Cohort study evaluating the burden of wounds to the UK’s National Health Service in 2017/2018

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Original research

Julian F Guest ‍ ‍,1 Graham W Fuller,1 Peter Vowden2

To cite: Guest JF, Fuller GW, Vowden P. Cohort study evaluating the burden of wounds to the UK’s National Health Service in 2017/2018: update from 2012/2013. BMJ Open 2020;10:e045253. doi:10.1136/ bmjopen-2020-045253 ►► Prepublication history and supplemental materials for this paper is available online.

To view these files, please visit the journal online (http://​dx.​doi.​ org/​10.​1136/b​ mjopen-​2020-​ 045253).

Received 28 September 2020 Revised 19 November 2020 Accepted 23 November 2020

© Author(s) (or their employer(s)) 2020. Re-­use permitted under CC BY-­NC. No commercial re-­use. See rights and permissions. Published by BMJ. 1

Catalyst Consultants, Poole, UK Bradford Teaching Hospitals NHS Foundation Trust, Bradford, UK

2

Correspondence to Dr Julian F Guest; j​ ulian.​guest@c​ atalyst-​health.​ com

ABSTRACT Objective To evaluate the prevalence of wounds managed by the UK’s National Health Service (NHS) in 2017/2018 and associated health outcomes, resource use and costs.

Design Retrospective cohort analysis of the electronic records of patients from The Health Improvement Network (THIN) database.

Setting Primary and secondary care sectors in the UK. Participants Randomly selected cohort of 3000 patients from the THIN database who had a wound in 2017/2018.

Primary and secondary outcome measures Patients’ characteristics, wound-­related health outcomes, healthcare resource use and total NHS cost of patient management.

Results There were an estimated 3.8 million patients with a wound managed by the NHS in 2017/2018, of which 70% healed in the study year; 89% and 49% of acute and chronic wounds healed, respectively. An estimated 59% of chronic wounds healed if there was no evidence of infection compared with 45% if there was a definite or suspected infection. Healing rate of acute wounds was unaffected by the presence of infection. Smoking status appeared to only affect the healing rate of chronic wounds.

Annual levels of resource use attributable to wound management included 54.4 million district/community nurse visits, 53.6 million healthcare assistant visits and 28.1 million practice nurse visits. The annual NHS cost of wound management was £8.3 billion, of which £2.7 billion and £5.6 billion were associated with managing healed and unhealed wounds, respectively. Eighty-­one per cent of the total annual NHS cost was incurred in the community.

Conclusion The annual prevalence of wounds increased by 71% between 2012/2013 and 2017/2018. There was a substantial increase in resource use over this period and patient management cost increased by 48% in real terms.

There needs to be a structural change within the NHS in order to manage the increasing demand for wound care and improve patient outcomes.

INTRODUCTION Our 2012/2013 burden of wounds study estimated that the UK’s National Health Service (NHS) managed 2.2 million patients with a wound at a cost of £5.3 billion.1–3 An estimated 61% of all wounds in that burden of wounds study healed in the study year (79%

Strengths and limitations of this study ►► This is the first study to estimate how the health eco-

nomic burden of wounds to the UK’s National Health Service (NHS) has changed over the last 5 years. ►► This study was undertaken using real-­ world evidence derived from the anonymised records of a randomised sample of 3000 patients in The Health Improvement Network database (a nationally representative database of clinical practice among >11 million patients registered with general practitioners in the UK). ►► The estimates were derived following a systematic analysis of patients’ characteristics, wound-­related health outcomes and community-­based and secondary care resource use pertaining to wound care contained in the patients’ electronic records. ►► The annual number of 3.8 million wounds in 2017/2018 may be an underestimate since some of the patients in our data set may have had multiple wounds, but this is not transparent in the patients’ records and it is very difficult to retrospectively extricate resource use for different wounds from the records of a patient with multiple wounds of the same aetiology. ►► The analysis does not consider the potential impact of those wounds that remained unhealed beyond the study period, nor the potential impact of managing patients with wounds being cared for in residential and nursing homes.

of acute wounds and 43% of chronic wounds).

Patients were predominantly managed in the community with 18.6 million practice nurse visits, 10.9 million community nurse visits, 7.7 million general practitioner (GP) visits and 3.4 million hospital outpatient visits. Five years ago, patients also received 97.1 million drug prescriptions and 262.2 million dressings. Additionally, only 16% of all cases with an ulcer of the lower limb had a Doppler ankle brachial pressure index (ABPI) recorded in their records.1 This study led to such concern among politicians that the UK Parliament (House

Guest JF, et al. BMJ Open 2020;10:e045253. doi:10.1136/bmjopen-2020-045253

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Cohort study evaluating the burden of wounds to the UK’s National Health Service in 2017/2018: update from 2012/2013

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METHODS Study design This was a retrospective cohort analysis of the anonymised case records of patients with a wound randomly extracted from The Health Improvement Network (THIN) database. The perspective of the analysis was the UK’s NHS. The THIN database The THIN database contains electronic records on >11 million anonymised patients entered by GPs from >560 practices across the UK. The patient composition within the THIN database has been shown to be representative of the UK population in terms of demographics and disease distribution18 and the database theoretically contains patients’ entire medical history. In particular, the database collects data on the dates that patients registered or left their practice as well as demographic data, such as date of birth and gender. Patients who reside at the same address or are members of the same family can be linked using a household identifier, provided they are registered with the same general practice.

All medical conditions and symptoms recorded electronically during a patient’s consultation in the general practice are recorded in the THIN database, thereby building up long computerised medical histories using Read Codes.19 GP prescribing is computerised and entered directly into the database. Prescriptions not issued electronically (eg, during home visits) are also entered; however, there is a possibility of under-­recording of such items. Information is also recorded on referrals 2

to secondary care, including the specialty. Secondary care information and other medically-­ related information received by the practice are entered into the database.

This includes details on hospital admissions, discharge medication, diagnosis, outpatient consultations, investigations and treatment outcomes. Details from other healthcare interventions, such as information on lifestyle and preventative healthcare, as well as a range of variables such as height, weight, body mass index, blood pressure, smoking, alcohol status, immunisation and laboratory test results are also recorded. Hence, the information contained in the THIN database reflects actual clinical practice. (THIN is a registered trademark of Cegedim SA in the UK and other countries. Reference made to the THIN database is intended to be descriptive of the data asset licensed by IQVIA, who interrogated the database and performed the randomisation independently of the authors. The authors had no direct access to the THIN database.)

Study population The study population comprised the anonymised case records of a randomly selected cohort of 3000 patients from the THIN database (provided to the authors by IQVIA) who had a wound between 1 March 2017 and 28 February 2018.

Patients were included in the data set if they: ►► Were 18 years of age or over. ►► Had one of 2086 wound-­related Read codes (online supplemental table S1). ►► Had continuous medical history in their case record from the first mention of a wound in the study year up to the time the data were extracted from the database, unless they died, in order to exclude patients who had moved or changed their general practice.

Patients were excluded from the data set if they had a surgical wound that healed within 4 weeks of the surgical procedure (since any resource use incurred would be due to the surgical procedure and not the wound) or if they had a dermatological tumour. These inclusion/exclusion criteria are identical to those used in our earlier 2012/2013 study.1 Every patient in the THIN database who fulfilled the study’s inclusion and exclusion criteria was assigned a random number by IQVIA. A representative sample was then generated by random selection of the random numbers of the whole cohort using a uniform distribution. As such, IQVIA advised that the random sample was representative of the whole population from which it was derived. The complete electronic records of the 3000 patients in the sample were then supplied to the authors, which enabled analysis of data both within and outside of the study period.

Patient and public involvement Patients and members of the public were not directly involved in this study. The study population was limited to the anonymised records of patients in the THIN database.

Guest JF, et al. BMJ Open 2020;10:e045253. doi:10.1136/bmjopen-2020-045253

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of Lords) debated developing a national strategy for improving the standards of wound care in the NHS.4 As a consequence, NHS England and NHS Improvement established the National Wound Care Strategy Programme in the last quarter of 2018.5 The aim of the programme is to scope the development of a national strategy for wound care in England that focuses on improving care relating to pressure ulcers, lower limb ulcers and surgical wounds.5 Between 2012 and 2017, there was an estimated 4% decline in the number of practice nurses and a 30% decline in the number of district nurses employed in front-­line patient care.6–9 During this period, we reported on unwarranted variation in wound care arising in part from inconsistencies in staff involvement and dressing choice and in many instances a lack of a coherent treatment plan.10–16 Hence, it is reasonable to assume that not all patients with equal need have always had access to, or received, the same continuous levels of healthcare.

However, patients should be afforded the best care available (within the context of limited resources) in order to obtain maximum health gains.17 The aim of this new study was to assess the extent of change in the burden of wounds over 5 years (ie, between 2012/2013 and 2017/2018) in terms of annual prevalence, health outcomes, healthcare resource use and NHS costs.

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Cost of patient management The NHS cost of wound care for each patient was estimated by assigning unit costs at 2017/2018 prices20–22 to Guest JF, et al. BMJ Open 2020;10:e045253. doi:10.1136/bmjopen-2020-045253

the quantity of healthcare resources used by individual patients from the time a patient entered the data set (ie, from 1 March 2017 or the start time of their wound if it occurred later) up to the time their wound healed or the end of the study period, whichever came first. The total cost of utilisation of each healthcare resource for the sample of 3000 patients was then combined in order to estimate their total NHS cost of wound management over the study period. The NHS cost of wound management for this cohort was then used to model the total cost of wound care provided to adult patients who were ≥18 years of age by the NHS in 2017/2018. The cost of wound care was also estimated by stratifying patients according to their category of wound. Accordingly, the study only considers the cost of patient management attributable to wounds in primary and secondary care settings, and does not estimate patients’ overall healthcare costs.

Sensitivity analyses Bootstrapping was undertaken to estimate the margin of error surrounding the annual prevalence of wounds and costs. This involved generating subsets of the data of each wound type on the basis of random sampling and replacing the data once sampled. These subsets enabled an estimation of the 95% confidence interval (CI) of (1) the annual number of wounds managed by the NHS in 2017/2018 and (2) the NHS costs of wound management.

Deterministic sensitivity analyses were performed on all of the model’s inputs to identify how the NHS cost of wound management would change by varying the different parameters in the model.

RESULTS Prevalence of wounds in the UK The base population of the THIN database in 2017/2018 was 2.4 million active adult patients who were ≥18 years of age. The database was interrogated, independently of the authors, to identify patients with at least one of the 2086 wound-­related Read codes (only 966 of the 2086 codes had been used). The search identified 174 569 adult patients with a wound in 2017/2018 who matched the study protocol’s inclusion and exclusion criteria. The UK’s population comprised 52.1 million adults who were ≥18 years of age in mid-2017.23 Using these variables, the outputs of the modelling were extrapolated to the whole adult population in the UK. Accordingly, the model estimated that there were 3.8 million adult patients with a wound in the UK in 2017/2018 who matched the study protocol’s inclusion and exclusion criteria, equivalent to 7% of the adult population (table 1). Bootstrapping was undertaken using 100 subsets of the counts of each wound type. This indicated the lower and upper 95% CIs of the annual number of wounds managed by the NHS in 2017/2018 to be 3.67 million and 3.96 million. Hence, the margin of error surrounding the estimated annual prevalence of wounds is around 3%.

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Study variables and statistical analyses Wound type was documented in the patients’ records and the authors categorised them as being either acute (ie, abscess, burn, open wound, unhealed surgical wound, trauma) or chronic (ie, diabetic foot ulcer, arterial leg ulcer, mixed leg ulcer, venous leg ulcer, unspecified leg ulcer, pressure ulcer). The following information was systematically extracted from the patients’ electronic records over the 12 months from 1 March 2017 to 28 February 2018 according to the protocol approved by the ethics committee. ►► Patients’ characteristics. ►► Patients’ comorbidities (defined as a non-­acute condition that patients were suffering from in the year before the start of their wound and not necessarily the year before the start of the study period). ►► Wound-­ related healthcare resource use (which included dressings, bandages, topical treatments, negative pressure wound therapy, district nurse and healthcare assistants visits (both of whom provide care within a patient’s home), practice nurse visits (who provide care within the general practice), GP visits, hospital outpatient visits, laboratory tests, prescribed medication (ie, analgesics, non-­steroidal anti-­inflammatory drugs (NSAIDs) and systemic anti-­ infectives (principally antibiotics)). ►► Clinical outcomes (ie, healing and putative infection).

If a patient received a bandage or dressing on a specific date, but a clinician visit was not documented in their record, it was assumed the patient had been seen outside of the general practice by a district/community nurse or healthcare assistant. No other assumptions were made regarding missing data and there were no other interpolations.

The use of individual healthcare resources was quantified for all the patients, individually. These quantities were then used to estimate the total utilisation of each healthcare resource attributable to wound management during the study period, stratified by wound type.

Clinical outcomes and wound-­ related healthcare resource use associated with the sample of 3000 patients were used to model the healing rates and the total annual amounts of healthcare resource use associated with wound care provided to adult patients who were ≥18 years of age by the NHS in 2017/18.

Differences between subgroups were tested for statistical significance using a χ2 test. Logistic regression was used to investigate relationships between baseline variables and clinical outcomes. The p values <0.05 were considered statistically significant and have been reported. All p values ≥0.05 were not considered to be statistically significant and these numerical values have not been reported.

All statistical analyses were performed using IBM SPSS Statistics (IBM UK, Portsmouth, Hampshire, UK).

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Annual prevalence Annual number of among the adult UK Annual number patients with a population of patients with a wound in 2017/2018 in 2017/2018 wound in 2012/20131

Percentage change in the annual number of patients with a wound between 2012/2013 and 2017/2018

Abscess Burn

293 000 (8%) 222 000 (6%)

0.0056 0.0043

160 000 (7%) 87 000 (4%)

83% 155%

Diabetic foot ulcer

326 000 (9%)

0.0063

169 000 (8%)

93%

Leg ulcer (arterial)

31 000 (1%)

0.0022

Leg ulcer (mixed)

102 000 (3%)

0.0003

24 000 (1%)

325%

Leg ulcer (unspecified)

361 000 (9%)

0.0069

420 000 (19%)

−14%

Leg ulcer (venous)

560 000 (15%)

0.0108

278 000 (13%)

101%

Open wound

337 000 (9%)

0.0065

240 000 (11%)

40%

Pressure ulcer

202 000 (5%)

0.0039

153 000 (7%)

32%

Surgical wound

519 000 (14%)

0.0100

253 000 (11%)

105%

Trauma

249 000 (7%)

0.0048

158 000 (7%)

58%

600 000 (16%) 3 802 000 (100%)

0.0115 0.0730

271 000 (12%) 2 222 000 (100%)

121% 71%

Unspecified Total

9 000 (<1%)

244%

Percentage of total number in parentheses.

Sixteen per cent of all wounds had no diagnosis and it was not possible to infer a wound type from the patients’ records. Additionally, 9% of all wounds were a leg ulcer without any further characterisation (ie, venous, arterial or mixed). Hence, the records of 25% of all wounds lacked a recorded differential diagnoses. In total, there were 1 million ulcers of the lower limb, which equates to 2.0% of the adult population having a lower limb ulcer in the study year. Of these, the number of diagnosed venous leg ulcers (560 000) indicates that 1.1% of all adults ≥18 years of age had such an ulcer in the study year. In addition, there were an estimated 326 000 diabetic foot ulcers, which equates to 9% of all adult diabetic patients (ie, 3.46 million individuals24) having a foot ulcer in the study year. There were an estimated 202 000 recorded pressure ulcers in the study year, equivalent to 0.4% of the total adult population (table 1).

Patients’ characteristics A representative sample of 3000 patients was randomly selected from the cohort of 174 569 patients with a wound-­ related Read code by IQVIA. Patients’ age in the randomly selected study population was a mean of 57.9 years and 67% were <65 years of age. A total of 56% of patients were female. Mean blood pressure was 130/77 mmHg and patients’ body mass index was a mean 29.1 kg/m2. An estimated 17% of patients were smokers, 30% were ex-­smokers and 52% were non-­smokers. A total of 73% of patients presented with a new wound in the study year (patients’ records predated the onset of the study period, enabling both pre-­existing and new wounds to be identified). Table 2 (online supplemental table S2) summarises patients’ characteristics according to wound type.

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The percentage of patients with different comorbidities in the year before the start of their wound (and not necessarily the year before the start of the study) stratified by wound type is summarised in table 3 (online supplemental table S3). A total of 95% of patients had at least one comorbidity in the year before the start of their wound. Moreover, patients had a mean of 4.1 comorbid conditions and 57% of all patients had diabetes. It is also noteworthy that 13% of patients with a pressure ulcer were recorded as suffering from malnutrition, whereas it was ≤5% of patients with other wound types.

Clinical outcomes The THIN database does not define wound healing.

Wound healing was a clinical observation documented in the patient’s record by their managing clinician, but not necessarily confirmed by a specialist, and it is unknown if the clinicians who managed these patients used any consistent definition. Furthermore, if a wound was not recorded as being healed it was considered to be unhealed. This assumption was supported by continued clinician visits for wound care and the continued prescribing of wound care products. On this basis, table 4 (online supplemental table S4) summarises the recorded healing rates stratified by wound type and various sub-­groups between 1 March 2017 and 28 February 2018. A total of 70% of all wounds (n=2.7 million) healed in the study year; 89% of acute wounds healed and 49% of chronic wounds. An estimated 30% of all wounds (n=1.1 million) remained unhealed.

Patients’ age did not appear to affect the overall healing rate. However, 59% of chronic wounds healed if there was no evidence of infection compared with 45% if there was a definite or suspected infection. The healing rate among acute wounds was unaffected by the presence of infection Guest JF, et al. BMJ Open 2020;10:e045253. doi:10.1136/bmjopen-2020-045253

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Table 1 Annual number of adult patients with a wound and prevalence of different wound types in the UK

Open access

Diabetic Leg Other Other foot ulcer Open Pressure Surgical acute chronic All ulcer (venous) wound ulcer wound Unspecified wounds* wounds† wounds Mean age per patient (years) 62.3 Percentage male 51%

70.9 48%

53.4 40%

76.1 40%

55.4 42%

55.9 49%

48.4 40%

55.9 42%

57.9 44%

Percentage smoker

11%

7%

18%

7%

19%

22%

23%

18%

17%

Percentage ex-­smoker

37%

44%

29%

40%

29%

28%

20%

24%

30%

Percentage non-­smoker

52%

48%

51%

40%

52%

49%

55%

58%

52%

0%

1%

2%

13%

0%

1%

2%

0%

1%

Mean body mass index per 30.9 patient (kg/m2)

31.5

29.6

24.5

28.3

28.9

28.6

28.6

29.1

Percentage with new 61% wounds in the study period Percentage of all wounds 78% with a recorded infection

59%

87%

80%

77%

80%

81%

62%

73%

41%

94%

13%

35%

1%

24%

63%

40%

Percentage with unknown smoking status

*Other acute wounds comprise abscesses, burns and traumatic wounds. †Other chronic wounds comprise arterial, mixed and unspecified leg ulcers. Full details are available in online supplemental table S2.

(86% vs 91% among acute wounds with no evidence of infection). An estimated 38% of chronic wounds healed if patients were smokers compared with 55% and 58% if patients were non-­ smokers or ex-­ smokers, respectively.

Smoking status did not appear to affect the healing rate of acute wounds (table 4, online supplemental table S4).

For the whole cohort of patients with a wound, binary logistic regression suggested that cardiovascular disease (OR 0.57 (95% CI 0.46 to 0.71); p<0.001), immunological disorders (OR 0.62 (95% CI 0.45 to 0.86); p=0.003) and renal disorders (OR 0.56 (95% CI 0.43 to 0.73); p<0.001) were independent risk factors for non-­ healing during the study period. Additionally, the presence of renal disease was an independent risk factor for non-­healing of diabetic foot ulcers (OR 0.28 (95% CI 0.13 to 0.62); p=0.002), and diabetes was an independent risk factor for non-­healing of venous leg ulcers (OR 0.10 (95% CI 0.01 to 0.96); p<0.02).

Healthcare resource use associated with patient management Patients were predominantly managed in the community by GPs, practice nurses, district/community nurses and healthcare assistants. Table 5 (online supplemental table S5) summarises the percentage of patients who utilised different resources during the study year and table 6 shows the annualised resources associated with each wound type. All the hospital admissions attributable to venous and mixed leg ulcers appeared to be linked to a suspected infection. So too were 80% of admissions attributable to diabetic foot ulcers and 95% of admissions attributable to open wounds. All these hospitalised patients with a suspected infection were prescribed antibiotics. All the hospitalised open wounds and 50% of the diabetic foot ulcers healed in the study period, but none of the venous and mixed leg Guest JF, et al. BMJ Open 2020;10:e045253. doi:10.1136/bmjopen-2020-045253

ulcers healed. Less than 50% of admissions attributable to the other wound types appeared to be linked to a suspected infection and 90% of them healed during the study period. Only one-­third of admissions attributable to surgical wounds and trauma appeared to be linked to a suspected infection.

Patients’ treatment varied according to wound type and wound duration. Patients were prescribed a mix of dressings up to the time their wound healed or the end of the study period, whichever came first. Overall, patients’ dressings were changed every 3–4 days at a nursing visit. However, this varied according to wound type. On average: ►► Those patients with a burn or a venous leg ulcer had one nursing visit/dressing change every 2–3 days. ►► Those patients with a diabetic foot ulcer, arterial leg ulcer, mixed leg ulcer, pressure ulcer or surgical wound had one nursing visit/dressing change every 3–4 days. ►► Those patients with an unspecified leg ulcer, open wound, trauma or unspecified wound had one nursing visit/dressing change every 4–5 days. ►► Those patients with an abscess had one nursing visit/ dressing change every 5–6 days.

Less than 1% of patients were prescribed the same dressing for the duration of their wound or study period.

On average, patients were prescribed a mean of eight different dressing types over the study period, ranging from a mean of four different dressing types for patients with a burn to a mean of nine different dressing types for patients with an unclassified wound. In addition to dressings and bandages, varying percentages of patients were prescribed analgesics, NSAIDs and antibiotics as shown in table 5 (online supplemental table S5).

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Table 2 Patients’ baseline characteristics

Guest JF, et al. BMJ Open 2020;10:e045253. doi:10.1136/bmjopen-2020-045253

13%

Immunological

25% 20% 39% 30% 45% 5.7

Ophthalmological

Psychiatric

Renal

Respiratory Mean number of comorbidities per patient

33% 4.0

30%

15%

4%

7%

33%

59%

4%

11%

19%

19%

37%

52%

78% 41%

36% 4.1

12%

35%

11%

14%

18%

49%

1%

10%

25%

34%

67%

69%

44% 51%

Open wound

33% 5.6

40%

33%

33%

27%

67%

73%

13%

7%

27%

47%

60%

60%

53% 40%

Pressure ulcer

38% 4.3

14%

35%

13%

18%

22%

57%

1%

9%

28%

37%

59%

63%

47% 51%

Surgical wound

37% 4.2

16%

35%

10%

19%

17%

56%

3%

9%

24%

35%

52%

57%

51% 45%

Unspecified

Those with diabetes are a subset of those with an endocrinological comorbidity. *Other acute wounds comprise abscesses, burns and traumatic wounds. †Other chronic wounds comprise arterial, mixed and unspecified leg ulcers. Full details are available in online supplemental table S3.

24%

Oncological

62%

Neurological

Musculoskeletal

2%

28%

Genitourinary

Malnutrition

42%

Gastroenterological

100%

99%

Endocrinological

Diabetes

70% 60%

Cardiovascular Dermatological

Leg ulcer (venous)

39% 3.8

7%

39%

11%

15%

18%

48%

1%

8%

23%

31%

51%

54%

36% 51%

43% 4.4

18%

47%

15%

17%

24%

62%

4%

6%

23%

32%

34%

38%

54% 52%

Other Other acute chronic wounds* wounds†

38% 4.1

18%

35%

12%

16%

24%

56%

3%

9%

24%

33%

57%

60%

53% 49%

All wounds

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6 Diabetic foot ulcer

Table 3 Percentage of patients with a comorbidity in the year before the start of their wound

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Open access

Diabetic Leg Other Other foot ulcer Open Pressure Surgical acute chronic All ulcer (venous) wound ulcer wound Unspecified wounds* wounds† wounds Wounds that healed in the study period New wounds that healed in the study period

52%

37%

90%

60%

85%

85%

88%

49%

70%

60%

56%

90%

75%

86%

88%

86%

36%

76%

Existing wounds that healed 40% in the study period

9%

90%

0%

80%

73%

93%

77%

56%

Wounds that healed with no evidence of infection

57%

50%

93%

62%

87%

86%

91%

54%

77%

Wounds that healed with recorded evidence of infection

50%

18%

89%

50%

81%

38%

78%

46%

60%

Wounds that healed among smokers

33%

25%

88%

33%

82%

85%

89%

43%

64%

Wounds that healed among ex-­smokers Wounds that healed among non-­smokers

53%

39%

88%

67%

83%

88%

87%

48%

70%

56%

38%

93%

75%

88%

84%

90%

52%

74%

*Other acute wounds comprise abscesses, burns and traumatic wounds. †Other chronic wounds comprise arterial, mixed and unspecified leg ulcers. Full details are available in online supplemental table S4.

Assessment of peripheral perfusion is a recognised requirement for leg ulcer and diabetic foot management.

However, only 15% of all those with a leg or foot ulcer had a Doppler ABPI recorded in their records, of which 75% were prescribed some form of compression. Of the 85% who did not have their ABPI recorded, 29% were prescribed compression bandages/hosiery (table 7).

Over 90% of the patients with a recorded venous leg ulcer were prescribed compression bandages/hosiery, irrespective of whether they had their ABPI recorded; so too did >50% of patients with a recorded diabetic foot ulcer (table 7).

the 30% of wounds that did not heal within the study year.

In addition, within the study period, the cost per healed wound ranged from £358 to £4684 per patient and that of an unhealed wound ranged from £831 to £7886 per patient (table 10).

Eighty-­ one per cent of the total annual NHS cost was incurred in the community and the remainder in secondary care. However, the distribution of costs varied according to wound type, with 68% and 85% of the total annual NHS cost of managing acute and chronic wounds, respectively, being incurred in the community and the remainder in secondary care.

NHS cost of patient management The total annual NHS cost of managing 3.8 million patients with a wound was estimated to be £8.3 billion (95% CI £7.9 to £8.5) billion (table 8). The use of 100 bootstrapped samples indicated a 5% margin of error around the costs (table 8). When the bootstrapping was repeated using 1000 subsets of cost data, the margin of error decreased to 1% (ie, 95% CI £8.2 to £8.4 billion).

District/community nurse visits were the primary cost driver accounting for 29% of all costs and GP office visits were the secondary cost driver accounting for a further 18% of the total cost. Healthcare assistant visits accounted for 17% of the total cost, practice nurse visits for 7% and wound care products for a further 6% (table 8).

Resource use associated with managing the unhealed wounds was substantially greater than that of managing the healed wounds (table 9). Consequently, the annual cost of managing the 70% of wounds that healed was estimated to be £2.7 billion compared with £5.6 billion for

Sensitivity analyses When the healing rate of each wound type was simultaneously varied by ±25%, the total annual NHS cost of wound management changed by ±16%. When the estimated annual number of each wound type was individually changed by ±25%, the total annual NHS cost of wound management changed by 10% or less. When the estimated amounts of resource use were individually varied by ±25%, the total annual NHS cost of managing 3.8 million wounds changed by 7% or less. When the unit costs of wound care products were simultaneously varied by ±25%, the total annual NHS cost of managing 3.8 million patients with a wound changed by <3%.

Guest JF, et al. BMJ Open 2020;10:e045253. doi:10.1136/bmjopen-2020-045253

DISCUSSION The 2012/2013 burden of wounds study1 2 incorporated a predictive model3 which forecast that the prevalence of wounds would increase by 11% per annum. Thus, 7

BMJ Open: first published as 10.1136/bmjopen-2020-045253 on 22 December 2020. Downloaded from http://bmjopen.bmj.com/ on January 6, 2021 by guest. Protected by copyright.

Table 4 Healing rates in the study period

Open access

Diabetic Leg Other Other foot ulcer Open Pressure Surgical acute chronic All ulcer (venous) wound ulcer wound Unspecified wounds* wounds† wounds District/community nurse visits Healthcare assistant visits

96%

85%

24%

60%

46%

44%

34%

85%

38%

93%

81%

21%

40%

46%

44%

25%

87%

36%

Practice nurse visits

94%

96%

97%

93%

97%

98%

96%

85%

97%

GP office visits

97%

100%

90%

93%

82%

62%

89%

100%

84%

Dressings

100%

100%

100%

100%

100%

100%

100%

100%

100%

Compression bandaging/ hosiery

15%

93%

5%

0%

3%

6%

2%

40%

6%

Prescribed analgesics/ non-­ steroidal anti-­inflammatories

57%

81%

12%

53%

24%

20%

17%

46%

21%

Prescribed antibiotics

92%

81%

81%

67%

43%

26%

56%

86%

50%

Hospital outpatient visits with a nurse

35%

37%

8%

0%

18%

31%

15%

20%

17%

Accident and emergency attendances

23%

30%

8%

7%

8%

4%

13%

11%

8%

4%

7%

7%

13%

8%

8%

7%

4%

7%

15%

7%

4%

20%

8%

1%

4%

9%

5%

GP home visits

2%

11%

1%

13%

2%

1%

2%

2%

2%

Diagnostic tests

3%

0%

1%

0%

2%

3%

1%

4%

2%

Ambulance services

3%

4%

0%

0%

1%

1%

0%

1%

1%

Hospital admissions with surgery

2%

0%

0%

0%

6%

0%

2%

0%

2%

Specialist nurse visits‡

3%

0%

0%

7%

1%

1%

0%

2%

1%

Podiatrist visits Day cases

3% 0%

0% 0%

1% 0%

7% 0%

1% 1%

0% <1%

1% 0%

6% 0%

1% <1%

Hospital admissions without surgery Hospital outpatient visits with a physician/surgeon

*Other acute wounds comprise abscesses, burns and traumatic wounds. †Other chronic wounds comprise arterial, mixed and unspecified leg ulcers. Full details are available in online supplemental table S5. ‡Includes tissue viability nurses and diabetic nurse specialists.

GP, general practitioner.

the model predicted there would be 3.8 million patients with a wound in 2017/2018. The findings from the current analysis are consistent with the estimates from this predictive model, with the overall annual number of patients with a wound having increased by 71% over the 5 years to 3.8 million. However, the rate of increase varied according to wound type. The annual number of patients with a wound increased by ≥100% for many wound types, but some acute wounds increased by ≤83% and pressure ulcers by only 32%, perhaps due in part to the ongoing pressure ulcer prevention campaign.25 The model also predicted that costs would increase in parallel with prevalence. However, when the £5.3 billion1 was uprated to 2017/2018 prices (ie, £5.6 billion), it would appear that the annual cost of wound care has increased at an approximate rate of 8%–9% per annum. Hence, the overall annual NHS cost of wound care has increased by 48% in real terms over the 5 years.

8

The aim of this study was to assess the annual health economic burden of wounds by quantifying the amount of resource use and corresponding costs associated with wound management in 2017/2018. From the NHS’ perspective, resource use and corresponding cost of managing a patient with multiple wounds does not end until all the wounds heal. Some of the patients in our data set may have had multiple wounds, but this was not specifically listed within the database and was not transparent in the patients’ records. Furthermore, it would be very difficult to retrospectively extricate resource use for different wounds from the records of a patient with multiple wounds of the same aetiology. Notwithstanding this, it would be unusual for an individual to have two wounds of different aetiologies at the same time. However, it may be that in 2017/2018, some of the patients with an ulcer of the lower limb had a second ulcer, although it would be unlikely that patients with other wounds would Guest JF, et al. BMJ Open 2020;10:e045253. doi:10.1136/bmjopen-2020-045253

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Table 5 Percentage of patients who utilised resources in the study year

632.13

Guest JF, et al. BMJ Open 2020;10:e045253. doi:10.1136/bmjopen-2020-045253

9

1.14

2.29

4.57

0.00

2.29

1.14

Ambulance services

Hospital admissions with surgery

Specialist nurse visits*

Podiatrist visits

Day cases

2436.59

0.00

0.00

0.00

3.57

0.00

3.57

7.15

0.00

17.86

46.44

171.49

235.79

62.52

0.00

9.89

17.30

4.95

9.89

17.30

14.83

61.78

19.77

150.74

583.19

2948.13

588.14

5580.89 51 475.28

382.27

3428.04

0.00

13.64

0.00

0.00

0.00

0.00

0.00

6.82

0.00

10.23

20.47

242.17

0.00

4007.17

115.97

187.59

1020.07

895.38

Leg ulcer (arterial)

0.00

17.04

10.23

0.00

3.41

30.69

17.04

10.23

3.41

47.74

709.31

1473.18

1691.43

19 817.92

1173.09

1938.34

4671.18

4411.41

Leg ulcer (mixed)

0.00

0.00

0.00

0.00

0.00

47.53

0.00

28.52

19.01

19.01

190.11

1787.04

258.85

26 030.08

1102.64

1278.84

6946.81

6093.17

Leg ulcer (unspecified)

0.00

0.00

0.00

0.00

41.49

0.00

62.24

41.50

62.24

248.97

3672.33

5498.12

27 259.29

79 863.79

9855.13

14 461.10

17 619.78

17 459.02

Leg ulcer (venous)

0.00

0.89

0.00

0.00

0.00

3.58

5.37

14.31

33.98

30.41

43.82

641.18

239.70

6759.11

497.20

545.16

804.15

797.34

Open wound

0.00

13.44

13.44

0.00

0.00

0.00

40.32

40.32

26.88

40.32

0.00

1760.41

0.00

9467.04

1196.00

1128.81

3839.82

5789.24

1.87

1.87

0.93

34.57

4.67

14.02

11.21

40.18

60.74

57.93

286.86

922.26

260.19

27 172.85

983.00

1217.10

3047.33

2791.44

Pressure Surgical ulcer wound

1424.03

2356.74

2423.08

2305.39

0.00

0.32

0.00

3.46

0.00

2.83

1.89

18.26

23.30

13.23

18.26

177.91

0.00

0.90

0.00

3.74

0.00

5.37

23.29

24.18

5.37

78.81

35.83

600.07

1359.55

407.91

3.91

59.38

45.64

51.12

67.12

143.95

189.95

285.57

370.01

758.00

6467.37

17 873.33

30 928.35

264 499.43

20 090.58

28 062.63

53 647.40

54 413.86

Unspecified All wounds

4028.25 22 913.59

292.53

290.62

238.16

234.97

Trauma

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*Includes tissue viability nurses and diabetic nurse specialists.

GP, general practitioner.

5.72

Diagnostic tests

18.29

Hospital outpatient visits with a physician/surgeon

GP home visits

24.01

Hospital admissions without surgery

171.46

Hospital outpatient visits with a nurse

57.15

827.59

Prescribed medication

Accident and emergency attendances

160.32

Compression bandaging/hosiery

7383.46

GP office visits

Dressings

745.32

Practice nurse visits

484.97

1283.91 10 641.73

1111.38

Healthcare assistant visits

Diabetic foot ulcer

2124.01 10 443.18

Burn

District/community 1069.31 nurse visits

Abscess

Table 6 Annual amount of National Health Service resource use attributable to managing 3.8 million patients with a wound (thousands)

Open access

Open access

Ulcer type

Percentage who had a recorded Doppler

Venous leg ulcer

59%

Arterial leg ulcer

22%

Mixed leg ulcer

27%

41%

Diabetic foot ulcer

8%

88% 99% 0% 100%

73% 0%

Percentage of these who were prescribed a compression bandage/hosiery

0% 78%

Unspecified leg ulcer

All lower limb ulcers

Percentage who did not have a recorded Doppler

100% 0%

100%

26%

92%

12%

85%

75% 29%

50%

15%

have multiple wounds. If 10% of patients with an ulcer of the lower limb had a second ulcer, the total number of wounds would increase by 5% from 3.8 million to 4.0 million. The implication of this is that the NHS may have managed more than 3.8 million wounds in 2017/2018.

Nevertheless, the estimated amount of resource use and corresponding costs as presented would remain unchanged since all the resources and wound care products used in managing each patient were documented in their record (despite the lack of granularity surrounding the number of wounds they may have had).

Another study limitation was the exclusion of a wound if it recurred after having healed during the study period.

If 10% of the diabetic foot ulcers, venous leg ulcers and pressure ulcers and 5% of the other leg ulcers recurred after healing in the study period, it would imply that 3.8 million patients had 3.97 million wounds in 2017/2018.

If these wounds recurred, on average, at the 6 months mid-­point, the annual NHS cost of wound care could be potentially 2% higher than estimated at £8.5 billion.

In the 2012/2013 data set, 65% of all the patients with a wound were 65 years of age or older.1 2 However, in the 2017/2018 data set, only 33% of patients were 65 years of age or older. This was a significant difference (p<0.001), suggesting that wounds are no longer predominantly the preserve of the elderly. In 2012/2013, 39% of all patients were non-­smokers. However, by 2017/2018, this percentage had increased significantly to 52% (p<0.001). In parallel with these changes in the patient demographics, there was a change in the distribution of comorbidities. In particular, in 2012/2013, 73% and 37% of patients had cardiovascular and musculoskeletal disorders, but in 2017/2018 an estimated 53% (p<0.001) and 56% (p<0.02) had cardiovascular and musculoskeletal 10

disorders, respectively. Most striking, however, was that 29% of the 2012/2013 cohort had diabetes compared with 57% in 2017/18 (p<0.05). Additionally, the variation in the mean number of comorbidities associated with different wound types in this study parallels the variation in Charlson Comorbidity Index associated with different wound types observed in a patient population in Asia.26 Over the 5-­ year period, the healing rate of acute wounds increased by a mean of 13% and that of chronic wounds by a mean of 14%. However, within this estimate, the healing rate of diabetic foot ulcers and pressure ulcers increased by 27% and 43%, respectively, but the healing rate of venous and mixed leg ulcers decreased by 21% and 29%, respectively. The percentage of patients accessing different resources increased over the 5 years and so too did the absolute amount of resource use. For example, between 2012/2013 and 2017/2018, there was >10 000% increase in the number of healthcare assistant visits (from 0.5 million to 53.6 million), a 399% increase in the number of district/community nurse visits (from 10.9 million to 54.4 million), 164% increase in the number of GP visits (from 7.7 million to 20.3 million), 100% increase in the number of hospital outpatient visits (from 3.4 million to 6.8 million) and 51% increase in the number of practice nurse visits (from 18.6 million to 28.1 million). In addition, there was a 2% decrease in the number of specialist nurse visits and a 104% increase in the amount of wound care products used. The changes in the annual cost of these resources mirror the changes in utilisation of these resources. Accordingly, the NHS cost of wound care in 2017/2018 was an estimated £8.3 billion, which is approaching the combined annual NHS cost of managing osteo and rheumatoid arthritis, which was reported to be £10.2 billion in 2017.27 The shift towards greater utilisation of community-­based resources is reflected in the distribution of care between secondary care and the community. In 2012/2013, 48% of the costs of managing acute wounds and 78% of the costs of managing chronic wounds were incurred in the community and the remainder in secondary care.1 2 In 2017/2018, 68% and 85% of the costs of managing acute and chronic wounds, respectively, were incurred in the community and the remainder in secondary care.

This present study has also highlighted that resource use associated with managing the 30% of wounds that did not heal in the study year was substantially greater than that of managing the 70% of wounds that did heal within the study year (eg, 325% more hospital outpatient visits, 178% more practice nurse visits, 171% more GP visits, 118% more accident and emergency attendances, 97% more district/community nurse visits and 85% more healthcare assistant visits). Consequently, the annual cost of managing wounds that healed within the study year was estimated to be £2.7 billion compared with £5.6 billion for the 30% of wounds that did not heal within the study year.

In addition, the mean cost of an unhealed wound (£3700) was approximately 2.5 times more than that of a wound that healed during the study period (£1500). Sensitivity Guest JF, et al. BMJ Open 2020;10:e045253. doi:10.1136/bmjopen-2020-045253

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Table 7 Use of Doppler in patients with an ulcer of the lower limb to measure ankle brachial pressure index

£95.58

£28.29

£33.38

£22.51

£16.66

£48.12

£46.78

Hospital admissions £30.25 without surgery

£15.65

£10.81

£12.90

GP office visits

Healthcare assistant £28.90 visits

£16.65

District/community nurse visits

Hospital outpatient visits with a nurse

Practice nurse visits

Wound care products

Prescribed medication

Guest JF, et al. BMJ Open 2020;10:e045253. doi:10.1136/bmjopen-2020-045253

£7.44

£9.16

£2.44

£0.69

£0.35

£0.31

£0.84

£0.00

£0.00

£233.52

£233.17 to £233.97 £241.31 to £253.68

Accident and emergency attendances

Hospital outpatient visits with a physician/surgeon

GP home visits

Ambulance services

Podiatrist visits

Day cases

Specialist nurse visits*

Diagnostic tests

Total cost

95% confidence intervals around the total cost†

11

£95.26

£0.00

£0.00

£0.00

£1.85

£0.00

£0.00

£0.91

£1.64

£0.00

£3.74

£5.80

£3.94

£1.99

£0.00

£26.52

£8.58

£40.29

Leg ulcer (arterial)

£1250.56 to £86.78 to £1292.10 £97.85

£1277.36

£0.03

£1.11

£0.00

£1.34

£1.49

£1.80

£8.23

£24.15

£20.69

£45.55

£92.48

£71.99

£56.65

£24.91

£276.69

£180.31

£469.94

Diabetic foot ulcer

£563.53 to £594.45

£602.88

£0.06

£0.66

£0.00

£2.31

£0.52

£2.07

£1.36

£7.65

£0.00

£22.67

£38.14

£40.71

£68.90

£11.06

£121.45

£86.81

£198.51

£704.66 to £740.45

£717.35

£0.09

£0.00

£0.00

£0.00

£0.00

£0.00

£3.80

£3.05

£0.00

£27.76

£39.24

£26.86

£18.47

£61.67

£180.62

£81.60

£274.19

Leg ulcer Leg ulcer (mixed) (unspecified)

£180.35

£0.01

£0.00

£0.00

£0.12

£0.00

£0.65

£1.91

£4.87

£0.00

£10.00

£10.68

£11.45

£4.26

£42.82

£20.91

£36.79

£35.88

Open wound

£2973.68; £175.64 to £3261.84 to £182.46

£3204.05

£0.00

£0.00

£0.00

£0.00

£6.27

£7.56

£5.53

£39.89

£0.00

£84.36

£225.10

£303.68

£356.69

£201.92

£458.11

£729.28

£785.66

Leg ulcer (venous)

£501.67 to £577.57

£571.98

£0.00

£0.86

£0.00

£1.82

£0.00

£4.90

£5.37

£6.46

£0.00

£27.09

£19.05

£23.71

£0.00

£33.86

£99.84

£88.50

£260.52

Pressure ulcer

£96.09

£0.01

£0.00

£0.00

£0.04

£0.00

£0.23

£2.43

£2.12

£7.33

£2.79

£5.50

£6.10

£1.77

£29.36

£6.19

£21.65

£10.57

Trauma

£549.61

£0.04

£0.24

£0.66

£0.00

£0.81

£2.94

£0.72

£5.74

£0.00

£20.90

£38.36

£49.49

£58.28

£99.31

£63.00

£105.38

£103.74

Unspecified

£540.69 to £93.10 to £539.47 to £555.76 £97.87 £571.17

£546.93

£0.03

£0.06

£1.37

£0.25

£0.71

£1.36

£5.35

£9.28

£73.12

£14.30

£33.57

£25.56

£27.86

£76.53

£79.23

£72.74

£125.61

Surgical wound

£7,896.93 to £8466.51

£8320.01

£0.28

£2.93

£2.87

£8.04

£10.15

£23.07

£38.05

£121.45

£124.19

£275.74

£531.38

£589.32

£628.18

£634.20

£1394.84

£1486.71

£2448.61

Total

(100%)

(<1%)

(<1%)

(<1%)

(<1%)

(<1%)

(<1%)

(<1%)

(1%)

(1%)

(3%)

(6%)

(7%)

(8%)

(8%)

(17%)

(18%)

(29%)

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Percentage of total cost in parentheses. *Includes tissue viability nurses and diabetic nurse specialists. †Based on 100 bootstrapped samples.

GP, general practitioner.

£244.63

£0.01

£0.00

£0.00

£0.00

£0.00

£0.87

£0.00

£13.38

Hospital admissions £9.67 with surgery

£3.68

£12.65

£10.18

Burn

Abscess

Table 8 Annual cost of National Health Service (NHS) resource use attributable to managing 3.8 million patients with a wound (£ million at 2017/2018 prices).

Open access

Open access

Annual number (thousand)

Healed

Annual cost (£ million)

Unhealed

Healed

Unhealed

Percentage difference in resource cost (%)

1288%

£0.68

£9.47

1293%

Number of patients with a wound Ambulance services

2677.00 4.51

Hospital outpatient visits

1286.85

5466.09

325%

£130.85

£535.38

309%

Practice nurse visits

7430.80

20 631.83

178%

£156.05

£433.27

178%

GP visits

5460.16

14 820.37

171%

£407.22

£1102.56

171%

16.11

43.27

169%

£2.18

£5.86

169%

5593.33

12 280.00

120%

£86.72

£189.02

118%

238.34

519.66

118%

£38.19

£83.26

118%

18 342.87

36 070.99

97%

£825.59

£1623.02

97%

£181.06

£350.32

93%

Podiatrist visits Prescribed medication Accident and emergency attendances District/community nurse visits

1125.00 62.61

Percentage difference in resource use (%)

Wound care products (dressings/ bandages/hosiery/creams/ointments/ tapes, etc) Healthcare assistant visits Specialist nurse visits* Hospital admissions and day cases Diagnostic tests Total

18 816.65

34 830.75

85%

£489.23

£905.61

85%

21.12

24.52

16%

£1.35

£1.58

17%

286.73

138.31

−52%

£427.89

£333.37

−22%

86.89

57.06

−34%

£0.19 £2747.20

£0.09 £5572.81

−53% 103%

*Includes tissue viability nurses and diabetic nurse specialists.

GP, general practitioner.

analysis showed the healing rate to have a large effect on the cost of wound care and regression analysis indicated that the presence of cardiovascular disease or immunological disorders or renal disorders were all independent

risk factors for non-­healing during the study period. In the 2012/2013 study both nutritional deficiency and diabetes were independent risk factors for non-­healing during the study period.1 In this study, only a mean of

Table 10 Total annual National Health Service (NHS) cost (at 2017/2018 prices) of wound care attributable to managing 3.8 million patients with a wound and cost per patient, stratified by healing Total NHS cost for all patients (£ million)

Mean annual NHS cost per patient

Healed wounds

Healed wounds

Unhealed wound

Unhealed wounds

Abscess Burn

152.12 140.23

81.40 104.40

£604.88 £754.81

£1977.94 £2922.16

Diabetic foot ulcer

490.11

787.25

£2874.36

£5056.71

Leg ulcer (arterial)

53.70

41.56

£2623.83

£4061.31

Leg ulcer (mixed)

143.77

459.11

£4684.15

£6411.01

Leg ulcer (unspecified)

379.58

337.77

£1901.79

£2089.98

Leg ulcer (venous)

422.56

2781.49

£2036.67

£7886.05

Open wound

127.51

52.84

£421.83

£1515.03

Pressure ulcer

90.44

481.54

£747.75

£5972.28

Surgical wound

389.92

157.01

£884.11

£2024.49

Trauma Unspecified

83.78 273.48

12.31 276.13

£358.09 £533.82

£831.63 £3146.03

12

Guest JF, et al. BMJ Open 2020;10:e045253. doi:10.1136/bmjopen-2020-045253

BMJ Open: first published as 10.1136/bmjopen-2020-045253 on 22 December 2020. Downloaded from http://bmjopen.bmj.com/ on January 6, 2021 by guest. Protected by copyright.

Table 9 Annual amount and corresponding cost (at 2017/2018 prices) of National Health Service (NHS) resource use attributable to managing 3.8 million patients with a wound, stratified by healing

Open access

Guest JF, et al. BMJ Open 2020;10:e045253. doi:10.1136/bmjopen-2020-045253

a ‘triple integration’ of primary and specialist care, physical and mental health services and health with social care.32 Additionally, commissioners will be tasked to share decisions with providers on population health, service redesign and long term plan implementation.32 Such a change in the system may facilitate getting the optimum care to patients at the right time in the right setting in order to improve the patient experience and health outcomes, thereby freeing-­up healthcare resources and reducing costs. However, will this method of care delivery improve wound care and associated patient outcomes?

The introduction of truly seamless care with integrated electronic patient records would improve overall patient management. However, patients with wounds need face-­ to-­face interaction with clinicians on a regular basis to monitor progress and have their dressings changed. The authors are therefore of the opinion that this model would require the NHS to establish dedicated wound care clinics in the community at which patients receive consistent and integrated care from clinicians with qualified experience in wound care, with the clinics linking directly to electronic patient records which are integrated across all healthcare sectors. These clinics could provide both direct care and holistic assessments of patients allowing coordinated management of any comorbidities which may impact on wound healing The advantages and disadvantages of using the THIN database for this study have been previously discussed.1 In summary, the advantage of using the THIN database is that the patient pathways and associated resource use are based on real-­world evidence derived from clinical practice. However, the possibility of resource use associated with managing a comorbidity being conflated with that of wound management cannot be excluded. While the study results are compelling, the analyses were based on clinicians’ entries into their patients’ records and inevitably subject to a certain amount of imprecision and lack of detail. Moreover, the computerised information in the THIN database is collected by GPs for clinical care purposes and not for research. Prescriptions issued by GPs and practice nurses are recorded in the database, but it does not specify whether the prescriptions were dispensed or detail patient compliance with the product.

Despite these limitations, it is the authors’ opinion that the THIN database affords one of the best sources of real-­world evidence for clinical practice in the UK, since it is representative of the whole UK population18 33 and there are only minor differences between this and other real-­world evidence databases in the UK.33 Moreover, the changes between 2012/2013 and 2017/2018 are clinically relevant, since the sample size in this study was 3000 patients versus 1000 patients in the earlier study. Furthermore, a review of Medline in August 2020 identified 283 articles in peer-­ reviewed journals in which the THIN database had been used to characterise clinical practice in a wide range of therapeutic areas in the UK, of which 28 had been published in BMJ Open since 2014. Notwithstanding this, it is not possible to ascertain from the data 13

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3% of patients had malnutrition, possibly reflecting the significantly lower age of the study population. However, 13% of patients with a pressure ulcer had malnutrition and their BMI was a mean of 24.5 kg/m2 which was lower than that of patients with other wound types. Diabetes was not found to exert an independent effect on healing possibly because 59% of the patients with diabetes also had cardiovascular disease, 19% had renal disease, and 11% had immunological disorders. In addition, 61% of the patients with diabetes had musculoskeletal disorders and 38% had a mental health condition (principally depression and anxiety). The age of the patients with diabetes was a mean of 59.2 years per patient and 44% were male.

This and many other studies10–12 28 29 have shown that wound management is predominantly a nurse-­led discipline. Nevertheless, there still seems to be minimal clinical involvement of tissue viability nurses and other specialist nurses in direct patient management. In addition, dressing and bandage types were continually switched at successive wound dressing changes for the majority of patients, suggesting confusion and conflict within the treatment plan. It was not possible to determine which professional groups were the decision makers in relation to changes in dressing type and what the goal of treatment changes were as this information was not specifically recorded in the patients’ records. Moreover, an estimated 25% of all wounds being managed within the NHS in 2017/2018 lacked a recorded differential diagnosis in the patient’s record. Furthermore, only 15% of patients with an ulcer on the lower limb had a vascular assessment with Doppler ABPI recorded in their records, contrary to national guidance.30 31 Nevertheless, we observed a 14% decrease in the proportion of patients with unspecified leg ulcers since 2015 which may be due to an increase in measuring ABPI even if it was not documented in the patients’ records. It remains unclear and disappointing to find that records still lacked documentation of this essential investigation. Moreover, 5 years later, patients’ records still appear to lack any evidence of consistent reporting of wound management processes.

This may be indicative of the difficulties experienced by non-­specialist healthcare professionals in the community with establishing a working diagnosis.

It seems unclear how the NHS can best respond to the ever-­increasing demand for wound care. The NHS Long Term Plan32 has described how the NHS will move to a new service model in which patients will have properly joined-­up care at the right time in the optimal care setting.

This will involve having online ‘digital’ GP consultations, and redesigned hospital support in order to free-­up about one-­third of outpatient appointments.32 Additionally, GP practices will be funded to create integrated teams of GPs, community health and social care staff.32 These expanded community health teams will provide fast support to people in their own homes.32 Ultimately, the NHS will aim to create Integrated Care Systems everywhere by April 2021, which bring together local organisations to deliver

Open access

Acknowledgements The authors thank Kathryn Vowden, University of Bradford, Bradford, UK, for her appraisal and input into this manuscript.

Contributors JFG designed the study, obtained the THIN data set, managed the analyses, performed some analyses, checked all the other analyses, and wrote the

14

manuscript. GWF conducted much of the analyses. PV scrutinised the analyses, suggested further analyses and helped interpret some of the findings. All the authors were involved in revising the manuscript and gave final approval. JFG is the guarantor of this work and, as such, had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Funding This study was funded by JFG, the lead author and by a donation from Essity, Hull, UK. Competing interests None declared.

Patient consent for publication Not required.

Ethics approval Ethics approval to use anonymised patients’ records from the THIN database for this study was obtained from the Research Ethics Committee that appraises studies using the THIN database (Reference number 18THIN093).

Provenance and peer review Not commissioned; externally peer reviewed.

Data availability statement Data are available upon reasonable request. All data relevant to the study are included in the article or uploaded as supplemental information. The THIN data set cannot be shared as this restriction was a condition of the ethics approval obtained from the Research Ethics Committee (Reference number 18THIN093). Questions concerning the data underlying the results can be sent to the corresponding author.

Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-­reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.

Open access This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-­NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-­commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-­commercial. See: http://​creativecommons.​org/​licenses/​by-​nc/​4.​0/.

ORCID iD Julian F Guest http://​orcid.​org/​0000-​0003-​0162-​2007

REFERENCES

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4 House of Lords Hansard. House of Lords debate on developing a strategy for improving the standards of wound care in the NHS, 2017. Available: https://​hansard.​parliament.​uk/​lords/​2017-​ 11-​22/​debates/​6C57E65A-​A04D-​449B-​82E9-​C836F088A696/​ NHSWoundCare 5 NHS England. National wound care strategy programme. Available: https://www.​ahsnnetwork.​com/​about-​academic-​health-​science-​ networks/​national-​programmes-​priorities/​national-​wound-​care-​ strategy-​programme 6 NHS Digital. General practice provisional tables december 2017nurse, 2018. Available: https://​digital.​nhs.​uk/​data-​and-​information/​ publications/​statistical/​general-​and-​personal-​medical-​services/​as-​at-​ 31-​december-​2017-​provisional-​experimental-​statistics 7 NHS Digital. NHS-­staf-­sept-2016-­summ, 2017. Available: https://​ digital.​nhs.​uk/​data-​and-​information/​publications/​statistical/​nhs-​ workforce-​statistics/​nhs-​workforce-​statistics-​november-​2016-​ provisional-​statistics 8 House of Commons Health Committee. The nursing workforce Second Report of Session 2017–19: HC353, 2018. Available: https://​

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set whether some of the changes between 2012/2013 and 2017/2018 are due to increased complexity of wound aetiology and a decrease in competency of the clinical staff caring for these patients. There is no recognised complexity index/score for wounds so any measure of this would be subjective. Additionally, the low involvement of senior staff in patient management may indicate competency as a possible issue, but this cannot be quantified.

The analysis does not consider the potential impact of those wounds that remained unhealed beyond the study period. The THIN database may have under-­recorded use of some healthcare resources outside the GP’s surgery if not documented in the GP records, and the impact of this was addressed in sensitivity analyses. In particular, not all community records may have been linked to the GP records. The analysis excluded hospital-­ based prescribing, but this should have minimal impact on the results as most prescribing is undertaken by GPs and nurses in the community. Also excluded is the potential impact of managing patients with wounds being cared for in residential and nursing homes.

The analysis only considered the annual cost of NHS resource use for the ‘average adult patient’, and no attempt was made to stratify resource use and costs according to gender, comorbidities, wound size, wound severity and other disease-­related factors. Also excluded were the costs incurred by patients and indirect societal costs as a result of patients taking time off work. In 2012/2013, only 35% of patients with a wound were of working age. However, in 2017/2018 nearly 70% of the cohort was less than 65 years of age and 6% of patients in this age group were admitted into hospital. In April 2018, the gross median salary for full-­time employees was £569 per week.34 Hence, the indirect societal cost in lost gross domstic product (GDP) arising from hospitalisation (assuming 96% of these patients were in full-­time employment35) amounted to £87 million. This is likely to be an underestimate, since a proportion of patients are likely to be absent from work due to their wound, but residing in their home. Nevertheless, this is a relatively negligible indirect cost considering that nocturia (which predominantly affects the elderly population) accounts for over £4 billion in lost GDP.36 Notwithstanding the study’s limitations, real-­ world evidence highlights the substantial burden that wounds continue to impose on the NHS in an average year. Clinical and economic benefits to both patients and the NHS could accrue from strategies that focus on (1) accurate diagnosis, (2) preventing infection and (3) improving wound-­healing rates. However, these benefits are unlikely to be realised unless there is a structural change within the NHS in order to manage the increasing demand for wound care.

Open access

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23 Office for National Statistics, 2017. Available: https://www.​ons.​ gov.​uk/​peop​lepo​pula​tion​andc​ommunity/​popu​lati​onan​dmig​ration/​ populationestimates/​datasets/​popu​lati​ones​tima​tesf​oruk​engl​anda​ ndwa​less​cotl​anda​ndno​rthe​rnir​eland 24 Diabetes UK. Facts and figures, 2019. Available: https://www.​ diabetes.​org.​uk/​professionals/​position-​statements-​reports/​statistics 25 React to Red Skin. Available: http://www.​reacttoredskin.​co.​uk/ 26 Lo ZJ, Lim X, Eng D, et al. Clinical and economic burden of wound care in the tropics: a 5-­year institutional population health review. Int Wound J 2020;17:790–803.

27 Arthritis Research UK. The Nation’s Joint Problem, 2017. Available: https://www.​arthritiscare.​org.​uk 28 Guest JF, Taylor RR, Vowden K, et al. Relative cost-­effectiveness of a skin protectant in managing venous leg ulcers in the UK. J Wound Care 2012;21:389–98.

29 Guest JF, Ayoub N, Greaves T. Clinical outcomes and cost-­ effectiveness of an externally applied electroceutical device in managing venous leg ulcers in clinical practice in the UK. J Wound Care 2015;24:572–80.

30 Scottish Intercollegiate Guidelines Network. SIGN guideline 120: management of chronic venous leg ulcers. 2010, 2010. Available: http://​sign.​ac.​uk/​pdf/​sign120.​pdf 31 National Institute for Health and Care Excellence (NICE). Diabetic foot problems: prevention and management. NICE guidelines [NG19], 2015. Available: https:// ​nice.​org.​uk/​guidance/​ng19 [Accessed 30 Nov 2016].

32 NHS England. The NHS long term plan, 2019. Available: https://www.​ longtermplan.​nhs.​uk/ 33 Kneale D, Khatwa M, Thomas J. Identifying and appraising promising sources of UK clinical health and social care data for use

by NICE, 2016. Available: https://​eppi.​ioe.​ac.​uk/​cms/​Default.​aspx?​ tabid=​3673 34 Office for National Statistics. Employee earnings in the UK: 2018, 2018. Available: https://www.​ons.​gov.​uk/​empl​oyme​ntan​dlab​ourm​ arket/​peopleinwork/​earn​ings​andw​orki​nghours/​bulletins/​annu​alsu​rvey​ ofho​ursa​ndea​rnings/​2018 35 Office for National Statistics. Unemployment, 2018. Available: https:// www.​ons.​gov.​uk/​empl​oyme​ntan​dlab​ourm​arket/​peoplenotinwork/​ unemployment 36 Weidlich D, Andersson FL, Oelke M, et al. Annual direct and indirect costs attributable to nocturia in Germany, Sweden, and the UK. Eur J Health Econ 2017;18:761–71.

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publications.​parliament.​uk/​pa/​cm201719/​cmselect/​cmhealth/​353/​ 353.​pdf Royal College of Nursing. The UK nursing labour market review 2018, 2018. Available: https://www.​rcn.​org.​uk Guest JF, Fuller GW, Vowden P. Clinical outcomes and cost-­ effectiveness of three different compression systems in newly-­diagnosed venous leg ulcers in the UK. J Wound Care 2017;26:244–54.

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Alderwick H, Robertson R, Appleby J, et al. Better value in the NHS. The role of changes in clinical practice, 2015. Available: www.​ kingsfund.​org.​uk Blak BT, Thompson M, Dattani H, et al. Generalisability of the health improvement network (thin) database: demographics, chronic disease prevalence and mortality rates. Inform Prim Care 2011;19:251–5.

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BMJ Publishing Group Limited (BMJ) disclaims all liability and responsibility arising from any reliance placed on this supplemental material which has been supplied by the author(s)

Supplemental material

Read code 14F3.00 14F4.00 14F5.00 14F6.00 14F7.00 22L..00 22L1.00 22L2.00 22L3.00 22L3.11 22L4.00 22L5.00 22L6.00 22Q..00 22Q0.00 22Q1.00 22Q3.00 22Q4.00 22Q6.00 22Q8.00 22Q9.00 22QA.00 22QB.00 26B8.00 26B8.11 2924.00 2Fb..00 2FF..00 2FF1.00 2FF2.00 2FF3.00 2FFZ.00 2FG7.00 2FI..00 2FI2.00 2FI3.00 2FI4.00 2FIZ.00 2G48.00 2G4E.00 2G54.00 2G55.00 2G5H.00 2G5L.00 2G5Q.00 2G5R.00 2G5S.00 2G5T.00 2G5V.00

BMJ Open

Description H/O: chronic skin ulcer H/O: Admission in last year for diabetes foot problem H/O: venous leg ulcer H/O: foot ulcer H/O: arterial lower limb ulcer O/E - wound healing O/E - Wound healed O/E - Wound healing well O/E - Wound healing badly O/E wound healing delayed O/E - Wound infected O/E - protruding suture O/E - wound necrotic Wound observation Length of wound Width of wound Wound dirty Depth of wound Wound discharge Critical colonisation of wound Traumatic wound Surgical wound Fungating wound O/E - ulcerated breast lesion O/E - ulcer on breast O/E - trophic skin ulceration Granulation of tissue O/E - skin ulcer O/E - no skin ulcer O/E - skin ulcer present O/E - depth of ulcer O/E - skin ulcer NOS O/E - healed burn scar O/E - sinus in skin O/E -skin sinus-post operation O/E - skin sinus -after injury O/E - suppuration skin sinus O/E - skin sinus NOS O/E - ankle ulcer Healed leg ulcer O/E - Right foot ulcer O/E - Left foot ulcer O/E - Right diabetic foot - ulcerated O/E - Left diabetic foot - ulcerated O/E - No left foot ulcer O/E - No right foot ulcer O/E - right healed foot ulcer O/E - left healed foot ulcer O/E - right chronic diabetic foot ulcer

Guest JF, et al. BMJ Open 2020; 10:e045253. doi: 10.1136/bmjopen-2020-045253

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Supplemental material

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BMJ Open

O/E - left chronic diabetic foot ulcer Ischaemic toe O/E - infected toe O/E - gangrene Surgical biopsy taken Leg ulcer assessment Wound assessment SINBAD (site,isch,neuro,bact inf,depth) wound classification Pressure sore Superficial pressure sore Deep pressure sore Pressure sore -deep + superfic Waterlow pressure sore risk score Waterlow major surgery/trauma score Medley pressure sore risk score Maelor pressure ulcer risk assessment score Maelor score EPUAP (European pressure ulcer advisory panel) grade 1 ulcer EPUAP (European pressure ulcer advisory panel) grade 2 ulcer EPUAP (European pressure ulcer advisory panel) grade 3 ulcer EPUAP (European pressure ulcer advisory panel) grade 4 ulcer Wound microscopy, culture and sensitivities Wound exudate sample Wound swab Wound swab culture positive Wound swab culture negative Skin ulcer swab taken Skin wound swab taken Photography of wound Wound repair review Curettage of lesion of skin or subcutaneous tissue Curettage of lesion of skin including head and neck Curettage and cauterisation of lesion of skin head or neck Curettage and cauterisation of lesion of skin NEC Curettage and cauterisation of skin wart NEC Curettage of lesion of skin of head or neck NEC Curettage of sinus NEC Curettage of wound NEC Other specified curettage of lesion of skin Curettage of lesion of skin NOS Toilet or clean burnt skin of head or neck Toilet or clean burnt skin NEC Debridement of burnt skin of head and neck Debridement of burnt skin NEC Toilet to burnt skin of head or neck NEC Tangent excision of burnt skin of head or neck Tangent excision of burnt skin NEC Removal of slough from burnt skin NEC Escharotomy of burnt skin NEC Cleansing and sterilisation of burnt skin of head or neck

Guest JF, et al. BMJ Open 2020; 10:e045253. doi: 10.1136/bmjopen-2020-045253

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Supplemental material

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BMJ Open

Dress burnt skin head or neck us vacuum assisted clos device Cleansing and sterilisation of burnt skin NEC Dressing burnt skin using vacuum assisted closure device NEC Other specified toilet to burnt skin Toilet to burnt skin NOS Other skin toilet Debridement of skin NEC Debridement of wound of skin NEC Debridement of skin of head or neck NEC Removal of slough from skin NEC Removal of slough from skin of head or neck NEC Toilet to skin of head or neck NEC Cleaning of skin wound NEC Cleaning of skin wound of head or neck Cleansing and sterilisation of skin of head or neck NEC Cleansing and sterilisation of skin NEC Dres skin head or neck us vacuum assisted closure device NEC Dressing of skin using vacuum assisted closure device NEC Removal of slough from skin using pressurised fluid jet Other specified toilet to skin Other toilet to skin NOS Dressing of skin or wound Dressing of skin Dressing of burnt skin of head or neck Dressing of burnt skin NEC Dressing of skin of head or neck NEC Dressing of skin NEC Dressing of skin of head or neck NEC Dressing of skin ulcer NEC Attention to dressing of burn of head or neck Attention to dressing of burnt skin NEC Attention to dressing of skin of head or neck NEC Attention to dressing of skin NEC Two layer compression bandage for skin ulcer Four layer compression bandaging for skin ulcer Three layer compression bandage for skin ulcer Other specified dressing of skin Dressing of skin NOS Dermabrasion of skin of head or neck Dermabrasion of skin NEC Refashioning of scar Delivery of rehabilitation for burns Dressing of wound Dressing of ulcer Dressing of burn Attention to dressing of skin Checking dressing of skin Change of dressing Other wound dressing Wound dressing NOS

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Supplemental material

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BMJ Open

Immobilisation of wound Glueing of wound Treatment of wound with maggots Wound care Post-operative wound care Post-surgical wound care Compression hosiery procedure Oxygenation of slough Wound dressing requested by accident and emergency service Suture removal requested by accident and emergency service Dietary education for wound healing Dietary advice for wound healing Advice given about wound care Skin care Leg ulcer care pathway Agreeing on leg ulcer treatment plan Leg ulcer compression therapy finished Leg ulcer compression therapy started Admit to burns unit Burns referral Referral for complex wound care Referral to leg ulcer clinic Complex wound care - enhanced services administration Complex skin ulcer care enhanced services administration Review of wound repair - enhanced services administration Review of wound repair Seen in primary care leg ulcer clinic Seen in burns clinic Seen by tissue viability nurse specialist Postop wound management gen secondary care done by practice Attending leg ulcer clinic Amoebic skin ulceration Tuberculosis of skin and subcutaneous tissue Tuberculosis of skin and subcutaneous tissue NOS Gas gangrene Gas gangrene-neck Gas gangrene-back Gas gangrene-shoulder Gas gangrene-arm Gas gangrene-forearm Gas gangrene-hand Gas gangrene-pelvis Gas gangrene-thigh Gas gangrene-leg Gas gangrene-foot Gas gangrene caused by organism NOS Aleppo boil Baghdad boil Delhi boil Urban cutaneous leishmaniasis NOS

Guest JF, et al. BMJ Open 2020; 10:e045253. doi: 10.1136/bmjopen-2020-045253

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Supplemental material

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BMJ Open

Asian desert cutaneous leishmaniasis Ethiopian cutaneous leishmaniasis American cutaneous leishmaniasis Chiclero ulcer American mucocutaneous leishmaniasis Leishmaniasis NOS Trypanosomiasis Cutaneous myiasis Wound myiasis Diabetes mellitus with gangrene Diabetes with gangrene Diabetes mellitus, adult with gangrene Insulin dependent diabetes mellitus with ulcer Type I diabetes mellitus with ulcer Type 1 diabetes mellitus with ulcer Insulin dependent diabetes mellitus with gangrene Type I diabetes mellitus with gangrene Type 1 diabetes mellitus with gangrene Non-insulin dependent diabetes mellitus with ulcer Type II diabetes mellitus with ulcer Type 2 diabetes mellitus with ulcer Non-insulin dependent diabetes mellitus with gangrene Type II diabetes mellitus with gangrene Type 2 diabetes mellitus with gangrene Type 1 diabetes mellitus with ulcer Type I diabetes mellitus with ulcer Insulin dependent diabetes mellitus with ulcer Type 1 diabetes mellitus with gangrene Type I diabetes mellitus with gangrene Insulin dependent diabetes mellitus with gangrene Type 2 diabetes mellitus with ulcer Type II diabetes mellitus with ulcer Type 2 diabetes mellitus with gangrene Type II diabetes mellitus with gangrene Abscess of external ear Peripheral gangrene Gangrene of toe Gangrene of foot Gangrene of finger Gangrene of thumb Gangrene of hand Varicose veins of the leg with ulcer Varicose veins of the leg with ulcer and eczema Infected varicose ulcer Venous ulcer of leg Abscess of lip Lip ulcer Abscess of anal and rectal regions Rectal abscess Perianal abscess

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Supplemental material

J540.11 J541.00 J542.00 J543.00 J544.00 J545.00 J546.00 J54z.00 K272000 K272100 K272200 K272300 K27y500 K284600 K424000 K424011 K424100 K424111 K424200 K424z00 K425.00 K425000 K425100 K425200 K425z00 L394500 L441.00 L441000 L441100 L441200 L441z00 L442.00 L442.11 L442.12 L442000 L442100 L442200 L442z00 L443.00 L443.11 L443.12 L443000 L443100 L443200 L443z00 L45..00 L450.00 L450.11 L450.12 L450000

BMJ Open

Perianal cellulitis Ischiorectal abscess Submucous ano-rectal abscess Pelvi-rectal abscess Ano-rectal fissure abscess Intrasphincteric abscess Rectal abscess Ano-rectal abscess NOS Penile abscess Penile boil Penile carbuncle Cellulitis of penis Chronic ulcer of penis Fournier's gangrene of scrotum Abscess of vulva Abscess of labia Carbuncle of vulva Boil of vulva Furuncle of vulva Other abscess of vulva NOS Ulceration of vulva Ulceration of vulva unspecified Ulceration of vulva in diseases EC Ulceration of vulva in Behcet's disease Ulceration of vulva NOS Infection of obstetric surgical wound Caesarean wound disruption Caesarean wound disruption unspecified Caesarean wound disruption - delivered with p/n complication Caesarean wound disruption with postnatal complication Caesarean wound disruption NOS Obstetric perineal wound disruption Breakdown of perineum Episiotomy breakdown Obstetric perineal wound disruption unspecified Obstetric perineal wound disruption - deliv + p/n comp Obstetric perineal wound disruption with p/n complication Obstetric perineal wound disruption NOS Other complication of obstetric surgical wound Haematoma - perineal wound Infection - perineal wound Other complication of obstetric surgical wound unspecified Other complication obstetric surg wound -delivered +p/n comp Other complication obstetric surgical wound with p/n comp Other complication of obstetric surgical wound NOS Obstetric breast infections Obstetric nipple infection Abscess of nipple - obstetric Nipple infection - obstetric Obstetric nipple infection unspecified

Guest JF, et al. BMJ Open 2020; 10:e045253. doi: 10.1136/bmjopen-2020-045253

BMJ Publishing Group Limited (BMJ) disclaims all liability and responsibility arising from any reliance placed on this supplemental material which has been supplied by the author(s)

Supplemental material

L450100 L450200 L450300 L450400 L450z00 L451.00 L451.11 L451000 L451100 L451200 L451300 L451400 L451z00 Lyu6A00 M....00 M0...00 M00..00 M000.00 M000000 M000100 M000200 M000300 M000z00 M001.00 M002.00 M002000 M002100 M002200 M002300 M002400 M002500 M002600 M002700 M002z00 M003.00 M003000 M003100 M003200 M003300 M003400 M003z00 M004.00 M004000 M004100 M004200 M004z00 M005.00 M005000 M005100 M005z00

BMJ Open

Obstetric nipple infection - delivered Obstetric nipple infection - delivered with p/n complication Obstetric nipple infection with antenatal complication Obstetric nipple infection with postnatal complication Obstetric nipple infection NOS Obstetric breast abscess Purulent mastitis - obstetric Obstetric breast abscess unspecified Obstetric breast abscess - delivered Obstetric breast abscess - deliv with postnatal complication Obstetric breast abscess with antenatal complication Obstetric breast abscess with postnatal complication Obstetric breast abscess NOS [X]Infection of caesarean section wound following delivery Skin and subcutaneous tissue diseases Skin and subcutaneous tissue infections Carbuncle Carbuncle of face Carbuncle of ear Carbuncle of face (excluding eye) Carbuncle of nasal septum Carbuncle of temple region Carbuncle of face NOS Carbuncle of neck Carbuncle of trunk Carbuncle of chest wall Carbuncle of breast Carbuncle of back Carbuncle of abdominal wall Carbuncle of umbilicus Carbuncle of flank Carbuncle of groin Carbuncle of perineum Carbuncle of trunk NOS Carbuncle of upper arm and forearm Carbuncle of shoulder Carbuncle of axilla Carbuncle of upper arm Carbuncle of elbow Carbuncle of forearm Carbuncle of upper arm and forearm NOS Carbuncle of hand Carbuncle of wrist Carbuncle of thumb Carbuncle of finger Carbuncle of hand NOS Carbuncle of buttock Carbuncle of anus Carbuncle of gluteal region Carbuncle of buttock NOS

Guest JF, et al. BMJ Open 2020; 10:e045253. doi: 10.1136/bmjopen-2020-045253

BMJ Publishing Group Limited (BMJ) disclaims all liability and responsibility arising from any reliance placed on this supplemental material which has been supplied by the author(s)

Supplemental material

M006.00 M006000 M006100 M006200 M006300 M006400 M006z00 M007.00 M007000 M007100 M007200 M007z00 M00y.00 M00y000 M00yz00 M00z.00 M01..00 M010.00 M010000 M010100 M010200 M010300 M010400 M010z00 M011.00 M012.00 M012000 M012100 M012200 M012300 M012400 M012500 M012600 M012700 M012z00 M013.00 M013000 M013100 M013200 M013300 M013400 M013z00 M014.00 M014000 M014100 M014200 M014z00 M015.00 M015000 M015100

BMJ Open

Carbuncle of leg (excluding foot) Carbuncle of hip Carbuncle of thigh Carbuncle of knee Carbuncle of lower leg Carbuncle of ankle Carbuncle of leg (excluding foot) NOS Carbuncle of foot Carbuncle of foot unspecified Carbuncle of heel Carbuncle of toe Carbuncle of foot NOS Carbuncle of other specified site Carbuncle of head (excluding face) Carbuncle of other specified site NOS Carbuncle NOS Furuncle - boil Boil of face Boil of ear Boil of face (excluding eye) Boil of nasal septum Boil of temple region Boil of external nose Boil of face NOS Boil of neck Boil of trunk Boil of chest wall Boil of breast Boil of back Boil of abdominal wall Boil of umbilicus Boil of flank Boil of groin Boil of perineum Boil of trunk NOS Boil of upper arm and forearm Boil of shoulder Boil of axilla Boil of upper arm Boil of elbow Boil of forearm Boil of upper arm and forearm NOS Boil of hand Boil of wrist Boil of thumb Boil of finger Boil of hand NOS Boil of buttock Boil of anus Boil of gluteal region

Guest JF, et al. BMJ Open 2020; 10:e045253. doi: 10.1136/bmjopen-2020-045253

BMJ Publishing Group Limited (BMJ) disclaims all liability and responsibility arising from any reliance placed on this supplemental material which has been supplied by the author(s)

Supplemental material

M015z00 M016.00 M016000 M016100 M016200 M016300 M016400 M016z00 M017.00 M017000 M017100 M017200 M017z00 M01y.00 M01y000 M01yz00 M01z.00 M01z.11 M01z.12 M01z000 M02..00 M020.00 M020000 M020100 M020111 M020112 M020200 M020300 M020311 M020400 M020500 M020z00 M021.00 M021000 M021100 M021200 M021300 M021z00 M021z11 M02z.00 M02z.11 M02z.12 M02z.13 M02z.14 M03..00 M03..11 M03..12 M03..13 M030.00 M030000

BMJ Open

Boil of buttock NOS Boil of leg (excluding foot) Boil of hip Boil of thigh Boil of knee Boil of lower leg Boil of ankle Boil of leg (excluding foot) NOS Boil of foot Boil of foot unspecified Boil of heel Boil of toe Boil of foot NOS Boil of other specified site Boil of head (excluding face) Boil of other specified site NOS Boil NOS Recurrent boils Boils of multiple sites Multiple boils Cellulitis and abscess of finger and toe Cellulitis and abscess of finger Cellulitis and abscess of finger unspecified Finger pulp abscess Felon Whitlow Onychia of finger Paronychia of finger Perionychia of finger Finger web space infection Pulp space infection of finger/thumb Cellulitis and abscess of finger NOS Cellulitis and abscess of toe Cellulitis and abscess of toe unspecified Onychia of toe Paronychia of toe Pulp space infection of toe Cellulitis and abscess of toe NOS Perionychia of toe Cellulitis and abscess of digit NOS Nail infection NOS Paronychia Infected nailfold Nailfold infected Other cellulitis and abscess Abscess of skin area excluding digits of hand or foot Acute lymphangitis of skin excluding digits of hand or foot Cellulitis of skin area excluding digits of hand or foot Cellulitis and abscess of face Cellulitis and abscess of cheek (external)

Guest JF, et al. BMJ Open 2020; 10:e045253. doi: 10.1136/bmjopen-2020-045253

BMJ Publishing Group Limited (BMJ) disclaims all liability and responsibility arising from any reliance placed on this supplemental material which has been supplied by the author(s)

Supplemental material

M030011 M030100 M030111 M030200 M030300 M030400 M030500 M030600 M030z00 M031.00 M031.11 M032.00 M032000 M032100 M032200 M032300 M032400 M032500 M032600 M032700 M032800 M032z00 M033.00 M033000 M033100 M033200 M033300 M033400 M033z00 M034.00 M034.11 M034000 M034011 M034012 M034013 M034014 M034100 M034z00 M035.00 M036.00 M036.11 M036000 M036100 M036200 M036300 M036400 M036z00 M037.00 M037.11 M037000

BMJ Open

Cellulitis and abscess of cheek Cellulitis and abscess of nose (external) Cellulitis and abscess of nose Cellulitis and abscess of chin Cellulitis and abscess of submandibular region Cellulitis and abscess of forehead Cellulitis and abscess of temple region Cellulitis of face Cellulitis and abscess of face NOS Cellulitis and abscess of neck Cervical abscess Cellulitis and abscess of trunk Cellulitis and abscess of chest wall Cellulitis and abscess of breast Cellulitis and abscess of back Cellulitis and abscess of abdominal wall Cellulitis and abscess of umbilicus Cellulitis and abscess of flank Cellulitis and abscess of groin Cellulitis and abscess of perineum Cellulitis of trunk Cellulitis and abscess of trunk NOS Cellulitis and abscess of arm Cellulitis and abscess of shoulder Cellulitis and abscess of axilla Cellulitis and abscess of upper arm Cellulitis and abscess of elbow Cellulitis and abscess of forearm Cellulitis and abscess of arm NOS Cellulitis and abscess of hand excluding digits Cellulitis and abscess of hand Cellulitis and abscess of hand unspecified Abscess of dorsum of hand Abscess of palm of hand Cellulitis of dorsum of hand Cellulitis of palm of hand Cellulitis and abscess of wrist Cellulitis and abscess of hand NOS Cellulitis and abscess of buttock Cellulitis and abscess of leg excluding foot Cellulitis and abscess of leg Cellulitis and abscess of hip Cellulitis and abscess of thigh Cellulitis and abscess of knee Cellulitis and abscess of lower leg Cellulitis and abscess of ankle Cellulitis and abscess of leg NOS Cellulitis and abscess of foot excluding toe Cellulitis and abscess of foot Cellulitis and abscess of foot unspecified

Guest JF, et al. BMJ Open 2020; 10:e045253. doi: 10.1136/bmjopen-2020-045253

BMJ Publishing Group Limited (BMJ) disclaims all liability and responsibility arising from any reliance placed on this supplemental material which has been supplied by the author(s)

Supplemental material

M037100 M037200 M037z00 M038.00 M03y.00 M03y000 M03y011 M03z.00 M03z000 M03z100 M03zz00 M060.00 M061.00 M061.11 M062.00 M063.00 M06z.00 M07..00 M070200 M070300 M07y.00 M07yz00 M07yz11 M07yz12 M07yz13 M07z.00 M07z.12 M07z.13 M07z.14 M07z000 M07z100 M07z200 M09..00 M090.00 M091.00 M092.00 M092000 M092100 M092200 M093.00 M094.00 M094000 M095.00 M09y.00 M0y..00 M0z..00 M0z..11 M1...00 M2...00 M27..00

BMJ Open

Cellulitis and abscess of heel Cellulitis in diabetic foot Cellulitis and abscess of foot NOS Cellulitis of external ear Other specified cellulitis and abscess Cellulitis and abscess of head unspecified Abscess of scalp Cellulitis and abscess NOS Cellulitis NOS Abscess NOS Cellulitis and abscess NOS Pilonidal cyst with abscess Pilonidal cyst with no abscess Dermal sinus Pilonidal sinus with abscess Pilonidal sinus without abscess Pilonidal sinus/cyst NOS Other local infections of skin and subcutaneous tissue Pyoderma gangrenosum Pyoderma ulcerosum tropicalum Local infection of skin or subcutaneous tissue OS Other spec local skin/subc infection NOS Infection toe Infection foot Infection finger Local infection skin/subcut tissue NOS Infected skin ulcer Septic spots Infected dermatitis Infection foot Infection toe Infection finger Cutaneous abscess [X]Abscess of face [X]Abscess of neck [X]Abscess of trunk [X]Abscess of buttock [X]Abdominal wall abscess [X]Perineal abscess [X]Abscess of buttock [X]Abscess of limb [X]Abscess of axilla Skin abscess [X]Abscess of other site Other specified infections of skin or subcutaneous tissue Skin and subcut tissue infection NOS Infected sebaceous cyst Other skin and subcutaneous tissue inflammatory conditions Other skin and subcutaneous tissue disorders Chronic skin ulcer

Guest JF, et al. BMJ Open 2020; 10:e045253. doi: 10.1136/bmjopen-2020-045253

BMJ Publishing Group Limited (BMJ) disclaims all liability and responsibility arising from any reliance placed on this supplemental material which has been supplied by the author(s)

Supplemental material

M270.00 M270.11 M270.12 M270.13 M270.14 M270000 M270100 M270200 M270300 M270400 M270500 M270600 M270700 M270z00 M271.00 M271.11 M271.12 M271.13 M271.14 M271.15 M271000 M271100 M271200 M271300 M271400 M271500 M271600 M271700 M272.00 M273.00 M274.00 M27y.00 M27z.00 M2y4D00 M2yA.00 M2yB.00 M2yz.11 M2z0.00 Myu0.00 Myu0100 R153300 S002.00 S002000 S002100 S002200 S002300 S002400 S002500 S002600 S002z00

BMJ Open

Decubitus (pressure) ulcer Bed sore Plaster ulcer Pressure sore Decubitus ulcer and pressure area Hospital acquired pressure ulcer Nursing home acquired pressure ulcer Community hospital acquired pressure ulcer Hospice acquired pressure ulcer Stage I decubitus ulcer and pressure area Stage II decubitus ulcer Stage III decubitus ulcer Stage IV decubitus ulcer Decubitus ulcer and pressure area NOS Non-pressure ulcer lower limb Foot ulcer Ischaemic leg ulcer Leg ulcer NOS Neurogenic leg ulcer Trophic leg ulcer Ischaemic ulcer diabetic foot Neuropathic diabetic ulcer - foot Mixed diabetic ulcer - foot Arterial leg ulcer Mixed venous and arterial leg ulcer Venous ulcer of leg Traumatic leg ulcer Neuropathic foot ulcer Ulcer of skin Non-healing leg ulcer Recurrent leg ulcer Chronic ulcer of skin, other specified sites Chronic skin ulcer NOS Macerated perianal skin Skin sinus Fistula of skin Skin lesion Skin lesion [X]Infections of the skin and subcutaneous tissue [X]Other specified local infections/skin+subcutaneous tissue [D]Positive culture findings in wound Open fracture vault of skull without intracranial injury Open #skull vlt no intracranial injury, unspec state consc Open #skull vlt no intracranial injury, no loss of consc Open #skull vlt no intracranial injury, <1hr loss of consc Open #skull vlt no intracranial injury, 1-24hr loss of consc Open #skull vlt no intracranial injury, >24hr LOC+recovery Open #skull vlt no intracranial inj, >24hr LOC not restored Open #skull vlt no intracranial injury, LOC unspec duration Open #skull vlt no intracranial injury + concussion unspec

Guest JF, et al. BMJ Open 2020; 10:e045253. doi: 10.1136/bmjopen-2020-045253

BMJ Publishing Group Limited (BMJ) disclaims all liability and responsibility arising from any reliance placed on this supplemental material which has been supplied by the author(s)

Supplemental material

S003.00 S003000 S003100 S003200 S003300 S003400 S003500 S003600 S003z00 S012.00 S012000 S012100 S012200 S012300 S012400 S012500 S012600 S012z00 S013.00 S013000 S013100 S013200 S013300 S013400 S013500 S013600 S013z00 S032.00 S032000 S032100 S032200 S032300 S032400 S032500 S032600 S032z00 S033.00 S033000 S033100 S033200 S033300 S033400 S033500 S033600 S033z00 S042000 S042100 S042200 S042300 S042400

BMJ Open

Open fracture vault of skull with intracranial injury Open #skull vlt + intracranial injury, unspec state of consc Open #skull vlt + intracranial injury, no loss of consc Open #skull vlt + intracranial injury, <1hr loss of consc Open #skull vlt + intracranial injury, 1-24hr loss of consc Open #skull vlt + intracranial injury, >24hr LOC + recovery Open #skull vlt + intracranial inj, >24hr LOC not restored Open #skull vlt + intracranial injury, LOC unspec duration Open #skull vlt with intracranial injury + concussion unspec Open fracture base skull without mention intracranial injury Open #skull bse no intracranial inj, unspec state of consc Open #skull bse no intracranial injury, no loss of consc Open #skull bse no intracranial injury, <1hr loss of consc Open #skull bse no intracranial injury, 1-24hr loss of consc Open #skull bse no intracranial injury, >24hr LOC+recovery Open #skull bse no intracranial inj, >24hr LOC not restored Open #skull bse no intracranial injury, LOC unspec duration Open #skull bse no intracranial injury + concussion unspec Open fracture base of skull with intracranial injury Open #skull bse + intracranial injury, unspec state of consc Open #skull bse + intracranial injury, no loss of consc Open #skull bse + intracranial injury, <1hr loss of consc Open #skull bse + intracranial injury, 1-24hr loss of consc Open #skull bse + intracranial injury, >24hr LOC + recovery Open #skull bse + intracranial inj, >24hr LOC not restored Open #skull bse + intracranial injury, LOC unspec duration Open #skull bse + intracranial injury + concussion unspec Open #skull NOS without mention of intracranial injury Open #skull NOS no intracranial inj, unspec state of consc Open #skull NOS no intracranial inj, no loss of consc Open #skull NOS no intracranial inj, <1hr loss of consc Open #skull NOS no intracranial inj, 1-24hrs loss of consc Open #skull NOS no intracranial inj, >24hrs LOC + recovery Open #skull NOS no intracranial inj, >24hrs LOC not restored Open #skull NOS no intracranial inj, LOC unspec duration Open #skull NOS no intracranial inj + concussion unspec Open fracture of skull NOS with intracranial injury Open #skull NOS + intracranial inj, unspec state of consc Open #skull NOS + intracranial inj, no loss of consc Open #skull NOS + intracranial inj, <1hr loss of consc Open #skull NOS + intracranial inj, 1-24hrs loss of consc Open #skull NOS + intracranial inj, >24hrs LOC + recovery Open #skull NOS + intracranial inj, >24hrs LOC not restored Open #skull NOS + intracranial inj, LOC unspec duration Open #skull NOS + intracranial inj + concussion unspec Open #skull/face, mult, no intracranial inj, unspec consc Open #skull/face, mult, no intracranial inj, no loss consc Open #skull/face, mult, no intracranial inj, <1hr LOC Open #skull/face, mult, no intracranial inj, 1-24hrs LOC Open #skull/face, mult, no intracran inj, >24hr LOC+recovery

Guest JF, et al. BMJ Open 2020; 10:e045253. doi: 10.1136/bmjopen-2020-045253

BMJ Publishing Group Limited (BMJ) disclaims all liability and responsibility arising from any reliance placed on this supplemental material which has been supplied by the author(s)

Supplemental material

S042500 S042600 S042z00 S043.00 S043000 S043100 S043200 S043300 S043400 S043500 S043600 S043z00 S611000 S611100 S611200 S611300 S611400 S611500 S611600 S611z00 S613.00 S613000 S613100 S613200 S613300 S613400 S613500 S613600 S613z00 S615000 S615100 S615200 S615300 S615400 S615500 S615600 S615z00 S617.00 S617000 S617100 S617200 S617300 S617400 S617500 S617600 S617z00 S61y000 S61y100 S61y200 S61y300

BMJ Open

Open #skull/face,mult,no intracran inj,>24hr LOC no restored Open #skull/face,mult,no intracran inj, LOC unspec duration Open #skull/face,mult,no intracran inj, concussion unspec Mult #skull/face + other bones, open + intracranial injury Open #skull/face, mult + intracranial inj, unspec consc Open #skull/face, mult + intracranial inj, no loss consc Open #skull/face, mult + intracranial inj, <1hr LOC Open #skull/face, mult + intracranial inj, 1-24hrs LOC Open #skull/face, mult + intracran inj, >24hr LOC + recovery Open #skull/face,mult + intracran inj, >24hr LOC no restored Open #skull/face, mult + intracran inj, LOC unspec duration Open #skull/face, mult + intracran inj + concussion, unspec Cortex cont + open intracranial wound + unspec state consc Cortex cont + open intracranial wound + no loss of consc Cortex cont + open intracranial wound + <1hr loss of consc Cortex cont + open intracranial wound + 1-24hr loss of consc Cortex cont + open intracranial wnd + >24hr LOC + recovery Cortex cont + open intracranial wnd + >24hr LOC not restored Cortex cont + open intracranial wnd + LOC unspec duration Cortex cont + open intracranial wound + concussion unspec Cortex laceration with open intracranial wound Cortex lacn + open intracranial wound + unspec state consc Cortex lacn + open intracranial wound + no loss of consc Cortex lacn + open intracranial wound + <1hr loss of consc Cortex lacn + open intracranial wound + 1-24hr loss of consc Cortex lacn + open intracranial wound + >24hr LOC + recovery Cortex lacn + open intracranial wnd + >24hr LOC not restored Cortex lacn + open intracranial wnd + LOC unspec duration Cortex lacn + open intracranial wound + concussion unspec Hind brain cont + open intracranial wnd + unspec state consc Hind brain cont + open intracranial wound + no loss consc Hind brain cont + open intracranial wound + <1hr loss consc Hind brain cont + open intracranial wnd + 1-24hr loss consc Hind brain cont + open intracranial wnd +>24hr LOC +recovery Hind brain cont + open intracran wnd +>24hr LOC not restored Hind brain cont + open intracranial wnd +LOC unspec duration Hind brain cont + open intracranial wnd + concussion unspec Hind brain laceration with open intracranial wound Hind brain lacn + open intracranial wnd + unspec state consc Hind brain lacn + open intracranial wnd + no loss consc Hind brain lacn + open intracranial wnd + <1hr loss consc Hind brain lacn + open intracranial wnd + 1-24hr loss consc Hind brain lacn + open intracranial wnd+>24hr LOC + recovery Hind brain lacn open intracranial wnd+>24hr LOC not restored Hind brain lacn + open intracran wnd + LOC unspec duration Hind brain lacn + open intracranial wnd + concussion unspec Brain cont + open intracranial wound + unspec state consc Brain cont + open intracranial wound + no loss of consc Brain cont + open intracranial wound + <1hr loss of consc Brain cont + open intracranial wound + 1-24hr loss of consc

Guest JF, et al. BMJ Open 2020; 10:e045253. doi: 10.1136/bmjopen-2020-045253

BMJ Publishing Group Limited (BMJ) disclaims all liability and responsibility arising from any reliance placed on this supplemental material which has been supplied by the author(s)

Supplemental material

S61y400 S61y500 S61y600 S61yz00 S621000 S621100 S621200 S621300 S621400 S621500 S621600 S621z00 S623000 S623100 S623200 S623300 S623400 S623500 S623600 S623z00 S625000 S625100 S625200 S625300 S625400 S625500 S625600 S625z00 S62A100 S631.00 S631000 S631100 S631200 S631300 S631400 S631500 S631600 S631z00 S641.00 S641000 S641100 S641200 S641300 S641400 S641500 S641600 S641z00 S642100 S645100 S701.00

BMJ Open

Brain cont + open intracranial wound + >24hr LOC + recovery Brain contusion + open intracr wound+>24hr LOC not ful reco Brain cont + open intracranial wound + LOC unspec duration Brain cont + open intracranial wound + concussion unspec Subarachnoid h'ge inj + open intracran wound + unspec consc Subarachnoid h'ge inj + open intracranial wound + no LOC Subarachnoid h'ge inj + open intracran wound+<1hr loss consc Subarachnoid h'ge inj + open intracran wnd+1-24hr loss consc Subarach h'ge inj + open intracran wnd +>24hr LOC + recovery Subarach h'ge inj + open intracran wnd+>24hr LOC -restored Subarach h'ge inj + open intracran wnd+LOC unspec duration Subarachnoid h'ge inj + open intracran wnd+concussion unspec Subdural h'ge inj + open intracranial wound + unspec consc Subdural h'ge inj + open intracranial wound+no loss consc Subdural h'ge inj + open intracranial wound+<1hr loss consc Subdural h'ge inj + open intracranial wnd+1-24hr loss consc Subdural h'ge inj + open intracran wound+>24hr LOC +recovery Subdural h'ge inj + open intracran wnd+>24hr LOC -restored Subdural h'ge inj + open intracran wnd+LOC unspec duration Subdural h'ge inj + open intracranial wnd+concussion unspec Extradural h'ge inj + open intracranial wnd + unspec consc Extradural h'ge inj + open intracranial wound+no loss consc Extradural h'ge inj + open intracranial wnd+<1hr loss consc Extradural h'ge inj + open intracran wnd+1-24hr loss consc Extradural h'ge inj + open intracran wnd+>24hr LOC+recovery Extradural h'ge inj + open intracran wnd+>24hr LOC -restored Extradural h'ge inj + open intracran wnd+LOC unspec duration Extradural h'ge inj + open intracran wnd+concussion unspec Traumatic extradural haematoma with open intracranial wound Other cerebral h'ge after injury + open intracranial wound Oth cerebral h'ge inj + open intracran wnd + unspec consc Oth cerebral h'ge inj + open intracranial wnd+no loss consc Oth cerebral h'ge inj + open intracran wnd+<1hr loss consc Oth cerebral h'ge inj + open intracran wnd+1-24hr loss consc Oth cereb h'ge inj + open intracran wnd+>24hr LOC + recovery Oth cereb h'ge inj + open intracran wnd+>24hr LOC -restored Oth cereb h'ge inj + open intracran wnd+LOC unspec duration Oth cereb h'ge inj + open intracran wnd+concussion unspec Intracranial injury NOS + open intracranial wound Intracranial inj NOS + open intracranial wnd + unspec consc Intracranial inj NOS + open intracranial wound+no loss consc Intracranial inj NOS + open intracranial wnd+<1hr loss consc Intracranial inj NOS + open intracranial wnd + 1-24hr LOC Intracranial inj NOS + open intracran wnd+>24hr LOC+recovery Intracran inj NOS + open intracran wnd+>24hr LOC -restored Intracran inj NOS + open intracran wnd+LOC unspec duration Intracranial inj NOS + open intracran wnd+concussion unspec Traumatic cerebral oedema with open intracranial wound Intracranial injury with prolonged coma with open wound Open traumatic pneumothorax

Guest JF, et al. BMJ Open 2020; 10:e045253. doi: 10.1136/bmjopen-2020-045253

BMJ Publishing Group Limited (BMJ) disclaims all liability and responsibility arising from any reliance placed on this supplemental material which has been supplied by the author(s)

Supplemental material

S703.00 S705.00 S711.00 S711000 S711100 S711200 S711300 S711z00 S713000 S713100 S713200 S713z00 S73yz00 S8...00 S8...12 S8...13 S80..00 S80..11 S80..12 S800.00 S803.00 S804.00 S80y.00 S80z.00 S81..00 S81..12 S810.00 S81z.00 S82..00 S820.00 S820000 S820100 S820w00 S820z00 S821.00 S821000 S821100 S821z00 S82v.00 S82v011 S82v012 S82v100 S82v300 S82vz00 S82w.00 S82w000 S82w100 S82w300 S82wz00 S82x.00

BMJ Open

Open traumatic haemothorax Open traumatic haemopneumothorax Heart injury, open Heart injury with open wound into thorax, unspecified Heart contusion, with open wound into thorax Heart laceration open, without penetration of heart chambers Heart laceration open, with penetration of heart chambers Heart injury with open wound into thorax NOS Lung injury with open wound into thorax, unspecified Lung contusion with open wound into thorax Lung laceration with open wound into thorax Lung injury with open wound into thorax, NOS Gastrointestinal tract injury with open wound to cavity NOS Open wound of head, neck and trunk Open wound of head Open wound of trunk Open wound of ocular adnexa Open wound of eyelid Periocular open wound Eyelid skin and periocular area laceration Penetrating wound of orbit without mention of foreign body Penetrating wound of orbit with foreign body Other open ocular adnexa wound Open wound of ocular adnexa NOS Open wound of eyeball Open wound of eye Ocular laceration without intraocular prolapse Open wound of eyeball NOS Open wound of ear Open wound of external ear Open wound of external ear, unspecified Open wound of ear auricle Other open wound of external ear Open wound of external ear not otherwise specified Open wound of external ear with complication Open wound of external ear with complication, unspecified Open wound of ear auricle with complication Open wound of external ear with complication, NOS Other open wound of ear Open wound of drumhead without complication Open wound of tympanic membrane without complication Open wound of ear ossicle Open wound of cochlea Other open wound of ear NOS Other open wound of ear with complication Open wound of ear drum with complication Open wound of ear ossicle with complication Open wound of cochlea with complication Other open wound of ear with complication NOS Open wound of ear, uncomplicated not otherwise specified

Guest JF, et al. BMJ Open 2020; 10:e045253. doi: 10.1136/bmjopen-2020-045253

BMJ Publishing Group Limited (BMJ) disclaims all liability and responsibility arising from any reliance placed on this supplemental material which has been supplied by the author(s)

Supplemental material

S82y.00 S82z.00 S83..00 S830.00 S830100 S831.00 S832.00 S832000 S832100 S832200 S832300 S832x00 S832z00 S833.00 S833000 S833100 S833200 S833300 S833x00 S833z00 S834.00 S834000 S834100 S834200 S834300 S834400 S834500 S834600 S834x00 S834z00 S835.00 S835000 S835100 S835200 S835300 S835400 S835500 S835x00 S835z00 S836.00 S836000 S836100 S836200 S836400 S836500 S836600 S837100 S837200 S837400 S837500

BMJ Open

Open wound of ear with complication, NOS Open wound of ear NOS Other open wound of head Open wound of scalp Avulsion of scalp Open wound of scalp with complication Open wound of nose Open wound of nose, unspecified Open wound of nasal septum Open wound of nasal cavity Open wound of nasal sinus Multiple wounds of nose Open wound of nose NOS Open wound of nose with complication Open wound of nose with complication, unspecified Open wound of nasal septum with complication Open wound of nasal cavity with complication Open wound of nasal sinus with complication Multiple open wounds of nose with complication Open wound of nose with complication, NOS Open wound of face Open wound of face, unspecified Open wound of cheek Open wound of forehead Open wound of eyebrow Open wound of lip Open wound of jaw Open wound of chin Multiple open wounds of face Open wound of face, NOS Open wound of face with complication Open wound of face with complication, unspecified Open wound of cheek with complication Open wound of forehead with complication Open wound of eyebrow with complication Open wound of lip with complication Open wound of jaw with complication Multiple open wounds of face with complication Open wound of face with complication, NOS Open wound in mouth Open wound in mouth, unspecified Open wound of buccal mucosa Open wound of gum Open wound of tongue Open wound of mouth floor Open wound of palate Open wound of buccal mucosa with complication Open wound of gum with complication Open wound of tongue with complication Open wound of mouth floor with complication

Guest JF, et al. BMJ Open 2020; 10:e045253. doi: 10.1136/bmjopen-2020-045253

BMJ Publishing Group Limited (BMJ) disclaims all liability and responsibility arising from any reliance placed on this supplemental material which has been supplied by the author(s)

Supplemental material

S837600 S83x.00 S83y.00 S83z.00 S84..00 S840.00 S840.11 S840.12 S840000 S840100 S840200 S840z00 S841.00 S841.11 S841.12 S841000 S841100 S841200 S841z00 S842.00 S843.00 S844.00 S845.00 S84x.00 S84x000 S84x100 S84xz00 S84xz11 S84y.00 S84y000 S84y100 S84yz00 S84z.00 S85..00 S850.00 S850000 S851.00 S852.00 S853.00 S855.00 S85X.00 S85z.00 S86..00 S86..11 S86..12 S860.00 S860000 S861.00 S86z.00 S87..00

BMJ Open

Open wound of palate with complication Other open wound of head Other open wound of head with complication Open wound of head NOS Open wound of neck Open wound of larynx and trachea Open wound of larynx without complication Open wound of trachea without complication Open wound of larynx and trachea, unspecified Open wound of larynx Open wound of trachea Open wound of larynx and trachea not otherwise specified Open wound of larynx and trachea with complication Open wound of larynx with complication Open wound of trachea with complication Open wound of larynx and trachea with complication, unspec Open wound of larynx with complication Open wound of trachea with complication Open wound of larynx and trachea with complication, NOS Open wound of thyroid Open wound of thyroid with complication Open wound of pharynx Open wound of pharynx with complication Other open wound of neck Open wound of neck nape Open wound of supraclavicular region Open wound of neck, NOS Open wound of throat NOS Other open wound of neck with complication Open wound of neck nape with complication Open wound of supraclavicular region with complication Open wound of neck with complication, NOS Open wound of neck NOS Open wound of chest wall Open wound of chest wall, uncomplicated Degloving injury chest wall Open wound of chest wall with complication Open wound of front wall of thorax Multiple open wounds of thoracic wall Open wound of back wall of thorax Open wound of thorax, part unspecified Open wound of chest wall NOS Open wound of back Open wound of loin Open wound of lumbar region Open wound of back, uncomplicated Degloving injury back Open wound of back with complication Open wound of back NOS Open wound of buttock

Guest JF, et al. BMJ Open 2020; 10:e045253. doi: 10.1136/bmjopen-2020-045253

BMJ Publishing Group Limited (BMJ) disclaims all liability and responsibility arising from any reliance placed on this supplemental material which has been supplied by the author(s)

Supplemental material

S87..11 S870.00 S870000 S871.00 S87z.00 S88..00 S880.00 S880000 S881.00 S882.00 S882000 S882100 S882200 S882z00 S883.00 S883000 S883100 S883z00 S884.00 S884000 S884100 S884200 S884z00 S885.00 S885000 S885100 S885200 S885z00 S886.00 S887.00 S88x.00 S88y.00 S88z.00 S89..00 S890.00 S891.00 S892.00 S892000 S892100 S892200 S892300 S892z00 S893.00 S893000 S893100 S893200 S893300 S893z00 S894.00 S894000

BMJ Open

Open wound of sacroiliac region Open wound of buttock, uncomplicated Degloving injury buttock Open wound of buttock with complication Open wound of buttock NOS Open wound of external genital organs Open wound of penis Degloving injury penis Open wound of penis with complication Open wound of scrotum and testes Open wound of scrotum Open wound of testes Degloving injury scrotum Open wound of scrotum and testes not otherwise specified Open wound of scrotum and testes with complication Open wound of scrotum with complication Open wound of testes with complication Open wound of scrotum and testes with complication, NOS Open wound of vulva Open wound of vulva, unspecified Open wound of labium majus Open wound of labium minus Open wound of vulva, NOS Open wound of vulva with complication Open wound of vulva with complication, unspecified Open wound of labium majus with complication Open wound of labium minus with complication Open wound of vulva with complication, NOS Open wound of vagina Open wound of vagina with complication Other open wound of external genital organ Other open wound of external genital organ with complication Open wound of external genital organ NOS Other open wounds of other sites, excluding limbs Open wound of breast Open wound of breast with complication Open wound of anterior abdominal wall Open wound of epigastric region Open wound umbilical region Open wound of hypogastric region Open wound of pubic region without complication Open wound anterior abdominal wall without complication NOS Open wound of anterior abdominal wall with complication Open wound of epigastrium with complication Open wound of umbilical region with complication Open wound of hypogastrium with complication Open wound of pubic region with complication Open wound of anterior abdominal wall with complication NOS Open wound of lateral abdominal wall Open wound of hypochondrium

Guest JF, et al. BMJ Open 2020; 10:e045253. doi: 10.1136/bmjopen-2020-045253

BMJ Publishing Group Limited (BMJ) disclaims all liability and responsibility arising from any reliance placed on this supplemental material which has been supplied by the author(s)

Supplemental material

S894100 S894111 S894200 S894300 S894311 S894400 S894500 S894z00 S895.00 S895000 S895100 S895111 S895200 S895300 S895311 S895400 S895z00 S89v.00 S89v000 S89v100 S89vz00 S89w.00 S89w000 S89w100 S89wz00 S89x.00 S89y.00 S89z.00 S8A..00 S8z..00 S8z..11 S8z..12 S8z..13 S9...00 S9...11 S9...12 S90..00 S900.00 S900000 S900100 S900200 S900300 S900400 S900x00 S900z00 S901.00 S901000 S901100 S901200 S901300

BMJ Open

Open wound of lumbar region Open wound of flank without complication Open wound of iliac region Open wound of inguinal region Open wound of groin without complication Open wound of flank without complication Open wound of loin Open wound of lateral abdominal wall NOS Open wound of lateral abdominal wall with complication Open wound of hypochondrium with complication Open wound of lumbar region with complication Open wound of flank with complication Open wound of iliac region with complication Open wound of inguinal region with complication Open wound of groin with complication Open wound of flank with complication Open wound of lateral abdominal wall with complication, NOS Other and unspecified open wound of trunk Open wound of pelvic region Open wound of perineum Other and unspecified open wound of trunk, NOS Other and unspecified open wound of trunk with complication Open wound of pelvic region with complication Open wound of perineum with complication Other and unspecified open wound trunk with complication NOS Multiple open wounds, of unspecified site Multiple open wounds with complication, of unspecified site Other open wounds NOS Open wounds involving head with neck Open wound of head, neck and trunk NOS Laceration NOS Traumatic ulcer NOS Laceration Open wound of upper limb Laceration of arm Open wound of arm Open wound of shoulder region and upper limb Open wound of shoulder/upper limb without complication Open wound of shoulder region Open wound of scapular region Open wound of axillary region Open wound of upper arm Multiple open wounds of shoulder and upper arm Multiple open wounds of upper arm Open wound of shoulder and upper limb NOS Open wound of shoulder and upper limb with complication Open wound of shoulder region with complication Open wound of scapular region with complication Open wound of axillary region with complication Open wound of upper arm with complication

Guest JF, et al. BMJ Open 2020; 10:e045253. doi: 10.1136/bmjopen-2020-045253

BMJ Publishing Group Limited (BMJ) disclaims all liability and responsibility arising from any reliance placed on this supplemental material which has been supplied by the author(s)

Supplemental material

S901x00 S901z00 S902.00 S902.11 S902000 S902100 S902200 S902300 S902x00 S902z00 S903.00 S903000 S903100 S903200 S903300 S90z.00 S91..00 S910.00 S910000 S910100 S910200 S910300 S910400 S910z00 S911.00 S911000 S911100 S911200 S911z00 S912.00 S912.11 S912000 S912100 S912200 S912300 S912400 S912z00 S913.00 S913000 S913100 S913200 S913300 S91z.00 S92..00 S920.00 S920000 S920100 S920200 S921.00 S922.00

BMJ Open

Multiple open wounds of upper arm with complication Open wound of shoulder and upper arm with complication, NOS Open wound of shoulder/upper limb with tendon involvement Open wound of arm with tendon injury Open wound of shoulder region with tendon involvement Open wound of scapular region with tendon involvement Open wound of axillary region with tendon involvement Open wound of upper arm with tendon involvement Multiple open wounds of upper arm with tendon involvement Open wound shoulder/upper arm with tendon involvement, NOS Degloving injury, shoulder or upper arm Degloving injury, shoulder area Degloving injury, scapular area Degloving injury, axilla Degloving injury, upper arm Open wound of shoulder region and upper arm NOS Open wound of elbow, forearm and wrist Open wound of lower arm without mention of complication Open wound of forearm Open wound of elbow Open wound of wrist, unspecified Open wound of wrist, volar Open wound of wrist, dorsal Open wound of lower arm, NOS Open wound of lower arm with complication Open wound of forearm with complication Open wound of elbow with complication Open wound of wrist with complication Open wound of lower arm with complication, NOS Open wound of lower arm with tendon involvement Open wound of lower arm with tendon injury Open wound of forearm with tendon involvement Open wound of elbow with tendon involvement Open wound of wrist with tendon involvement Complete division extensor tendon wrist Complete division flexor tendon wrist Open wound of lower arm with tendon involvement, NOS Degloving injury lower arm Degloving injury, forearm Degloving injury, elbow area Degloving injury wrist, volar Degloving injury wrist, dorsum Open wound of elbow, forearm and wrist NOS Open wound of hand, excluding finger(s) Open wound of hand without mention of complication Open wound of hand, palm Open wound of hand, dorsum Multiple open wounds of wrist and hand Open wound of hand with complication Open wound of hand with tendon involvement

Guest JF, et al. BMJ Open 2020; 10:e045253. doi: 10.1136/bmjopen-2020-045253

BMJ Publishing Group Limited (BMJ) disclaims all liability and responsibility arising from any reliance placed on this supplemental material which has been supplied by the author(s)

Supplemental material

S923.00 S923000 S923100 S924.00 S925.00 S92z.00 S93..00 S93..11 S93..12 S93..13 S93..14 S930.00 S930000 S930100 S930200 S931.00 S932.00 S932.11 S932000 S932100 S932200 S932300 S932400 S932500 S932600 S932700 S933.00 S933000 S933100 S933200 S933300 S933400 S933500 S934.00 S935.00 S936.00 S937.00 S938.00 S93z.00 S94..00 S940.00 S941.00 S942.00 S942.11 S94z.00 S96X.00 S9z..00 SA...00 SA...11 SA...12

BMJ Open

Degloving injury hand Degloving injury hand, palmar Degloving injury hand, dorsum Severe multi tissue damage hand Massive multi tissue damage hand Open wound of hand, excluding fingers, NOS Open wound of finger(s) or thumb Open wound of fingernail Open wound of nail Open wound of thumb Open wound of thumbnail Open wound of finger or thumb without mention of complicatn Open wound, finger Open wound, finger, multiple Open wound, thumb Open wound of finger or thumb with complication Open wound of finger or thumb with tendon involvement Open wound of finger with tendon injury Complete division, flexor digitorum superficialis tendon Complete division, flexor digitorum profundus tendon Complete division, both flexor tendons Complete division, extensor digitorum tendon Mallet finger with open tendon injury Complete division, flexor pollicis longus tendon Complete division, extensor pollicis longus tendon Mallet thumb with open tendon injury Degloving injury, finger Degloving injury, finger unspecified Degloving injury, finger, multiple Ring avulsion injury, class 1 Ring avulsion injury, class 2 Ring avulsion injury, class 3 Ring avulsion injury, class 4 Degloving injury, thumb Open wound fingernail Open wound thumbnail Open wound of finger with damage to nail Open wound of thumb with damage to nail Open wound of finger(s) NOS Multiple and unspecified open wound of upper limb Multiple/unspec open wound upper limb without complication Multiple/unspec open wound of upper limb with complication Multiple/unspec open wound upper limb with tendon involved Multiple/unspec open wound of upper limb with tendon injury Multiple and unspecified open wound of upper limb NOS Comb traum amp of (part of) fing(s) + oth part wrist/hand Open wound of upper limb NOS Open wound of lower limb Open wound of leg Laceration - leg

Guest JF, et al. BMJ Open 2020; 10:e045253. doi: 10.1136/bmjopen-2020-045253

BMJ Publishing Group Limited (BMJ) disclaims all liability and responsibility arising from any reliance placed on this supplemental material which has been supplied by the author(s)

Supplemental material

SA0..00 SA00.00 SA00000 SA00100 SA00z00 SA01.00 SA01000 SA01100 SA01z00 SA02.00 SA02.11 SA02000 SA02100 SA02200 SA02300 SA02z00 SA03.00 SA03000 SA03100 SA04.00 SA05.00 SA0z.00 SA1..00 SA10.00 SA10000 SA10100 SA10200 SA10z00 SA11.00 SA11000 SA11100 SA11200 SA11z00 SA12.00 SA12.11 SA12000 SA12100 SA12200 SA12300 SA12400 SA12z00 SA13.00 SA13000 SA13100 SA13200 SA14.00 SA15.00 SA16.00 SA1z.00 SA2..00

BMJ Open

Open wound of hip and thigh Open wound of hip and thigh without mention of complication Open wound of hip Open wound of thigh Open wound hip and thigh, NOS Open wound of hip and thigh with complication Open wound of hip with complication Open wound of thigh with complication Open wound of hip and thigh with complication, NOS Open wound of hip and thigh with tendon involvement Open wound of hip and thigh with tendon injury Open wound of hip with tendon involvement Open wound of thigh with tendon involvement Complete division, quadriceps tendon Complete division, hamstring tendon Open wound of hip and thigh with tendon involvement, NOS Degloving injury, hip or thigh Degloving injury, hip Degloving injury, thigh Severe multi tissue damage hip or thigh Massive multi tissue damage hip or thigh Open wound of hip and thigh NOS Open wound of knee, leg and ankle Open wound of knee, leg and ankle without complication Open wound of knee Open wound of leg Open wound of ankle Open wound of knee, leg and ankle NOS Open wound of knee, leg and ankle with complication Open wound of knee with complication Open wound of lower leg with complication Open wound of ankle with complication Open wound of knee/leg/ankle with complication, NOS Open wound of knee, leg and ankle with tendon involvement Open wound of leg with tendon injury Open wound of knee with tendon involvement Open wound of lower leg with tendon involvement Open wound of ankle with tendon involvement Complete division, patellar tendon Complete division, tendocalcaneus (Achilles tendon) Open wound of knee/leg/ankle with tendon involvement, NOS Degloving injury, knee or leg or ankle Degloving injury, knee Degloving injury, lower leg Degloving injury, ankle Severe multi tissue damage lower leg Massive multi tissue damage lower leg Multiple injuries of ankle and foot Open wound of knee, leg and ankle NOS Open wound of foot, excluding toe(s)

Guest JF, et al. BMJ Open 2020; 10:e045253. doi: 10.1136/bmjopen-2020-045253

BMJ Publishing Group Limited (BMJ) disclaims all liability and responsibility arising from any reliance placed on this supplemental material which has been supplied by the author(s)

Supplemental material

SA2..11 SA20.00 SA20100 SA20200 SA20300 SA21.00 SA22.00 SA22.11 SA22000 SA22100 SA23.00 SA23000 SA23100 SA23200 SA24.00 SA25.00 SA2z.00 SA3..00 SA3..11 SA30.00 SA31.00 SA32.00 SA32.11 SA33.00 SA33000 SA33100 SA34.00 SA3z.00 SA4..00 SA40.00 SA41.00 SA42.00 SA4z.00 SA9..00 SAA..00 SAz..00 SC10.00 SC11.00 SC15.00 SC15.11 SC16.00 SC17.00 SC17.11 SC18.00 SC19.00 SC1A.00 SC38.00 SC3A.00 SC3C.00 SC3D000

BMJ Open

Open wound of heel Open wound of foot without mention of complication Open wound foot, plantar Open wound foot, dorsum Open wound, heel Open wound of foot with complication Open wound of foot with tendon involvement Open wound of foot with tendon injury Complete division, flexor tendon, foot Complete division, extensor tendon, foot Degloving injury, foot Degloving injury foot, plantar Degloving injury foot, dorsum Degloving injury heel Severe multi tissue damage foot Massive multi tissue damage foot Open wound of foot NOS Open wound of toe(s) Open wound of toenail Open wound of toe(s) without mention of complication Open wound of toe(s) with complication Open wound of toe(s) with tendon involvement Open wound of toe(s) with tendon injury Degloving injury toe(s) Degloving injury toe Degloving injury, multiple toes Open wound of toe(s) with damage to nail Open wound of toe(s) NOS Multiple and unspecified open wound of lower limb Multiple and unspec open wound leg, without complication Multiple and unspec open wound of leg with complication Multiple and unspec open wound leg with tendon involvement Multiple and unspecified open wound of lower limb NOS Multiple open wounds of hip and thigh Open wounds involving multiple regions of lower limb(s) Open wound of lower limb NOS Late effect of open wound of head, neck and trunk Late effect of open wound arm or leg without tendon injury Late effect of burn of eye, head and neck Late effect of burn of head or neck Late effect of burn of wrist and hand Late effect of burn of arm, leg and foot Late effect of burn of arm or leg Late effect of other burns Late effect of burn NOS Late effect of burn of upper limb Sequelae of open wound of head Sequelae of superficial injury + open wound of neck + trunk Sequelae of open wound of upper limb Sequelae of open wound of lower limb

Guest JF, et al. BMJ Open 2020; 10:e045253. doi: 10.1136/bmjopen-2020-045253

BMJ Publishing Group Limited (BMJ) disclaims all liability and responsibility arising from any reliance placed on this supplemental material which has been supplied by the author(s)

Supplemental material

SC44.00 SC44000 SC44100 SC44200 SD01.00 SD01.11 SD01000 SD01100 SD01200 SD01z00 SD03.00 SD03000 SD03100 SD03200 SD03z00 SD05.00 SD05.11 SD05000 SD05100 SD05200 SD05z00 SD11.00 SD11000 SD11100 SD11200 SD11300 SD11400 SD11500 SD11600 SD11700 SD11800 SD11900 SD11A00 SD11B00 SD11B11 SD11B12 SD11C00 SD11z00 SD13.00 SD13000 SD13100 SD13200 SD13300 SD13400 SD13500 SD13600 SD13700 SD13800 SD13900 SD13A00

BMJ Open

Sequelae of burns, corrosions and frostbite Sequelae of burn, corrosion and frostbite of trunk Sequelae of burn, corrosion and frostbite of lower limb Seq/burn+corros classfbl only accord extent/body surf involv Abrasion or friction burn of head, infected Abrasion or friction burn of head, infected Abrasion of face, infected Abrasion of neck, infected Abrasion of scalp, infected Abrasion or friction burn of head, infected, NOS Blister of head, infected Blister of face, infected Blister of neck, infected Blister of scalp, infected Blister of head, infected, NOS Insect bite, nonvenomous, of head, infected Insect bite, nonvenomous, of head, infected Insect bite, nonvenomous, of face, infected Insect bite, nonvenomous, of neck, infected Insect bite, nonvenomous, of scalp, infected Insect bite, nonvenomous, of head, infected, NOS Abrasion or friction burn of trunk, infected Abrasion of interscapular region, infected Abrasion of chest wall, infected Abrasion of breast, infected Abrasion of abdominal wall, infected Abrasion of back, infected Abrasion of buttock, infected Abrasion of anus, infected Abrasion of flank, infected Abrasion of groin, infected Abrasion of perineum, infected Abrasion of penis, infected Abrasion of scrotum and testis, infected Abrasion or friction burn of scrotum, infected Abrasion or friction burn of testis, infected Abrasion of vulva, infected Abrasion or friction burn of trunk, infected, NOS Blister of trunk, infected Blister of interscapular region, infected Blister of chest wall, infected Blister of breast, infected Blister of abdominal wall, infected Blister of back, infected Blister of buttock, infected Blister of anus, infected Blister of flank, infected Blister of groin, infected Blister of perineum, infected Blister of penis, infected

Guest JF, et al. BMJ Open 2020; 10:e045253. doi: 10.1136/bmjopen-2020-045253

BMJ Publishing Group Limited (BMJ) disclaims all liability and responsibility arising from any reliance placed on this supplemental material which has been supplied by the author(s)

Supplemental material

SD13B00 SD13B11 SD13B12 SD13C00 SD13D00 SD13z00 SD15.00 SD15000 SD15100 SD15200 SD15300 SD15400 SD15500 SD15600 SD15700 SD15800 SD15900 SD15A00 SD15B00 SD15B11 SD15B12 SD15C00 SD15D00 SD15z00 SD1z.00 SD1z000 SD1z100 SD1z200 SD1z300 SD1z400 SD1z500 SD1z600 SD1z700 SD1z800 SD1z900 SD1zA00 SD1zB00 SD1zC00 SD1zz00 SD21.00 SD21000 SD21100 SD21200 SD21300 SD21z00 SD23.00 SD23000 SD23100 SD23200 SD23300

BMJ Open

Blister of scrotum and testis, infected Blister of scrotum, infected Blister of testis, infected Blister of vulva, infected Blister of vagina, infected Blister of trunk, infected, NOS Insect bite, nonvenomous, of trunk, infected Insect bite, nonvenomous, of interscapular region, infected Insect bite, nonvenomous, of chest wall, infected Insect bite, nonvenomous, of breast, infected Insect bite, nonvenomous, of abdominal wall, infected Insect bite, nonvenomous, of back, infected Insect bite, nonvenomous, of buttock, infected Insect bite, nonvenomous, of anus, infected Insect bite, nonvenomous, of flank, infected Insect bite, nonvenomous, of groin, infected Insect bite, nonvenomous, of perineum, infected Insect bite, nonvenomous, of penis, infected Insect bite, nonvenomous, of scrotum and testis, infected Insect bite, nonvenomous, of scrotum, infected Insect bite, nonvenomous, of testis, infected Insect bite, nonvenomous, of vulva, infected Insect bite, nonvenomous, of vagina, infected Insect bite, nonvenomous, of trunk, infected, NOS Superficial injury of trunk NOS, infected Superficial injury of interscapular region NOS, infected Superficial injury of chest wall NOS, infected Superficial injury of breast NOS, infected Superficial injury of abdominal wall NOS, infected Superficial injury of back NOS, infected Superficial injury of buttock NOS, infected Superficial injury of anus NOS, infected Superficial injury of flank NOS, infected Superficial injury of groin NOS, infected Superficial injury of perineum NOS, infected Superficial injury of penis NOS, infected Superficial injury of scrotum and testis NOS, infected Superficial injury of vulva NOS, infected Superficial injury of trunk NOS, infection NOS Abrasion or friction burn of shoulder/upper arm, infected Abrasion of shoulder, infected Abrasion of scapular region, infected Abrasion of axilla, infected Abrasion of upper arm, infected Abrasion or friction burn shoulder/upper arm, infected, NOS Blister of shoulder and upper arm, infected Blister of shoulder, infected Blister of scapular region, infected Blister of axilla, infected Blister of upper arm, infected

Guest JF, et al. BMJ Open 2020; 10:e045253. doi: 10.1136/bmjopen-2020-045253

BMJ Publishing Group Limited (BMJ) disclaims all liability and responsibility arising from any reliance placed on this supplemental material which has been supplied by the author(s)

Supplemental material

SD23z00 SD25.00 SD25000 SD25100 SD25200 SD25300 SD25z00 SD2z.00 SD2z000 SD2z100 SD2z200 SD2z300 SD2zz00 SD31.00 SD31000 SD31100 SD31200 SD31z00 SD33.00 SD33000 SD33100 SD33200 SD33z00 SD35.00 SD35000 SD35100 SD35200 SD35z00 SD3z.00 SD3z000 SD3z100 SD3z200 SD3zz00 SD41.00 SD43.00 SD45.00 SD4z.00 SD51.00 SD53.00 SD55.00 SD5z.00 SD61.00 SD61.11 SD61000 SD61100 SD61200 SD61300 SD61400 SD61z00 SD63.00

BMJ Open

Blister of shoulder and upper arm, infected, NOS Insect bite, nonvenomous, of shoulder/upper arm, infected Insect bite, nonvenomous, of shoulder, infected Insect bite, nonvenomous, of interscapular region, infected Insect bite, nonvenomous, of axilla, infected Insect bite, nonvenomous, of upper arm, infected Insect bite, nonvenomous, shoulder/upper arm, infected, NOS Superficial injury of shoulder and upper arm NOS, infected Superficial injury of shoulder NOS, infected Superficial injury of scapular region NOS, infected Superficial injury of axilla NOS, infected Superficial injury of upper arm NOS, infected Superficial injury shoulder/upper arm, infection NOS Abrasion or friction burn of lower arm, infected Abrasion of elbow, infected Abrasion of forearm, infected Abrasion of wrist, infected Abrasion or friction burn of lower arm, infected, NOS Blister of lower arm, infected Blister of elbow, infected Blister of forearm, infected Blister of wrist, infected Blister of lower arm, infected, NOS Insect bite, nonvenomous, of lower arm, infected Insect bite, nonvenomous, of elbow, infected Insect bite, nonvenomous, of forearm, infected Insect bite, nonvenomous, of wrist, infected Insect bite, nonvenomous, of lower arm, infected, NOS Superficial injury of lower arm NOS, infected Superficial injury of elbow NOS, infected Superficial injury of forearm NOS, infected Superficial injury of wrist NOS, infected Superficial injury of lower arm, infected NOS Abrasion or friction burn of hand, infected Blister of hand, infected Insect bite, nonvenomous, of hand, infected Superficial injury of hand NOS, infected Abrasion or friction burn of finger, infected Blister of finger, infected Insect bite, nonvenomous, of finger, infected Superficial injury of finger NOS, infected Abrasion or friction burn of lower limb, infected Abrasion or friction burn of leg, infected Abrasion of hip, infected Abrasion of thigh, infected Abrasion of knee, infected Abrasion of lower leg, infected Abrasion of ankle, infected Abrasion or friction burn of lower limb, infected, NOS Blister of lower limb, infected

Guest JF, et al. BMJ Open 2020; 10:e045253. doi: 10.1136/bmjopen-2020-045253

BMJ Publishing Group Limited (BMJ) disclaims all liability and responsibility arising from any reliance placed on this supplemental material which has been supplied by the author(s)

Supplemental material

SD63.11 SD63000 SD63100 SD63200 SD63300 SD63400 SD63z00 SD65.00 SD65.11 SD65000 SD65100 SD65200 SD65300 SD65400 SD65z00 SD6z.00 SD6z000 SD6z100 SD6z200 SD6z300 SD6z400 SD6zz00 SD71.00 SD71.11 SD71.12 SD71000 SD71100 SD71z00 SD73.00 SD73.11 SD73000 SD73100 SD73z00 SD75.00 SD75.11 SD75000 SD75100 SD75z00 SD7z.00 SD7z000 SD7z100 SD7zz00 SD91.00 SD95.00 SD96000 SD99.00 SD9z.00 SH...00 SH1..00 SH1..11

BMJ Open

Blister of leg, infected Blister of hip, infected Blister of thigh, infected Blister of knee, infected Blister of lower leg, infected Blister of ankle, infected Blister of lower limb, infected, NOS Insect bite, nonvenomous, of lower limb, infected Insect bite, nonvenomous, of leg, infected Insect bite, nonvenomous, of hip, infected Insect bite, nonvenomous, of thigh, infected Insect bite, nonvenomous, of knee, infected Insect bite, nonvenomous, of lower leg, infected Insect bite, nonvenomous, of ankle, infected Insect bite, nonvenomous, of lower limb, infected, NOS Superficial injury of lower limb, infected Superficial injury of hip NOS, infected Superficial injury of thigh NOS, infected Superficial injury of knee NOS, infected Superficial injury of lower leg NOS, infected Superficial injury of ankle NOS, infected Superficial injury of lower limb, infected, NOS Abrasion or friction burn of foot and toe, infected Abrasion or friction burn of heel, infected Abrasion or friction burn of toenail, infected Abrasion of foot, infected Abrasion of toe, infected Abrasion or friction burn of foot and toe, infected, NOS Blister of foot and toe, infected Blister of heel, infected Blister of foot, infected Blister of toe, infected Blister of foot and toe, infected, NOS Insect bite, nonvenomous, of foot and toe, infected Insect bite, nonvenomous, of heel, infected Insect bite, nonvenomous, of foot, infected Insect bite, nonvenomous, of toe, infected Insect bite, nonvenomous, of foot and toe, infected, NOS Superficial injury of foot and toe NOS, infected Superficial injury of foot NOS, infected Superficial injury of toe NOS, infected Superficial injury of foot and toe, infected, NOS Abrasion or friction burn, infected, NOS Insect bite, nonvenomous, infected, NOS Foreign body in skin wound Tick bite, infected Other superficial injury, infected, NOS Burns Burn of the face, head or neck Face burns

Guest JF, et al. BMJ Open 2020; 10:e045253. doi: 10.1136/bmjopen-2020-045253

BMJ Publishing Group Limited (BMJ) disclaims all liability and responsibility arising from any reliance placed on this supplemental material which has been supplied by the author(s)

Supplemental material

SH1..12 SH10.00 SH10000 SH10100 SH10200 SH10300 SH10400 SH10500 SH10600 SH10700 SH10800 SH10900 SH10x00 SH10z00 SH11.00 SH11.11 SH11000 SH11100 SH11200 SH11300 SH11400 SH11500 SH11600 SH11700 SH11800 SH11900 SH11x00 SH11z00 SH12.00 SH12.11 SH12000 SH12100 SH12111 SH12200 SH12211 SH12300 SH12311 SH12400 SH12411 SH12500 SH12511 SH12600 SH12611 SH12700 SH12711 SH12800 SH12811 SH12900 SH12911 SH12A00

BMJ Open

Head burns Unspecified thickness burn of the face, head or neck Unspecified thickness burn of unspecified part of face/head Unspecified thickness burn of the ear Unspecified thickness burn of the eye Unspecified thickness burn of the lip(s) Unspecified thickness burn of the chin Unspecified thickness burn of the nose Unspecified thickness burn of the scalp Unspecified thickness burn of the forehead Unspecified thickness burn of the cheek Unspecified thickness burn of the neck Unspecified thickness burn multiple sites face, head or neck Unspecified thickness burn of the face, head or neck NOS Superficial burn of the face, head or neck Erythema of head or neck, first degree burn Superficial burn of unspecified part of the face or head Superficial burn of the ear Superficial burn of the eye Superficial burn of the lip(s) Superficial burn of the chin Superficial burn of the nose Superficial burn of the scalp Superficial burn of the forehead Superficial burn of the cheek Superficial burn of the neck Superficial burn of multiple sites of the face, head or neck Superficial burn of the face, head or neck NOS Partial thickness burn of the face, head or neck Blister of face, head and neck, second degree burn Superficial part. thickness burn unspecified part face/head Superficial partial thickness burn of the ear Ear - 2nd degree burn Superficial partial thickness burn of the eye Eye - 2nd degree burn Superficial partial thickness burn of the lip(s) Lip - 2nd degree burn Superficial partial thickness burn of the chin Chin - 2nd degree burn Superficial partial thickness burn of the nose Nose - 2nd degree burn Superficial partial thickness burn of the scalp Scalp - 2nd degree burn Superficial partial thickness burn of the forehead Forehead - 2nd degree burn Superficial partial thickness burn of the cheek Cheek - 2nd degree burn Superficial partial thickness burn of the neck Neck - 2nd degree burn Deep partial thickness burn of unspecified part of face/head

Guest JF, et al. BMJ Open 2020; 10:e045253. doi: 10.1136/bmjopen-2020-045253

BMJ Publishing Group Limited (BMJ) disclaims all liability and responsibility arising from any reliance placed on this supplemental material which has been supplied by the author(s)

Supplemental material

SH12B00 SH12C00 SH12D00 SH12E00 SH12F00 SH12G00 SH12H00 SH12J00 SH12K00 SH12x00 SH12z00 SH13.00 SH13000 SH13100 SH13200 SH13300 SH13400 SH13500 SH13600 SH13700 SH13800 SH13900 SH13A00 SH13x00 SH13z00 SH14.00 SH14000 SH14100 SH14200 SH14300 SH14400 SH14500 SH14600 SH14700 SH14800 SH14900 SH14x00 SH14z00 SH15.00 SH15000 SH15100 SH15200 SH15300 SH15400 SH15500 SH15600 SH15700 SH15800 SH15900 SH15x00

BMJ Open

Deep partial thickness burn of the ear Deep partial thickness burn of the eye Deep partial thickness burn of the lip(s) Deep partial thickness burn of the chin Deep partial thickness burn of the nose Deep partial thickness burn of the scalp Deep partial thickness burn of the forehead Deep partial thickness burn of the cheek Deep partial thickness burn of the neck Partial thickness burn of multiple sites face, head or neck Partial thickness burn of the face, head or neck NOS Full thickness burn of the face, head or neck Full thickness burn of unspecified part of the face or head Full thickness burn of the ear Full thickness burn of the eye Full thickness burn of the lip(s) Full thickness burn of the chin Full thickness burn of the nose Full thickness burn of the scalp Full thickness burn of the forehead Full thickness burn of the cheek Full thickness burn of the neck Corrosion of third degree of head and neck Full thickness burn of multiple sites of face, head or neck Full thickness burn of the face, head or neck NOS Deep full thick burn face/head/neck - without loss body part Deep full thick burn unspec.part face/head-no loss body part Deep full thickness burn of ear without loss of body part Deep full thickness burn of eye without loss of body part Deep full thickness burn of lip(s) without loss of body part Deep full thickness burn of chin without loss of body part Deep full thickness burn of nose without loss of body part Deep full thickness burn of scalp without loss of body part Deep full thickness burn forehead without loss of body part Deep full thickness burn of cheek without loss of body part Deep full thickness burn of neck without loss of body part Deep full thickness burn multip sites face/head/neck- no BPL Deep full thick burn, no loss body part, face/head/neck NOS Deep full thick burn face/head/neck, with loss of body part Deep full thickness burn unspec part of face/head, with BPL Deep full thickness burn of the ear, with loss of body part Deep full thickness burn of the eye, with loss of body part Deep full thickness burn of lip(s), with loss of body part Deep full thickness burn of the chin, with loss of body part Deep full thickness burn of the nose, with loss of body part Deep full thickness burn of scalp, with loss of body part Deep full thickness burn of forehead, with loss of body part Deep full thickness burn of cheek, with loss of body part Deep full thickness burn of the neck, with loss of body part Deep full thick burn multip parts face/head/neck - with BPL

Guest JF, et al. BMJ Open 2020; 10:e045253. doi: 10.1136/bmjopen-2020-045253

BMJ Publishing Group Limited (BMJ) disclaims all liability and responsibility arising from any reliance placed on this supplemental material which has been supplied by the author(s)

Supplemental material

SH15z00 SH16.00 SH16000 SH16100 SH1z.00 SH2..00 SH20.00 SH20000 SH20100 SH20200 SH20300 SH20400 SH20500 SH20600 SH20x00 SH20z00 SH21.00 SH21.11 SH21000 SH21100 SH21200 SH21300 SH21400 SH21500 SH21600 SH21700 SH21x00 SH21z00 SH22.00 SH22.11 SH22000 SH22100 SH22200 SH22300 SH22400 SH22500 SH22600 SH22700 SH22800 SH22900 SH22A00 SH22B00 SH22C00 SH22D00 SH22E00 SH22x00 SH22z00 SH23.00 SH23000 SH23100

BMJ Open

Deep full thick burn, with loss body part,face/head/neck NOS Corrosion of head and neck Corrosion of first degree of head and neck Corrosion of second degree of head and neck Burn of the face, head or neck NOS Burn of the trunk Unspecified thickness burn of the trunk Unspecified thickness burn of unspecified part of the trunk Unspecified thickness burn of the breast Unspecified thickness burn of the chest wall Unspecified thickness burn of the abdominal wall Unspecified thickness burn of the back (excluding buttock) Unspecified thickness burn of the buttock Unspecified thickness burn of the genitalia Unspecified thickness burn of multiple sites of the trunk Unspecified thickness burn of the trunk NOS Superficial burn of the trunk Erythema of trunk, 1st degree burn Superficial burn of unspecified part of the trunk Superficial burn of the breast Superficial burn of the chest wall Superficial burn of the abdominal wall Superficial burn of the back (excluding buttock) Superficial burn of the buttock Superficial burn of the genitalia Corrosion of first degree of trunk Superficial burn of multiple sites of the trunk Superficial burn of the trunk NOS Partial thickness burn of the trunk Blister of trunk, second degree burn Superficial partial thickness burn unspecified part of trunk Superficial partial thickness burn of the breast Superficial partial thickness burn of the chest wall Superficial partial thickness burn of the abdominal wall Superficial partial thickness burn of back (excl buttock) Superficial partial thickness burn of the buttock Superficial partial thickness burn of the genitalia Deep partial thickness burn of the trunk, unspecified Deep partial thickness burn of the breast Deep partial thickness burn of the chest wall Deep partial thickness burn of the abdominal wall Deep partial thickness burn of the back (excluding buttock) Deep partial thickness burn of the buttock Deep partial thickness burn of the genitalia Corrosion of second degree of trunk Partial thickness burn of multiple sites of the trunk Partial thickness burn of the trunk NOS Full thickness burn of the trunk Full thickness burn of the trunk, unspecified Full thickness burn of the breast

Guest JF, et al. BMJ Open 2020; 10:e045253. doi: 10.1136/bmjopen-2020-045253

BMJ Publishing Group Limited (BMJ) disclaims all liability and responsibility arising from any reliance placed on this supplemental material which has been supplied by the author(s)

Supplemental material

SH23200 SH23300 SH23400 SH23500 SH23600 SH23700 SH23x00 SH23z00 SH24.00 SH24000 SH24100 SH24200 SH24300 SH24400 SH24500 SH24600 SH24x00 SH24z00 SH25.00 SH25000 SH25100 SH25200 SH25300 SH25400 SH25500 SH25600 SH25x00 SH25z00 SH26.00 SH2z.00 SH3..00 SH30.00 SH30000 SH30100 SH30200 SH30300 SH30400 SH30500 SH30600 SH30x00 SH30z00 SH31.00 SH31.11 SH31000 SH31100 SH31200 SH31300 SH31400 SH31500 SH31600

BMJ Open

Full thickness burn of the chest wall Full thickness burn of the abdominal wall Full thickness burn of the back (excluding buttock) Full thickness burn of the buttock Full thickness burn of the genitalia Corrosion of third degree of trunk Full thickness burn of multiple sites of the trunk Full thickness burn of the trunk NOS Deep full thickness burn of trunk without loss of body part Deep full thickness burn of trunk unsp, no loss of body part Deep full thickness burn of breast without loss of body part Deep full thickness burn of chest without loss of body part Deep full thickness burn of abdom.wall, no loss of body part Deep full thickness burn of back without loss of body part Deep full thickness burn of buttock, no loss of body part Deep full thickness burn of genitalia, no loss of body part Deep full thickness burn multiple sites trunk, no BPL Deep full thickness burn of trunk, no loss of body part NOS Deep full thickness burn of trunk, with loss of body part Deep full thickness burn of trunk unsp, with loss body part Deep full thickness burn of breast, with loss of body part Deep full thickness burn of chest, with loss of body part Deep full thickness burn of abd.wall, with loss of body part Deep full thickness burn of back, with loss of body part Deep full thickness burn of buttock, with loss of body part Deep full thickness burn of genitalia, with loss body part Deep full thickness burn multiple sites trunk with BPL Deep full thickness burn of trunk, with loss body part, NOS Corrosion of unspecified degree of trunk Burn of the trunk NOS Burn of the arm (excluding wrist and hand) Unspecified thickness burn of the arm Unspecified thickness burn of the arm, unspecified Unspecified thickness burn of the forearm Unspecified thickness burn of the elbow Unspecified thickness burn of the upper arm Unspecified thickness burn of the axilla Unspecified thickness burn of the shoulder Unspecified thickness burn of the scapular region Unspecified thickness burn of multiple sites of the arm Unspecified thickness burn of the arm NOS Superficial burn of the arm Erythema of arm, first degree burn Superficial burn of the arm, unspecified Superficial burn of the forearm Superficial burn of the elbow Superficial burn of the upper arm Superficial burn of the axilla Superficial burn of the shoulder Superficial burn of the scapular region

Guest JF, et al. BMJ Open 2020; 10:e045253. doi: 10.1136/bmjopen-2020-045253

BMJ Publishing Group Limited (BMJ) disclaims all liability and responsibility arising from any reliance placed on this supplemental material which has been supplied by the author(s)

Supplemental material

SH31x00 SH31z00 SH32.00 SH32.11 SH32000 SH32100 SH32200 SH32300 SH32400 SH32500 SH32600 SH32700 SH32800 SH32900 SH32A00 SH32B00 SH32C00 SH32D00 SH32x00 SH32z00 SH33.00 SH33000 SH33100 SH33200 SH33300 SH33400 SH33500 SH33600 SH33x00 SH33z00 SH34.00 SH34000 SH34100 SH34200 SH34300 SH34400 SH34500 SH34600 SH34x00 SH34z00 SH35.00 SH35000 SH35100 SH35200 SH35300 SH35400 SH35500 SH35600 SH35x00 SH35z00

BMJ Open

Superficial burn of multiple sites of the arm Superficial burn of the arm NOS Partial thickness burn of the arm Blister of arm, second degree burn Superficial partial thickness burn of the arm, unspecified Superficial partial thickness burn of the forearm Superficial partial thickness burn of the elbow Superficial partial thickness burn of the upper arm Superficial partial thickness burn of the axilla Superficial partial thickness burn of the shoulder Superficial partial thickness burn of scapular region Deep partial thickness burn of the arm, unspecified Deep partial thickness burn of the forearm Deep partial thickness burn of the elbow Deep partial thickness burn of the upper arm Deep partial thickness burn of the axilla Deep partial thickness burn of the shoulder Deep partial thickness burn of the scapular region Partial thickness burn of multiple sites of the arm Partial thickness burn of the arm NOS Full thickness burn of the arm Full thickness burn of the arm, unspecified Full thickness burn of the forearm Full thickness burn of the elbow Full thickness burn of the upper arm Full thickness burn of the axilla Full thickness burn of the shoulder Full thickness burn of the scapular region Full thickness burn of multiple sites of the arm Full thickness burn of the arm NOS Deep full thickness burn of arm without loss of body part Deep full thickness burn of arm unsp, no loss of body part Deep full thickness burn of forearm, no loss of body part Deep full thickness burn of elbow without loss of body part Deep full thickness burn of upper arm, no loss of body part Deep full thickness burn of axilla without loss of body part Deep full thickness burn of shoulder, no loss of body part Deep full thickness burn of scapular, no loss of body part Deep full thickness burn of multiple sites of arm, no BPL Deep full thickness burn without loss of body part-arm NOS Deep full thickness burn of arm, with loss of body part Deep full thickness burn of arm unsp, with loss of body part Deep full thickness burn of forearm, with loss of body part Deep full thickness burn of elbow, with loss of body part Deep full thickness burn of upper arm,with loss of body part Deep full thickness burn of axilla, with loss of body part Deep full thickness burn of shoulder, with loss of body part Deep full thickness burn of scapular, with loss of body part Deep full thickness burn of multiple sites of arm with BPL Deep full thickness burn-, with loss of body part-arm NOS

Guest JF, et al. BMJ Open 2020; 10:e045253. doi: 10.1136/bmjopen-2020-045253

BMJ Publishing Group Limited (BMJ) disclaims all liability and responsibility arising from any reliance placed on this supplemental material which has been supplied by the author(s)

Supplemental material

SH36.00 SH36000 SH36100 SH36200 SH3z.00 SH4..00 SH40.00 SH40.11 SH40.12 SH40.13 SH40.14 SH40000 SH40100 SH40200 SH40300 SH40400 SH40500 SH40600 SH40700 SH40x00 SH40z00 SH41.00 SH41.11 SH41.12 SH41.13 SH41.14 SH41.15 SH41000 SH41100 SH41200 SH41300 SH41400 SH41500 SH41600 SH41700 SH41x00 SH41z00 SH42.00 SH42.11 SH42.12 SH42.13 SH42.14 SH42.15 SH42000 SH42100 SH42200 SH42300 SH42400 SH42500 SH42600

BMJ Open

Corros/unspecf degree/shoulder+upper limb,except wrist+hand Corrosion/1st degree shoulder+upper limb,except wrist+hand Corrosion/2nd degree/shoulder and upper limb exc wrist+hand Corros/third degree/shoulder and upper limb, exc wrist+hand Burn of the arm (excluding wrist and hand) NOS Burn of the wrist(s) and hand(s) Unspecified thickness burn of the wrist and hand Unspecified degree burn of finger Unspecified degree burn of hand Unspecified degree burn of thumb Unspecified degree burn of wrist Unspecified thickness burn of the hand, unspecified Unspecified thickness burn of a single finger Unspecified thickness burn of the thumb Unspecified thickness burn of more than one finger Unspecified thickness burn of the thumb and finger(s) Unspecified thickness burn of the palm of hand Unspecified thickness burn of the back of hand Unspecified thickness burn of the wrist Unspecified thickness burn of multiple sites of wrist/hand Unspecified thickness burn of the wrist or hand NOS Superficial burn of the wrist and hand Erythema of wrist and hand,first degree burn First degree burn of finger First degree burn of hand First degree burn of thumb First degree burn of wrist Superficial burn of the hand, unspecified Superficial burn of a single finger Superficial burn of the thumb Superficial burn of more than one finger Superficial burn of the thumb and finger(s) Superficial burn of the palm of hand Superficial burn of the back of hand Superficial burn of the wrist First degree burn of multiple sites of the wrist or hand Superficial burn of the wrist or hand NOS Partial thickness burn of the wrist and hand Blister of wrist and hand, second degree burn Second degree burn of finger Second degree burn of hand Second degree burn of thumb Second degree burn of wrist Superficial partial thickness burn of hand, unspecified Superficial partial thickness burn of a single finger Superficial partial thickness burn of the thumb Superficial partial thickness burn of more than one finger Superficial partial thickness burn of thumb and finger(s) Superficial partial thickness burn of palm of hand Superficial partial thickness burn of back of hand

Guest JF, et al. BMJ Open 2020; 10:e045253. doi: 10.1136/bmjopen-2020-045253

BMJ Publishing Group Limited (BMJ) disclaims all liability and responsibility arising from any reliance placed on this supplemental material which has been supplied by the author(s)

Supplemental material

SH42700 SH42800 SH42900 SH42A00 SH42B00 SH42C00 SH42D00 SH42E00 SH42F00 SH42x00 SH42z00 SH43.00 SH43.11 SH43.12 SH43.13 SH43.14 SH43000 SH43100 SH43200 SH43300 SH43400 SH43500 SH43600 SH43700 SH43x00 SH43z00 SH44.00 SH44.11 SH44.12 SH44.13 SH44.14 SH44000 SH44100 SH44200 SH44300 SH44400 SH44500 SH44600 SH44700 SH44x00 SH44z00 SH45.00 SH45.11 SH45.12 SH45.13 SH45.14 SH45000 SH45100 SH45200 SH45300

BMJ Open

Superficial partial thickness burn of the wrist Deep partial thickness burn of the hand, unspecified Deep partial thickness burn of a single finger Deep partial thickness burn of the thumb Deep partial thickness burn of more than one finger Deep partial thickness burn of the thumb and finger(s) Deep partial thickness burn of the palm of hand Deep partial thickness burn of back of hand Deep partial thickness burn of wrist Partial thickness burn of multiple sites of the wrist/hand Partial thickness burn of the wrist or hand NOS Full thickness burn of the wrist and hand Third degree burn of finger Third degree burn of hand Third degree burn of thumb Third degree burn of wrist Full thickness burn of the hand, unspecified Full thickness burn of a single finger Full thickness burn of the thumb Full thickness burn of more than one finger Full thickness burn of the thumb and finger(s) Full thickness burn of the palm of hand Full thickness burn of the back of hand Full thickness burn of the wrist Full thickness burn of multiple sites of the wrist or hand Full thickness burn of the wrist or hand NOS Deep full thickness burn of wrist/hand, no loss of body part Deep third degree burn of finger,without loss of a body part Deep third degree burn of hand, without loss of a body part Deep third degree burn of thumb, without loss of a body part Deep third degree burn of wrist, without loss of a body part Deep full thickness burn of hand unsp, no loss of body part Deep full thickness burn of a finger, no loss of body part Deep full thickness burn of thumb without loss of body part Deep full thickness burn of >1 finger, no loss of body part Deep full thickness burn of thumb+fing, no loss of body part Deep full thickness burn of palm hand, no loss of body part Deep full thickness burn of back hand, no loss of body part Deep full thickness burn of wrist without loss of body part Deep full thickness burn-multiple sites wrist/hand, no BPL Deep full thickness burn of wrist/hand,no loss body part NOS Deep full thickness burn of wrist/hand, with loss body part Deep third degree burn of finger with loss of a body part Deep third degree burn of hand with loss of a body part Deep third degree burn of thumb with loss of a body part Deep third degree burn of wrist with loss of a body part Deep full thickness burn of hand unsp, with loss body part Deep full thickness burn of a finger, with loss of body part Deep full thickness burn of thumb, with loss of body part Deep full thickness burn of >1 finger, with loss body part

Guest JF, et al. BMJ Open 2020; 10:e045253. doi: 10.1136/bmjopen-2020-045253

BMJ Publishing Group Limited (BMJ) disclaims all liability and responsibility arising from any reliance placed on this supplemental material which has been supplied by the author(s)

Supplemental material

SH45400 SH45500 SH45600 SH45700 SH45x00 SH45z00 SH46.00 SH46000 SH46100 SH46200 SH4z.00 SH5..00 SH5..11 SH50.00 SH50000 SH50100 SH50200 SH50300 SH50400 SH50500 SH50600 SH50x00 SH50z00 SH51.00 SH51.11 SH51000 SH51100 SH51200 SH51300 SH51400 SH51500 SH51600 SH51x00 SH51z00 SH52.00 SH52.11 SH52000 SH52100 SH52200 SH52300 SH52400 SH52500 SH52600 SH52700 SH52800 SH52900 SH52A00 SH52B00 SH52C00 SH52D00

BMJ Open

Deep full thickness burn of thumb+fing, with loss body part Deep full thickness burn of palm hand, with loss body part Deep full thickness burn of back hand, with loss body part Deep full thickness burn of wrist, with loss of body part Deep full thickness burn-multiple sites wrist/hand with BPL Deep full thickness burn wrist/hand, with loss body part NOS Corrosion of wrist and hand Corrosion of first degree of wrist and hand Corrosion of second degree of wrist and hand Corrosion of third degree of wrist and hand Burn of wrist or hand NOS Burn of lower limbs Leg burns Unspecified thickness burn of the leg Unspecified degree burn of the leg, unspecified Unspecified thickness burn of the toe(s) Unspecified thickness burn of the foot Unspecified thickness burn of the ankle Unspecified thickness burn of the lower leg Unspecified thickness burn of the knee Unspecified thickness burn of the thigh Unspecified thickness burn of multiple sites of the leg Unspecified thickness burn of the leg NOS Superficial burn of the leg Erythema of leg, first degree burn Superficial burn of the leg, unspecified Superficial burn of the toe(s) Superficial burn of the foot Superficial burn of the ankle Superficial burn of the lower leg Superficial burn of the knee Superficial burn of the thigh Superficial burn of multiple sites of the leg Superficial burn of the leg NOS Partial thickness burn of the leg Blister of leg, second degree burn Superficial partial thickness burn of the leg, unspecified Superficial partial thickness burn of the toe(s) Superficial partial thickness burn of the foot Superficial partial thickness burn of the ankle Superficial partial thickness burn of the lower leg Superficial partial thickness burn of the knee Superficial partial thickness burn of the thigh Deep partial thickness burn of the leg, unspecified Deep partial thickness burn of the toe(s) Deep partial thickness burn of the foot Deep partial thickness burn of the ankle Deep partial thickness burn of the lower leg Deep partial thickness burn of the knee Deep partial thickness burn of the thigh

Guest JF, et al. BMJ Open 2020; 10:e045253. doi: 10.1136/bmjopen-2020-045253

BMJ Publishing Group Limited (BMJ) disclaims all liability and responsibility arising from any reliance placed on this supplemental material which has been supplied by the author(s)

Supplemental material

SH52x00 SH52z00 SH53.00 SH53000 SH53100 SH53200 SH53300 SH53400 SH53500 SH53600 SH53x00 SH53z00 SH54.00 SH54000 SH54100 SH54200 SH54300 SH54400 SH54500 SH54600 SH54x00 SH54z00 SH55.00 SH55000 SH55100 SH55200 SH55300 SH55400 SH55500 SH55600 SH55x00 SH55z00 SH56.00 SH56000 SH56100 SH56200 SH57.00 SH57000 SH57100 SH57200 SH5z.00 SH6..00 SH60.00 SH61.00 SH62.00 SH62000 SH62100 SH63.00 SH64.00 SH65.00

BMJ Open

Partial thickness burn of multiple sites of the leg Partial thickness burn of the leg NOS Full thickness burn of the leg Full thickness burn of the leg, unspecified Full thickness burn of the toe(s) Full thickness burn of the foot Full thickness burn of the ankle Full thickness burn of the lower leg Full thickness burn of the knee Full thickness burn of the thigh Full thickness burn of multiple sites of the leg Full thickness burn of the leg NOS Deep full thickness burn of leg without loss of body part Deep full thickness burn of leg unsp, no loss of body part Deep full thickness burn of toe(s) without loss of body part Deep full thickness burn of foot without loss of body part Deep full thickness burn of ankle without loss of body part Deep full thickness burn of lower leg without loss of body Deep full thickness burn of knee without loss of body part Deep full thickness burn of thigh without loss of body part Deep full thickness burn-mult.leg without loss of body part Deep full thickness burn, no loss of body part, of leg NOS Deep full thickness burn of leg, with loss of body part Deep full thickness burn of leg unspec, with loss body part Deep full thickness burn of toe(s), with loss of body part Deep full thickness burn of foot, with loss of body part Deep full thickness burn of ankle, with loss of body part Deep full thickness burn of lower leg, with loss body part Deep full thickness burn of knee, with loss of body part Deep full thickness burn of thigh, with loss of body part Deep full thickness burn-mult.leg, with loss of body part Deep full thickness burn, with loss of body part, of leg NOS Burn and corrosion of hip and lower limb,except ankle & foot Corrosion of first degree of hip+lower limb,exc ankle + foot Corrosion/2nd degree/hip+lower limb,except ankle & foot Corrosion/third degree/hip+lower limb except ankle and foot Corrosion of ankle and foot Corrosion of first degree of ankle and foot Corrosion of second degree of ankle and foot Corrosion of third degree of ankle and foot Burn of the lower limb NOS Burn of multiple specified sites Unspecified thickness burn of multiple specified sites Superficial burn of multiple specified sites Partial thickness burn of multiple specified sites Superficial partial thickness burn multiple specified sites Deep partial thickness burn of multiple specified sites Full thickness burn of multiple specified sites Deep full thickness burn multiple specified sites, no BPL Deep full thickness burn multiple specified sites, with BPL

Guest JF, et al. BMJ Open 2020; 10:e045253. doi: 10.1136/bmjopen-2020-045253

BMJ Publishing Group Limited (BMJ) disclaims all liability and responsibility arising from any reliance placed on this supplemental material which has been supplied by the author(s)

Supplemental material

SH66.00 SH66000 SH66100 SH66300 SH6z.00 SH8..00 SH80.00 SH80000 SH80100 SH80z00 SH81.00 SH81000 SH81100 SH81200 SH81300 SH81400 SH81z00 SH82.00 SH82000 SH82100 SH82200 SH82300 SH82z00 SH83.00 SH83000 SH83100 SH83200 SH83300 SH83400 SH83z00 SH84.00 SH84000 SH84100 SH84200 SH84300 SH84400 SH84500 SH84z00 SH85.00 SH85000 SH85100 SH85200 SH85300 SH85400 SH85500 SH85600 SH85z00 SH86.00 SH86000 SH86100

BMJ Open

Corrosions of multiple regions, unspecified degree Corros/multiple reg,no more than first-deg corros mentioned Corrosion/multi reg,no more than second-deg corros mentioned Corros/multi reg,at least one corros/third degree mentioned Burn of multiple specified sites NOS Burns as a percentage of body surface (BS) involved Burn involving <10% of body surface (BS) Burn:<10% of body surface, 10%/unspec BS full thickness Corrosions involving less than 10% of body surface Burn:<10% of body surface NOS Burn involving 10-19% of body surface (BS) Burn: 10-14% of body surface,<10%/unsp BS full thickness Burn: 10-14% of body surface, 10-14% BS full thickness Burn: 15-19% of body surface,<10%/unsp BS full thickness Burn: 15-19% of body surface, 10-19% BS full thickness Corrosions involving 10-19% of body surface Burn: 10-19% of body surface NOS Burn involving 20-29% of body surface (BS) Burn: 20-29% of body surface,<10%/unspec BS full thickness Burn: 20-29% of body surface, 10-19% BS full thickness Burn: 20-29% of body surface, 20-29% BS full thickness Corrosions involving 20-29% of body surface Burn: 20-29% of body surface NOS Burn involving 30-39% of body surface (BS) Burn: 30-39% of body surface,<10%/unspec BS full thickness Burn: 30-39% of body surface, 10-19% BS full thickness Burn: 30-39% of body surface, 20-29% BS full thickness Burn: 30-39% of body surface, 30-39% BS full thickness Corrosions involving 30-39% of body surface Burn: 30-39% of body surface NOS Burn involving 40-49% of body surface (BS) Burn: 40-49% of body surface,<10%/unspec BS full thickness Burn: 40-49% of body surface, 10-19% BS full thickness Burn: 40-49% of body surface, 20-29% BS full thickness Burn: 40-49% of body surface, 30-39% BS full thickness Burn: 40-49% of body surface, 40-49% BS full thickness Corrosions involving 40-49% of body surface Burn: 40-49% of body surface NOS Burn involving 50-59% of body surface (BS) Burn: 50-59% of body surface,<10%/unspec BS full thickness Burn: 50-59% of body surface, 10-19% BS full thickness Burn: 50-59% of body surface, 20-29% BS full thickness Burn: 50-59% of body surface, 30-39% BS full thickness Burn: 50-59% of body surface, 40-49% BS full thickness Burn: 50-59% of body surface, 50-59% BS full thickness Corrosions involving 50-59% of body surface Burn: 50-59% of body surface NOS Burn involving 60-69% of body surface (BS) Burn: 60-69% of body surface,<10%/unspec BS full thickness Burn: 60-69% of body surface, 10-19% BS full thickness

Guest JF, et al. BMJ Open 2020; 10:e045253. doi: 10.1136/bmjopen-2020-045253

BMJ Publishing Group Limited (BMJ) disclaims all liability and responsibility arising from any reliance placed on this supplemental material which has been supplied by the author(s)

Supplemental material

SH86200 SH86300 SH86400 SH86500 SH86600 SH86700 SH86z00 SH87.00 SH87000 SH87100 SH87200 SH87300 SH87400 SH87500 SH87600 SH87700 SH87800 SH87z00 SH88.00 SH88000 SH88100 SH88200 SH88300 SH88400 SH88500 SH88600 SH88700 SH88800 SH88900 SH88z00 SH89.00 SH89000 SH89100 SH89200 SH89300 SH89400 SH89500 SH89600 SH89700 SH89800 SH89900 SH89A00 SH89z00 SH8z.00 SH9..00 SH90.00 SH91.00 SH91.11 SH92.00 SH92.11

BMJ Open

Burn: 60-69% of body surface, 20-29% BS full thickness Burn: 60-69% of body surface, 30-39% BS full thickness Burn: 60-69% of body surface, 40-49% BS full thickness Burn: 60-69% of body surface, 50-59% BS full thickness Burn: 60-69% of body surface, 60-69% BS full thickness Corrosions involving 60-69% of body surface Burn: 60-69% of body surface NOS Burn involving 70-79% of body surface (BS) Burn: 70-79% of body surface,<10%/unspec BS full thickness Burn: 70-79% of body surface, 10-19% BS full thickness Burn: 70-79% of body surface, 20-29% BS full thickness Burn: 70-79% of body surface, 30-39% BS full thickness Burn: 70-79% of body surface, 40-49% BS full thickness Burn: 70-79% of body surface, 50-59% BS full thickness Burn: 70-79% of body surface, 60-69% BS full thickness Burn: 70-79% of body surface, 70-79% BS full thickness Corrosions involving 70-79% of body surface Burn: 70-79% of body surface NOS Burn involving 80-89% of body surface (BS) Burn: 80-89% of body surface,<10%/unspec BS full thickness Burn: 80-89% of body surface, 10-19% =full thickness Burn: 80-89% of body surface, 20-29% BS full thickness Burn: 80-89% of body surface, 30-39% BS full thickness Burn: 80-89% of body surface, 40-49% BS full thickness Burn: 80-89% of body surface, 50-59% BS full thickness Burn: 80-89% of body surface, 60-69% BS full thickness Burn: 80-89% of body surface, 70-79% BS full thickness Burn: 80-89% of body surface, 80-89% BS full thickness Corrosions involving 80-89% of body surface Burn: 80-89% of body surface, NOS Burn involving >90% of body surface (BS) Burn: >90% of body surface, <10%/unspec BS full thickness Burn: >90% of body surface, 10-19% BS full thickness Burn: >90% of body surface, 20-29% BS full thickness Burn: >90% of body surface, 30-39% BS full thickness Burn: >90% of body surface, 40-49% BS full thickness Burn: >90% of body surface, 50-59% BS full thickness Burn: >90% of body surface, 60-69% BS full thickness Burn: >90% of body surface, 70-79% BS full thickness Burn: >90% of body surface, 80-89% BS full thickness Burn: >90% of body surface, >90% BS full thickness Corrosions involving 90% or more of body surface Burn: >90% of body surface NOS Burn as a percentage of body surface involved NOS Burn - unspecified Unspecified degree of burn NOS Superficial burn NOS First degree burn Partial thickness burn NOS Second degree burn

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Supplemental material

SH92000 SH92100 SH93.00 SH93.11 SH94.00 SH95.00 SH9z.00 SHz..00 SK03.00 SK1x200 SK1x500 SK1x700 SK1x800 SK1x900 SK1xA00 SP23.00 SP23000 SP23011 SP23100 SP23200 SP23300 SP23400 SP23z00 SP23z11 SP23z12 SP23z13 SP24300 SP25000 SP25100 SP25500 SP25600 SP25700 SP25800 SP28.00 SQ...00 Syu0200 Syu0A00 Syu1300 Syu1400 Syu2500 Syu2600 Syu3200 Syu3300 Syu4100 Syu5200 Syu6200 Syu7100 Syu8200 Syu9200 Syu9300

BMJ Open

Superficial partial thickness burn NOS Deep partial thickness burn NOS Full thickness burn NOS Third degree burn Deep full thickness burn, without loss of body part, NOS Deep full thickness burn, with loss of body part, NOS Burn - unspecified Burns NOS Post-traumatic wound infection NEC Multiple open wounds of neck Multiple open wounds of abdomen, lower back and pelvis Multiple open wounds of forearm Multiple open wounds of lower leg Open wounds involv thorax with abdomen,lwr back and pelvis Open wounds invol multi regions of up limb(s) wth lw limb(s) Operation wound disruption Operation wound dehiscence Postoperative wound breakdown Operation wound rupture Surgical wound necrosis Burst abdomen NEC Breakdown of totally implantable venous access device port Operation wound disruption NOS Delayed healing surgical wound Healing delayed surgical wound Wound surgical healing delayed Foreign body left in wound Postoperative stitch abscess Postoperative wound abscess Postoperative wound infection, unspecified Postoperative wound infection-deep Postoperative wound infection-superficial MRSA infection of postoperative wound Postoperative wound sinus Open wounds involving multiple body regions [X]Open wound of other parts of head [X]Penetrating wound of orbit with or without foreign body [X]Open wound of other parts of the neck [X]Open wound of neck, part unspecified [X]Open wound of other parts of thorax [X]Open wound of thorax, part unspecified [X]Open wound of oth and unspecif external genital organs [X]Open wound oth & unspecif part abdomen/lower back/pelvis [X]Open wound of oth & unspecif parts of should & upper arm [X]Open wound of other parts of forearm [X]Open wound of other parts of wrist and hand [X]Open wound of other parts of hip and thigh [X]Open wound of other parts of lower leg [X]Open wound of other parts of foot [X]Open wound of other parts of ankle and foot

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Supplemental material

SyuA100 SyuBA00 SyuD.00 SyuD000 SyuD800 SyuD900 SyuJ000 TG80000 TG80100 TG80200 TG80300 TG80400 TG80500 TG80600 TG80700 TG80800 TG80900 TG80A00 TG80B00 TG80C00 TG80D00 TG80y00 TG80z00 TGyz700 Z174M00 Z174M11 Z174N00 Z174N11 Z174N12 Z174O00 Z174O11 Z174P00 Z174Q00 Z1B..00 Z1B..11 Z1B..12 Z1B1.00 Z1B1100 Z1B1200 Z1B1300 Z1B1311 Z1B1312 Z1B1313 Z1B1400 Z1B2.00 Z1B2100 Z1B2111 Z1B2200 Z1B2300 Z1B3.00

BMJ Open

[X]Open wounds involving other combinations of body regions [X]Open wound of unspecified body region [X]Burns and corrosions [X]Burns of other parts of eye and adnexa [X]Burns of mult reg, at least 1 burn of 3rd deg mentioned [X]Corrosn multi reg, at least 1 corr of 3rd deg mentioned [X]Post-traumatic wound infection, not elsewhere classified Accidental burning/scalding caused by boiling water, unspec Accidental burning/scalding caused by boiling liquid, unspec Accidental burning or scalding caused by liquid metal Accidental burning or scalding caused by steam Accidental burning/scalding by boiling water from kettle Accidental burning/scalding by boiling water from saucepan Accidental burning or scalding caused by tea Accidental burning or scalding caused by coffee Accidental burning or scalding caused by chocolate Accidental burning or scalding caused by milk Accidental burning/scalding caused by soup, stew or curries Accidental burning or scalding caused by fat Accidental burning or scalding caused by steam from kettle Accidental burning or scalding by steam from car radiator Accidental burning or scalding caused by other hot vapour Accidental burning/scalding caused by hot liquid/vapour NOS Accidental wound NOS Pressure area care PAC - Pressure area care Wound care WOUND TREATMENT WOUND THERAPY Post-surgical wound care Post-operative wound care Pressure sore care Skin ulcer care Dressing of skin or wound Application of dressing Dressing Attention to dressing of skin Checking dressing of skin Checking dressing for leakage Change of dressing Repeating dressing Reapplying a fresh dressing Redressing wound Attention to dressing of burnt skin Dressing of skin Dressing of burnt skin Burn dressing Covering burnt skin with plastic bag Dressing of skin ulcer Dressing of pressure sore

Guest JF, et al. BMJ Open 2020; 10:e045253. doi: 10.1136/bmjopen-2020-045253

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Z1O6100 Z1R2.00 Z1R2.11 Z1R2.12 Z1R3.00 Z1R3.11 Z1R3.12 Z1R3.13 Z1R3100 Z1R3200 Z1R4.00 Z1R4.11 Z1R5.00 ZA13E00 ZA14.00 ZA14.11 ZA14100 ZA14200 ZQ37.00 ZQ38.00 ZQ38.11 ZQ39.00 ZQ39.11 ZQ39.12 ZQ39.13 ZQ3A.00 ZQ3A.11 ZR1V.00 Zw02D00 Zw02E00 Zw02F00 Zw02G00 Zw02H00 Zw02J00 ZX14.00 ZX14300 ZX14400

BMJ Open

Exposing wound to air Cleaning wound Cleansing wound Wound toilet Debridement of skin Debridement of wound of skin Wound debridement Wound debridement Debridement of wound with topical agent Surgical debridement of wound Removal of slough from skin Desloughing wound Removal of contaminant from skin Insertion of quill in the nail bed Ablation of nail bed Ablation of nail matrix Total ablation of nail matrix Partial ablation of nail matrix Wound assessment Assessment of fluid loss from wound Assessing seepage from wound Pressure sore assessment Decubitus ulcer assessment Pressure ulcer assessment Bed sore assessment Assessment of burn injuries Assessment of levels of burns ASEPSIS score for wound infection [Q] Open fracture grade 1 [Q] Open fracture grade 2 [Q] Open fracture grade 3 [Q] Open fracture grade 3A [Q] Open fracture grade 3B [Q] Open fracture grade 3C Damaging own wounds Poking fingers into wound Inserting objects into wound

Guest JF, et al. BMJ Open 2020; 10:e045253. doi: 10.1136/bmjopen-2020-045253

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BMJ Open

Table S2: Patientsâ&#x20AC;&#x2122; baseline characteristics.

Diabetic

Leg ulcer

Leg ulcer

Leg ulcer

Leg ulcer

Open

Pressure

Surgical

foot ulcer

(arterial)

(mixed)

(unspecified)

(venous)

wound

ulcer

wound

47.1

62.3

57.4

67.0

52.6

70.9

53.4

76.1

55.4

52.4

55.9

57.9

42%

35%

51%

22%

57%

39%

48%

40%

40%

42%

41%

49%

44%

Percentage smoker

29%

24%

11%

13%

10%

21%

7%

18%

7%

19%

16%

22%

17%

Percentage ex-smoker

19%

19%

37%

32%

30%

21%

44%

29%

40%

29%

23%

28%

30%

51%

56%

52%

55%

60%

58%

48%

51%

40%

52%

59%

49%

52%

1%

1%

0%

0%

0%

0%

1%

2%

13%

0%

2%

1%

1%

29.7

27.9

30.9

28.8

32.3

27.6

31.5

29.6

24.5

28.3

27.8

28.9

29.1

79%

79%

61%

33%

50%

68%

59%

87%

80%

77%

84%

80%

73%

27%

13%

78%

52%

47%

68%

41%

94%

13%

35%

29%

1%

40%

Abscess

Burn

46.0

Percentage male

Mean age per patient (years)

Percentage nonsmoker

Trauma Unspecified

All wounds

Percentage with unknown smoking status Mean body mass index per patient (kg/m2) Percentage with new wounds in the study period Percentage of all wounds with a recorded infection

Guest JF, et al. BMJ Open 2020; 10:e045253. doi: 10.1136/bmjopen-2020-045253

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BMJ Open

Table S3: Percentage of patients with a comorbidity in the year before the start of their wound. Those with diabetes are a subset of those with endocrinological comorbidities.

Abscess Burn

Diabetic

Leg ulcer

Leg ulcer

Leg ulcer

Leg ulcer

Open

Pressure Surgical

foot ulcer

(arterial)

(mixed)

(unspecified)

(venous)

wound

ulcer

wound

Trauma Unspecified

All wounds

Cardiovascular

36%

35%

70%

67%

83%

45%

78%

44%

53%

47%

38%

51%

53%

Dermatological

48%

52%

60%

44%

63%

50%

41%

51%

40%

51%

54%

45%

49%

Endocrinological

52%

56%

99%

78%

97%

18%

52%

69%

60%

63%

55%

57%

60%

50%

52%

100%

78%

97%

13%

37%

67%

60%

59%

51%

52%

57%

Gastroenterological

29%

32%

42%

67%

33%

29%

19%

34%

47%

37%

31%

35%

33%

Genito-urinary

21%

24%

28%

44%

33%

18%

19%

25%

27%

28%

24%

24%

24%

Immunological

7%

11%

13%

11%

17%

3%

11%

10%

7%

9%

8%

9%

9%

Malnutrition

0%

2%

2%

0%

0%

5%

4%

1%

13%

1%

2%

3%

3%

Musculoskeletal

41%

56%

62%

67%

63%

61%

59%

49%

73%

57%

49%

56%

56%

Neurological

16%

21%

24%

11%

27%

24%

33%

18%

67%

22%

17%

17%

24%

Oncological

14%

16%

25%

11%

20%

16%

7%

14%

27%

18%

15%

19%

16%

Ophthalmological

8%

15%

20%

0%

27%

13%

4%

11%

33%

13%

11%

10%

12%

Psychiatric

44%

40%

39%

33%

53%

47%

15%

35%

33%

35%

32%

35%

35%

Renal

8%

5%

30%

22%

33%

13%

30%

12%

40%

14%

9%

16%

18%

Respiratory

38%

44%

45%

56%

43%

42%

33%

36%

33%

38%

36%

37%

38%

3.7

4.1

5.7

6.0

5.7

3.9

4.0

4.1

5.6

4.3

3.8

4.2

4.1

Diabetes

Mean number of comorbidities per patient

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BMJ Open

Table S4: Healing rates in the study period.

Wounds that healed in the study period New wounds that healed in the study period Existing wounds that healed in the study period Wounds that healed with no evidence of infection Wounds that healed with recorded evidence of infection Wounds that healed among smokers Wounds that healed among exsmokers Wounds that healed among non-smokers

Abscess

Burn

Diabetic foot ulcer

Leg ulcer (arterial)

Leg ulcer (mixed)

Leg ulcer (unspecified)

Leg ulcer (venous)

Open wound

Pressure ulcer

Surgical wound

Trauma

Unspecified

All wounds

86%

84%

52%

47%

30%

55%

37%

90%

60%

85%

94%

85%

70%

85%

80%

60%

40%

27%

38%

56%

90%

75%

86%

94%

88%

76%

89%

96%

40%

50%

33%

92%

9%

90%

0%

80%

96%

73%

56%

92%

85%

57%

50%

34%

60%

50%

93%

62%

87%

95%

86%

77%

69%

75%

50%

45%

25%

52%

18%

89%

50%

81%

91%

38%

60%

84%

87%

33%

37%

28%

48%

25%

88%

33%

82%

96%

85%

64%

90%

75%

53%

47%

32%

53%

39%

88%

67%

83%

95%

88%

70%

87%

87%

56%

50%

30%

58%

38%

93%

75%

88%

96%

84%

74%

Guest JF, et al. BMJ Open 2020; 10:e045253. doi: 10.1136/bmjopen-2020-045253

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BMJ Open

Table S5: Percentage of patients who utilised resources in the study year. â&#x20AC; Includes tissue viability nurses and diabetic nurse specialists.

Abscess

Burn

Diabetic foot ulcer

Leg ulcer (arterial)

Leg ulcer (mixed)

Leg ulcer (unspecified)

Leg ulcer (venous)

Open wound

Pressure ulcer

Surgical wound

Trauma

Unspecified

All wounds

37%

52%

96%

89%

93%

82%

85%

24%

60%

46%

15%

44%

38%

32%

27%

93%

89%

99%

84%

81%

21%

40%

46%

15%

44%

36%

Practice nurse visits

96%

94%

94%

100%

100%

79%

96%

97%

93%

97%

98%

98%

97%

GP office visits

94%

79%

97%

100%

100%

100%

100%

90%

93%

82%

93%

62%

84%

Dressings Compression bandaging/ hosiery Prescribed analgesics/nonsteroidal antiinflammatories Prescribed antibiotics Hospital outpatient visits with a nurse Accident & emergency attendances Hospital admissions without surgery Hospital outpatient visits with a physician/surgeon GP home visits

100%

100%

100%

100%

100%

100%

100%

100%

100%

100%

100%

100%

100%

2%

5%

15%

0%

100%

26%

93%

5%

0%

3%

0%

6%

6%

22%

19%

57%

67%

87%

32%

81%

12%

53%

24%

10%

20%

21%

82%

42%

92%

97%

90%

84%

81%

81%

67%

43%

37%

26%

50%

11%

32%

35%

22%

33%

16%

37%

8%

0%

18%

5%

31%

17%

16%

18%

23%

22%

27%

5%

30%

8%

7%

8%

5%

4%

8%

7%

8%

4%

0%

3%

5%

7%

7%

13%

8%

5%

8%

7%

4%

0%

15%

22%

7%

8%

7%

4%

20%

8%

7%

1%

5%

District/community nurse visits Healthcare assistant visits

2%

3%

2%

0%

10%

0%

11%

1%

13%

2%

1%

1%

2%

Diagnostic tests

1%

2%

3%

0%

10%

3%

0%

1%

0%

2%

1%

3%

2%

Ambulance services Hospital admissions with surgery Specialist nurse visitsâ&#x20AC;

1%

0%

3%

0%

3%

0%

4%

0%

0%

1%

0%

1%

1%

2%

2%

2%

0%

0%

0%

0%

0%

0%

6%

1%

0%

2%

0%

0%

3%

0%

10%

0%

0%

0%

7%

1%

0%

1%

1%

Podiatrist visits

1%

0%

3%

33%

17%

0%

0%

1%

7%

1%

<1%

0%

1%

Day Cases

1%

0%

0%

0%

0%

0%

0%

0%

0%

1%

0%

<1%

<1%

Guest JF, et al. BMJ Open 2020; 10:e045253. doi: 10.1136/bmjopen-2020-045253