Le slide presentate da Pasquale Longobardi, Direttore Sanitario del Centro Iperbarico di Ravenna al 5° Congresso WUWHS (World Union of Wound Healing Societies), conferenza mondiale dedicata alla cura delle ulcere della pelle e alle ferite difficili, Firenze 25-29 settembre 2016

1. P. Longobardi
Hyperbaric & Diving Medicine
S.Anna School Adv Studies,
Pisa (I)
THE ECONOMIC
ANALYSIS OF HBOT
IN WOUND CARE
Pasquale Longobardi
Hyperbaric Centre Ravenna
Affiliated researcher Sciences for Life Institute, Superior School for Advanced
Studies Sant’Anna, Pisa (Italy)
President 2016-2018 Italian Diving and Hyperbaric Society (SIMSI)
direzione@iperbaricoravenna.it

2. P. Longobardi
Hyperbaric & Diving Medicine
S.Anna School Adv Studies,
Pisa (I)
prevalence of “open” wounds
and cost of VLU in Europe (2015)
In UK in 2012-2013 there was a
prevalence of 2.2 milions of
wounds (11% open wounds).
Cost €6,1 billion (£5,3 billion)
The cost of 12 months old wounds is doubled

3. P. Longobardi
Hyperbaric & Diving Medicine
S.Anna School Adv Studies,
Pisa (I)
Crude and Age-Adjusted Hospital Discharge Rates for
Nontraumatic Lower Extremity Amputation
per 1,000 Diabetic Population USA 1988–2009
Caroline Fife
1998
$43,800
2010
$58,582
in 2015 US Government spending in Health Care rose
over 11.7% (17,5% of GNP).
In the USA, Wound Care cost over $20 billion
with 5-7 million wounds annually

4. P. Longobardi
Hyperbaric & Diving Medicine
S.Anna School Adv Studies,
Pisa (I)
Healthcare decision making process to
identify the economic sustainability
• the available evidence.
• good value for money
(cost effectivenes )
• Ensuring equity of access
to HBOT in the Nation
• Evaluating the absolute
proactive investments
COSTS
QUALITY
Quality-increasing
and cost-saving
innovation

5. P. Longobardi
Hyperbaric & Diving Medicine
S.Anna School Adv Studies,
Pisa (I)
HBOT is recommended in DFU as
part of a multidisciplinary care pathway
GRADE level of evidence: 2
The level of recommendation
depend on the care pathway:
2A when it is appropriate
2B when it is unclear or not
completely appropriate
GRADE level of evidence
and recommendation
1B

6. P. Longobardi
Hyperbaric & Diving Medicine
S.Anna School Adv Studies,
Pisa (I)
Why is it so hard to do the right
thing in wound care?
• 6% DFU patients had "Gold Standard" TCC
used1. Cost of care was half that of those that did not.
• 17% VLU patients received adequate compression1.
• 16% of the leg ulcers were evaluated with Doppler
(required in guidelines)2
These procedure are considered time consuming.
Reimbursement is inadequate.
Lack of familiarity with Clinical Practice Guidelines
1 US WOUND REGISTER
C. Fife, WOUNDS 2012
2

7. P. Longobardi
Hyperbaric & Diving Medicine
S.Anna School Adv Studies,
Pisa (I)
Cost of Wounds increases in the presence of
comorbidities and with length of time
US WOUND REGISTER
C. Fife, WOUNDS 2012
Co-morbid conditions correlated to longer weeks to heal:
• Diabetes (p=0.007)
• Systemic antibiotics (p=0.003)
• Renal failure (p=0.028)
• Immunocompromise (p=0.02)
• Smoking (p=0.02)
Cost ≥ 2 commorbities $4282
vs $3601 (p = 000024; + 16%)
The cost of unhealed wounds
increases with longer lenght
of time in service.

8. P. Longobardi
Hyperbaric & Diving Medicine
S.Anna School Adv Studies,
Pisa (I)
Average value
2009 2014
Nobilio L. Health & Social Care Regional Agency of Emilia Romagna, 2015
VALUE FOR MONEY
Leg amputation ICD9-CM: 84.13–84.19)
From 2009 to 2014, the standardized major amputation rate
in Romagna was half the average in the Region
(45% less than the USA in the same period - Medicare)
Piacenza (EMILIA)
Ravenna (ROMAGNA)

9. P. Longobardi
Hyperbaric & Diving Medicine
S.Anna School Adv Studies,
Pisa (I)
Cost of a leg amputation procedures
• average cost of a leg amputation was 14,070 € (£12,000)
• costs for prosthetic limbs, rehabilitation and wound care
in the year after an amputation was 23,451€ (£20,000)
• Costs of home adaptations, community care, care homes
and wheelchairs (borne by local communities)
€37,521

10. P. Longobardi
Hyperbaric & Diving Medicine
S.Anna School Adv Studies,
Pisa (I)
Economic burden of DFU
and amputations in the USA
• Medicare beneficiaries with a
Lower Extremity Amputation
(LEA) have been seen by their
outpatient health care provider
about 12 times per year and
are hospitalized about 2 times
per year.
• The cost of amputation is
estimated about $ 52,000 per year
https://www.effectivehealthcare.ahrq.gov/ehc/products/294/639/Data
-Points_3_Diabetic-Foot-Ulcers-Amputations_Report_03-2011.pdf
Caroline Fife
Gil J FAIJ 2013

11. P. Longobardi
Hyperbaric & Diving Medicine
S.Anna School Adv Studies,
Pisa (I)
The costs to the patient and family
• lost wages, co-payments and deductibles
• modifications for disabled living
(reduced quality of life):
– poor ambulation (60%-80% are unable
to walk),
– chronic pain (95%), depression (35%),
– lengthy healing process and hospital
readmissions (22% at 30 days)
– contralateral amputation (36%-50%),
– high 2-year mortality rates (30%-50%)

12. P. Longobardi
Hyperbaric & Diving Medicine
S.Anna School Adv Studies,
Pisa (I)
Value of the HBOT for the money spent
HBOT ≤ 35 sessions
NNT 4 (p = 0.03)
HBOT > 35 sessions
NNT 3 (p = 0.009)
Number Needed to Treat (NNT) is the estimate of the
number of patients that need to be treated in order to have
an impact on one person.

13. P. Longobardi
Hyperbaric & Diving Medicine
S.Anna School Adv Studies,
Pisa (I)
Value for money
(30 HBOT sessions, NNT 4)
Nation
Cost
HBOT
session
Number
HBOT
sessions
NNT
Cost HBOT
to save an
amputation
Cost
amputation
Value for
money
Belgium 110€ 30 4 13.200€ 11.515€ 1.685-€
Czech 70€ 30 4 8.400€ 2.500€ 5.900-€
France 222€ 30 4 26.640€ 61.519€ 34.879€
Italy 81€ 30 4 9.720€ 10.800€ 1.080€
Malta 35€ 30 4 4.200€ 3.000€ 1.200-€
Norway 367€ 30 4 44.000€ 9.800€ 34.200-€
Spain NHS 50€ 30 4 6.000€ 17.500€ 11.500€
Spain private 150€ 30 4 18.000€ 17.500€ 500-€
Turkey NHS 19€ 30 4 2.280€ 1.065€ 1.215-€
UK 197€ 30 4 23.640€ 37.521€ 13.881€
USA 364€ 30 4 43.680€ 46.233€ 2.553€
saving

14. P. Longobardi
Hyperbaric & Diving Medicine
S.Anna School Adv Studies,
Pisa (I)
Value for money
(40 HBOT sessions, NNT 3)
Nation
Cost
HBOT
session
Number
HBOT
sessions
NNT
Cost HBOT
to save an
amputation
Cost
amputation
(1)
Value for
money
Belgium 110€ 40 3 13.200€ 11.515€ 1.685-€
Czech 70€ 40 3 8.400€ 2.500€ 5.900-€
France 222€ 40 3 26.640€ 61.519€ 34.879€
Italy 81€ 40 3 9.720€ 10.800€ 1.080€
Malta 35€ 40 3 4.200€ 3.000€ 1.200-€
Norway 367€ 40 3 44.000€ 9.800€ 34.200-€
Spain NHS 50€ 40 3 6.000€ 17.500€ 11.500€
Spain private 150€
40 3
18.000€ 17.500€ 500-€
Turkey NHS 19€ 40 3 2.280€ 1.065€ 1.215-€
UK 197€ 40 3 23.640€ 37.521€ 13.881€
USA 364€
40 3
43.680€ 46.233€ 2.553€
saving

15. P. Longobardi
Hyperbaric & Diving Medicine
S.Anna School Adv Studies,
Pisa (I)
Value for money
(cost of amputation standardized for UK value)
Nation
Cost
HBOT
session
Number
HBOT
sessions
NNT
Cost HBOT
to save an
amputation
Cost
amputation
Value for
money
Belgium 110€ 30 4 13.200€ 37.521€ 24.321€
Czech 70€ 30 4 8.400€ 37.521€ 29.121€
France 222€ 30 4 26.640€ 37.521€ 10.881€
Italy 81€ 30 4 9.720€ 37.521€ 27.801€
Malta 35€ 30 4 4.200€ 37.521€ 33.321€
Norway 367€ 30 4 44.000€ 37.521€ 6.479-€
Spain NHS 50€ 30 4 6.000€ 37.521€ 31.521€
Spain private 150€ 30 4 18.000€ 37.521€ 19.521€
Turkey NHS 19€ 30 4 2.280€ 37.521€ 35.241€
UK 197€ 30 4 23.640€ 37.521€ 13.881€
USA 364€ 30 4 43.680€ 37.521€ 6.159-€
saving

16. P. Longobardi
Hyperbaric & Diving Medicine
S.Anna School Adv Studies,
Pisa (I)
Equity of access
Web 11%
Press 2%
Word of mouth 12% G.Ps. 10%
Specialist
Physicians 65%
2015: 1,073 patients /
17,933 HBOT sessions
NHS England Report D11X02 on
HBOT (2016): 61% of a survey
respondents (295/482) reported lacking an
in depth knowledge on HBOT. 34%
reported significant barriers to access
HBOT. 8.5% felt the barriers were
impossible to overcome

17. P. Longobardi
Hyperbaric & Diving Medicine
S.Anna School Adv Studies,
Pisa (I)
PROACTIVE INVESTMENTS
NHS England Report D11X02 on HBOT (2016): there
would be significant resource implications of expanding
the availability of HBOT to satisfy the potential demand
Decrease in
number of AKA
Number of
patients in UK
Annual UK saving
to the NHS
5% 34 £ 1 million
10% 68 £ 2 million
In a previous report (2012) the same NHS realized the saving
in case of a decreasing in the number of major amputations

18. P. Longobardi
Hyperbaric & Diving Medicine
S.Anna School Adv Studies,
Pisa (I)
PROACTIVE INVESTMENTS
Decision model
a further 19-35 HBOT
chambers (7 patients each)
would be required in Canada
HBOT STANDARD CARE
ALONE
12-year cost for
DFU patient
CND$
40,695
CND$
49,786
Quality-Adjusted
Life-Years (QALYs)
3,64 3,01
7 person
HBOT chambers
Chuck AW Int J Technol Assess Health Care 2008

19. P. Longobardi
Hyperbaric & Diving Medicine
S.Anna School Adv Studies,
Pisa (I)
Conclusion
http://www.vas-int.net/no-more-vascular-amputations.html
HBOT is an adjunctive therapy
that is cost effective only in an
appropriate care pathway.
It is useful to promote the knowledge of Guidelines for
Wound Care, also supporting international programs such as
Horizon 2020: the EU Research and
Innovation programme with €80 billion of
funding available from 2014 to 2020

20. P. Longobardi
Hyperbaric & Diving Medicine
S.Anna School Adv Studies,
Pisa (I)
Acknowledgements
• Belgium: Peter Germonpré; Roland Vanden Eede
• Czech Republic: Pavel Macura
• France: Daniel Mathieu
• Malta: Ramiro Cali-Corleo
• Norway: Martin Heer
• Spain: Jordi Desola
• Turkey: Maide Cimsit; Akin Savas Toklu
• United Kingdom: Marc Glover
• USA: Caroline Fife
We wish to thank these colleagues for sharing with us the
data of their own Nation.

21. P. Longobardi
Hyperbaric & Diving Medicine
S.Anna School Adv Studies,
Pisa (I)
www.iperbaricoravennablog.it
Stories and advices from our patients
What is essential, is
invisible to the eye.
Tell us your story
www.espertidivulnologia.it