Non-absorbable and slowly absorbed sutures are often used to close wounds. The results of aliterature review and economic assessment challenged these methods
Judith Hargreaves MSc, DBA, RGN is associate director, global health economics and outcomes research, Ethicon Products, Livingston.
Hargreaves J (2010) A review assessing the most cost effective way of closing skin after surgical procedures. Nursing Times; 106: early online publication.
Background Topical skin adhesives (TSAs) and short-term absorbable sutures (STASs) are not as widely used in surgery as non-absorbable or slowly absorbed sutures.
Aim To assess the effectiveness and cost of skin closure techniques for surgical wounds.
Method Data from clinical trials was used to assess the effectiveness of different skin closure methods. NHS costs were determined from questionnaires sent to nurses to identify treatment elements for individual patients.
Results The study found TSAs and STASs were as effective as traditional surgical wound closure methods.
Discussion and conclusion Increasing the use of TSAs and STASs in routine surgery could lead to considerable cost savings for the NHS without compromising clinical effectiveness or safety.
Keywords: Skin closure, Wound closure, Sutures, Tissue adhesives, Surgery
- This article has been double-blind peer reviewed
- Increased use of topical skin adhesives (TSAs) and short-term absorbable sutures (STASs) for skin closure could provide shorter clinical treatment pathways for surgical patients;
- This could release staff to perform other duties and increase bed use in acute surgical wards;
- Increased use of TSAs and STASs could cut the overall cost of surgery.
Techniques for skin closure following a surgical procedure have remained relatively unchanged over the last 30 years. Most wounds are closed with absorbable or non-absorbable sutures or staples as these are thought to be inexpensive and reliable. Despite the increased use of topical skin adhesives (TSAs) in accident and emergency departments, their adoption in surgery remains low. This could be because clinicians consider them more expensive and less reliable than traditional methods.
The study had two objectives: to determine the effectiveness of the different methods and materials used for skin closure following surgery, and to estimate the total cost to the NHS of available wound closure methods.
A literature survey was carried out to determine the effectiveness of the different wound closure methods, along with an economic assessment to determine their cost to the NHS.
The study reviewed randomised controlled clinical trials of skin closure techniques and materials using The Cochrane Central Register of Clinical Trials, The Cochrane Library, MEDLINE and EMBASE, along with a number of medical and surgical journals. The search was restricted to published articles in English using specific search terms. The studies were assessed for quality of method of randomisation, blinding and follow-up. We also assessed the comparability of the control and treatment groups at entry. Our assessments were not blinded and were subjective.
A questionnaire on wound closure was developed to estimate NHS costs. This was distributed to theatre nurses, ward nurses, day surgery nurses, outpatient nurses, practice nurses and community nurses during September 2006. We calculated equipment costs using average prices from NHS logistics for hospital equipment and drug tariff costs for primary care (NHS, 2006). Staff costs were calculated according to unit cost of health and social care 2006 (Curtis and Netten, 2006). Only direct costs to the NHS were considered for the economic analysis.
There were 7.2 million NHS operations in England in 2006 (Curtis and Netten, 2006; DH, 2006). A standard power calculation based on this figure revealed 400 responses to the questionnaire were required from each nursing group to produce statistically meaningful results. Anticipating a return rate of one in 10, we distributed 4,000 questionnaires to each group, a total of 20,000 questionnaires.
The questionnaire asked for information about the surgery performed in the respondents’ centres. To increase the homogeneity of our sample, we excluded traumatic wounds treated in accident and emergency departments or walk in centres, and surgical cases where complications occurred that prolonged the surgery or hospital stay. We also excluded patients with type 1 diabetes, patients taking long term steroids, those undergoing procedures where wounds were closed with sterile skin strips, and cardiac surgery patients. To calculate the time cost we constructed a treatment pathway for each patient, from when the surgeon began to close the skin to when the patient’s wound no longer needed any healthcare intervention.
Non-absorbable v absorbable sutures
Five studies compared non-absorbable synthetic sutures with absorbable synthetic sutures in the closure of surgical wounds within a hospital setting. Differences between the studies in suture techniques, materials and study methodology generally precluded the pooling of results, although some subgroup analyses were possible. One study compared the cost-effectiveness of non-absorbable monofilament sutures and absorbable multifilament sutures (Angelini et al, 1984). The researchers found non-absorbable monofilament sutures were a faster and less costly way to close a wound than absorbable multifilament sutures – 144 seconds against 264 seconds, and 15p against 72p per 10cm of wound respectively.
The incidence of surgical site infection (SSI) was generally low in all five studies. However, two found significantly fewer SSIs with interrupted mattress sutures of non-absorbable monofilament than with subcuticular sutures of absorbable multifilament.
Suture type with non-absorbable sutures
The one study that compared subcuticular nylon sutures with interrupted nylon sutures after appendectomy found no significant differences. However, some studies reported statistically significant advantages in cosmetic appearance with non-absorbable subcuticular sutures. One study (Angelini et al, 1984) found using non-absorbable subcuticular sutures was faster than closing with non-absorbable vertical mattress sutures and less costly - 15p against 72p per 10cm of wound closure respectively.
Sutures v staples
Thirteen studies compared sutures with staples. The three studies that assessed cost effectiveness found the costs associated with staples were substantially higher than for sutures. There was little difference in SSI rates and the rates of dehiscence were too low for meaningful comparisons.
TSA v sutures
Fourteen studies compared TSAs with sutures. Five assessed butyl-cyanoacrylate adhesive and nine assessed octyl-cyanoacrylate.
Wound infection was reported as an outcome in nine studies but definitions of infection and the times at which it was assessed varied. Only one study had wound infection as the primary outcome and was the only study to report that using a TSA to close the wound resulted in fewer SSIs than skin sutures (Silvestri et al, 2006).
Wound dehiscence was used as an outcome in 10 studies. There were very few reports of dehiscence with most of the studies reporting no cases in either the TSA or suture groups. Most of those that reported dehiscence found no significant differences. Only one study, which assessed groin incisions in children, found more cases of dehiscence associated with the use of TSA (van den Ende et al, 2000). Another study comparing TSA with sutures in closing 52 groin wounds in 45 infants wearing nappies found no cases of wound dehiscence with either method (Ferlise et al, 2001).
Twelve studies reported cosmetic appearance as an outcome. Of the five that made statistical comparisons, three reported no statistical differences between sutures and TSAs. One study found no difference at 90 days, but cosmetic appearance was better with TSA after one year (Toriumi et al, 1998). Another study found both patients and doctors rated cosmetic appearance as better with TSA than sutures (van den Ende et al, 2000)
Patient satisfaction was measured in four studies. One found that 13 out of 20 patients preferred TSA to sutures (Greene et al, 1999) and another also reported higher patient satisfaction with TSA compared with sutures. Two studies found no statistically significant differences between the two methods.
Five studies assessed the cost-effectiveness of TSAs. One found it took longer to close wounds with TSAs than with sutures, but the other four found that wound closure took less time with TSAs compared with sutures. Three studies found substantial cost savings when TSAs were used instead of sutures.
A total of 4,964 usable questionnaires were returned by the nurses. Patients and the type of wound closure used were similar across all types of surgery, except for orthopaedic surgery where 59% of wounds were closed with staples compared with 17% for general surgery and 4% for day case surgery.
Wound lengths and the time taken for skin closure were compared for the different closure methods. Use of long-term absorbable sutures was associated with longer wounds, whereas the use of staples and TSA was associated with shorter wounds. The average wound length was 8.31cm and the average time for skin closure was 7.20 minutes.
Time-associated costs for the different wound closure methods were also compared. The total time cost to close the skin ranged from £37.07 for non-absorbable sutures to £18.45 for TSA.
The costs and utilisation of the different closure methods and the total costs per complete patient treatment pathway were used to develop a decision tree model for skin closure.
The estimated cost to the NHS of wound closure and removal of sutures was £56.61 per patient. Sensitivity analyses determined that inflation in healthcare personnel salaries of 2.5% would increase the overall cost per patient to £57.70. A 2.5% increase in both the price of equipment and salaries would increase the cost to £57.87 per patient. Changing to the cheapest alternative product would reduce the cost to £55.55 per patient.
The total cost per patient could be cut to £46.02 by:
- Reducing the number of wounds closed with medium-term absorbable sutures from 32% to 12%;
- Reducing the number of wounds closed with non-absorbable sutures from 33% to 13%;
- Increasing the number of wounds closed with short-term absorbable sutures from 16% to 46%;
- Increasing the number of wounds closed with TSAs from 4% to 26%;
- Stopping the use of staples.
This represents a cost saving to the NHS of £1,059 per 100 patients.
Absorbable v non-absorbable sutures
The comparison of different suture materials and methods in the studies was complicated because in many of the studies two or more parameters varied simultaneously. Although two studies found statistically significant differences, changing two or more factors means that we cannot conclude with certainty whether there is any significant difference between absorbable and non-absorbable sutures, or between monofilaments and multifilaments. The one study that examined the cost-effectiveness of non-absorbable monofilaments compared with absorbable multifilament sutures did not report the cost of removing the sutures, therefore not representing the full cost of the different closure methods. However, this study found that the incidence of SSI was higher for subcuticular absorbable sutures than for interrupted mattress non-absorbable sutures. Given that the average cost of treating an SSI is £2,100 per patient (Plowman et al, 2001), this suggests some advantages of non-absorbable interrupted mattress sutures.
Staples v sutures
Although the costs were higher with staples than with sutures, none of the studies included staff costs in their assessments. The apparently higher cost of closing with staples is in part offset because it is faster to close with staples than with sutures (Angelini et al, 1984; Eldrup et al, 1981) However, absorbable sutures do not need to be removed like staples, therefore reducing staff costs.
TSAs v sutures
Infections, dehiscence rates, cosmetic appearance and patient satisfaction were generally similar for TSAs and sutures. In the study that reported higher dehiscence rates with TSAs than sutures, the adhesive was used to close groin wounds mainly in paediatric patients wearing nappies. As the manufacturer of this adhesive recommends it should not be used in areas subject to excessive rubbing, and that the wound should be kept dry for the first five days, the clinical relevance of the apparent difference in the study is questionable. Another study of groin wounds in infants wearing nappies found no cases of dehiscence with either TSAs or sutures.
The Health Protection Agency (2006) estimates that around 4.2% of surgical procedures will develop an SSI. One theoretical advantage of TSAs over other skin closure methods is that their use eliminates a potential source of infection - needle tracks into the subcuticular tissue. The adhesive also produces a microbial barrier over the surface of the wound. An analysis of published studies commissioned by the National Institute for Health and Clinical Excellence (NICE, 2008) - published after we conducted our literature survey - confirmed the infection rate is lower with TSAs than with sutures.
The studies we reviewed indicated that TSAs and short-term absorbable sutures offer the same clinical outcomes as longer-term absorbable and non-absorbable sutures and staples. The higher costs of materials could make TSAs and short-term absorbable sutures seem more costly than traditional methods. However, this does not take into account the costs associated with nurses’ time in removing sutures. When all time costs are included, TSAs offer substantial cost savings over sutures. Considering 86% of staples and 48% of non-absorbable sutures were removed on the ward during hospital stay (Fig 1), it is worth investigating how many patients were kept on the ward purely for the removal of wound closures, thus adding to the cost of treatment and making the bed unavailable. The use of TSAs would allow patients to go home earlier, reducing the cost per procedure and allowing a higher throughput of patients in acute beds. With hospital stays costing an average of £254 per night (Curtis and Netten, 2006), even small reductions in the duration of stay could have major implications for the cost of surgical care.
The average district general hospital (DGH) performs around 30,000 surgical procedures a year. (NHS Information Centre, 2006). At a cost of £56.61 per patient, the cost of skin closures in these procedures will be around £1,698,300. With around 7.2 million surgical procedures undertaken every year, the cost of closure amounts to £407,592,000 for the NHS in England. Changing to TSAs could save a typical DGH around £447,600 per year and the NHS £114.6m per year.
An alternative way of determining the cost-effectiveness of wound closure methods would be to carry out a survey over a longer period of time, following each patient from the surgical closure in theatre to removal or an equivalent endpoint such as acceptable healing. This would take into account factors such as costs associated with problems developing after suture removal and the costs of scar care. However, this would be much more expensive to conduct, and the amount of information needed from each respondent could reduce the return rate.
Further studies would also be useful to determine the costs and usage patterns of skin closure techniques outside the types of surgery analysed in this survey, for example in cardiothoracic and plastic surgery. The absence of some types of surgery from our questionnaire means that extrapolations from our literature review may not be fully justified as some of the studies involved surgery types excluded from our questionnaire.
TSAs and STASs are as effective and safe as non-absorbable sutures, clips or staples for skin closure following surgery. Increasing the use of TSAs and STASs could reduce NHS costs with no loss of clinical effectiveness or safety. The use of TSAs and STASs could also reduce the amount of staff time needed in the closure and management of surgical wounds, freeing staff to perform other duties and helping divert funds to other areas of healthcare.
The author would like to thank Julie Robertson and Pat Fairlamb NHS PASA for their help in the early stages of the research, and Dr JR Carpenter, a member of the European Medical Writers’ Association, (Rx Communications Ltd, UK) for medical writing services on behalf of Ethicon, UK, Ltd who paid for the study and the preparation of this manuscript. Further project management and editorial support was provided by Rx Communications Ltd, UK, funded by Ethicon, UK, Ltd. The manuscript was developed in adherence to the guidelines of the European Medical Writers’ Association (Jacobs & Wager, 2005).
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