Chronic Wounds

Management

The management and treatment of chronic wounds, including decubitus ulcers, is challenging. Most chronic wounds will heal only if the underlying cause (ie, venous stasis, pressure, infection) is addressed. Also, cleaning the wound to remove nonviable tissue, microorganisms, and foreign bodies is essential to create optimal conditions for either re-epithelialization (ie, healing by secondary intention) or preparation for wound closure with skin grafts or flaps (ie, healing by primary intention). Therefore, debridement, irrigation, whirlpool treatments, and wet-to-dry dressings are common components of chronic wound care.

Negative pressure wound therapy (NPWT) involves the use of a negative pressure therapy or suction device to aspirate and remove fluids, debris, and infectious materials from the wound bed to promote the formation of granulation tissue. The devices may also be used as an adjunct to surgical therapy or as an alternative to surgery in a debilitated patient. Although the exact mechanism has not been elucidated, it is hypothesized that negative pressure contributes to wound healing by removing excess interstitial fluid, increasing the vascularity of the wound, reducing edema, and/or creating beneficial mechanical forces that lead to cell growth and expansion.

A nonpowered (mechanical) NPWT system has also been developed; the Smart Negative Pressure Wound Care System is portable and lightweight (3 oz) and can be worn underneath clothing. This system consists of a cartridge, dressing, and strap; the cartridge acts as the negative pressure source. The system is reported to generate negative pressure levels similar to other NPWT systems. This system is fully disposable.

The focus of this policy is the use of NPWT in the outpatient setting. It is recognized that patients may begin using the device in the inpatient setting as they transition to the outpatient setting.

Regulatory Status

Negative pressure therapy or suction devices cleared by the FDA for treating chronic wounds include, but are not limited to: Vacuum-Assisted Closure® Therapy (V.A.C., also known as negative pressure wound therapy; KCI); Versatile 1™ (V1) Wound Vacuum System (Blue Sky Medical), RENASYS™ EZ PLUS (Smith & Nephew), Foryou NPWT NP32 Device (Foryou Medical Electronics), and PICO Single Use Negative Pressure Wound Therapy System (Smith & Nephew).

Portable systems include the RENASYS™ GO (Smith & Nephew), XLR8 PLUS (Genadyne Biotechnologies), extriCARE® 2400 NPWT System (Devon Medical), the V.A.C. Via™ (KCI), and the PICO Single Use Negative Pressure Wound Therapy System (Smith & Nephew). The Prevena™ Incision Management System (KCI) is designed specifically for closed surgical incisions.

A nonpowered NPWT device, the SNaP® Wound Care System (Spiracur, acquired by Acelity in 2015), is a class II device requiring notification to market but not having the FDA premarket approval. In 2009, it was cleared for marketing by the FDA through the 510(k) pathway (K081406) and is designed to remove small amounts of exudate from chronic, traumatic, dehisced, acute, or subacute wounds and diabetic and pressure ulcers.

NPWT devices with instillation include the V.A.C. VERAFLO™ Therapy device (KCI/Acelity). It was cleared for marketing in 2011 by the FDA through the 510(k) pathway (K103156) and is designed to allow for controlled delivery and drainage of topical antiseptic and antimicrobial wound treatment solutions and suspensions.

No NPWT device has been cleared for use in infants and children.

In November 2009, the FDA issued an alert concerning complications and deaths associated with NPWT systems. An updated alert was issued in February 2011.^1,

FDA product code: OMP.

Related Policies

• Recombinant and Autologous Platelet-Derived Growth Factors as a Treatment of Wound Healing and Other Non-Orthopedic Conditions (Policy #004 in the Treatment Section)
• Electrostimulation and Electromagnetic Therapy for Treating Wounds (Policy #069 in the Treatment Section)
• Non-Contact Ultrasound Treatment for Wounds (Policy #122 in the Treatment Section)
• Bioengineered Skin and Soft Tissue Substitutes (Policy #148 in the Treatment Section)

A. Ulcers and Wounds in the Home Setting:
The member has a chronic (being present for at least 30 days) Stage 3 or 4 pressure injury, neuropathic (e.g., diabetic) ulcer, venous or arterial insufficiency ulcer, chronic ulcer of mixed etiology, or complications of a surgically created or traumatic wound. A complete wound therapy program described in criterion 1 and criteria 2, 3, or 4, as applicable, depending on the type of wound, should have been tried or considered and ruled out prior to application of negative-pressure wound therapy.
1. For all ulcers or wounds, the following components of a wound therapy program must include a minimum of all of the following general measures, which should either be addressed, applied, or considered and ruled out prior to application of negative-pressure wound therapy:
a) Documentation in the member’s medical record of evaluation, care, and wound measurements by a licensed medical professional, and
b) Application of dressings to maintain a moist wound environment, and
c) Debridement of necrotic tissue if present; and
d) Evaluation of and provision for adequate nutritional status.

2. For Stage 3 or 4 pressure injury:
a) The member has been appropriately turned and positioned, and
b) The member has used a group 2 (e.g., alternating pressure and low air loss mattresses and overlays) or group 3 (e.g., air-fluidized bed) support surface for pressure ulcers on the posterior trunk or pelvis (a group 2 or 3 support surface is not required if the injury is not on the trunk or pelvis), and
c) The member’s moisture and incontinence have been appropriately managed.

3. For neuropathic (e.g., diabetic) ulcers:
a) The member has been on a comprehensive diabetic management program, and
b) Reduction in pressure on a foot ulcer has been accomplished with appropriate modalities.

4. For venous insufficiency ulcers:
a) Compression bandages and/or garments have been consistently applied, and
b) Leg elevation and ambulation have been encouraged.

5. For surgically created or trumatic wound:
• Accelerated granulation therapy is necessary which cannot be achieved by other available topical wound treatment.

B. Ulcers and Wounds Encountered in an Inpatient Setting:
1. An ulcer or wound (described under I.A. above) is encountered in the inpatient setting and, after wound treatments described under I.A.1. through I.A.4. as applicable have been tried or considered and ruled out, powered negative-pressure wound therapy is considered medically necessary and may be initiated.
2. The member has complications of a surgically created wound (e.g., dehiscence, post-sternotomy mediastinitis) or a traumatic wound (e.g., pre-operative flap or graft) where there is documentation of the medical necessity for accelerated formation of granulation tissue which cannot be achieved by other available topical wound treatments (e.g., other conditions of the member that will not allow for healing times achievable with other topical wound treatments).

In either situation I.B.1. or I.B.2., powered negative-pressure wound therapy will be considered medically necessary when treatment continuation is ordered beyond discharge to the home or post-acute setting.

For wounds and ulcers described under I.A. or I.B. above, in order for continued powered negative-pressure wound therapy to be considered medically necessary, a licensed medical professional must do the following:
1. On a regular basis, directly access the wound(s) being treated, and supervise or directly perform the negative-pressure wound therapy dressing changes, and
2. On at least a monthly basis, document changes in the ulcer’s dimensions and characteristics.

For wounds and ulcers described under I.A. or I.B. above, powered negative-pressure wound therapy will not be considered medically necessary when any of the following occurs:
1. When criteria under policy statement II above (Continued Medical Necessity) cease to be met;

2. When in the judgment of the treating physician, adequate wound healing has occurred to the degree that negative-pressure wound therapy may be discontinued;
3. Any measurable degree of wound healing (defined as improvement occurring in either surface area [length times width], or depth of the wound) has failed to occur over the prior month. There must be documentation in the member’s medical record of quantitative measurements of wound characteristics including wound length and width (surface area), or depth, serially observed and documented, over a specified time interval. The recorded wound measurements must be consistently and regularly updated and must have demonstrated progressive wound healing from month to month;

4. Four months (including the time negative-pressure wound therapy was applied in an inpatient setting prior to discharge to the home) have elapsed using negative-pressure wound therapy for any wound. The medical necessity of continued negative-pressure wound therapy beyond 4 months will be given individual consideration based upon additional required documentation from the treating physician; or

5. When the equipment and supplies are no longer being used for the member's wound, whether or not due to a physician’s order.

1. Negative-pressure wound therapy pumps must be capable of accommodating more than one wound dressing set for multiple wounds on a member. Therefore, more than one negative-pressure wound therapy pump billed per member for the same time period is not considered medically necessary.
2. Generally, a maximum of 15 dressings kits per wound per month is considered medically necessary unless there is documentation that the wound size requires more than one dressing kit for each dressing change.
3. Generally, a maximum of 10 canister sets per month is considered medically necessary unless there is documentation indicating a large volume of drainage (greater than 90 ml of exudates per day). For high volume exudative wounds, a stationary pump with the largest capacity canister must be used.

o There are complications of a surgically created wound (e.g., dehiscence, post sternotomy disunion with exposed sternal bone, post sternotomy mediastinitis, or postoperative disunion of the abdominal wall).
o There is a traumatic wound (e.g., preoperative flap or graft, exposed bones, tendons, or vessels) and a need for accelerated formation of granulation tissue not achievable by other topical wound treatments (e.g., the individual has comorbidities that will not allow for healing times usually achievable with other available topical wound treatments).
o There is a chronic, non-healing ulcer with lack of improvement despite standard wound therapy, including the application of dressings, debridement of necrotic tissue (if present), maintenance of an adequate nutritional status, and weekly evaluations with documentation of wound measurements (i.e., length, width, and depth) in ONE of the following clinical situations:
· Acute wounds
· Subacute and dehisced wounds
· Traumatic wounds
· Ulcers (such as diabetic or pressure)
· Chronic Stage III or Stage IV pressure ulcer
· Chronic diabetic neuropathic ulcer
· Chronic venous ulcer
· Flaps and grafts

· The presence in the wound of necrotic tissue with eschar, if debridement is not attempted;
· Osteomyelitis within the vicinity of the wound that is not concurrently being treated with intent to cure;
· Cancer present in the wound;
· The presence of an open fistula to an organ or body cavity within the vicinity of the wound

· Necrotic tissue with eschar present,
· Untreated osteomyelitis,
· Non-enteric and unexplored fistulas,
· Malignancy in the wound,
· Exposed vasculature,
· Exposed nerves,
· Exposed anastomotic site, or
· Exposed organs.

FIDE-SNP:
For members enrolled in a Fully Integrated Dual Eligible Special Needs Plan (FIDE-SNP): (1) to the extent the service is covered under the Medicare portion of the member’s benefit package, the above Medicare Coverage statement applies; and (2) to the extent the service is not covered under the Medicare portion of the member’s benefit package, the above Medicaid Coverage statement applies.

[RATIONALE: This policy was developed in 1999 and has been updated regularly with searches of the MEDLINE database. The most recent literature update was performed through October 31, 2019.

Evidence reviews assess the clinical evidence to determine whether the use of technology improves the net health outcome. Broadly defined, health outcomes are the length of life, quality of life (QOL), and ability to function¾including benefits and harms. Every clinical condition has specific outcomes that are important to patients and managing the course of that condition. Validated outcome measures are necessary to ascertain whether a condition improves or worsens; and whether the magnitude of that change is clinically significant. The net health outcome is a balance of benefits and harms.

To assess whether the evidence is sufficient to draw conclusions about the net health outcome of technology, 2 domains are examined: the relevance, and quality and credibility. To be relevant, studies must represent one or more intended clinical use of the technology in the intended population and compare an effective and appropriate alternative at a comparable intensity. For some conditions, the alternative will be supportive care or surveillance. The quality and credibility of the evidence depend on study design and conduct, minimizing bias and confounding that can generate incorrect findings. TheRCT is preferred to assess efficacy; however, in some circumstances, nonrandomized studies may be adequate. RCTs are rarely large enough or long enough to capture less common adverse events and long-term effects. Other types of studies can be used for these purposes and to assess generalizability to broader clinical populations and settings of clinical practice.

This review was informed by a 2000 TEC Assessment that evaluated negative pressure therapy of pressure ulcers, venous ulcers, and diabetic ulcers.^2, Literature updates for this review have focused on comparative trials with the features described in the 2000 TEC Assessment (eg, enrollment of patients with wounds refractory to standard treatment, randomization, optimal standard wound care treatment in the control arm, and clinically important endpoints). Also, literature has been sought on the potential benefits of negative pressure wound therapy (NPWT) for the healing of acute wounds.

NPWT devices are classified as either powered (ie, requiring an electrical power source or batteries) or nonpowered (mechanical). Most evidence found in the literature is for electrically powered devices with large canisters (eg, the Vacuum-Assisted Closure Therapy device [V.A.C. system]), and so the main discussion of evidence refers to this type of device. A number of portable devices have entered the market and are particularly relevant for use in the outpatient setting. Some portable devices are designed specifically for surgical incisions. Evidence on the newer portable devices is discussed following the review of evidence on the larger electrically powered devices.

The primary endpoints of interest for trials of wound closure are as follows, consistent with guidance from the FDA for the industry in developing products for the treatment of chronic cutaneous ulcer and burn wounds:

1. Incidence of complete wound closure
2. Time to complete wound closure (reflecting accelerated wound closure)
3. Incidence of complete wound closure following surgical wound closure
4. Pain control

The authors of a systematic review for the Agency for Healthcare Research and Quality and the Centers for Medicare & Medicaid Services (2014) reported that due to insufficient evidence, they were unable to draw conclusions about the efficacy or safety of NPWT in the home setting.^3, There were 3 retrospective cohort studies on diabetic foot ulcers and arterial ulcers, an RCT and 2 retrospective cohort studies on pressure ulcers, and a retrospective cohort on venous ulcers. Six studies used the V.A.C., and the other used the Smart Negative Pressure (SNaP) Wound Care System device. Reviewers found that interpretation of available data was limited by variability in the types of comparator groups, methodologic limitations, and poor reporting of outcomes.^4,

Another Agency for Healthcare Research and Quality assessment was performed to inform the HCPCS coding decisions for NPWT devices. This 2009 assessment found no studies showing a therapeutic distinction between different NPWT devices.^5,

A 2019 Cochrane review update evaluated NPWT compared with standard dressings for surgical wound healing by primary closure. Thirty RCTs were included for analysis (n = 2957).^6, NPWT was associated with a reduced risk of surgical site infection (SSI) (23 studies [n=2547], relative risk [RR] 0.67; 95% CI, 0.53 to 0.85; I2=8.51%). However, subgroup analysis by surgery type only maintained a significant benefit for groin surgery (4 studies [n=206]; RR 0.48; 95% CI, 0.3 to 0.74; I2=0%) and did not show a significant difference for abdominal and colorectal surgery, Caesarean section, hip/knee arthroplasty, open fractures, vascular surgery, sternotomy surgery laparotomy, and mixed procedures. No significant difference was found for the rates of mortality and wound dehiscence between treatments. Certainty of evidence was deemed low per GRADE criteria, with only 3 trials allocating more than 100 participants. Very low-grade certainty evidence suggests a higher risk of developing skin blisters with NPWT (6 studies [n=597]; RR 6.64; 95% CI, 3.16 to 13.95). Studies were generally limited by imprecision and unclear or high-risk of bias in allocation concealment and blinding of outcome assessors. The analysis was also limited by inclusion of studies with mixed or unclear intervention types and no subgroup analysis for traditional and portable or single-use systems. Additionally, one study featured the use of a new generation V.A.C. device utilizing instillation. Nine studies identified the PICO system, 4 studies identified the Prevena system, 4 studies described but did not clearly identify portable or single-use devices, 3 studies identified the V.A.C. device, and 9 studies described but did not clearly identify an NPWT device.

A systematic review and meta-analysis by Li et al (2019) was conducted comparing the effectiveness and safety of NPWT with standard surgical dressing or conventional therapy for prevention of SSI.^7,A total of 45 RCTs assessing 6624 adult patients were included for analysis. Studies utilized a variety of NPWT devices, including V.A.C., PICO, and Prevena systems. Inclusion criteria did not impose restrictions on SSI grading systems or on surgery types. Surgeries for infected or chronic non-healing wounds including diabetic, venous, and arterial ulcers were excluded. Overall, NPWT was associated with a 40% reduction in SSI risk compared to control, with moderate heterogeneity (RR 0.58; 95% CI, 0.49 to 0.69; I2=19%; p<0.00001). This significant reduction in risk was particularly maintained in high-risk surgical patients (32 RCTs; RR 0.60; 95% CI, 0.50 to 0.73; I2=23%; p<0.00001). There was no significant effect of NPWT on wound dehiscence, hematoma occurrence, hospital admission, or length of hospital stay. The certainty of the evidence, based on GRADE criteria was graded as low to very low due to serious risk of bias stemming from lack of blinding and methodological flaws in SSI assessment and standardization. The authors suggest that further studies are warranted to elucidate the optimal protocol for NPWT utilization.

Diabetic Lower-Extremity Ulcers and Amputation Wounds

Clinical Context and Therapy Purpose

The purpose of outpatient NPWT is to provide a treatment option that is an alternative to or an improvement on existing therapies in patients with diabetic lower-extremity ulcers or amputation wounds.

The question addressed in this policy is: Does NPWT improve outcomes when used for the outpatient treatment of pressure ulcers, diabetic foot ulcers, venous ulcers, burn wounds, and traumatic or surgical wounds; and to assess the evidence on the use of portable NPWT devices?

The following PICO was used to select literature to inform this review.

Patients

The relevant population of interest is individuals with diabetic lower-extremity ulcers or amputation wounds.

Interventions

The therapy being considered is outpatient NPWT.

Comparators

Comparators of interest include standard wound care.

Outcomes

The general outcomes of interest are symptoms, change in disease status, morbid events, QOL, and treatment-related morbidity. Though not completely standardized, follow-up for diabetic lower-extremity ulcers or amputation wounds symptoms would typically occur in the months to years after starting treatment.

Study Selection Criteria

Methodologically credible studies were selected using the following principles:

a. To assess efficacy outcomes, comparative controlled prospective trials were sought, with a preference for RCTs;
b. In the absence of such trials, comparative observational studies were sought, with a preference for prospective studies.
c. To assess long-term outcomes and adverse events, single-arm studies that capture longer periods of follow-up and/or larger populations were sought
d. Studies with duplicative or overlapping populations were excluded.

A 2013 Cochrane review of NPWT for treating foot wounds in patients with diabetes^8,was updated in 2018 to include 11 RCTs (n=972) with sample sizes ranging from 15 to 341 participants.^9, Two studies addressed post-amputation wounds and all other studies described treatment of diabetic foot ulcers. Only one study comparing NPWT and moist dressings for post-amputation wounds reported a follow-up time (n=162), and a statistically significant improvement in the proportion of wounds healed (RR 1.44, 95% CI, 1.03 to 2.01) was demonstrated after a follow-up duration of 16 weeks. The median time to healing was 21 days shorter for the NPWT group (hazard ratio 1.91, 95% CI, 1.21 to 2.99) compared with moist dressings. Data from 3 studies suggest that people with diabetic foot ulcers allocated to NPWT may be at reduced risk of amputation compared to moist dressings (RR 0.33, 95% CI, 0.15 to 0.70, I²=0%). Reviewers concluded that there was some evidence to suggest that NPWT was more effective than standard care, but the findings were uncertain due to the risk of bias in the unblinded studies. Reviewers recommended further study to reduce uncertainty around decision-making.

A systematic review by Wynn and Freeman (2019) evaluating NPWT for diabetic foot ulcers reported similar benefits in wound healing and the reduction of amputation incidence.^10,However, reviewers emphasized limitations in the present body of evidence, including methodological flaws such as the absence of validated tools for the measurement of wound depth and area, lack of statistical power calculations, and heterogeneity in pressure settings employed during therapy.

Randomized Controlled Trials

The largest study of NPWT for diabetic foot ulcers was a multicenter industry-sponsored RCT by Blume et al (2008) that compared NPWT with advanced moist wound therapy.^11, Included were 342 patients with Wagner grade 2 or grade 3 foot ulcers of at least 2 cm²; the chronicity of the ulcers was not described. Based on intention-to-treat analysis, a greater proportion of NPWT-treated foot ulcers achieved the primary endpoint of complete ulcer closure (43.2% vs. 28.9%, p=0.007) within the 112-day active treatment phase. For the 240 (72%) patients who completed the active treatment phase, 60.8% of NPWT-treated ulcers closed compared with 40.0% of ulcers treated with advanced moist wound therapy. NPWT patients also experienced significantly fewer secondary amputations (4.1% vs. 10.2%, p=0.035).

Nonrandomized Studies

Borys et al (2018) conducted a prospective observational study to assess the short-term efficacy, safety, and long-term outcomes of NPWT in treating diabetic foot ulcers. Researchers assigned 75 patients to NPWT (n=53) or standard care (n=22) based on wound size. Analysis after 1-year follow-up showed similar results for both groups, leading researchers to conclude NPWT is a safe alternative to but not necessarily more efficacious than the current standard of care. Limitations include small sample size, the observational design, and nonconsideration of risk factors other than wound size.^12,

Section Summary: Diabetic Lower-Extremity Ulcers and Amputation Wounds

The evidence on NPWT for diabetic lower-extremity ulcers and amputation wounds includes RCTs andsystematic reviews of RCTs. Although there is some uncertainty due to the risk of bias in the unblinded studies, there were higher rates of wound healing and fewer amputations with NPWT, supporting its use for diabetic lower-extremity ulcers and amputation wounds.

Chronic Pressure Ulcers

Clinical Context and Therapy Purpose

The purpose of outpatient NPWT is to provide a treatment option that is an alternative to or an improvement on existing therapies in patients with chronic pressure ulcers.

The question addressed in this policy is: Does NPWT improve outcomes when used for the outpatient treatment of pressure ulcers, diabetic foot ulcers, venous ulcers, burn wounds, and traumatic or surgical wounds; and to assess the evidence on the use of portable NPWT devices?

The following PICO was used to select literature to inform this review.

Patients

The relevant population of interest is individuals with chronic pressure ulcers.

Interventions

The therapy being considered is outpatient NPWT.

Comparators

Comparators of interest include standard wound care.

Outcomes

The general outcomes of interest are symptoms, change in disease status, morbid events, QOL, and treatment-related morbidity. Though not completely standardized, follow-up for chronic pressure ulcers would typically occur in the months to years after starting treatment.

Study Selection Criteria

Methodologically credible studies were selected using the following principles:

a. To assess efficacy outcomes, comparative controlled prospective trials were sought, with a preference for RCTs;
b. In the absence of such trials, comparative observational studies were sought, with a preference for prospective studies.
c. To assess long-term outcomes and adverse events, single-arm studies that capture longer periods of follow-up and/or larger populations were sought.

Systematic Reviews

A 2015 Cochrane review included 4 RCTs of NPWT (total n=149 patients) for treating pressure ulcers in any care setting, although most of the patients were treated in a hospital setting.^8, Three trials were considered to be at high-risk of bias, and all evidence was considered to be of very low-quality. Only 1 trial reported on complete wound healing, which occurred in only 1 of the 12 study participants. Reviewers concluded there is high uncertainty about the potential benefits and/or harms for this indication.

Randomized Controlled Trials

One representative trial, from 2003 (noted in the 2015 Cochrane review as “awaiting further information from the authors”), randomized 24 patients with pressure ulcers of the pelvic region to NPWT or standard wound care.^13, All patients with pelvic pressure ulcers were eligible for enrollment and were not required to be refractory to standard treatment. There was no significant group difference for the main outcome measure, time to 50% reduction of wound volume (mean, 27 days in the NPWT group vs. 28 days in the control group). Findings were limited by the small number of patients in the study, the possibility that the control group might not have received optimal wound management, and lack of information on the time to complete wound healing.

Section Summary: Chronic Pressure Ulcers

The evidence on outpatient NPWT for chronic pressure ulcers includes RCTs and systematic reviews. However, all trials were of low-quality and at high-risk of bias. Also, most patients were treated in an inpatient setting.

Lower-Extremity Ulcers due to Venous Insufficiency

Clinical Context and Therapy Purpose

The purpose of outpatient NPWT is to provide a treatment option that is an alternative to or an improvement on existing therapies in patients with lower-extremity ulcers due to venous insufficiency.

The question addressed in this policy is: Does NPWT improve outcomes when used for the outpatient treatment of pressure ulcers, diabetic foot ulcers, venous ulcers, burn wounds, and traumatic or surgical wounds; and to assess the evidence on the use of portable NPWT devices?

The following PICO was used to select literature to inform this review.

Patients

The relevant population of interest is individuals with lower-extremity ulcers due to venous insufficiency.

Interventions

The therapy being considered is outpatient NPWT.

Comparators

Comparators of interest include compression therapy.

Outcomes

The general outcomes of interest are symptoms, change in disease status, morbid events, QOL, and treatment-related morbidity. Though not completely standardized, follow-up for lower-extremity ulcers due to venous insufficiency symptoms would typically occur in the months to years after starting treatment.

Study Selection Criteria

Methodologically credible studies were selected using the following principles:

a. To assess efficacy outcomes, comparative controlled prospective trials were sought, with a preference for RCTs;
b. In the absence of such trials, comparative observational studies were sought, with a preference for prospective studies.
c. To assess longer-term outcomes and adverse events, single-arm studies that capture longer periods of follow-up and/or larger populations were sought.
d. Studies with duplicative or overlapping populations were excluded.

A 2015 Cochrane review of NPWT for venous insufficiency identified a single RCT with 60 patients.^14,This trial, published by Vuerstaek et al (2006), was performed in an inpatient setting in conjunction with skin grafts and compared the efficacy of NPWT using the V.A.C. system (n=30) with conventional moist wound care (n=30) in patients hospitalized with chronic venous and/or arterial leg ulcers of greater than 6 months in duration.^15, Full-thickness punch skin grafts from the thigh were applied, followed by 4 days of NPWT or conventional care to assure complete graft adherence. Each group then received standard care with nonadhesive dressings and compression therapy until complete healing (primary outcome) occurred. The median time to complete healing was 29 days in the NPWT group and 45 days in the control group (p=0.001). Ninety percent of ulcers treated with NPWT healed within 43 days, compared with 48% in the control group. These results would suggest that NPWT significantly hastened wound healing, although the use of skin autografts makes it difficult to discern the contribution of NPWT to the primary outcome. The 2015 Cochrane review did not identify any RCT evidence on the effectiveness of NPWT as a primary treatment for leg ulcers, nor was there any evidence on the use of NPWT in the home setting.

Section Summary: Lower-Extremity Ulcers due to Venous Insufficiency

A single RCT has been identified on use of NPWT for the treatment of lower-extremity ulcers due to venous insufficiency in the hospital setting. No evidence was identified on treatment in the home setting.

Burn Wounds

Clinical Context and Therapy Purpose

The purpose of outpatient NPWT is to provide a treatment option that is an alternative to or an improvement on existing therapies in patients with burn wounds.

The question addressed in this policy is: Does NPWT improve outcomes when used for the outpatient treatment of pressure ulcers, diabetic foot ulcers, venous ulcers, burn wounds, and traumatic or surgical wounds; and to assess the evidence on the use of portable NPWT devices?

The following PICO was used to select literature to inform this review.

Patients

The relevant population of interest is individuals with burn wounds.

Interventions

The therapy being considered is outpatient NPWT.

Comparators

Comparators of interest include standard wound care.

Outcomes

The general outcomes of interest are symptoms, change in disease status, morbid events, QOL, and treatment-related morbidity. Follow-up at months to years if of interest to monitor relevant outcomes.

Study Selection Criteria

Methodologically credible studies were selected using the following principles:

a. To assess efficacy outcomes, comparative controlled prospective trials were sought, with a preference for RCTs;
b. In the absence of such trials, comparative observational studies were sought, with a preference for prospective studies.
c. To assess long-term outcomes and adverse events, single-arm studies that capture longer periods of follow-up and/or larger populations were sought.
d. Studies with duplicative or overlapping populations were excluded.

A 2014 Cochrane review of NPWT for burn wounds identified an interim report (abstract) of an RCT on NPWT in patients with partial-thickness burns.^16, The abstract did not provide enough evidence to draw any conclusions on the efficacy of NPWT on partial-thickness burn wounds.

Not included in the Cochrane review was a trial by Bloemen et al (2012) on the effect of NPWT on graft take in full-thickness burn wounds.^17, This multicenter, 4-armed RCT enrolled 86 patients and compared a split-skin graft with or without a dermal substitute (MatriDerm), with or without NPWT. Outcome measures included graft take at 4 to 7 days after surgery, the rate of wound epithelialization, and scar parameters at 3 and 12 months postoperatively. Graft take, and wound epithelialization did not differ significantly between groups. Most measures of scar quality also did not differ significantly between groups.

An expert panel convened to develop evidence-based recommendations for the use of NPWT reported that the evidence base in 2011 was strongest for the use of NPWT on skin grafts and weakest as a primary treatment for burns.^18,

Case Series

A retrospective case series by Ehrl et al (2017) examined outcomes for 51 patients treated for burned hands with topical negative pressure wound (TNPW) therapy at a single-center; of the initial 51 patients, only 30 patients (47 hands) completed follow-up, which was conducted an average of 35 months after injury and included physical examination.^19,Before TNPW therapy, patients received escharotomy or superficial débridement if needed, or split-thickness skin grafts for third-degree burns and the TNPW gloves used allowed caregivers to assess patients’ fingertips for perfusion. Ergotherapy was initiated following evidence of epithelialization. Primary endpoints were a dorsal extension of the fingers and capability of complete active fist closure, with the majority of patients achieving one or both outcomes: the first endpoint was reached in 85.1% (n=40) of the cases; the second endpoint was reached in 78.7% of hands (n=37). When evaluated using the Disabilities of the Arm, Shoulder, and Hand questionnaire (scoring range, 0-100; with 0=no disability), patients with injuries resulting in hypertrophic scarring had significantly worse scores (28.8) than patients without similar scarring (11.7; p<0.05). Despite a number of limitations, including heterogeneity of burned areas (2.5% to 70% throughout the series), the authors acknowledged TNPW therapy as standard treatment at the institution from which these data were drawn.

Section Summary: Burn Wounds

The evidence on NPWT as a primary treatment of partial-thickness burns is limited. A retrospective case series reported functional outcomes in most patients treated for hand burns with NPWT. One RCT on NPWT for skin grafts showed no benefit for graft take, wound epithelialization, or scar quality.

Traumatic and Surgical Wounds

Clinical Context and Therapy Purpose

The purpose of outpatient NPWT is to provide a treatment option that is an alternative to or an improvement on existing therapies in patients with traumatic or surgical wounds.

The question addressed in this policy is: Does NPWT improve outcomes when used for the outpatient treatment of pressure ulcers, diabetic foot ulcers, venous ulcers, burn wounds, and traumatic or surgical wounds; and to assess the evidence on the use of portable NPWT devices?

The following PICO was used to select literature to inform this review.

Patients

The relevant population of interest is individuals with traumatic or surgical wounds.

Interventions

The therapy being considered is outpatient NPWT.

Comparators

Comparators of interest include standard wound care.

Outcomes

The general outcomes of interest are symptoms, change in disease status, morbid events, QOL, and treatment-related morbidity. Follow-up within weeks to months if of interest for outpatient NPWT to monitor relevant outcomes.

Study Selection Criteria

Methodologically credible studies were selected using the following principles:

a. To assess efficacy outcomes, comparative controlled prospective trials were sought, with a preference for RCTs;
b. In the absence of such trials, comparative observational studies were sought, with a preference for prospective studies.
c. To assess long-term outcomes and adverse events, single-arm studies that capture longer periods of follow-up and/or larger populations were sought.
d. Studies with duplicative or overlapping populations were excluded.

Systematic Reviews

Selected systematic reviews and meta-analyses evaluating the use of NPWT in surgical and/or traumatic wounds are summarized in Table 1.

Table 1. Summary of SR-MAs of NPWT versus Standard Therapy in Surgical Wounds

Review	RCT	Other Studies	Participants1	N (Range)	Major Outcomes	Study Quality	Relevance
Cochrane (2014)20,	9	0	Individuals with wounds expected to heal by primary intention (eg, surgical closure, skin grafts)	785	SSI (NSD) Wound dehiscence (NSD) Reoperation (NSD) Seroma/hematoma (NSD) Skin graft failure (NSD)	Unclear or high risk of bias noted	Unclear; inclusion of “home-made” devices and focus on inpatient therapy
De Vries et al (2016)21,	6	15	Individuals treated with prophylactic NPWT in clean and contaminated surgery	RCT: 277 (13-141) Other: 1099 (23-237)	Surgical site infection (RCT: p=0.04; Other: p<0.00001; NSD for trauma/orthopedic surgery)	Low quality of evidence due to lack of blinding in outcome assessment	Unclear; focus on inpatient therapy
Cochrane (2018)9,	7	0	Individuals with open traumatic wounds (open fractures and other types)	1377 (40-586)	Wound infection (NSD)	Unclear or high risk of bias noted	Limited; focus on inpatient therapy

NPWT: negative pressure wound therapy; NSD: no significant difference; RCT: randomized controlled trial; SR-MA: systematic review and meta-analysis; SSI: surgical site infection.
¹ Key eligibility criteria,
² Assessment according to Cochrane risk of bias criteria.

A 2014 Cochrane review evaluated the evidence on NPWT for skin grafts and surgical wounds expected to heal by primary intention.^20, Healing by primary intention occurs when the wound edges are brought together with sutures, staples, tape, or glue, and contrasts with healing by secondary intention, where the wound is left open to heal from the bottom up (eg, for chronic or infected wounds). Nine randomized trials (total n=785 patients) were included in the review. Three trials involved skin graft patients, 4 included orthopedic patients, and 2 included general surgery and trauma surgery patients. All trials had an unclear or high-risk of bias. There were no differences between standard dressing and NPWT for SSIs, wound dehiscence, reoperation (in incisional wounds), seroma/hematoma, or failed skin grafts. Pain intensity was reported to be lower with “home-made” NPWT compared with commercial devices. Most or all studies appeared to have used short-term application of NPWT in an inpatient setting.

A systematic review and meta-analysis by De Vries et al (2016) included 6 RCTs and 15 observational studies of SSIs after prophylactic NPWT.^21, One study selected used a portable device (PICO, described below), while the others used a V.A.C. Unlike the 2014 Cochrane review, studies on skin grafts were not included. Meta-analysis of the RCTs showed that use of NPWT reduced the rate of SSIs (odds ratio [OR], 0.56; 95% CI, 0.32 to 0.96; p=0.04), and reduced the SSI rate from 140 to 83 per 1000 patients. However, the quality of evidence was rated as low due to high-risk of bias in the nonblinded assessments and imprecision in the estimates. Subgroup meta-analysis of 4 RCTs in orthopedic/trauma surgery did not demonstrate significant benefit in regards to reducing risk of SSI (OR 0.58; 95% CI, 0.32 to 1.07).

A 2018 Cochrane review evaluated the effects of NPWT for open traumatic wounds (eg, open fractures or soft tissue wounds) managed in any care setting.^9,Seven RCTs were identified for the review with sample sizes ranging from 40 to 586 participants. Four studies (n=596) compared NPWT at 125 mmHg with standard care for open fracture wounds. Pooled data revealed no significant difference between groups in the number of participants with healed wounds (RR 0.48, 95% CI 0.81 to 1.27; I2=56%). Pooled data from 2 studies (n=509) utilizing NPWT at 125 mmHg on other open traumatic wounds demonstrated no significant difference in risk of wound infection compared to standard care (RR 0.61, 95% CI, 0.31 to 1.18). One study (n=463) assessing NPWT at 75 mmHg against standard care in other open traumatic wounds did not demonstrate a significant difference for wound infection risk (RR 0.44, 95% CI, 0.17 to 1.10). One study comparing NPWT at 125 mmHg against 75 mmHg in other open traumatic wounds also failed to demonstrate a significant difference in wound infection risk (RR 1.04, 95% CI, 0.31 to 3.51). Evidence was deemed low to very low in certainty and quality due to imprecision and risk of bias.

In contrast, a systematic review and meta-analysis by Liu et al (2018) highlighted a significantly lower infection rate, shorter wound coverage time, shorter wound healing time, and shorter hospitalization duration for NPWT versus conventional wound dressings in the treatment of open fractures (all p<0.00001).^22,Three of 6 included RCTs overlapped with the Cochrane review and one significantly weighted RCT (n=460) (see Costa et al [2018]^23, in Table 2 below) failing to demonstrate a benefit in infection risk for NPWT was missing in the Liu et al (2018) analysis, the only RCT identified by Cochrane to conduct blinded outcome assessment of wound healing and infection. However, the risk of bias in the Liu et al (2018) review was similarly reported as high or unclear. The baseline characteristics of cohort studies included in the analysis suffered from high heterogeneity, with most studies failing to achieve comparable initial injury severity scores based on the Gustilo-Anderson open fracture classification system. Finally, due to the severity of open fracture injuries, the outpatient clinical utility of NPWT for this form of trauma is unclear with most studies focusing on inpatient applications.

Sahebally et al (2018) performed a systematic review with meta-analysis to evaluate the effects of NPWT on SSIs in closed laparotomy incisions.^24, Researchers searched 4 databases through December 31, 2017, and screened bibliographies of retrieved studies to find further studies; 9 unique studies (3 RCTs, 2 prospective studies, and 4 retrospective studies) representing 1266 unique patients were included in the review. The analysis determined that NPWT was associated with a significantly lower rate of SSI compared with standard wound dressing (pooled OR: 0.25; 95% CI: 0.12-0.52; p<0.001). The review was limited by including mostly non-randomized studies and use of different NPWT devices.

Randomized Controlled Trials

Selected RCTs of NPWT for surgical or traumatic wounds are summarized in Table 2.

Table 2. Summary of Key RCTs of NPWT versus Standard Therapy in Surgical Wounds

Study; Trial	Surgery Received	No. of Participants	Notes on NPWT effectiveness	P-value
Stannard et al (2012)25,	Various, after fractures and other trauma	249	Fewer infections, less discharge than standard closure	0.049
Masden et al (2012)26,	Various	81	NSD in infection or healing	NR
Chio and Agrawal (2010)27,	Radial forearm donor site	43	NSD in wound complications or graft failure	NR
Javed et al (2018)28,	Open pacreaticoduodenectomy	123	9.7% of NPWT group developed infections, compared with 31.1% of standard closure group	0.003
Tanaydin et al (2018)29,	Bilateral breast reduction mammoplasty	32	Patients used as own control; NPWT associated with significantly lower risk of complication and improved pain and scarring compared with fixation strips	<0.004
Costa et al (2018); WOLLF23,	Severe open fracture of the lower limb	460	NSD in self-rated disability, number of deep SSI, or QOL scores	Disability: 0.13 SSI: 0.64 QOL: NR

NPWT: negative pressure wound therapy; NR: not reported; NSD: no significant difference; QOL: quality of life; RCT: randomized controlled trial; SSI: surgical site infection.

One of the largest studies on prophylactic NPWT for surgical wounds is a report from an investigator-initiated, industry-sponsored multicenter RCT of inpatient NPWT for closed surgical incisions by Stannard et al(2012).^25,(A preliminary report was published in 2006.^30,) Participants included 249 blunt trauma patients with 263 high-risk fractures (tibial plateau, pilon, calcaneus) requiring surgical stabilization. Patients were randomized to NPWT applied to the closed surgical incision or to standard postoperative dressings. All trial participants were maintained as inpatients until wound drainage was minimal, at which time NPWT was discontinued (mean, 59 hours; range, 21-213 hours). Patients in the NPWT group were ready for discharge in 2.5 days compared with 3.0 days for the control group (the difference was not statistically significant). The NPWT group had significantly fewer infections (10% of fractures) than the control group (19% of fractures; p=0.049). Wound dehiscence after discharge was observed less frequently in the NPWT group (8.6%) than in the control group (16.5%). These results would support the efficacy of the short-term use of NPWT when used under highly controlled conditions of inpatient care, but not the effectiveness of NPWT in the outpatient setting. A small 2015 RCT (n=20) of NPWT in an outpatient setting reported that patients treated with NPWT required significantly fewer dressing changes, reported significantly less pain, and experienced QOL improvements compared with standard wound care.^31,

Other randomized studies have reported no benefit for NPWT for surgical wounds, as reflected in the conclusions of various Cochrane reviews (described above).^20,9, For example, the RCT by Masden et al (2012) examined the use of NPWT for surgical closures at high-risk for nonhealing in 81 patients with comorbidities that included diabetes and peripheral vascular disease.^26, At a mean of 113 days follow-up, there were no significant differences in the proportions of patients with wound infection, time to develop infection or dehiscence between NPWT and dry dressing groups. Chio and Agrawal (2010) published results of a randomized trial of 54 patients comparing NPWT with a static pressure dressing for the healing of the radial forearm free flap donor site.^27, There were no statistically significant differences in wound complications or graft failure (percentage of area for graft failure, 7.2% for negative pressure vs 4.5% for standard dressing). Biter et al (2014) found no significant advantage of 2 weeks of NPWT in 49 patients who underwent surgical excision for pilonidal sinus disease.^32, Complete wound healing was achieved at a median of 84 days in the NPWT group and 93 days in controls.

Javed et al (2018) conducted a single-site RCT to evaluate the efficacy of NPWT for SSI after an open pacreaticoduodenectomy. Researchers randomized 123 patients treated from January 2017 through February 2018 to either NPWT (n=62) or standard closure (n=61). In the study, 9.7% of patients who received NPWT developed a postoperative infection at the site, compared with 31.1% of patients who received standard closure, anRR of 0.31 (95% CI: 0.13-0.73; p=0.003). Limitations of the study included being conducted at a high-volume treatment center and a lack of blinding.^28,

Tanaydin et al (2018) conducted an RCT to compare NPWT to standard wound care after a bilateral breast reduction mammoplasty.^29, In the study, 32 patients were given NPWT on one breast and fixation strips on the other, simultaneously serving as study group and control group. Sites treated with NPWT showed a significantly lower rate of complications (p<0.004) compared to fixation strips, as well as improved pain and scarring. Limitations included the small sample size and lack of blinding.

The Effect of Negative Pressure Wound Therapy vs Standard Wound Management on 12-Month Disability Among Adults With Severe Open Fracture of the Lower Limb (WOLLF trial by Costa et al (2018) randomized 460 patients with severe open fracture of the lower limb to NPWT (n=226) or standard wound management (n=234).^23, The primary outcome was the Disability Rating Index score (range, 0 [no disability] to 100 [completely disabled]) at 12 months, with a minimal clinically important difference of 8 points. Secondary outcomes included deep infection and QOL measures based on the EuroQol 5-dimensions questionnaire. Eighty-eight percent of participants completed the trial. There were no statistically significant differences in disability scores (45.5 vs. 42.4; p=0.13), in the number of deep infections (16 [7.1%] vs. 19 [8.1%]; p=0.64), or in quality of life measures in the NPWT and standard wound management groups, respectively.

Section Summary: Traumatic and Surgical Wounds

The evidence on the use of NPWT for individuals who have traumatic or surgical wounds includes RCTs and systematic reviews. One RCT found no benefit of NPWT on graft take and wound epithelialization in patients with full-thickness burns. NPWT showed no benefit for the treatment of patients with surgical wounds or skin grafts healing by primary intention, and a systematic review of NPWT for traumatic and surgical wounds found no differences between standard dressing and NPWT for any wound outcome measure. However, a small RCT suggested that prophylactic NPWT might reduce the number of dressing changes and pain when used in an outpatient setting. A small retrospective study reported improved epithelialization in patients free of comorbidities treated with NPWT. Additional study in a larger sample is needed to evaluate this outcome measure.

Portable Single-Use NPWT Devices for Any Wound Type (Acute and Nonhealing)

Clinical Context and Therapy Purpose

The purpose of portable single-use outpatient NPWT is to provide a treatment option that is an alternative to or an improvement on existing therapies in patients with any wound type (acute or nonhealing).

The question addressed in this policy is: Does NPWT improve outcomes when used for the outpatient treatment of pressure ulcers, diabetic foot ulcers, venous ulcers, burn wounds, and traumatic or surgical wounds; and to assess the evidence on the use of portable NPWT devices?

The following PICO was used to select literature to inform this review.

Patients

The relevant population of interest is individuals with any wound type (acute or nonhealing).

Interventions

The therapy being considered is portable single-use outpatient NPWT.

Comparators

Comparators of interest include standard NPWT.

Outcomes

The general outcomes of interest are symptoms, change in disease status, morbid events, QOL, and treatment-related morbidity. Follow-up at weeks to months is of interest for portable, single-use outpatient NPWT to monitor relevant outcomes.

Study Selection Criteria

Methodologically credible studies were selected using the following principles:

a. To assess efficacy outcomes, comparative controlled prospective trials were sought, with a preference for RCTs;
b. In the absence of such trials, comparative observational studies were sought, with a preference for prospective studies.
c. To assess long-term outcomes and adverse events, single-arm studies that capture longer periods of follow-up and/or larger populations were sought.

SNaP Wound Care System

The portable, nonpowered (mechanical) gauze-based SNaP Wound Care System became available in 2009. The device is designed to remove small amounts of exudate from chronic, traumatic, dehisced, acute, or subacute wounds and diabetic and pressure ulcers.

Armstrong et al (2011) reported on results of a planned interim analysis of an RCT comparing the SNaP Wound Care System with the V.A.C. Therapy for the treatment of chronic lower-extremity wounds.^33,Final results of this industry-sponsored multicenter noninferiority trial were reported in 2012.^34, The trial enrolled 132 patients with lower-extremity venous or diabetic ulcers with a surface area between 1 cm² and 100 cm² and diameter less than 10 cm present for more than 30 days despite appropriate care having. Dressings were changed per the manufacturer’s direction: 2 times per week in the SNaP group and 3 times per week in the V.A.C. group. Patients were assessed for up to 16 weeks or until complete wound closure; 83 (63%) patients completed the study. Intention-to-treat analysis with the last observation carried forward showed noninferiority in the primary outcome of wound size reduction at 4, 8, 12, and 16 weeks. When adjusted for differences in wound size at baseline, SNaP-treated subjects showed noninferiority to V.A.C.-treated subjects at 4, 12, and 16 weeks. Kaplan-Meier analysis showed no significant difference in complete wound closure between the 2 groups. At the final follow-up, 65.6% of the V.A.C. group and 63.6% of the SNaP group had wound closure. Survey data indicated that dressing changes required less time with the SNaP device and use of the SNaP device interfered less with mobility and activity than the V.A.C. device. Subgroup analysis (2015) of 40 patients with venous leg ulcers who completed the study showed a significant improvement in the percentage of those with complete wound closure treated with SNaP (57.9%) compared with the V.A.C. system (38.2%; p=0.008).^35, This study had a high loss to follow-up and lacked a comparison with standard treatment protocols.

A 2010 retrospective study with historical controls compared NPWT using the SNaP device (n=28) with wound care protocols using Apligraf, Regranex, and skin grafting (n=42) for the treatment of lower-extremity ulcers.^36,Seven (25%) patients in the SNaP-treated group could not tolerate the treatment and were discontinued from the study because of complications; they were considered treatment failures. Between-group estimates of time-to-wound healing by Kaplan-Meier analysis favored the SNaP treatment group. This study is limited by the use of historical controls, multiple modalities to treat controls, and a large number of dropouts. The authors noted that patients in the SNaP-treated group might have benefited from being in an experimental environment, particularly because wounds in this group were seen twice per week compared with variable follow-up in historical controls.

PICO Dressing

PICO is a portable single-use NPWT system that comes with 2 sterile dressings and has a lifespan of 7 days. Karlakki et al (2016) reported on an RCT with 220 patients that evaluated the use of the PICO device in a surgical center immediately after hip and knee arthroplasties.^37, The device was left on for 7 days, including the time after the hospital stay. Strengths of the trial included power and intention-to-treat analysis, but evaluators were not blinded. There were trends toward reductions in hospital length of stay (0.9 days; 95% CI, -0.2 to 2.5 days; p=0.07) and postoperative surgical wound complications (8.4% control vs. 2.0% PICO, p=0.06). However, most of the difference in length of stay was due to wound complications in 2 outliers in the control group (up to 61 days). The level of wound exudate was significantly reduced by the PICO device (p=0.007), with 4% of the study group and 16% of the control group having grade 4 (scale grade, 0-4) exudate. Blisters were observed in 11% of patients treated with the PICO system, although the blister occurrence was reported to be reduced when the dressing was stretched less.

Schwartz et al (2015) reported on an industry-funded pilot study assessing 12 patients who had small wounds of various types (total, 13 wounds).^38, A key selection criterion was a complete failure to progress over the previous 4 weeks. During the 4 weeks of PICO application, wound size decreased and wound appearance improved. There was no control group in this pilot study and no wound closures during the short follow-up period. The authors noted that in unpublished data, the device was not effective on the skin graft donor sites.

O’Leary et al (2017) published an RCT that allocated 50 patients to standard wound dressing or negative pressure wound dressing after abdominal surgery; patients had class I, II, or IIl wounds, and the treatment group was given the PICO dressing.^39, SSI was evaluated at 4 and 30 days following surgery, and results were analyzed both on per-protocol and intention-to-treat bases. Caregivers did not find a significant difference between groups after 4 days (p=0.516); however, at the 30-day follow-up, rates of SSIs were significantly lower for the group receiving negative pressure dressing than for the control group, both in per-protocol analysis (8.3% vs. 32.0%, p=0.043) and intention-to-treat analysis (12% vs. 32%, p=0.073). Univariate analysis showed a significant association between standard wound dressing and the likelihood of anSSI (p=0.040); for secondary outcomes (eg, cosmetic outcome, patient satisfaction), the authors reported no difference between groups. The mean length of stay was shorter for patients who received negative pressure dressings (6.1 days) than for control patients; however, when all reasons for delayed discharge were accounted for, the difference was not statistically significant (p=0.89). While comparatively small, this trial would indicate that negative pressure dressings resulted in a beneficial outcome for patients recovering from abdominal surgery regarding the occurrence of SSIs.

Strugala and Martin (2017) published a meta-analysis of comparative trials evaluating the PICO system for the prevention of surgical site complications.^40,A total of 1863 patients were represented by 10 RCTs and 7 observational studies. The rate of SSI was reduced by 51% with the PICO system compared to standard care (10 RCTs; RR 0.49; 95% CI, 0.34 to 0.69; p<0.0001). There was a significant reduction in wound dehiscence (17.4% vs. 12.8%; RR 0.71; 95% CI, 0.54 to 0.92; p<0.01) and mean hospital length of stay (-0.47 days; 95% CI, -0.71 to -0.23; p<0.0001) with the PICO system. It is unclear whether included studies captured outpatient utilization of the device.

Prevena System

Prevena is a single-use NPWT system designed specifically for incisions. Grauhan et al (2013) reported on a pseudorandomized trial (alternating assignment) with 150 consecutive obese patients who underwent cardiac surgery via a median sternotomy.^41, Use of the Prevena System for 6 to 7 days beginning immediately after suturing reduced rates of wound infection (4%) compared with standard wound care (4 vs. 16%; p=0.027). Gram-positive skin flora was found in 1 patient in the Prevena group and in10 patients in the wound care group. This study was performed in an inpatient setting. A randomized trial, The Use of Prevena Incision Management System on Clean Closed Sternal Midline Incisions in Subjects at High Risk for Surgical Site Occurrences (NCT02195310) involving a larger number of patients with sternal midline incisions was terminated in early 2017.

Pauser et al (2016) reported on a small RCT (n=21) evaluating Prevena in patients who had hemiarthroplasty for femoral neck fractures.^42, Use of the Prevena System significantly reduced seroma size, days of wound secretion, wound care time, and need for dressing changes.

Gombert et al (2018) published findings from the Closed Incision Negative Pressure Therapy Reduces Surgical Site Infections in Vascular Surgery (AIMS) trial, a prospective RCT evaluating Prevena in patients undergoing vascular groin surgery for peripheral artery disease (n=204).^43,The primary outcome was the rate of SSI with the Prevena System (n=98) compared to patients receiving standard wound dressings (n=90). Ten patients were excluded as screening failures and 6 patients were excluded due to early occlusion of treated vessels requiring de novo surgery. The Prevena System was removed at 5-7 days postoperatively. Patients were evaluated on the day of discharge (day 7), and again at 15 and 30 days post-surgery by blinded wound care nurses. Wounds were evaluated clinically according to Szilagyi classification criteria (grades I-III). Prophylactic antibiotics were administered to 13.2% of the Prevena group and 31.1% of the control group (p=0.004). The control group experienced more frequent SSI (33.3%; 30/90) than the Prevena group (13.2%; 13/98; p=0.0015). However, the absolute risk difference of -20.1 per 100 (95% CI, -31.9 to 8.2) was based on an increased rate of Szilagyi I SSI (24.6% vs. 8.1%; p=0.0012). Bacterial swabs were performed in each case of suspected SSI. Only 10/43 suspected infections returned positive swabs, 5 in each treatment arm, suggesting the study may have been biased by methodological flaws relating to subjective SSI assessment.

Murphy et al (2019) published findings from the Negative Pressure Wound Therapy Use to Decrease Surgical Nosocomial Events in Colorectal Resections (NEPTUNE) trial, a single-center, superiority designed prospective randomized open blinded endpoint controlled trial evaluating the use of the Prevena System on closed incisions compared to standard gauze dressings in patients undergoing colorectal resection via laparotomy (n=300).^44, The was no significant difference in the incidence of SSI at 30 days post-surgery between the Prevena and control groups (32% vs. 34%; p=0.68). No significant difference in length of hospital stay was reported.

Hussamy et al (2019) reported on an open-label RCT evaluating the Prevena System for incisional NPWT following cesarean delivery in women with class III obesity (Body Mass Index ≥ 40; n=222) compared to standard dressings (n=219).^45, The overall composite wound morbidity rate was not significantly different between the Prevena and control cohorts (17% vs. 19%; RR 0.9; 95% CI, 0.5 to 1.4).

Singh et al (2018) performed a systematic review and meta-analysis to evaluate the efficacy of the Prevena System in reducing SSI in closed incisions compared to traditional dressings.^46, The meta-analysis included 11 RCTs, 7 prospective studies, and 12 retrospectives studies. The Prevena System showed a significant reduction in SSI (11 RCTs [n=1579];OR 2.7; 95% CI, 2.0 to 3.6; I²=24%; p<00001). Analysis of studies by anatomical location (colorectal/abdominal, obstetrics, lower extremity, groin/vascular, and cardiac) continued to demonstrate a significant effect for the Prevena System in all categories based on the fixed-effects model. When the analyses were repeated with the random-effects model, a significant effect for the Prevena System was upheld for all anatomical categories except obstetrics (OR 1.7; 95% CI, 0.9 to 3.5; p=0.11). The analysis was limited by heterogeneity in outcome reporting and blinding practices. Only 4 of 30 included studies reported on wound categories established by the Centers for Disease Control.

Systematic Reviews

Yu et al (2019) published a meta-analysis of prophylactic NPWT after cesarean delivery in high-risk women with obesity. Six RCTs and 3 cohort studies primarily utilizing Prevena and PICO systems were included for analysis.^47,Compared to standard wound dressings, NPWT was associated with a significantly lower risk of SSI from 7 pooled studies (RR 0.45; 95% CI 0.31 to 0.66; I2=9.9%). Absolute risk reduction was -6.0% (95% CI, -10% to -3.0%) with a NNT of 17. NPWT was also associated with a statistically significant reduction in the number of composite wound complications (9 studies, RR 0.68; 95% CI 0.49 to 0.94), but no other secondary outcome measures (ie, dehiscence, seroma, endometritis, and hospital re-admission). The analysis was limited by heterogeneity in study inclusion criteria and outcome measures, including lack of standardized definitions for SSIs. Additionally, potential harms of treatment were not consistently reported across studies, whereas existing literature on the use of prophylactic NPWT in the context of other surgical procedures has reported high rates of side effects such as skin blisters, erythema, and wound bleeding.^48,Review authors recommend larger definitive trials to clarify clinical utility.

Section Summary: Portable Single-Use NPWT Devices for Any Wound Type

The evidence on portable single-use NPWT includes systematic reviews, an RCT of the PICO device, an RCT of the nonpowered SNaP System, and a pseudorandomized study of the Prevena Incision Management System. The PICO device was studied in an adequately powered but unblinded RCT of combined in- and outpatient use after total joint arthroplasty; also, a 2017 RCT compared the PICO device with standard dressing following abdominal surgery. Results showed some potential benefits but were not statistically significant. Further study in an outpatient setting is needed. One study of the SNaP System showed noninferiority to a V.A.C. device. However, interpretation of this study is limited by a high loss to follow-up and lack of a control group treated with dressings. The evidence base for the Prevena System is not sufficiently robust for conclusions on efficacy to be drawn. Well-designed comparative studies with larger numbers of patients are needed.

Summary of Evidence

For individuals who have diabetic lower-extremity ulcers or amputation wounds who receive outpatient NPWT, the evidence includes RCTs and systematic reviews of RCTs. The relevant outcomes are symptoms, change in disease status, morbid events, quality of life (QOL), and treatment-related morbidity. There was a higher rate of wound healing and fewer amputations with NPWT, although the studies were at risk of bias due to lack of blinding. The evidence is sufficient to determine that the technology results in a meaningful improvement in the net health outcome.

For individuals who have chronic pressure ulcers who receive outpatient NPWT, the evidence includes RCTs and systematic reviews. The relevant outcomes are symptoms, change in disease status, morbid events, QOL, and treatment-related morbidity. All trials are of low-quality and at high-risk of bias. Also, most study populations were treated in inpatient settings. The evidence is insufficient to determine the effects of the technology on health outcomes.

For individuals who have lower-extremity ulcers due to venous insufficiency who receive outpatient NPWT, the evidence includes an RCT and a systematic review. The relevant outcomes are symptoms, change in disease status, morbid events, QOL (quality of life), and treatment-related morbidity. A single RCT in patients with nonhealing leg ulcers who were treated with skin grafts found a faster rate of healing with NPWT when used in the inpatient setting. No studies were identified on the effectiveness of NPWT as a primary treatment for leg ulcers or for the use of NPWT in the outpatient setting. The evidence is insufficient to determine the effects of the technology on health outcomes.

For individuals who have burn wounds who receive outpatient NPWT, the evidence includes RCTs, systematic reviews, and case series. The relevant outcomes are symptoms, change in disease status, morbid events, QOL, and treatment-related morbidity. An interim report of an RCT evaluating NPWT in partial-thickness burns, summarized in a Cochrane review, did not permit conclusions on the efficacy of NPWT for this indication. A separate RCT comparing NPWT with split-skin grafts in patients with full-thickness burns did not show differences in graft take and wound epithelialization. A retrospective case series reported functional outcomes for most patients who were treated with NPWT at a single-center. The evidence is insufficient to determine the effects of the technology on health outcomes.

For individuals who have traumatic or surgical wounds who receive outpatient NPWT, the evidence includes RCTs and systematic reviews. The relevant outcomes are symptoms, change in disease status, morbid events, QOL, and treatment-related morbidity. There are limited data on NPWT as a primary treatment of partial-thickness burns. One RCT found no benefit of NPWT on graft take and wound epithelialization in patients with full-thickness burns. NPWT showed no benefit in the treatment of patients with surgical wounds or skin grafts healing by primary intention, and a systematic review of NPWT for traumatic and surgical wounds found no differences between standard dressing and NPWT for any wound outcome measure. However, a small RCT has suggested that prophylactic NPWT may reduce the number of dressing changes and pain when used in an outpatient setting. A small retrospective study reported improved epithelialization with NPWT in patients free of comorbidities. Additional study in larger samples is needed to evaluate this outcome measure. The evidence is insufficient to determine the effects of the technology on health outcomes.

For individuals who have any wound type (acute or nonhealing) who receive portable single-use outpatient NPWT, the evidence includes systematic reviews and RCTs. The relevant outcomes are symptoms, change in disease status, morbid events, QOL, and treatment-related morbidity. The evidence includes an RCT of the PICO Single Use Negative Pressure Wound Therapy System, an RCT of the nonpowered Smart Negative Pressure Wound Care System, and a pseudorandomized study of the Prevena Incision Management System. The PICO device was studied in an adequately powered but unblinded RCT of combined in- and outpatient use following total joint arthroplasty; also, a 2017 RCT compared the PICO device with standard dressing following abdominal surgery. Results showed some benefits, though not statistically significant. One study with the Smart Negative Pressure nonpowered Wound Care System showed noninferiority to a vacuum-assisted closure device. However, interpretation of this trial is limited by a high loss to follow-up and lack of a control group treated with dressings. These studies are insufficient to draw conclusions about its efficacy. Well-designed comparative studies with larger numbers of patients are needed to determine the effects of these technologies with greater certainty. The evidence is insufficient to determine the effects of the technology on health outcomes.

Overall, the evidence from comparative clinical trials has demonstrated there is a subset of problematic wounds for which the use of NPWT may provide a significant clinical benefit. However, due to clinical variability and limited data, it is not possible to determine prospectively which wounds are most likely to respond favorably to NPWT. In addition, clinical input supports a therapeutic trial of NPWT for chronic pressure ulcers that have failed to heal, for traumatic or surgical wounds that have failed to close when there is exposed bone, cartilage, tendon, or foreign material within the wound, and for nonhealing wounds in patients with underlying clinical conditions known to negatively impact wound healing. Therefore, a therapeutic trial of NPWT of not less than 14 days may be considered medically necessary for chronic wounds that have failed to heal, despite intense conventional wound therapy for at least 90 days, or for wounds of at least 30 days that have a high probability of failure to heal due to compounding factors involving the wound and the patient. For continued use of NPWT beyond 14 days to meet criteria for medical necessity, there must be objective evidence of wound healing, such as the development of healthy granulation tissue and progressive wound contracture.

SUPPLEMENTAL INFORMATION

Clinical Input From Physician Specialty Societies and Academic Medical Centers

While the various physician specialty societies and academic medical centers may collaborate with and make recommendations during this process, through the provision of appropriate reviewers, input received does not represent an endorsement or position statement by the physician specialty societies or academic medical centers, unless otherwise noted.

In response to requests, input was received from 2 physician specialty societies and 3 academic medical centers while this policy was under review in 2010. The input was near uniform in support of a therapeutic trial of negative pressure wound therapy (NPWT) for chronic pressure ulcers that have failed to heal; for traumatic or surgical wounds that have failed to close when there is exposed bone, cartilage, tendon, or foreign material within the wound; and for nonhealing wounds in patients with underlying clinical conditions known to negatively impact wound healing. Most input affirmed that therapeutic trials of NPWT for other acute or chronic wounds would not be medically necessary.

Practice Guidelines and Position Statements

International Expert Panel on Negative Pressure Wound Therapy

In 2011, an international expert panel on NPWT provided evidence-based recommendations for the use of NPWT in chronic wounds.^49, The panel made the following recommendations for the use of NPWT (see Table 3).

Table 3. Recommendations on Use of NPWT in Chronic Wounds

Condition	Recommendation	Gradea
Pressure ulcers, grade 3-4	“NPWT may be used until surgical closure is possible/desirable.”	C
	“NPWT should be considered to achieve closure by secondary intention…. to reduce wound dimensions…. [and] to improve the quality of the wound bed.”	B
Diabetic foot ulcers	“NPWT must be considered as an advanced wound care therapy…. [and] must be considered to achieve healing by secondary intention.”	A
	“NPWT should be considered in an attempt to prevent amputation or reamputation.”	B
Ischemic lower-limb wounds	“… NPWT … may be considered in specialist hands and never as an alternative for revascularisation.”	C
	“… NPWT is NOT indicated in acute limb ischemia.”	D
Venous leg ulcers	“If first-line therapy (compression) is not efficacious, NPWT should be considered to prepare the wound for surgical closure….”	B

NPWT: negative pressure wound therapy.
^a Grade A: based on high-quality meta-analyses, systematic reviews of RCTs, or RCTs with very low risk of bias; grade B: based on high-quality systematic reviews of case-control or cohort studies; grade C: based on well-conducted case-control or cohort studies; grade D: based on case series or expert opinion.

International Multidisciplinary Consensus Recommendations

Willy et al (2017) presented evidence-based consensus guidelines on the use of closed incision negative pressure therapy (ciNPT) following surgery.^50, Among the studies found were 100 randomized controlled studies on ciNPT, most of which found an association between the use of ciNPT and improved outcomes. Based on the evidence, the consensus panel recommended that surgeons evaluate risk in patients before surgery to determine whether patient comorbidities (ie, obesity or diabetes) or the nature of the surgery presents an increased danger of infection. In such cases, the panel recommended the use of ciNPT.

Infectious Diseases Society of America and Surgical Infection Society

Guidelines for the prevention of infections associated with combat-related injuries were endorsed in 2011 by the Infectious Diseases Society of America and the Surgical Infection Society.^51, The guidelines provided an IB recommendation (strong recommendation, moderate-quality evidence) that NPWT should be used to manage open wounds (excluding central nervous system injuries).

The 2012 guidelines from the Society for the diagnosis and treatment of diabetic foot infections stated that no adjunctive therapy has been proved to improve the resolution of infection, but for select diabetic foot wounds that are slow to heal, clinicians might consider using NPWT (weak recommendation, low-quality evidence).^52,

American College of Physicians

The American College of Physicians (2015) published guidelines on the treatment of pressure ulcers.^53, The guidelines stated there was low-quality evidence that the overall treatment effect of NPWT did not differ from the standard of care.

Association for the Advancement of Wound Care

The Association for the Advancement of Wound Care (2010) published guidelines on the care of pressure ulcers. NPWT was included as a potential second-line intervention if first-line treatments did not result in wound healing (level B evidence). The guidelines indicated that patients must be selected carefully for this procedure. The guidelines were updated in 2014 with additional validation.^54,

The Association (2010) supported guidelines on the care of venous ulcers.^55,The guidelines listed NPWT as a potential adjunctive therapy if conservative therapy does not work in 30 days. The guidelines noted there is limited evidence for NPWT (level B) compared with other adjunctive therapies

National Institute for Health and Care Excellence

The NICE (2013) issued guidance on NPWT for surgical wounds, concluding that “Current evidence on the safety and efficacy of negative pressure wound therapy (NPWT) for the open abdomen is adequate to support the use of this procedure.”^56,

A 2015 NICE guidance on diabetic foot problems, updated in October 2019, has recommended consideration of NPWT after surgical débridement for diabetic foot ulcers on the advice of the multidisciplinary foot care service.^57, It was noted that the evidence reviewed for NPWT was limited and of low-quality, and that it would be useful to have more evidence for this commonly used treatment.

The NICE (2014) issued guidance on the prevention and management of pressure ulcers.^58,The guidance stated, “Do not routinely offer adults negative pressure wound therapy to treat a pressure ulcer, unless it is necessary to reduce the number of dressing changes (for example, in a wound with a large amount of exudate).”Also, the guidance did not recommend NPWT for neonates, infants, or children.

U.S. Preventive Services Task Force Recommendations

Not applicable.

Ongoing and Unpublished Clinical Trials

Some currently unpublished trials that might influence this review are listed in Table 4.

Table 4. Summary of Key Trials

NCT No.	Trial Name	Planned Enrollment	Completion Date
Ongoing
NCT02664168	A Prospective, Randomized, Comparative Study to Assess the Prevention of Surgical Site Infection (SSI's) in Revision Total Joint Arthroplasty Patients Treated With Single-Use Negative Pressure Wound Therapy (PICO™) or Standard Care Dressings (AQUACEL® Ag SURGICAL Dressing)		Feb 2020 (recruiting)
NCT01528033a	Treatment Study of Vacuum-Assisted Closure for Postsurgical Subcutaneous Abdominal Wound Healing Impairments (SAWHI)	550	Jun 2018 (unknown)
NCT02309944	Negative Pressure Wound Therapy in Obese Gynecologic Oncology Patients	200	Dec 2020 (ongoing)
NCT02509260	Prevena™ Incisional Negative Pressure Wound Therapy in Re-operative Colorectal Surgery	298	Dec 2019 (recruiting)
NCT01913132	PICO Versus Standard Dressing Above Groin Incisions After Vascular Surgery - a Prospective Randomized Trial	644	Apr 2020 (recruiting)
NCT02348034a	A Randomized Controlled Trial Exploring the Ability of Negative Pressure Wound Therapy (NPWT) to Reduce Colorectal Surgical Site Infections (SSI)	398	Jul 2020 (recruiting)
NCT02954835	Negative Pressure Therapy for Closed Groin Wounds in Patients Undergoing Vascular Surgery	100	Dec 2019 (recruiting)
NCT02467998	The Registry of Negative Pressure Wound Therapy for Chronic Wounds and Ulcers	50,000	Jan 2020 (recruiting)
NCT03144726	Single Center Prospective Randomized Control Trial on Negative Pressure Wound Therapy for Incisions Following Major Lower-limb Amputation to Reduce Surgical Site Infection	290	Jul 2020
NCT02682316a	A Phase III Randomized Controlled Trial of Negative Pressure Wound Therapy in Post-Operative Incision Management	686	Feb 2021 (recruiting)
NCT01821664	Vascular Graft Infections - Epidemiology, Best Treatment Options, Imaging Modalities and Impact of Negative Pressure Wound Therapy	1800	Mar 2023 (recruiting)
NCT02813161	A Real World, Observational Registry of Diabetic Foot Ulcers and Quality of Care in Clinical Practice	10,000	Feb 2025 (recruiting)
Unpublished
NCT02799667	Randomized Controlled Trial: Do Single Use Negative Pressure Dressings Reduce Wound Complications in Women With a BMI >40 kg/m2 Undergoing Cesarean Delivery at a Tertiary Medical Center?	110	Terminated
NCT02020018a	Negative Pressure Wound Therapy for Prevention of Wound Infection After Heart Surgery	1869	Oct 2018 (completed)
NCT01191567	Negative Pressure Wound Therapy. Therapy Effects and the Impact on the Patient’s Quality of Life	200	Terminated
NCT02470806a	A Prospective, Randomized, Comparative Effectiveness Study of a Single-Use, Negative Pressure Wound Therapy System (PICO) Versus a Traditional Negative Pressure Wound Therapy System (tNPWT) in the Treatment of Lower Extremity Ulcers	163	Nov 2017 (completed)
NCT02395159	Reduction of Groin Wound Infections After Vascular Surgery in Patients With Risk Factors by the Use a Negative Pressure Wound Incision Management System (KCI Prevena)	204	Oct 2017 (completed)
NCT02739191	Negative Pressure Wound Therapy for Surgical Wounds of the Foot and Ankle	60	Aug 2017 (completed)
NCT02195310a	The Use of PrevenaTM Incision Management System on Clean Closed Sternal Midline Incisions in Subjects at High Risk for Surgical Site Occurrences	342	Terminated
NCT02064270a	A Prospective, Randomized, Controlled Clinical Study to Assess the Prevention of Postsurgical Incision Healing Complications in Patients Undergoing Primary or Revision Total Knee Arthroplasty (TKA) or Total Hip Arthroplasty (THA), Treated With Either Single-Use Negative Pressure Wound Therapy (NPWT) or Standard Postsurgical Dressings	526	Sep 2017 (completed)
NCT01890720a	Use of Incisional Negative Pressure Wound Therapy for Prevention of Postoperative Infections Following Caesarean Section in Women With BMI ≥30	876	Dec 2016 (completed)

NCT: national clinical trial.
^a Denotes industry-sponsored or cosponsored trial.]
________________________________________________________________________________________

Horizon BCBSNJ Medical Policy Development Process:

This Horizon BCBSNJ Medical Policy (the “Medical Policy”) has been developed by Horizon BCBSNJ’s Medical Policy Committee (the “Committee”) consistent with generally accepted standards of medical practice, and reflects Horizon BCBSNJ’s view of the subject health care services, supplies or procedures, and in what circumstances they are deemed to be medically necessary or experimental/ investigational in nature. This Medical Policy also considers whether and to what degree the subject health care services, supplies or procedures are clinically appropriate, in terms of type, frequency, extent, site and duration and if they are considered effective for the illnesses, injuries or diseases discussed. Where relevant, this Medical Policy considers whether the subject health care services, supplies or procedures are being requested primarily for the convenience of the covered person or the health care provider. It may also consider whether the services, supplies or procedures are more costly than an alternative service or sequence of services, supplies or procedures that are at least as likely to produce equivalent therapeutic or diagnostic results as to the diagnosis or treatment of the relevant illness, injury or disease. In reaching its conclusion regarding what it considers to be the generally accepted standards of medical practice, the Committee reviews and considers the following: all credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, physician and health care provider specialty society recommendations, the views of physicians and health care providers practicing in relevant clinical areas (including, but not limited to, the prevailing opinion within the appropriate specialty) and any other relevant factor as determined by applicable State and Federal laws and regulations.

___________________________________________________________________________________________________________________________

Index:
Negative-Pressure Wound Therapy
MiniV.A.C. Device
Vacuum-Assisted Closure (VAC) Therapy
VAC Therapy
V.A.C. Device
Wound Therapy, Negative-Pressure
V.A.C ATS System
V.A.C. Instill System
InfoV.A.C. Therapy System
V.A.C. Freedom System
ActiV.A.C. Therapy System
Versatile 1 Wound Vacuum System
Vista Versatile 1 Portable
SNaP Wound Care System

References:
1. U.S. Food and Drug Administration. UPDATE on Serious Complications Associated with Negative Pressure Wound Therapy Systems: FDA Safety Communication. 2011 Feb; http://wayback.archive-it.org/7993/20170722215801/https://www.fda.gov/MedicalDevices/Safety/AlertsandNotices/ucm244211.htm. Accessed December 2, 2019.

2. Blue Cross and Blue Shield Association Technology Evaluation Center (TEC). Vacuum-assisted closure in the treatment of chronic wounds. TEC Assessments. 2000;Volume 15:Tab 23.

3. Rhee SM, Valle MF, Wilson LM, et al. Negative Pressure Wound Therapy Technologies For Chronic Wound Care in the Home Setting. Evidence Report/Technology Assessment (Contract No. 290-201-200007-I) Rockville, MD: Agency for Healthcare Research and Quality; 2014.

4. Rhee SM, Valle MF, Wilson LM, et al. Negative pressure wound therapy technologies for chronic wound care in the home setting: A systematic review. Wound Repair Regen. Jul-Aug 2015;23(4):506-517. PMID 25845268

5. Sullivan N, Snyder DL, Tipton K, et al. Technology assessment: Negative pressure wound therapy devices (Contract No. 290-2007-10063). Rockville, MD: Agency for Healthcare Research and Quality; 2009.

6. Webster J, Liu Z, Norman G, et al. Negative pressure wound therapy for surgical wounds healing by primary closure. Cochrane Database Syst Rev. 2019 Mar 26;3:CD009261. PMID: 30912582

7. Li HZ, Xu XH, Wang DW, et al. Negative pressure wound therapy for surgical site infections: a systematic review and meta-analysis of randomized controlled trials. Clin Microbiol Infect. 2019 Nov;25(11):1328-1338. PMID: 31220604

8. Dumville JC, Hinchliffe RJ, Cullum N, et al. Negative pressure wound therapy for treating foot wounds in people with diabetes mellitus. Cochrane Database Syst Rev. Oct 17 2013;10(10):CD010318. PMID 24132761

9. Iheozor-Ejiofor Z, Newton K, Dumville JC, et al. Negative pressure wound therapy for open traumatic wounds. Cochrane Database Syst Rev. 2018 Jul 3;7:CD012522. PMID: 29969521

10. Wynn M, Freeman S. The efficacy of negative pressure wound therapy for diabetic foot ulcers: A systematised review. J Tissue Viability. 2019 Aug;28(3):152-160. PMID: 31056407

11. Blume PA, Walters J, Payne W, et al. Comparison of negative pressure wound therapy using vacuum-assisted closure with advanced moist wound therapy in the treatment of diabetic foot ulcers: a multicenter randomized controlled trial. Diabetes Care. Apr 2008;31(4):631-636. PMID 18162494

12. Borys S, Hohendorff J, Koblik T, et al. Negative-pressure wound therapy for management of chronic neuropathic noninfected diabetic foot ulcerations - short-term efficacy and long-term outcomes. Endocrine. Dec 2018;62(3):611-616. PMID 30099674

13. Wanner MB, Schwarzl F, Strub B, et al. Vacuum-assisted wound closure for cheaper and more comfortable healing of pressure sores: a prospective study. Scand J Plast Reconstr Surg Hand Surg. Mar 2003;37(1):28-33. PMID 12625392

14. Dumville JC, Land L, Evans D, et al. Negative pressure wound therapy for treating leg ulcers. Cochrane Database Syst Rev. Jul 14 2015;7(7):CD011354. PMID 26171910

15. Vuerstaek JD, Vainas T, Wuite J, et al. State-of-the-art treatment of chronic leg ulcers: A randomized controlled trial comparing vacuum-assisted closure (V.A.C.) with modern wound dressings. J Vasc Surg. Nov 2006;44(5):1029-1037; discussion 1038. PMID 17000077

16. Dumville JC, Munson C, Christie J. Negative pressure wound therapy for partial-thickness burns. Cochrane Database Syst Rev. Dec 15 2014;12(12):CD006215. PMID 25500895

17. Bloemen MC, van der Wal MB, Verhaegen PD, et al. Clinical effectiveness of dermal substitution in burns by topical negative pressure: a multicenter randomized controlled trial. Wound Repair Regen. Nov-Dec 2012;20(6):797-805. PMID 23110478

18. Runkel N, Krug E, Berg L, et al. Evidence-based recommendations for the use of Negative Pressure Wound Therapy in traumatic wounds and reconstructive surgery: steps towards an international consensus. Injury. Feb 2011;42 Suppl 1:S1-12. PMID 21316515

19. Ehrl D, Heidekrueger PI, Broer PN, et al. Topical negative pressure wound therapy of burned hands: functional outcomes. J Burn Care Res. Mar 31 2017. PMID 28368916

20. Webster J, Scuffham P, Stankiewicz M, et al. Negative pressure wound therapy for skin grafts and surgical wounds healing by primary intention. Cochrane Database Syst Rev. Oct 7 2014;10(10):CD009261. PMID 25287701

21. De Vries FE, Wallert ED, Solomkin JS, et al. A systematic review and meta-analysis including GRADE qualification of the risk of surgical site infections after prophylactic negative pressure wound therapy compared with conventional dressings in clean and contaminated surgery. Medicine (Baltimore). Sep 2016;95(36):e4673. PMID 27603360

22. Liu X, Zhang H, Cen S, et al. Negative pressure wound therapy versus conventional wound dressings in treatment of open fractures: A systematic review and meta-analysis. Int J Surg. 2018 May;53:72-79. PMID: 29555530

23. Costa ML, Achten J, Bruce J, et al. Effect of Negative Pressure Wound Therapy vs Standard Wound Management on 12-Month Disability Among Adults With Severe Open Fracture of the Lower Limb: The WOLLF Randomized Clinical Trial. JAMA. 2018 Jun 12;319(22):2280-2288. PMID: 29896626

24. Sahebally SM, McKevitt K, Stephens I, et al. Negative Pressure Wound Therapy for Closed Laparotomy Incisions in General and Colorectal Surgery: A Systematic Review and Meta-analysis. JAMA Surg. Nov 1 2018;153(11):e183467. PMID 30267040

25. Stannard JP, Volgas DA, McGwin G, 3rd, et al. Incisional negative pressure wound therapy after high-risk lower extremity fractures. J Orthop Trauma. Jan 2012;26(1):37-42. PMID 21804414

26. Masden D, Goldstein J, Endara M, et al. Negative pressure wound therapy for at-risk surgical closures in patients with multiple comorbidities: a prospective randomized controlled study. Ann Surg. Jun 2012;255(6):1043-1047. PMID 22549748

27. Chio EG, Agrawal A. A randomized, prospective, controlled study of forearm donor site healing when using a vacuum dressing. Otolaryngol Head Neck Surg. Feb 2010;142(2):174-178. PMID 20115970

28. Javed AA, Teinor J, Wright M, et al. Negative Pressure Wound Therapy for Surgical-site Infections: A Randomized Trial. Ann Surg. Oct 10 2018. PMID 30308616

29. Tanaydin V, Beugels J, Andriessen A, et al. Randomized Controlled Study Comparing Disposable Negative-Pressure Wound Therapy with Standard Care in Bilateral Breast Reduction Mammoplasty Evaluating Surgical Site Complications and Scar Quality. Aesthetic Plast Surg. Aug 2018;42(4):927-935. PMID 29442143

30. Stannard JP, Robinson JT, Anderson ER, et al. Negative pressure wound therapy to treat hematomas and surgical incisions following high-energy trauma. J Trauma. Jun 2006;60(6):1301-1306. PMID 16766975

31. Monsen C, Acosta S, Mani K, et al. A randomised study of NPWT closure versus alginate dressings in peri-vascular groin infections: quality of life, pain and cost. J Wound Care. Jun 2015;24(6):252, 254-256, 258-250. PMID 26075373

32. Biter LU, Beck GM, Mannaerts GH, et al. The use of negative-pressure wound therapy in pilonidal sinus disease: a randomized controlled trial comparing negative-pressure wound therapy versus standard open wound care after surgical excision. Dis Colon Rectum. Dec 2014;57(12):1406-1411. PMID 25380007

33. Armstrong DG, Marston WA, Reyzelman AM, et al. Comparison of negative pressure wound therapy with an ultraportable mechanically powered device vs. traditional electrically powered device for the treatment of chronic lower extremity ulcers: a multicenter randomized-controlled trial. Wound Repair Regen. Mar-Apr 2011;19(2):173- 180. PMID 21362084

34. Armstrong DG, Marston WA, Reyzelman AM, et al. Comparative effectiveness of mechanically and electrically powered negative pressure wound therapy devices: a multicenter randomized controlled trial. Wound Repair Regen. May-Jun 2012;20(3):332-341. PMID 22564228

35. Marston WA, Armstrong DG, Reyzelman AM, et al. A multicenter randomized controlled trial comparing treatment of venous leg ulcers using mechanically versus electrically powered negative pressure wound therapy. Adv Wound Care (New Rochelle). Feb 1 2015;4(2):75-82. PMID 25713749

36. Lerman B, Oldenbrook L, Eichstadt SL, et al. Evaluation of chronic wound treatment with the SNaP wound care system versus modern dressing protocols. Plast Reconstr Surg. Oct 2010;126(4):1253-1261. PMID 20885246

37. Karlakki SL, Hamad AK, Whittall C, et al. Incisional negative pressure wound therapy dressings (iNPWTd) in routine primary hip and knee arthroplasties: A randomised controlled trial. Bone Joint Res. Aug 2016;5(8):328- 337. PMID 27496913

38. Schwartz JA, Goss SG, Facchin F, et al. Single-use negative pressure wound therapy for the treatment of chronic lower leg wounds. J Wound Care. Feb 2015;24 Suppl 2:S4-9. PMID 25647506

39. O'Leary DP, Peirce C, Anglim B, et al. Prophylactic negative pressure dressing use in closed laparotomy wounds following abdominal operations: a randomized, controlled, open-label trial: The P.I.C.O. Trial. Ann Surg. Jun 2017;265(6):1082-1086. PMID 27926575

40. Strugala V, Martin R. Meta-Analysis of Comparative Trials Evaluating a Prophylactic Single-Use Negative Pressure Wound Therapy System for the Prevention of Surgical Site Complications. Surg Infect (Larchmt). 2017 Oct;18(7):810-819. PMID: 28885895

41. Grauhan O, Navasardyan A, Hofmann M, et al. Prevention of poststernotomy wound infections in obese patients by negative pressure wound therapy. J Thorac Cardiovasc Surg. May 2013;145(5):1387-1392. PMID 23111014

42. Pauser J, Nordmeyer M, Biber R, et al. Incisional negative pressure wound therapy after hemiarthroplasty for femoral neck fractures - reduction of wound complications. Int Wound J. Oct 2016;13(5):663-667. PMID 25125244

43. Gombert A, Babilon M, Barbati ME, et al. Closed Incision Negative Pressure Therapy Reduces Surgical Site Infections in Vascular Surgery: A Prospective Randomised Trial (AIMS Trial). Eur J Vasc Endovasc Surg. 2018 Sep;56(3):442-448. PMID: 29970335

44. Murphy PB, Knowles S, Chadi SA, et al. Negative Pressure Wound Therapy Use to Decrease Surgical Nosocomial Events in Colorectal Resections (NEPTUNE): A Randomized Controlled Trial. Ann. Surg. 2019 Jul;270(1). PMID 30499799

45. Hussamy DJ, Wortman AC, McIntire DD, et al. Closed Incision Negative Pressure Therapy in Morbidly Obese Women Undergoing Cesarean Delivery: A Randomized Controlled Trial. Obstet Gynecol. 2019 Oct;134(4). PMID 31503147

46. Singh DP, Gabriel A, Parvizi J, et al. Meta-Analysis of Comparative Trials Evaluating a Single-Use Closed-Incision Negative-Pressure Therapy System. Plast Reconstr Surg. 2019 Jan;143:41S-46S. PMID: 30586103

47. Yu L, Kronen RJ, Simon LE, et al. Prophylactic negative-pressure wound therapy after cesarean is associated with reduced risk of surgical site infection: a systematic review and meta-analysis. Am J Obstet Gynecol. 2018 Feb;218(2):200-210.e1. PMID: 28951263

48. Karlakki S, Brem M, Giannini S, Khanduja V, Stannard J, Martin R. Negative pressure wound therapy for management of the surgical incision in orthopaedic surgery: A review of evidence and mechanisms for an emerging indication. Bone Joint Res. 2013 Dec 18;2(12):276-84. PMID: 24352756

49. Vig S, Dowsett C, Berg L, et al. Evidence-based recommendations for the use of negative pressure wound therapy in chronic wounds: steps towards an international consensus. J Tissue Viability. Dec 2011;20 Suppl 1:S1-18. PMID 22119531

50. Willy C, Agarwal A, Andersen CA, et al. Closed incision negative pressure therapy: international multidisciplinary consensus recommendations. Int Wound J. Apr 2017;14(2):385-398. PMID 27170231

51. Hospenthal DR, Murray CK, Andersen RC, et al. Guidelines for the prevention of infections associated with combat-related injuries: 2011 update: endorsed by the Infectious Diseases Society of America and the Surgical Infection Society. J Trauma. Aug 2011;71(2 Suppl 2):S210-234. PMID 21814089

52. Lipsky BA, Berendt AR, Cornia PB, et al. 2012 Infectious Diseases Society of America clinical practice guideline for the diagnosis and treatment of diabetic foot infections. J Am Podiatr Med Assoc. Jan-Feb 2013;103(1):2-7. PMID 23328846

53. Qaseem A, Humphrey LL, Forciea MA, et al. Treatment of pressure ulcers: a clinical practice guideline from the American College of Physicians. Ann Intern Med. Mar 03 2015;162(5):370-379. PMID 25732279

54. Association for the Advancement of Wound Care (AAWC). Guideline of Pressure Ulcer Guidelines. 2010; https://aawconline.memberclicks.net/assets/appendix%20c%20guideline%20icvug-textformatrecommendations- final%20v42%20changessaved18aug17.pdf. Accessed December 2, 2019.

55. Association for the Advancement of Wound Care (AAWC). International Consolidated Venous Ulcer Guideline (ICVUG) 2015 (Update of AAWC Venous Ulcer Guideline, 2005 and 2010) 2015; https://aawconline.memberclicks.net/assets/docs/appendix%20b-1_icvugevidencesummarytable-v66- 18aug17%20-2.pdf. Accessed December 3, 2019.

56. National Institute for Health and Care Excellence (NICE). Negative Pressure Wound Therapy for the Open Abdomen [IPG467]. 2013; https://www.nice.org.uk/guidance/ipg467. Accessed December 2, 2019.

57. National Institute for Health and Care Excellence (NICE). Diabetic Foot Problems: Prevention and Management [NG19]. 2019; https://www.nice.org.uk/guidance/ng19/evidence. Accessed December 2, 2019.

58. National Institute for Health and Care Excellence (NICE). Pressure ulcers: prevention and managment [CG179]. 2014; https://www.nice.org.uk/guidance/cg179. Accessed December 2, 2019.

59. Dumville JC, Owens GL, Crosbie EL, et al. Negative pressure wound therapy for treating surgical wounds healing by secondary intention. Cochrane Database of Systematic Reviews. 2015, Issue 6. Art. No.: CD011278; https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD011278.pub2/pdf/CDSR/CD011278/CD011278_abstract.pdf

Codes:
(The list of codes is not intended to be all-inclusive and is included below for informational purposes only. Inclusion or exclusion of a procedure, diagnosis, drug or device code(s) does not constitute or imply authorization, certification, approval, offer of coverage or guarantee of payment.)

CPT*

97605
97606
97607
97608

A6550
A7000 - A7001
A9272
E2402
K0743
K0744 - K0746