The Effects of TeleWound Management on Use of Service and Financial Outcomes


663

TELEMEDICINE AND e-HEALTH
Volume 13, Number 6, 2007
© Mary Ann Liebert, Inc.
DOI: 10.1089/tmj.2007.9971

Original Research

The Effects of TeleWound Management on Use of
Service and Financial Outcomes

RILEY S. REES, M.D., and NOURA BASHSHUR, M.H.S.A.

ABSTRACT

This study investigated the effects of a TeleWound program on the use of service and finan-
cial outcomes among homebound patients with chronic wounds. The TeleWound program
consisted of a Web-based transmission of digital photographs together with a clinical proto-
col. It enabled homebound patients with chronic pressure ulcers to be monitored remotely
by a plastic surgeon. Chronic wounds are highly prevalent among chronically ill patients in
the United States (U.S.). About 5 million chronically ill patients in the U.S. have chronic
wounds, and the aggregate cost of their care exceeds $20 billion annually. Although 25% of
home care referrals in the U.S. are for wounds, less than 0.2% of the registered nurses in the
U.S. are wound care certified. This implies that the majority of patients with chronic wounds
may not be receiving optimal care in their home environments. We hypothesized that Tele-
Wound management would reduce visits to the emergency department (ED), hospitalization,
length of stay, and visit acuity. Hence, it would improve financial performance for the hos-
pital. A quasi-experimental design was used. A sample of 19 patients receiving this inter-
vention was observed prospectively for 2 years. This was matched to a historical control group
of an additional 19 patients from hospital records. Findings from the study revealed that Tele-
Wound patients had fewer ED visits, fewer hospitalizations, and shorter length of stay, as
compared to the control group. Overall, they encumbered lower cost. The results of this clin-
ical study are striking and provide strong encouragement that a single provider can affect
positive clinical and financial outcomes using a telemedicine wound care program. Tele-
Wound was found to be a credible modality to manage pressure ulcers at lower cost and pos-
sibly better health outcomes. The next step in this process is to integrate the model into daily
practice at bellwether medical centers to determine programmatic effectiveness in larger clin-
ical arenas.

Wound Care Center, Department of Plastic Surgery, University of Michigan Health System, Ann Arbor, Michigan.

INTRODUCTION

THIS STUDY WAS AIMED at investigating the ef-fects of a TeleWound program on the use
of service and financial outcomes among home-

bound patients with chronic wounds. The Tele-
Wound program was internally developed at
the University of Michigan Health System
(UMHS), jointly designed by the Telemedicine
Resource Center and Department of Plastic



Surgery. The program allows homebound pa-
tients with pressure ulcers to receive distance
care and remote monitoring from their plastic
surgeon. It utilizes a store-and-forward system
and consists of Web-based digital photography
and standardized clinical protocols. Measures
of use of service include frequency of emer-
gency department (ED) visits, outpatient clinic
visits, hospitalization and length of hospital
stay, number of outpatient clinic contacts (other
than visits), and outpatient visit acuity. Finan-
cial outcome measures were limited to the
UMHS’s direct and indirect costs.

MATERIALS AND METHODS

Chronic wounds are highly prevalent among
chronically ill patients in the United States
(U.S.). Typically, the cost of care for such pa-
tients is quite substantial. Overall, it has been
estimated that about 5 million chronically ill
patients in the total population of the U.S. have
chronic wounds, and the aggregate cost of care
for them exceeds $20 billion annually. More-
over, this cost increases with advancing age at
the rate of about 10% per year.1 Another esti-
mate places the number of patients with
chronic wounds at 6 million, overall, or nearly
2% of the total U.S. population.2

Pressure ulcers occur frequently among
hospitalized patients. It has been estimated
that about 2.5 million hospitalized patients re-
ceive treatment for pressure ulcers each year.3
Their care is very costly. For instance in 1999,
the estimate for the total cost of caring for
hospital-acquired pressure ulcers was be-
tween $2.2 and $3.6 billion per year.3 The cost
of care for a single hospitalized patient with a
pressure ulcer ranged between $5,000 and
$40,000.4–6 The estimated cost for surgical clo-
sure of a pressure sore ranged from $75,000 to
$90,000. Often, the hospital does not get fully
reimbursed for this cost.1 Hence, the average
hospital in the U.S. incurs between $400,000
and $700,000 in direct costs to treat pressure
ulcers annually, and a large portion of this cost
is not reimbursable.3,7

There is empirical evidence that demon-
strates a strong association between pressure

ulcer and hospital length of stay.8 Under the
prospective payment system, the required care
for these patients places hospitals at a signifi-
cant financial disadvantage, particularly the
loss of revenue as a result of the prolonged hos-
pitalization.1 The problem is all the more acute
among the elderly. Indeed, 70% of all pressure
ulcers occur among patients who are 70 years
of age or older.8 Additionally, pressure ulcers
greatly increase the risk for osteomyelitis of the
pelvis and septicemia,8 and cellulitis.9 For in-
stance, nearly two thirds, or 65%, of elderly pa-
tients hospitalized with hip fractures develop
pressure ulcers.10 Among other investigators,
Allman et al. found that pressure ulcers con-
stitute a “significant predictor of both length of
hospital stay and total hospital costs,4,11,12” in-
creased risk of amputation and death.3,4,11,12

Several factors contribute to the high cost of
treatment for pressure ulcers. These include
nursing time, physician time, surgical proce-
dures—flaps and debridement—and, of
course, longer hospitalization for complica-
tions. There is also the added cost of expensive
devices and products, such as specialty beds,
pressure-relieving devices, pharmacotherapy,
and rehabilitation. The experience can be
painful and disfiguring. In addition to the
physical symptoms, afflicted patients may suf-
fer from the sequelae of low self-esteem, em-
barrassment, and “body image disturbances.”
Indeed, the problem degrades quality of life
and functional performance among patients.
This becomes all the more serious when con-
sidering that such patients often experience
slow recovery because of having comorbidities.
Often, they become dependent on a caregiver
to change their dressings and to help them with
basic activities of daily living. In turn, care-
givers have to devote time and energy to care
for these patients, who tend to be elderly par-
ents. The burden on caregivers is substantial,
and it can disrupt the normal routines of nu-
clear families.13

Since many of these patients require profes-
sional help in their home environments, there
was a concomitant increase in the demand for
homecare services.14 From the wound care per-
spective, this increased the demand for home
health services. However, it was not a boon for

REES AND BASHSHUR664



home health agencies that have to operate un-
der the Prospective Payment System because
the increased demand did not generate addi-
tional revenue.15 Nonetheless, the actual in-
crease in the number of homecare patients with
acute and chronic wounds resulted in the
prominence of the homecare setting for the care
of these patients.16 For instance, between 2000
and 2005, the average number of home health
visits per patient was expected to increase from
65 to 82.17 Yet overall reimbursement has been
declining. Dansky et al. reported that home
health agencies are currently being reimbursed
at levels 2% lower than 1993–1994 levels.18,19

Nearly a quarter of home care referrals in the
U.S. are for wounds.20 Homecare agencies com-
plain about the deficit they incur in treating
such patients. Although their cost ranges be-
tween $8,000 and $30,000 per year, their reim-
bursement is limited to about $2,500 on a na-
tional level.20

Nurses who are specialty trained in wound
care can reduce the cost of care by applying
their knowledge, skill, and efficient use of re-
sources.20,21 Indeed, it has been demonstrated
that effective and timely treatment of chronic
wounds is based on high-quality, standard-
ized, “community-based specialty care”,20,22,23
and that chronic wounds heal more rapidly in
the home setting when the care is provided by
specially trained nurses, as compared to their
counterparts.24 However, less than 0.2% of the
registered nurses in the U.S. are wound care
certified. This implies that the vast majority of
such patients do not receive optimal care in
their home environments.20

Description of the intervention

The TeleWound program consists of a Web-
based transmission of digital photographs and
a clinical protocol that enables homebound pa-
tients who have chronic pressure ulcers to be
monitored remotely by a plastic surgeon who
is a specialist in wound care management.
These patients have been receiving their nor-
mal care from their plastic surgeon when they
visit the office. However, care in their homes
has been provided by a home health agency.
Those participating in the TeleWound program

are visited by the TeleWound nurse in their
homes. During these visits, the nurse takes a
digital photograph of each wound, as shown in
Figure 1, and completes a standardized wound
assessment form, which captures detailed data
such as (but not limited to) wound location,
size, stage, drainage, odor, presence of exposed
bone, “feel” of bone if exposed, percent necrotic
tissue, dressing regime, and products used.
There are also two open-ended sections, one
where the TeleWound nurse documents her
overall assessment, and another section for
communication/questions from the nurse to
the physician. The information is relayed on a
secure Web-based platform to the manager of
the program who arranges the complete file for
the physician.

The digital camera model chosen was the
Nikon CoolPix 4500 model (Nikon, Melville,
NY), plus a Nikon CoolLight S-1. The Cool-
Light is a ring light that attaches directly to the
camera. It ensures consistent lighting for all im-
ages, because the ambient light situation in the
homecare environment is often unpredictable.
(Flash is never used because it tends to “wash
out” the wound color.)

Digital photography employs an explicit but
simple protocol, including specifications as an-
gling the camera “head on” to wound, taking
the photo between 10 and 18 inches away from
the wound, placing a paper ruler and wound
identifier tag in close proximity to the wound,
and capturing the wound, tag, and ruler in each

TELEWOUND MANAGEMENT 665

FIG. 1. Digital transmission of TeleWound photograph.

http://www.liebertonline.com/action/showImage?doi=10.1089/tmj.2007.9971&iName=master.img-000.jpg&w=228&h=170


photo. The tag is preprinted with a large red
circle. This red circle is the same hue and in-
tensity of healthy wound bed tissue, and is
used to compare the color of the actual wound
to a standardized color. The nurse also makes
sure the wound is centered in the photograph,
without shadows, and uses a contrasting back-
ground. After executing this task, the nurse re-
views the photographs. If they are found inad-
equate, new photographs are obtained. All
photographs and protocols are transmitted
over a Virtual Private Network within 24
hours.

In-home TeleWound visits are conducted by
the nurse either weekly or biweekly, depend-
ing on the stability of the wound. The surgeon
reviews the information within 36 hours of re-
ceiving it, and makes treatment decisions based
on the data, except when alerted to an emer-
gency situation by the nurse or manager. The
surgeon determines whether or not a change of
order is indicated or whether a clinic visit or
surgical debridement should be scheduled. The
surgeon also responds to the nurse’s questions
and comments, which were relayed in the
open-ended sections of the wound assessment
form.

STUDY DESIGN

The leading hypothesis in this study posits
that the TeleWound management program will
result in reduced frequency of visits to the ED,
reduced hospitalization and length of stay, re-
duced visit acuity, and improved financial per-
formance. Moreover, it is expected that the
longer patients participate in the TeleWound
program, the greater the effects.

A quasiexperimental design was chosen as
the most feasible approach to test this multi-
part hypothesis. It consists of an improved non-
equivalent control group design, in which the
experimental (TeleWound) cases are observed
prospectively, whereas the control group is a
matched historical group. The improvement
over the traditional nonequivalent group de-
sign derives from matching cases with compa-
rable controls. The TeleWound group consisted
of 19 patients who gave informed consent to

participate in the study. Of those who were
asked to participate in the study, two refused
after the start of the project. Hence, the total
pool consisted of 21 patients. In order to ensure
the reliability of the analysis, these cases were
included in the study only if they participated
in the TeleWound program for a minimum of
3 months. Moreover, for analytic purposes, the
experimental (TeleWound) group of 19 subjects
was further subdivided into “established” pa-
tients (those who have participated in the pro-
gram for 12 months or more from the start of
the project) and “nonestablished” patients
(those who have participated less than 12
months). The experience of the subset of “es-
tablished” patients was examined separately
because its members were expected to show a
larger effect than the group as a whole. The
TeleWound group consisted of 11 males and 8
females. The “established” subset among them
consisted of 7 males and 4 females.

Nineteen controls were matched by wound
type, comorbidities, distance of residence to
clinic, and payer mix. These cases were selected
from hospital records. All received their
wound care from the same surgeon but not nec-
essarily from the same home health agency.
Distance from home was calculated by placing
home address and the address of the clinic into
MapQuest®, which computed mileage for each
address. Visit acuity was abstracted from the
electronic medical record, where it is system-
atically coded.

The two groups were not matched by age.
However, all subjects of the study are patients
of a single provider and receive treatment in
the same outpatient clinic as the experimental
group. The data for the TeleWound group were
collected prospectively for a period of 2 years,
whereas the data for the control group were ab-
stracted from the electronic master records for
the same period.

The dependent variables: use of service and
financial performance

Use of service measures was straightfor-
ward. They included number of ED visits,
number of outpatient clinic visits, number of
inpatient hospitalizations, length of stay, num-

REES AND BASHSHUR666



ber of outpatient clinic contacts, and level of
outpatient visit acuity. This latter variable was
abstracted from hospital financial records. A
“clinic contact” is defined as any type of con-
tact (phone calls, nursing notes, etc.) with the
plastic surgeon or plastic surgery nurse, which
was recorded in the electronic medical record.
Financial outcome measures examined were
based on inpatient and outpatient health sys-
tem direct and indirect costs. These data cov-
ered 2 full calendar years, 2004 and 2005. Fac-
tors such as wound healing time were not
measured in the study.

DATA ANALYSIS AND FINDINGS

The analysis of the data consisted of com-
paring the utilization experiences of the two
groups—TeleWound (experimental) and con-
trol—over a 2-year period. A further assess-
ment is made for the subset of “established pa-
tients” in order to test the secondary hypothesis
to the effect that experience in the TeleWound
program tends to increase the magnitude of the
effect. The significance of the difference be-
tween the TeleWound and control groups is as-
certained by the �2 and their contingency coef-

ficients (p values). The value of �2 was calcu-
lated using the standard formula. Although
several of the dependent variables were con-
tinuous, we had to collapse the categories be-
cause of the small sample size.

ED visits

For the 2 years combined, patients in the
TeleWound group made a total of 19 ED visits,
whereas the control group made a total of 39
such visits. The averages for the two groups
were 0.84 and 2.05, respectively, that is, on av-
erage, patients in the TeleWound group made
less than 1 visit to the ED over a 2-year period,
whereas those in the control group averaged
more than 2 visits. This trend is even more dra-
matic among established patients. Nine of 11
in the TeleWound group did not make any ED
visits and only 2 had 1 or more visits, whereas
the reverse is true of the control group (data
are shown in Table 1).

Number of ED visits: TeleWound patients
are much less likely to use the ED than the con-
trol group, and the TeleWound group uses the
ED less frequently. The TeleWound program
intervention is positively related to absence of
ED use, and negatively related to number of
ED visits. These effects increase the longer pa-

TELEWOUND MANAGEMENT 667

TABLE 1. EMERGENCY DEPARTMENT VISITS BY TELEWOUND AND CONTROL GROUPS

Total sample Established patients only

One or One or
No more No more

visits visits Total Mean visits visits Total Mean

TeleWound group 11 8 19 0.84 9 2 11 0.45
Control group 5 14 19 2.05 2 9 11 2.82

�2 � 3.89 p � 0.049 �2 � 8.91 p � 0.003

TABLE 2. OUTPATIENT CLINIC VISITS BY TELEWOUND AND CONTROL GROUPS

Total sample Established patients only

Ten or 11 or Ten or 11 or
fewer more fewer more
visits visits Total Mean visits visits Total Mean

TeleWound group 8 11 19 11.12 7 4 11 9.36
Control group 10 9 19 10.00 3 8 11 13.09

�2 � 0.42 p � 0.746 �2 � 2.93 p � 0.087



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tients participate in the program. The differ-
ences between the two groups are statistically
significant.

Outpatient visits

The TeleWound group made more outpa-
tient visits than the control group (a total of 211
versus 190, or an average of 11.12 versus 10.0).
However, these differences were not statisti-
cally significant as measure by the �2. Among
established patients, the TeleWound group
made fewer outpatient visits than did the con-
trol group. Again, the differences were not sta-
tistically significant. Hence, this part of the hy-
pothesis was not substantiated by the data
(Table 2).

Hospitalization

We employed 2 measures of hospitalization
in this study: number of hospital admissions
and length of stay. For the 2 years, the Tele-
Wound group had a total of 50 admissions,
whereas the number for the control group was
nearly double (93 admissions). When examined
in more detail (as shown in Table 3), no patients
in the TeleWound group were admitted more
than 6 times, as compared to 5 patients in the

control group who were in the same category.
The difference between the two groups is sta-
tistically significant. The established patients
demonstrated this difference even more
starkly. The average for the TeleWound group
of established patients was nearly 2 admissions
(1.91), whereas the average for the control
group was more than threefold (6.09).

The same trends were observed with regards
to length of stay (data shown in Table 4). The
TeleWound group spent a total of 399 days in
the hospital over the 2-year period, whereas the
control group spent a total of 732 days. Stated
differently, the patients in the TeleWound
group spent an average of 21 days in the hos-
pital during 2004 and 2005, whereas patients in
the control group spent an average of 38.53
days in the hospital. Among established pa-
tients the difference was even more substantial.
Seven of the 11 established patients in the Tele-
Wound group spent 6 days or less in the hos-
pital, as compared to only 1 in the control
group with the same length of stay.

Clinic contacts

The program intervention was not designed
to reduce contact between patients and clini-
cians; it was designed to reduce the cost of car-

TELEWOUND MANAGEMENT 669

TABLE 4. LENGTH OF HOSPITAL STAY BY TELEWOUND AND CONTROL GROUPS FOR BOTH 2004 AND 2005

Total sample Established patients only

5 Days 6 or 6 Days 7 Days
or more or or

less days Total Mean less more Total Mean

TeleWound group 10 9 19 21.00 7 4 11 12.45
Control group 9 16 19 38.53 1 10 11 48.18

�2 � 5.73 p � 0.017 �2 � 7.07 p � 0.008

TABLE 5. OUTPATIENT CONTACTS BY TELEWOUND AND CONTROL GROUPS

Total sample Established patients only

15 16 15 16
Contacts Contacts Contacts Contacts
or fewer or more Total Mean or fewer or more Total Mean

TeleWound group 8 11 19 16.11 5 6 11 14.73
Control group 11 8 19 13.63 4 7 11 17.00

�2 � 0.95 p � 0.330 �2 � 0.19 p � 0.665



ing for complex, chronic wounds. Indeed, all
patients with chronic wounds (in both the Tele-
Wound and control groups) were encouraged
to contact the clinic when they had a problem
or a question, and they were not charged for
such contacts. We wanted to ascertain whether
the 2 groups differed in terms of this variable.
The findings confirmed the similarity of the 2
groups, as shown in Table 5.

Visit acuity

We assessed differences in visits between the
TeleWound and control groups at 3 levels:
high, medium, and low acuity. No differences
between the 2 groups were observed among
those having either high- or low-acuity visits.

On the other hand, there were significant dif-
ferences among those having medium-acuity
visits. This finding implies that the program
had no effect on the intensity of care during
outpatient visits when the patients had either
serious or small problems. It did make a dif-
ference for those in between. However, that ef-
fect disappeared among established patients.
(Data shown for medium acuity only, Table 6)

Financial outcomes

In order to assess financial outcomes, we ex-
amined “all cost data” generated by study pa-
tients for calendar years 2004 and 2005, for both
groups: TeleWound and control. “All cost
data” is defined as any cost related to any and

REES AND BASHSHUR670

TABLE 6. OUTPATIENT VISIT ACUITY BY TELEWOUND AND CONTROL GROUPS MEDIUM ACUITY ONLY

Total sample Established patients only

5 Visits 6 Visits 5 Visits 6 Visits
or fewer or more Total Mean or fewer or more Total Mean

TeleWound group 4 13 19 6.21 3 7 11 5.64
Control group 9 5 19 4.53 5 4 11 5.45

�2 � 5.24 p � 0.022 �2 � 0.44 p � 0.508

TABLE 7. TOTAL FINANCIAL OUTCOMES

All financial data Wound-related care only

Direct Indirect Direct Indirect
Total costs Total costs Total costs Total costs

Patient direct per indirect per direct per indirect per
type costs patient costs patient costs patient costs patient

Inpatient
Year 04 TeleWound 433,970 22,841 242,874 12,783 61,506 3,237 34,100 1,795
Year 05 TeleWound 122,011 6,422 64,323 3,385 30,677 1,615 16,299 858
Total $555,981 $29,262 $307,197 $16,168 $92,183 $4,852 $50,399 $2,653

Year 04 Non-TW 459,809 24,200 272,055 14,319 193,311 10,174 114,757 6,040
Year 05 Non-TW 425,687 22,405 237,289 12,489 106,265 5,593 58,122 3,059
Total $885,496 $46,605 $509,344 $26,808 $299,576 $15,767 $172,879 $9,099

Outpatient
Year 04 TeleWound 118,257 6,224 55,052 2,897 26,826 1,412 15,343 808
Year 05 TeleWound 121,752 6,408 52,389 2,757 11,746 618 6,671 351
Total $240,009 $12,632 $107,441 $5,654 $38,572 $2,030 $22,014 $1,159

Year 04 Non-TW 43,575 2,293 24,959 1,314 18,670 983 11,345 597
Year 05 Non-TW 28,386 1,494 16,863 888 8,818 464 6,416 338
Total $71,961 $3,787 $41,822 $2,202 $27,488 $1,447 $17,761 $935

n � 19



all care these patients received at our health
system, both inpatient and outpatient, regard-
less of whether or not the care was wound re-
lated. Direct costs are those costs driven by and
directly attributable to each individual patient.
They are variable in nature, since they are gen-
erated by rendering care to that individual, per
episode of care. Direct costs are essentially
“controllable.” On the other hand, indirect
costs are those costs spread across all patients,
and are fixed in nature.

Data shown in Table 7 reveal that both indi-
rect and direct inpatient costs were consider-
ably less for the TeleWound group as com-
pared to the control group. Inpatient costs also
decreased from year 1 to year 2 for the Tele-
Wound group from $22,481 to $6,422, whereas
they stayed relatively stable from year to year
for the control group, from $24,200 to $22,405.
On the other hand, outpatient direct costs for
the TeleWound group remained almost the
same, $6,224 versus $6,408, and it declined for
the control group from $2,293 to $1,494. The
reason for the decline among the control group
is not clear.

We also examined cost data related to wound
management only, including services provided
by any department or service unit within the

health system. In all likelihood, we were able
to account for all costs because all these patients
were regular clients of the health system. How-
ever, we cannot be certain that no other costs
were incurred if other providers were used.
These data are also presented in Table 7.

All costs incurred for wound management
only declined for both groups. However, the
TeleWound group experienced a slightly
greater decline. On the inpatient side, the Tele-
Wound group experienced a decline from an
average of $3,237 to $1,615, whereas the aver-
age for the control group declined from $10,174
to $5,593. The most notable differential exists
between the total direct inpatient costs for the
TeleWound group versus the control group—
the difference is staggering ($92,183 compared
to $299,576, respectively). Similar trends of de-
cline are observed for outpatient costs.

If we consider the total inpatient and outpa-
tient costs for the 2 groups, the advantage is
still held by the TeleWound group for both
types of costs. The TeleWound group incurred
an average total direct (inpatient plus outpa-
tient) cost of $6,882, and the control group in-
curred an average of $17,214. For total indirect
(inpatient and outpatient) costs, the Tele-
Wound group incurred an average of $3,811,

TELEWOUND MANAGEMENT 671

TABLE 8. FINANCIAL OUTCOMES FOR ESTABLISHED PATIENTS ONLY

All financial data Wound-related care only

Direct Indirect Direct Indirect
Total costs Total costs Total costs Total costs

Patient direct per indirect per direct per indirect per
type costs patient costs patient costs patient costs patient

Inpatient
Year 04 TeleWound 198,518 18,047 109,778 9,980 30,003 2,728 16,325 1,484
Year 05 TeleWound 17,291 1,572 9,068 824 16,105 1,464 8,343 758
Total $215,809 $19,619 $118,846 $10,804 $46,108 $4,192 $24,668 $2,242

Year 04 Non-TW 226,320 20,575 128,731 11,70 110,906 10,082 62,879 5,716
Year 05 Non-TW 385,392 35,036 214,707 19,519 95,181 8,653 52,645 4,786
Total $611,712 $55,610 $343,438 $31,222 $206,087 $18,735 $115,524 $10,502

Outpatient
Year 04 TeleWound 50,572 4,597 16,577 1,507 11,814 1,074 7,217 656
Year 05 TeleWound 25,406 2,310 12,685 1,153 6,049 550 3,475 316
Total $75,978 $6,907 $29,262 $2,660 $17,863 $1,624 $10,692 $972

Year 04 Non-TW 34,035 3,094 19,542 1,777 16,754 1,523 10,220 929
Year 05 Non-TW 20,057 1,823 12,129 1,103 7,179 653 5,368 488
Total $54,092 $4,917 $31,671 $2,880 $23,933 $2,176 $15,588 $1,417

n � 11



and the non-TeleWound group incurred an av-
erage of $10,034. For both types of costs, the ad-
vantage lies with the TeleWound group.

Finally, we examined the financial outcomes
for the established patients only. This is the
subset of 11 established cases in the TeleWound
group who were also matched with the control
group. We examined total financial outcomes
related to all care received at the health system
as well as financial outcomes related to wound
management only. It may be recalled that we
expected the established patients to show a
greater effect from the intervention.

Among established TeleWound patients, the
average inpatient direct cost for all care de-
clined from $18,047 in 2004 to $1,572 in 2005,
whereas the control group experienced a sub-
stantial increase from $20,575 in 2004 to
$35,036 in 2005. The decline in average cost of
all outpatient care was relatively similar be-
tween the TeleWound and control groups (as
shown in Table 8). However, overall, the Tele-
Wound group had a substantial advantage
over the control group. The comparisons in
their total costs for the 2 years combined are
as follows: The total average direct cost (inpa-
tient and outpatient) for the TeleWound group
was $26,526 and $60,528 for the control group.
Average indirect costs were $2,748 for the Tele-
Wound group and $34,101 for the control
group.

These differences become even more dra-
matic when we examine wound management
costs only. Average inpatient direct costs for
the TeleWound group were $4,192 for both
years, whereas the control group incurred an
average of $18,735 per patient. Indirect costs
were also markedly different: the TeleWound
group incurred an average of $2,242 per pa-
tient, and the control group incurred an aver-
age cost of $10,502.

If we consider the total inpatient and outpa-
tient costs for the 2 groups, a clear advantage
is held by the TeleWound group for both types
of costs. The TeleWound group incurred an av-
erage total direct (inpatient plus outpatient)
cost of $5,816, and the control group incurred
an average of $20,911. For total indirect (inpa-
tient and outpatient) costs, the TeleWound
group incurred an average of $3,215 and the
non-TeleWound group incurred an average of
$11,919.

CONCLUSION

The urgent needs of our aging population, in
particular, nursing home residents, prisoners,
and Veterans Hospital patients, provide strong
incentives to develop innovative methods to
deliver clinically appropriate and cost-effective
wound care. Despite the proliferation of
wound care centers, often patients with pres-
sure ulcers and associated multiple comorbidi-
ties are poorly suited for management at these
sites. Hence, we investigated the appropriate-
ness of telemedicine for in-home wound man-
agement. Telemedicine is a particularly attrac-
tive strategy for those with spinal cord injuries,
because their transportation is always difficult,
time consuming, and expensive.

The leading hypothesis for this study posited
that subjects managed with a combination of
traditional wound care plus telemedicine
would have superior financial outcomes over
subjects managed with a traditional “only see
the doctor in person” approach. We utilized a
case-controlled study design in which patients
in the control group were carefully matched for
wound type, comorbidities, distance of resi-
dence to clinic, and payer mix. Primary out-
come variables included services provided and
financial performance. The subjects were fol-
lowed up between 12 and 24 months. A single
provider managed all the outpatient visits and
attended all of the telemedicine sessions to
evaluate the wounds.

The results of this clinical study are striking
and provide strong encouragement that a sin-
gle provider can affect positive clinical and fi-
nancial outcomes using a telemedicine wound
care program. For example, the telemedicine
group had 50% fewer emergency department
visits than the control group. Furthermore, the
subjects in the telemedicine group averaged
less than 1 emergency department visit each,
during the 2-year period of the study. This is a
particularly important statistic because presen-
tation in an emergency room with a pressure
ulcer and fever virtually guarantees hospital
admission.

The analysis of the data provides insight into
the impact of an emergency visit on hospital-
ization. In the telemedicine group, hospitaliza-
tion occurred half as many times as in the con-
trol group. Although all subjects in the trial

REES AND BASHSHUR672



required hospitalization, the incidence was
threefold higher in the control group. The most
telling statistic is the length of stay during hos-
pitalization because it is an indicator of acuity
of illness and is a significant driver of cost. There
were 54% fewer days of hospitalization in the
telemedicine group versus the controls. Thus,
the data show that telemedicine wound care
lowers the admission rate as well as actual
length of stay for subjects with pressure ulcers.
Clearly, fewer hospital days would increase rev-
enue margins for hospitals using the prospec-
tive payment system for pressure ulcers.

Good management of subjects in the trial
came at a small price. The paradigm shift from
on-site clinic care to remote telemedicine visits
required that the telemedicine group be “seen”
more frequently than the controls. Although
the difference was not statistically significant,
it does imply more oversight from the clinician
because the telemedicine group was evaluated
weekly via digital photography and nursing as-
sessments. This factor led to the success of the
TeleWound program as a credible modality to
manage pressure ulcers at a lower cost and pos-
sibly better health outcomes. Cost savings were
even more dramatic on the inpatient side.

The impact factor of this study will be a
function of technology use by clinicians who
manage wounds. Surgeons are particularly
well-suited for this task because they aggres-
sively debride wounds and have short seg-
ments of time to devote to reviewing tele-
medicine photos and nursing assessments.
Hospitals will profit immensely from this ap-
proach because hospital beds are at a pre-
mium, and their goals are to maximize rev-
enue, access, and quality of care. The next step
in this process is to integrate the model into
daily practice at bellwether medical centers to
determine programmatic effectiveness in
larger clinical arenas.

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Address reprint requests to:
Noura Bashshur, M.H.S.A.

Department of Plastic Surgery
University of Michigan Health System

Domino’s Farms
Lobby A, P.O. Box 441

24 Frank Lloyd Wright Drive
Ann Arbor, MI 48106

E-mail: nourab@umich.edu

REES AND BASHSHUR674



This article has been cited by:

1. Caroline Chanussot-Deprez, José Contreras-Ruiz. 2009. Telemedicine in wound care. International Wound Journal 5:5, 651-654.
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