AIP Conference Proceedings 2344, 050008 (2021); https://doi.org/10.1063/5.0047187 2344, 050008
© 2021 Author(s).
Cost-efficacy of skin grafting techniques
using negative pressure wound therapy and tissue-engineered skin for burns
Cite as: AIP Conference Proceedings 2344, 050008 (2021); https://doi.org/10.1063/5.0047187 Published Online: 23 March 2021
Muhammad Hanif Nadhif, Muhammad Satrio Utomo, Muhammad Farel Ferian, Farhan H. Taufikulhakim, Nadine H. P.
Soerojo, Muhammad Dzulkarnaen Nain, Prasandhya A. Yusuf, Anindya P. Susanto, and Theddeus O.H. Prasetyono
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Cost-Efficacy of Skin Grafting Techniques Using Negative Pressure Wound Therapy and Tissue-Engineered Skin for
Burns
Muhammad Hanif Nadhif
1,2, Muhammad Satrio Utomo
1,2,3,
Muhammad Farel Ferian
4, Farhan H. Taufikulhakim
4, Nadine H. P. Soerojo
4, Muhammad Dzulkarnaen Nain
4, Prasandhya A. Yusuf
1,2,a), Anindya P. Susanto
1,2,
Theddeus O.H. Prasetyono
2,5,61Department of Medical Physics, Faculty of Medicine, Universitas Indonesia, Jl. Salemba Raya No. 6, Central Jakarta, DKI Jakarta 10430 Indonesia
2Medical Technology Cluster, Indonesian Medical Education and Research Institute, Universitas Indonesia, Jl. Salemba Raya No. 6, Central Jakarta, DKI Jakarta 10430 Indonesia
3Research Center for Metallurgy and Materials, Indonesian Institute of Sciences, PUSPIPTEK Building 470, South Tangerang, Banten 15314 Indonesia
4Undergraduate Program, Faculty of Medicine, Universitas Indonesia, Jl. Salemba Raya No. 6, Central Jakarta, DKI Jakarta 10430 Indonesia
5Division of Plastic Surgery, Department of Surgery, Cipto Mangunkusumo Central Hospital/Faculty of Medicine, Universitas Indonesia, Jl. Salemba Raya No. 6, Central Jakarta, DKI Jakarta 10430 Indonesia
6Indonesian Clinical Training and Education Centre (ICTEC), Cipto Mangunkusumo Central Hospital, Jl. Pangeran Diponegoro No. 71, Senen, Central Jakarta, DKI Jakarta 10430 Indonesia
a)Corresponding author: prasandhya.a.yusuf@ui.ac.id
Abstract. Burns, which generate hypertrophic scar formation, may decrease functional and aesthetical aspects of patients’
quality of life. To date, grafting treatments were not only proceeded solitarily. The technological development of burn treatments emerged with approaches, such as negative pressure wound therapy (NPWT) and tissue-engineered skin (TES).
By incorporating negative pressure on the wound bed, NPWT was able to remove debris, remove exudates, maintain humidity, and improve epithelization. A latter development of wound management, TES, also showed prominent results of wound healing. Benefitting from tissue engineering approaches, TES provided the wound bed with extracellular matrix (ECM) and 3D structure to support wound healing. In some reports, NPWT was combined with TES to promote better efficacy. Unfortunately, the efficacies of NPWT, TES, or NPWT-TES hybrid as assisting approaches for skin drafting techniques are not reviewed yet, as well as the cost comparison of the three treatments. In this report, the comparison of skin grafting techniques assisted with the three treatments (NPWT, TES, or NPWT-TES hybrid) was investigated in terms of efficacy and cost. The review starts with brief technical aspects of the three treatments. Subsequently, the efficacy and cost analyses were discussed.
Keywords: cost, efficacy, grafting, NPWT, TES
INTRODUCTION
Up to 70% of burn wounds would lead to hypertrophic scar formation [1]. Moreover, excessive burn scarring could lead to scar contracture and a decrease in muscle and joint performance. Various treatments have been applied to repress the hypertrophic scar formation since it could decrease the patient's quality of life functionally and
aesthetically. Therefore, alternatives for burn wound treatment, especially one that involves remodeling of histological structure such as skin grafting has been a promising option that could decrease scar formation in burn wounds [1,2].
On the other hand, recent improvements in the management of acute burn wounds are believed to be one of the factors behind the decline of mortality rates related to burn wounds around the globe. These improvements include the application of negative pressure wound therapy (NPWT) and tissue-engineered skin (TES) separately and jointly to improve the efficacy of skin grafting techniques for burn wound treatment.
NPWT, also known as vacuum assistance technology (VAT), has been widely used in clinical practices such as in wound dressing and skin grafting applications due to its capability to remove exudates which can prevent the formation of hematoma and seroma, and maintain humidity which may improve the epithelization rate. NPWT involves adhesive semi-permeable cover usually made of polyurethane (PU) foam, collection cup, pressure regulator, and connector. On its application, the wound must be excised and cleaned to form a wound bed. NPWT will be then applied for three to five days.
TES makes use of a tissue engineering approach to develop artificial skin tissues that can substitute the damaged skin tissues. Developing TES requires stem cells, signals, and scaffolds. Integra® (LifeSciences, Inc., Plainsboro, NY), Terudermis® (Terumo, Tokyo, Japan), Pelnac™ (Gunze Ltd., Tokyo, Japan), and Biobrane™ (UDL Laboratories, Rockford, IL, USA) are four examples of TES commercially available products which are usually used.
The three mentioned TES (Integra®, Terudermis®, and Biobrane™) consist of derived type-1 collagen. Both Integra®
and Terudermis™ derived the collagen from bovines, while Biobrane™ extracted the collagen from porcine.
However, comparative studies on the application of NPWT and TES on skin grafting techniques for burn wound treatments, especially regarding their clinical and economical aspects are limited. Thus, this review aims to provide an analysis of the efficacy and cost of NPWT, TES, and NPWT-TES hybrid on skin grafting for burn wound treatments.
METHODS
The search for literature and publications was performed in September 2019 on PubMed and Cochrane Library online database. This review focuses on cases of patients with burn wounds of various etiologies that was treated by skin grafting using either NPWT, TES, or the hybrid of the two interventions. The gathered articles were investigated regarding the cost and efficacy analyses.
RESULTS Technical Aspects
Burn wounds are classified according to the depth of the affected skin layer. First-degree, or epidermal burns, only affect the epidermis layer. Second-degree burns, or partial burns, affect the epidermis and part of the dermis.
Furthermore, the second-degree burns can be classified into superficial and partial thickness burns that affect the two upper layers of skin (epidermis and superficial layer of dermis) and the layer of dermis, respectively. Third-degree or full-thickness burns affect the epidermis and a full layer of dermis [3]. Each type of wound requires a specialized approach to aid in accelerating wound closure. However, the fundamental approach is by skin grafting, usually autologous of origin, that is aided by either NPWT, TES, or the hybrid [4]. The following paragraphs discuss the technical aspects of the three types of intervention.
Technical Aspects of Skin Graft
Based on its origin, skin grafts can be classified into autologous (autograft) [5], allogeneic (allograft) [6], and xenogeneic (xenograft) [7]. In terms of skin thickness, skin grafts are divided into two types of grafts: full-thickness skin graft (FTSG) and split-thickness skin graft (STSG) [8,9]. The FTSG includes a whole layer of epidermis and dermis, as well as a small portion of subcutaneous fat, while the STSG only includes a whole layer of the epidermis and a small layer of the dermis [10]. The common FTSG donor sites are skin from the neck, nasolabial folds, eyelids, and upper extremities, whereas the STSG may be taken from anywhere on the bod [10,11]. Another major difference between FTSG and STSG is that the FTSG requires primary healing before grafting. Meanwhile, the STSG may heal secondarily without any intervention. After harvesting from the donor site, STSG is prepared by meshing so that it can better adhere to the wound surface and cover a larger area [10]. However, the cosmetic value of STSG may
decrease due to the checkerboard appearance caused by skin healing [11]. When applying the graft, several techniques can be applied such as tie-over dressing, reverse tie-over, fibrin glue, and negative pressure [11,12]. Complications that may occur after skin grafting are skin contraction and hyperpigmentation which are more likely to occur on thinner grafts [11].
Technical Aspects of NPWT
Skin grafting is usually accompanied by a dressing, one of which uses vacuum assistance, the so-called negative pressure wound therapy (NPWT) [12]. Using an NPWT device, a wound is enclosed, and the negative pressure is applied to the wound [13]. In general, NPWT is indicated for difficult graft fixation, accelerating granulation formation, and decreasing the bacterial load. The system consists of adhesive semi-permeable covers (mostly polyurethane foam), a collection cup, a device that regulates pressure, and a connector to connect the wound to the device [3,14]. NPWT has a safety mechanism that will stop the suction automatically if the fluid output from the wound increased drastically. It also has a battery pack that maintains the suction when a patient is out of bed [3]. On its application, the wound must be excised and cleaned to make wound bed first. After that, STSG will be placed directly on the wound bed and NPWT will be applied for 3 – 5 days [4].
Technical Aspects of TES
Tissue engineering is the use of engineering methods in developing biological substitutes to restore, maintain, or improve tissue function. This method is dependent on the use of 3D scaffolds as the template for the tissue to form.
These scaffolds are a part of the tissue engineering triad, along with cells and signals. The use of these scaffolds is to provide an environment that is suitable for the seeded cells to grow [15].
Tissue engineering scaffolds can be made of ceramics (e.g. hydroxyapatite), synthetic polymers (e.g. as poly-l- lactic acid or PLLA), and natural polymers (e.g. collagen) depending on the necessary requirements. Tissue- engineered skin (TES) with its ability to promote wound healing and to restore barrier function is one of the current treatment approaches for the management of burns, specifically for full-thickness injuries. Tissue-engineered skin is useful for the treatment of full-thickness injuries because of limited donor sites especially in patients with large total body surface area (TBSA) burns. To replace the damaged skin, skin grafts require tissue scaffolding [16,17].
Scaffold in tissue-engineered skin is needed to promote the colonization of fibroblasts and the production of collagen. Keratinocytes of the epidermal substitute then will attach with fibroblasts on the scaffold to develop a basement membrane. Integra®, Terudermis®, Pelnac™, and Biobrane™ are four examples of artificial dermis. Due to the unwanted effect of Pelnac™ that shows drastic contraction when applied, Pelnac™ is not recommended to be used as a dermal substitute for burn injuries. Therefore, the three main types of dermal substitutes that will be further discussed are only Integra®, Terudermis®, and Biobrane™ [17,18].
Integra® is a bi-laminate membrane consisting of a bovine tendon type-1 collagen-based dermal substitute of glycosaminoglycans and shark chondroitin-6-sulfate bonded to an epidermal substitute layer of semipermeable silicone [20]. However, two operations are necessary for the application of Integra®. The first operation is to apply the dermal matrix to the wound. To prevent drying, a moist dressing is applied on top of the matrix. The second operation is to remove the silicone layer after 2 – 3 weeks, and the split-thickness autograft is secured to the neodermis.
Terudermis® is applied to the wound with the silicone membrane [20]. Terudermis® is made of lyophilized collagen sponge from bovine dermal type-1 collagen that is crosslinked by dehydrothermal treatment. To keep a moist environment, saline-soaked gauze is put to cover the applied Terudermis®. This gauze needs to be changed once a day. After a pseudo-dermis is developed and has replaced Terudermis®, the silicone membrane can be removed. Once the silicone membrane is removed, split-thickness skin grafting can be performed.
Biobrane™ is a biosynthetic wound dressing which provides versatility, easy application, and low frequency of dressing changes [21]. Biobrane™ has also been proven to promote reepithelization [21]. The construction of Biobrane™ comprises silicone bonded to woven nylon containing peptides derived from type-1 collagen [22]. Unlike the former two dermal substitutes that consist of type-1 collagen with an origin from bovines, type-1 collagen in Biobrane™ is derived from porcine.
Technical Aspects of NPWT-TES Hybrid
The combination technique has the same mechanism and procedure as NPWT and tissue scaffold. After the wound has been excised and cleaned to make a wound bed, tissue scaffold which has completed the preparation is placed on it then followed by fixating STSG. Subsequently, NPWT is applied for 3-5 days. Wound inspection is then performed daily until the healing is complete (patients discharge or >95% wound closure) [23].
Efficacy Analysis
Efficacy of NPWT
Using an NPWT device, wound healing could be accelerated. Due to the negative pressure resulted from the device, the graft could remain intact on the wound [24]. The negative pressure also helped wound healing by increasing perfusion and providing gradient shift which decreases edema, hematoma, and seroma formation [25]. The device also provided mechanical stress that induces cellular activity such as neovascularization which in turn accelerated granulation formation [14]. Additionally, negative pressure also decreased bacterial count and risk of infection [23,24].
In a review by Kantak et al., it was suggested that NPWT improved the STSG take when used as a bolster dressing [16]. The study also pointed out that NPWT also helped to establish wound bed to increase the probability of skin graft take, limit inflammatory injury, provide dressing for larger burn wounds, and improve re-epithelialization of donor sites [17]. A study on electrical burn reported that NPWT reduced hematoma or seroma under the graft and lowers separation force between the graft along with it [14]. This effect explained why NPWT could improve skin grafting significantly [14]. Another study of extensive large burns on 12 patients with ≥15% of TBSA demonstrated successful graft takes with an average of 97% and re-epithelialization with an average of 11.25 days [17]. This suggested that the efficacy of NPWT was not only limited to small wounds but also large burns. NPWT would be more beneficial for burn wounds, considering graft loss occurred more frequently and with a higher rate in larger burns wounds [18]. Currently, the only A-level recommendation for NPWT was that NPWT had to be included in a wound therapy to improve the success of graft take, especially in a wound with a high rate of re-grafting, extensive burn areas, and wounds on difficult sites [26].
Prognosis studies of NPWT have also shown promising outcomes. Amongst 67 patients undergoing skin grafting with NPWT dressings, none of them returned for re-grafting. NPWT also promoted shorter hospital stays with the possibility of being discharged on the same day with a note of taking along the portable device home [27]. This early mobilization was a huge advantage in treating low compliance patients such as pediatric populations [27].
Even though NPWT has been proven to give many benefits, some limitations were still found. First, it was difficult to be applied to wounds near orifices and with excess drainage of fluids [3]. It was also reported that severe bleeding risk had become a major complication. It was believed that insufficient STSG (1:4 meshed) and low homeostasis of the wound bed were the reasons for the complication. However, another study stated that the reason behind it was the rupture of blood vessels because of the suction [28]. Furthermore, NPWT might also fail to operate properly. Some problems, including loss of power supply due to battery problems, tube occlusion, collector overflow, and malfunction mainly due to operator inexperience, were still reported [3].
Efficacy of TES
Greenwood demonstrated that it took four weeks to generate a form of composite cultured skin (CSS) [29].
However, granulation tissues were formed in four weeks and contraction occurred accordingly [29]. To solve these problems, Greenwood developed a seal called the biodegradable temporizing matrix (BTM) to delay the contraction of the wound until the CSS was ready to be implanted [29]. The BTM needed to be integrated with the wound, allowing the invasion of fibroblast and the formation of new blood vessels. When implanted, the seal was found to be too thin and it was slowly peeling off. Despite that, the graft adherence was rapid, and it was robust enough when applied on the posterior trunk. The seal was still integrated into the wound even when the patient lying on it [29].
The scaffold also had to resist infection. When the BTM was tested on porcine subjects, there were no infections detected. When the BTM was implanted in human patients, there was an infection that leads to taking off the seal, so the infection can be treated topically. From the cosmetic aspect, there was not found the mesh pattern when using BTM. The pigmentation was also great [29].
The scaffold had to be compartmentalized to prevent long stretches of linear collagen that can lead to wound contraction. They found out that continuous tissue formation in porcine still causes wound contraction. Their solution was to put a biodegradable polyurethane seal to minimize evaporative water loss to prevent further wound contraction.
Unfortunately, there was a fragmentation of the seal that eventually leads the granulation tissue to overgrow the seal and contract [29].
A study from Hori et al., which compared the contraction among the three dermal substitutes, showed that Integra™ and Terudermis™ were more suitable for preventing wound contraction due to its morphology. Integra™
had large pores to maximize cell growth. The composition of glycosaminoglycan and its high degree of cross-linking was properly adjusted to control the rate of degradation. Despite having many disadvantages, which included the need for performing multiple operations, the high risk of infections, and the high price, Integra™ provided improvements of outcomes including, but not limited to, good cosmetic appearance, acceleration of healing, and reduced scar formation. However, there was not found any significant difference between Integra™ and Terudermis™ in scar quality after 6 months in vivo, though clinical practices may yield different results [30].
Efficacy of NPWT-TES Hybrid
Currently, a study on the NPWT-TES hybrid therapy by Hop et al. The study was performed on 86 patients who were divided into 4 groups of intervention: STSG application of with tissue scaffolding combined with NPWT (DS- NPWT); STSG application with tissue scaffolding (DS); STSG application with NPWT (TNP); and STSG alone (ST).
Their study revealed that there was no significant difference in STSG take and epithelialization between the group that was applied using the DS-NPWT dressing and the group that was applied using the ST. All groups scored low on the Patient and Scar Assessment Scale (POSAS), indicating good scar quality. However, 12 months after the surgery, higher scar elasticity was observed on the group treated using the two types of an intervention [4].
In another study, NPWT was reported to shorten the interval of tissue scaffold (Integra™) and the skin graft placement. According to the manufacturer, it was recommended a minimum of 2 weeks interval before. On the other hand, Integra™ that was applied by NPWT can be placed by skin graft on an average of 8 days and already adhere to it in the next 4 days [31].
In brief, NPWT decrease wound contamination that in turn will decrease degradation of the tissue scaffolding.
Furthermore, NPWT improves vascularization of the scaffold. On the other hand, tissue scaffolding will help obtain a more elastic scar which represents a better function. In conclusion, NPWT combined with tissue scaffolding will further optimize the healing outcome [23,31].
Cost Analysis
The application of NPWT required more cost than the application of tissue-engineered material on skin grafting for burn wound management which limits various healthcare providers to the device [3]. Hop et al. conducted a cost study on (1) tissue scaffolding combined with NPWT, (2) STSG application with tissue scaffolding, (3) STSG application with NPWT, and (4) STSG alone [32]. An STSG application with tissue scaffolding had the highest mean total diagnostic procedure cost (1,581.96 USD), while STSG application with NPWT had the lowest cost (482.61 USD). This suggests that the application of tissue scaffolding alone requires more frequent diagnostic tests to prevent infection, while the application of NPWT is intended to support the prevention of infection.
In terms of total intervention cost, the application of TES combined with NPWT had the highest cost (27,829.82 USD) due to material, equipment, and personnel costs. Meanwhile, STSG alone had the lowest cost (26,712.13 USD).
Despite having the highest intervention costs, the application of tissue scaffolding combined with NPWT overall total cost per patient was the second highest (47,118.22 USD) behind NPWT only (50,180.11 USD). However, they did not include the potential costs of possible reconstructive surgeries and rehabilitations which could provide valuable insight into the long-term cost impact of the application of tissue scaffolding combined with NPWT.
Finally, the overall costs per patient of specialized burn care between groups were not significantly different. This suggests that the general monetary cost for burn wound treatments using all techniques should not be a major consideration to decide the treatment of choice inadequate resource settings. What is evident, however, is the amount of TBSA injured because >10% TBSA burns did incur higher costs in each group [32].
Overall cost and procedure time between cadaveric allograft and Biobrane™ were statistically similar. Cadaveric allograft procedure costed 1,128.36 ± 704.58 USD while Biobrane™ costed 898.79 ± 406.47 USD. Compared to the
%TBSA, the cadaveric allograft procedure costed 221.53 ± 104.07 USD per %TBSA while Biobrane™ costed 122.23
± 59.05 USD. The procedure time for cadaveric allograft procedure was 148.53 ± 65.51 minutes, while the Biobrane™
was 149.17 ± 50.00 minutes. Compared to the %TBSA, the procedure time per %TBSA for cadaveric allograft procedure was 54.78 ± 74.59 minutes. Meanwhile, Biobrane™ was 21.12 ± 10.66 minutes. Thus, the cost per minute per %TBSA for cadaveric allograft was 1.73 ± 0.93 USD and Biobrane™ was 0.96 ± 0.65 USD [21].
Biobrane™ was more cost-effective and time-efficient due to its ease of application. While cadaveric allograft sheets must be individually aligned and adjusted before placement to the patient, the Biobrane™ could be rapidly placed and secured. In addition, the application of Biobrane™ could also improve the post-operative healing process due to the prevention of hematoma formation and fewer days of immobilization compared to the cadaveric allograft procedure [21].
The cost model of burn wound treatments has been built with which consists of variable cost components such as analgesia, dressing, length of stay, theatre time, and grafting. The cost model was used to compare two burn wound management, the conservatively managed, and the modern aggressive surgical approaches. The conservatively managed burn wound management was done by the dressing of ointment cream and two-stages skin graft resulting in 9,238.23 USD. Meanwhile, the modern aggressive surgical approach was done including debridement and two-stages skin grafts which costs 6,125.02 USD. The cost reduction was due to shorter hospital stay length. While conservative approaches required lower cost for dressing and operation, the overall cost could not get lowered due to prolonged hospital stay [33].
A clinical trial study showed that an in-house-built disposable suction drain offered a more cost-efficient method compared to both permanent and portable NPWT systems. The study compared the cost-effectiveness between permanent NPWT, portable NPWT, and the disposable suction drain for split skin grafting. In the study, cost- effectiveness was calculated for a five days treatment period. The permanent NPWT system had a total cost of 2,222.10 USD including 227.10 USD for dressing devices with five inpatient hospital days. Meanwhile, the portable NPWT system had a total cost of 1,180.93 USD including 262.04 USD for dressing devices with one inpatient hospital days and an in-home treatment cost of 519.89 USD. Last, the disposable suction drain had a total cost of 403.19 USD with one inpatient hospital days including 4.19 USD for the dressing device [34].
The application of cultured epidermal autograft (CEA) in a group of patients for burn wound treatment resulted in a higher number of operations and longer hospital stays which produced higher overall cost compared to the traditional, non-CEA group [35]. While the application of CEA for burn wound treatment offered better outcome in terms of cosmetics compared to the traditional method, the donor-site healing times and the incidence of complications, such as sepsis and pneumonia, in both groups was similar [35]. The use of negative pressure dressing on split-thickness skin graft for traumatic extremities wounds lacked clinical benefit despite an increase in cost. The conventional dressing method costed 2,657.27 USD while the negative pressure dressing method costed 4,959.22 USD on average [36]. There are several ways to improve the cost-effectiveness of burn wound treatments, such as improving the burn wound depth assessment technique to avoid unnecessary surgery and allow skin grafting to be conducted effectively, using dressings or skin substitutes which has more cost-benefit factors and make use of recent technology such as telemedicine for cost-effective follow-up of the burn patients [37].
DISCUSSION
The summary of the abovementioned comparison between the three techniques are presented in Table 1.
Individually, both have been shown to improve graft take and wound epithelialization. However, NPWT and TES techniques have their own advantages and disadvantages. The NPWT application on wounds provides greater infection prevention, pigmentation, and mobility but with lesser cosmetic quality and a higher risk of bleeding.
Moreover, NPWT also shortens the STSG interval from 2 weeks to 8 days, which means shorter hospital stay and higher patient compliance. On the other hand, TES gives better cosmetic quality, but with lower mobility and higher risks of infection. Better efficacies and outcomes are potentially achieved by combining both techniques. The application of NPWT and TES gives high infection prevention, mobility, and cosmetic quality. Furthermore, the application of NPWT and TES together is not significantly impactful on total intervention cost, total specialized burn care cost, nor the overall total cost of care per patient. Thus, the evidence currently presented suggests that the application of both NPWT and TES could provide better outcomes within a relatively similar cost range than other groups of skin graft interventions.
TABLE 1. Comparison between NPWT, TES, and NPWT-TES hybrid
Aspects NPWT TES NPWT-TES Hybrid
Risk of infection Low [20—22] High [31] Low [22]
Mobility High [14] Low [24] High [14]
Graft take High [10] High [15] High [20]
Wound epithelization High [12,16] High [24] High [14]
Pigmentation Close to normal [10] Low [24] Low [24]
STSG application
interval N/A 14 days [23] 8 days [26]
Frequent
complications Bleeding [23] Infection and graft loss
[24] Bleeding [14]
Mean POSAS score on 12-month post-
operative (scar quality)
Low (good quality)
[14] Low (good quality) [14] Low (good quality) [14]
Compliance High [18] Low [25] High [26]
Re-grafting 0 N/A N/A
Device failure Possible [13] None [24] Possible [26]
Cost
Total intervention ~5,244.53 USD [30] ~5,558.63 USD [27,29] ~6,121.48 USD [30]
Total specialized
burn care ~28,510.75 USD [30] ~34,146.18 USD [27,29] ~27,829.82 USD [30]
Total cost per patient ~50,180.11 USD [30] ~48,165.98 USD [27,29] ~47,118.22 USD [30]
ACKNOWLEDGMENTS
This report is a final output of an Artificial Organ & Physiological Engineering module for Undergraduate Medical Students at the Faculty of Medicine, Universitas Indonesia. The elective module aims on introducing the latest medical technology for future physicians. The report is partially funded by PUTI Grant 2020 Universitas Indonesia.
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