title: Clinical and economic assessment of diabetic foot ulcer debridement with collagenase: results of a randomized controlled study.
abstract: BACKGROUND
  Despite significant advances, the treatment of diabetic foot ulcers (DFUs) remains a major therapeutic challenge for clinicians, surgeons, and other health care professionals. There is an urgent need for new strategies with clinically effective interventions to treat DFUs to reduce the burden of care in an efficient and cost-effective way.
  
  
  OBJECTIVE
  This randomized trial evaluated and compared the clinical effectiveness, tolerability, and costs of clostridial collagenase ointment (CCO) debridement to that of debridement using saline moistened gauze (SMG) and selective sharp debridement for the treatment of DFUs.
  
  
  METHODS
  Randomized, controlled, parallel group, multicenter, open-label, 12-week study of 48 patients with neuropathic DFUs randomized to 4 weeks of treatment with either CCO or SMG after baseline surgical debridement. The primary end point was the condition of the ulcer bed at the end of treatment as measured using a standardized wound assessment tool. Secondary end points were the percentage of reduction in wound area and therapeutic response rates. Adverse events were monitored for the tolerability analysis. In addition, a comparative cost-effectiveness analysis was performed from the perspective of the Centers for Medicare and Medicaid Services as a payer.
  
  
  RESULTS
  Both the CCO and SMG groups had significantly improved wound assessment scores after 4 weeks of treatment (CCO, -2.5, P = 0.007; SMG, -3.4, P = 0.006). Only CCO treatment resulted in a statistically significant decrease from baseline in the mean wound area at the end of treatment (P = 0.0164) and at the end of follow-up (P = 0.012). In addition, the CCO group exhibited a significantly better response rate at the end of follow-up compared with the SMG group (0.92 vs 0.75, P < 0.05). Reported adverse events were similar between the 2 treatment groups. None of the reported adverse events were considered to be related to treatment. The economic analysis indicated that the direct mean costs per responder in the physician office setting of care were $832 versus $1042 for the CCO group versus the SMG group, whereas the direct mean costs per responder in the hospital outpatient department setting were $1607 versus $1980.
  
  
  CONCLUSIONS
  CCO treatment provides equivalent debridement of DFUs similar to SMG while fostering better progress toward healing as measured by decreasing wound area over time and improved response rates at the end of follow-up. In addition, CCO yields a more favorable cost-effectiveness ratio in both the physician office and hospital outpatient department settings of care. ClinicalTrials.gov identifier: NCT01056198.
authors.affiliation: Associated Foot & Ankle Specialists LLC, Phoenix, Arizona.
authors.forename: Arthur
authors.initials: A
authors.lastname: Tallis
authors.forename: Travis A
authors.initials: TA
authors.lastname: Motley
authors.forename: Robert P
authors.initials: RP
authors.lastname: Wunderlich
authors.forename: Jaime E
authors.initials: JE
authors.lastname: Dickerson
authors.forename: Curtis
authors.initials: C
authors.lastname: Waycaster
authors.forename: Herbert B
authors.initials: HB
authors.lastname: Slade
mesh_terms: D000368:Aged; D017364:Collagenases / Q000191:economics / Q000378:metabolism / Q000627:therapeutic use*; D003362:Cost-Benefit Analysis; D003646:Debridement / Q000379:methods*; D017719:Diabetic Foot / Q000628:therapy*; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D016896:Treatment Outcome; D014945:Wound Healing / Q000187:drug effects*
chemical_list: D017364:Collagenases
keywords: Medicare and Medicaid; collagenase; cost minimization; debridement; diabetes; health economics; resource utilization and costs; saline moistened gauze; ulcer healing