Chronic wounds cost Singapore 0.07% of GDP

Chronic wounds impose a substantial economic burden on Singapore, costing the country approximately 0.07 percent of its gross domestic product (GDP) annually, as reported in a study.

In the report, the total annual cost of illness arising from chronic wounds is SGD 350 million, ranging between SGD 72 and 1,779 million. The use of healthcare services is the biggest cost driver, accounting for more than half of the total cost at SGD 185 million. [BMJ Open 2023;13:e065692]

For inpatients alone, the average number of acute bed days taken up by people with chronic wounds is 168,503 per year, which accounts for SGD 139 million or 40 percent of the total cost. On the other hand, SGD 37 million or 10 percent of the total cost is attributed to outpatients.

The total annual cost of the health outcomes that were lost due to chronic wounds was 2,077 QALYs (quality-adjusted life years), which is equivalent to SGD 166 million. However, the investigators express uncertainty about the true cost, as the range of estimates is between –2,657 to 29,029 QALYs with a corresponding value of between SGD –212 to 2,399 million.

These estimates were based on data from 3.49 million Singapore citizens and permanent residents, among whom 16,752 new individuals had a chronic wound in 2017. Of these, 598 individuals had venous ulcers, 2,206 had arterial insufficiency ulcers, 6,680 had diabetic ulcers, and 7,268 had pressure injuries.

Economic impact of skin ulcers

Described as causing a ‘silent epidemic’ that affects a large proportion of the world’s population, chronic wounds are those that fail to heal in a time sufficient for ‘normal’ healing, according to the investigators. “[These wounds] tend to present as a comorbid rather than primary condition among older individuals.” [Br J Dermatol 2022;187:141-148]

Skin ulcers are the most common type of chronic wounds and include venous, arterial, diabetic foot, and pressure ulcers. As reflected in the estimates, the economic impact of skin ulcers to the Singapore healthcare system is significant, owing to the associated costs of hospital admissions, outpatient care, medical devices and supplies, home healthcare, and loss of productivity. 

What makes the economic impact significant is because people with skin ulcers need regular, effective treatments, for the most part. If their condition gets too bad, they will need to be admitted to the hospital. Many patients will be admitted for other reasons, but their skin ulcer may make their stay longer. For those at high risk of complications from skin ulcers, procedures such as debridement, minor amputations, and major amputations may be performed. [Int Wound J 2020;17:790-80; Diabetes Metab Res Rev 2020;36 Suppl 1:e3242; Semin Vasc Surg 2021;34:47-53]

Chronic wounds are also prevalent among residents of aged care facilities, which incur additional costs for staff time and consumables. Home nursing services, as well as charities and volunteer groups that support the frail and elderly in their homes, also manage patients with skin ulcers. [Ann Epidemiol 2019;29:8-15]

Finally, skin ulcers can lead to productivity losses for both patients and their caregivers. For example, patients with skin ulcers may be unable to work or perform their usual activities, such as household chores or caring for their children, whereas family members of affected patients may have to take time off from work to care for their loved ones.

The value of prevention and management

What this cost of illness analysis tells us is that chronic wounds, skin ulcers mainly, are a recurring and unnecessary cost burden on the Singapore healthcare system and society as a whole. But this medical condition does not have to be a deadweight loss. The investigators argue that evidence-based prevention and management programs can help reduce the risk of chronic wounds developing, as well as accelerate healing and improve outcomes for patients who do develop chronic wounds, ultimately saving money.

For example, using optimal prevention practices for diabetic foot ulcers has been shown to reduce the economic burden on both patients and the health system in countries such as Peru, Australia, Thailand, and China. [BMC Health Serv Res 2015;15:483; Int Wound J 2017;14:616-628; Int J Low Extrem Wounds 2009;8:153-156; J Diabetes 2018;10:320-327]

In Denmark, US, and UK, nursing-led interventions, a quality improvement collaborative, and the standardized use of pressure injury bundles for the prevention of pressure injuries have been found to be cost-effective, yielding savings in total costs of hospital and social care. [J Med Econ 2013;16:1238-1245; Med Care 2011;49:385-392; J Wound Care 1999;8:312-316; Adv Wound Care 1998;11:22-29]

And in the UK and the US, compression therapy, clinical assessments, and the use of guidelines has been shown to be economically advantageous for the prevention of venous leg ulcers. [Health Trends 1993;25:146-148; BMJ 1996;312:1648-1651; J Vasc Surg 2002;35:950-957; Am J Surg 2002;183:132-137]

“Our findings provide fundamental information for researchers who wish to model the cost-effectiveness of programmes that will improve wound outcomes in the future. Understanding the baseline of costs and QALY outcomes form a useful start-point for any evaluation of interventions,” the investigators say.

Nevertheless, they acknowledge that their cost of illness analysis may have underestimated the extent of the costs of chronic wounds, given that relevant information was not available for many costs that the investigators themselves believe are present.