integrated tubing is protected by gauze wrap.
(i) easy to handle (ii) hospital admission not required (iii) good patient compliance and satisfaction (iv) require minimal training to maintain vacuum at home (v) can be applied to many cases at a time (vi) give adequate mobility to the patient.
[11] 1: (a) Nonrandomized studies.(b)Randomizedstudies.(c)Meta-analysis: the heterogeneity of the patients treated with NPWT makes it difficult to compare between different studies[11].Signi�cantly higher material expenses (  ), but signi�cantly lower nursing expenses (  ) and lower hospitalization costs (  ).ere was no signi�cant difference in total costs per patient between the two therapies.