Wound care


Her first introduction to this therapy came through her participation in a DFU trial, in which her patients anecdotally did very well. This was borne out by the trial results: those who were treated with continuous topical oxygen therapy were more likely to experience complete wound closure, compared to those who had only received the (very rigorous) standard of care. Cole has since published a series of case reports into its efficacy, having used it on patients with particularly complicated wound types. Through using near-infrared spectroscopy, she was able to assess the oxygen saturation in these wounds before and after applying topical oxygen therapy. “Week after week, we saw an increase in oxygen saturation in the tissues, and week over week, we saw a decrease in the wound area,” she recalls. “So as oxygen saturation went up, the area of the wound went down.”


She is now hoping to conduct further research, teasing out its exact mechanism of action. The study would look at gene expression in chronic wounds before and during treatment – how does a change in gene expression correlate with a change in the tissue?


“Patients often show a decrease in pain symptoms with application of continuous topical oxygen therapy, and it really happens almost immediately,” she says. “So what does that mean? And what are we doing for the wound that aids in that decrease in pain? Determining what genes are turned on or off in patients who receive topical oxygen therapy is a question I’d like to answer.” While further research would be desirable – for some people, the evidence probably still isn’t enough, notes Chadwick – there is arguably a strong case for integrating topical oxygen therapy into health systems. As is always the case with a new medical technology, the biggest question mark surrounds the health economics: what is the true value of deploying this therapy considering its upfront costs?


Getting oxygen into the system As matters stand, the technology is available worldwide, but health systems vary in what they deem worthy of coverage. Cole cites Mexico, India and Japan as countries where the technology has expansion potential. “In the US, it is available in the Veterans Affairs (VA) hospital system,” she says. “It is covered by Medicaid in certain states, while Medicare is going through the process of evaluating the evidence, to see whether it will cover the device and at what rate.”


In the UK, the treatment is being used in specialist centres. Chadwick says he is fond of the haemoglobin spray, because it doesn’t take much setting up. But it has yet to achieve broad


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application, largely due to concerns about the cost. “When you look at the cost of it over an initial period, it looks expensive,” he remarks. “But then, if you've done the health economics of it, you know that it will help heal a wound heal more quickly and reduce rates of infection and hospitalisation.”


While it takes a long time to change clinical practice, the shift is beginning. NICE has published recommendations on the haemoglobin spray (Granulox) and the continuous topical oxygen therapy (NATROX) and was generally supportive about both. In terms of costs, Granulox works out at £125 for 30 applications, or ten weeks of treatment, while NATROX is priced between £300 and £500 for 12 weeks of treatment. This should be set against the cost of managing an unhealed wound (anything up to £7,886 per person per year) and the cost of a diabetic foot amputation (up to £12,767).


“The cost of managing unhealed wounds is expected to rise about 40% over the next five years,” notes Chadwick. “But if we succeed in healing 1% more wounds, we will start to keep the costs more neutral, and if we heal about 4% more wounds, we’ll start to save money. So we need to start thinking differently about resource allocations.” In Cole’s view, deploying continuous topical oxygen therapy is a ‘no-brainer’. “In my personal experience, I’ve had great success,” she says. “Patients find it very easy to use, they’re very happy with the pain reduction, and I think it helps support quality of life. Patients are not impeded by this therapy and heal faster, so I think the sky’s the limit.” 


33


NICE is generally


supportive of continuous topical oxygen therapy.


Natrox Woundcare


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