***TASK*** the task is to summarize an input biomedical literature in six sentences 
    ***INPUT*** the input is a biomedical literature 
    ***OUTPUT*** the output is the summary of an input biomedical literature in six sentences 
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    Input: OBJECTIVE Determine the cost-effectiveness of extracellular matrix ( ECM ) relative to human fibroblast-derived dermal substitute ( HFDS ) on  diabetic foot ulcer ( DFU ) wound closure .  METHOD Outcomes data were obtained from a 12-week , r and omised , clinical trial of adults aged 18 years or older diagnosed with type 1 or type 2 diabetes with a DFU . Patients were treated with either ECM or HFDS treatment . A two-state Markov model ( healed and unhealed ) with a 1-week cycle length was developed using wound-closure rates from the trial to estimate the number of closed-wound weeks and the expected DFU cost per patient . Results were recorded over 12 weeks to estimate the number of closed-wound weeks per treatment and the average cost to achieve epithelialisation ( primary outcome ) . The perspective of the analysis was that of the payer , specifically the Centers for Medicare and Medicaid Services . No cost discounting was performed because of the short duration of the study . RESULTS The study consisted of 26 patients , with 13 in each group . In the ECM group , 10 wounds closed ( 77 % ) , with an average closure time of 36 days ; 11 wounds closed in the HFDS group ( 85 % ) , with an average closure time of 41 days . There was no significant difference between these results ( p=0.73 ) . Over 12 weeks , the expected cost per DFU was $ 2522 ( £ 1634 ) for ECM and $ 3889 ( £ 2524 ) for HFDS . Patients treated with HFDS  incurred total treatment costs that were approximately 54 % higher than those treated with ECM . Sensitivity analyses revealed that the total cost of care for two applications of HFDS was more costly than eight applications of ECM by approximately $ 500 ( £ 325 ) . CONCLUSION In patients with DFU  , ECM yielded similar clinical outcomes to HFDS but at a lower cost . Health-care providers should consider ECM as a cost-saving alternative to HFDS . DECLARATION OF INTEREST A.M. Gilligan , and C.R. Waycaster , are employees of Smith & Nephew Inc .. This study was funded by Smith & Nephew Inc .. A.L. L and sman , reports no conflicts of interest BACKGROUND Ulcers of the foot in people with diabetes mellitus are slow to heal and result in considerable cost and patient suffering . The prognosis is worst for ulcers of the heel . OBJECTIVE To assess both the clinical effectiveness and the cost-effectiveness of lightweight fibreglass casts in the management of  heel ulcers . DESIGN A pragmatic , multicentre , parallel , observer-blinded r and omised controlled trial . A central r and omisation centre used a computer-generated r and om number sequence to allocate participants to groups . SETTING Thirty-five specialist diabetic foot secondary care centres in the UK . Those recruited were aged ≥ 18 years and had diabetes mellitus complicated by ulcers of the heel of grade s 2 - 4 on the National Pressure Ulcer Advisory Panel and European Pressure Ulcer Advisory Panel scale . PARTICIPANTS In total , 509 participants [ 68 % male , 15 % with type 1 diabetes mellitus , mean age 67.5 years ( st and ard deviation 12.4 years ) ] were r and omised 1 : 1 to the intervention ( n = 256 ) or the control ( n = 253 ) arm . The primary outcome data were available for 425 participants ( 212 from the intervention arm and 213 from the control arm ) and exceeded the total required ; attrition was 16.5 % . The median ulcer area at baseline was 275 mm2 [ interquartile range ( IQR ) 104 - 683 mm2 ] in the intervention group and 206 mm2 ( IQR 77 - 649 mm2 ) in the control group . There were no differences between the two groups at baseline in any parameter , neither in relation to the participant nor in relation to their ulcer . INTERVENTIONS The intervention group received usual care supplemented by the addition of an individually moulded , lightweight , fibreglass heel cast . The control group received usual care alone . The intervention phase continued either until the participant 's ulcer had healed ( maintained for 28 days ) or for 24 weeks , whichever occurred first . During this intervention phase , the participants were review ed every 2 weeks , and the fibreglass casts were replaced when they were no longer usable . MAIN OUTCOME MEASURES The primary outcome measure was ulcer healing ( confirmed by a blinded observer and maintained for 4 weeks ) within 24 weeks . Other outcome measures included the time taken for the ulcer to heal , the percentage reduction in the cross-sectional area , the reduction in local pain , amputation , survival and health economic analysis . The study was powered to define a difference in healing of 15 % ( 55 % intervention vs. 40 % control ) . RESULTS Forty-four per cent ( n = 94 ) of the intervention group healed within 24 weeks , compared with 37 % ( n = 80 ) of the control participants ( odds ratio 1.42 , 95 % confidence interval 0.95 to 2.14 ; p = 0.088 ) , using an intention-to-treat analysis . No differences were observed between the two groups for any secondary outcome . LIMITATIONS Although the component items of care were st and ardised , because this was a pragmatic trial , usual care was not uniform . There was some evidence of a small excess of adverse events in the intervention group ; however , non-blinded observers documented these events . There was no excess of adverse device effects . CONCLUSIONS There may be a small increase in healing with the use of a heel cast , but the estimate was not sufficiently precise to provide strong evidence of an effect . There was no evidence of any subgroup in which the intervention appeared to be particularly effective . A health economic analysis suggested that it is unlikely that the intervention represents good value for money . The provision of a lightweight heel cast may be of benefit to some individuals , but we have found no evidence to justify the routine adoption of this in clinical practice . FUTURE WORK It is unlikely that further study of this intervention will have an impact on usual clinical care , and so future efforts should be directed towards other interventions design ed to improve the healing of ulcers in this population . TRIAL REGISTRATION Current Controlled Trials IS RCT N62524796 . FUNDING This project was funded by the National Institute for Health Research ( NIHR ) Health Technology Assessment programme and will be published in full in Health Technology Assessment ; Vol . 21 , No. 34 . See the NIHR Journals Library website for further project information OBJECTIVES To determine the comparative effectiveness and cost-effectiveness of three dressing products , N-A , Inadine and Aquacel , for patients with diabetic foot ulcers , as well as the feasibility and consequences of less frequent dressing changes by health-care professionals . DESIGN A multicentre , prospect i ve , observer-blinded , parallel group , r and omised controlled trial , with three arms . SETTING Established expert multidisciplinary clinics for the management of diabetic foot ulcers across the UK . PARTICIPANTS Patients over age 18 with type 1 or type 2 diabetes with a chronic ( present for at least 6 weeks ) full-thickness foot ulcer ( on or below the malleoli ) not penetrating to tendon , periosteum or bone , and with a cross-sectional area between 25 and 2500 mm(2 ) . INTERVENTIONS Participants were r and omised 1:1:1 to treatment with one of N-A ( a non-adherent , knitted , viscose filament gauze ) , Inadine ( an iodine-impregnated dressing ) , both traditional dressings , or Aquacel , a newer product . MAIN OUTCOME MEASURES The primary outcome measure was the number of ulcers healed in each group at week 24 . Secondary measures included time to healing , new ulcerations , major and minor amputations , and episodes of secondary infection . RESULTS A total of 317 patients were r and omised . After 88 withdrawals , 229 remained evaluable . A greater proportion of smaller ( 25 - 100 mm(2 ) ulcers healed within the specified time ( 48.3 % versus 37.3 % ; p = 0.048 ) . There was , however , no difference between the three dressings in terms of percentage healed by 24 weeks , or in the mean time to healing , whether analysed on the basis of intention to treat ( Inadine 44.4 % , N-A 38.7 % , Aquacel 44.7 % ; not significant ) or per protocol ( Inadine 55.2 % , N-A 59.4 % , Aquacel 63.0 % ; not significant ) . There was no difference in the quality of healing , as reflected in the incidence of recurrence within 12 weeks . Likewise , there was no difference in the incidence of adverse events , although a greater proportion of those r and omised to the non-adherent dressings were withdrawn from the study ( 34.9 % versus 29.1 % Aquacel and 19.4 % Inadine ; p = 0.038 ) . The only statistically significant difference found in the health economic analysis was the cost associated with the provision of dressings ( mean cost per patient : N-A 14.85 pounds , Inadine 17.48 pounds , Aquacel 43.60 pounds ) . The higher cost of Aquacel was not offset by the fewer dressings required . There was no difference in measures of either generic or condition-specific measures of quality of life . However , there was a significant difference in the change in pain associated with dressing changes between the first and second visits , with least pain reported by those receiving non-adherent dressings ( p = 0.012 ) . There was no difference in the costs of professional time , and this may relate to the number of dressing changes undertaken by non-professionals . Fifty-one per cent of all participants had at least one dressing change undertaken by themselves or a non-professional carer , although this ranged from 22 % to 82 % between the different centres . CONCLUSIONS As there was no difference in effectiveness , there is no reason why the least costly of the three dressings could not be used more widely across the UK National Health Service , thus generating potentially substantial savings . The option of involving patients and non-professional carers in changing dressings needs to be assessed more formally and could be associated with further significant reductions in health-care costs . TRIAL REGISTRATION Current Controlled Trials IS RCT N78366977 PURPOSE To evaluate potential cost savings , trial data were used to determine the clinical outcomes for i.v . ertapenem given once daily and i.v . piperacillin-tazobactam given every six hours daily in treating diabetic foot infections . METHODS A cost-minimization analysis ( CMA ) was conducted on the drug-dosing data of the subset of patients enrolled in a recent double-blind r and omized trial who were treated solely as in patients and were clinical ly evaluable at fi nal assessment ( n = 99 ) . Cost per dose was calculated from ( a ) average hospital acquisition price per dose for ertapenem ( $ 40.52 ) or piperacillin-tazobactam ( $ 13.58 ) , ( b ) average U.S. wages and benefits for labor , based on nine published time- and -motion studies of i.v . antibiotic preparation and administration ( $ 3.10 ) , and ( c ) consumable supplies , using a 40 % discount off the manufacturer list price ( $ 2.90 ) . For each patient , the actual number of antibiotic doses given was multiplied by total cost per dose . RESULTS There were no significant differences between antibiotic groups with respect to patient demographics , percentage with a severe wound , and mean days of i.v . therapy . Compared with piperacillin-tazobactam , patients treated with ertapenem received significantly fewer mean doses ( 25.5 versus 7.5 ; p < 0.0001 ) and lower antibiotic-related costs ( $ 502.76 versus $ 355.55 , respectively ; p < 0.001 ) . The $ 147.21 difference between groups accounts for approximately 3 % of total hospital Medicare reimbursements for these infections . CONCLUSION A CMA of treatment of diabetic foot infections showed that , compared with piperacillin-tazobactam given four times daily i.v . , ertapenem given once daily i.v . was associated with lower drug acquisition and supply costs and less time and labor devoted to preparation and administration of i.v . therapy A cost-effectiveness analysis was performed following a double-blind , r and omized study of ampicillin/sulbactam ( A/S ) versus imipenem/cilastatin ( I/C ) for the treatment of limb-threatening foot infections in 90 diabetic patients . There were no significant differences between the treatments in terms of clinical success rate , adverse-event frequency , duration of study antibiotic treatment , or length of hospitalization . Costs of the study antibiotics , treatment of failures and adverse events , and hospitalization were calculated . Mean per-patient treatment cost in the A/S group was $ 14,084 , compared with $ 17,008 in the I/C group ( P = .05 ) , primarily because of lower drug and hospitalization costs and less-severe adverse events in the A/S group . Sensitivity analyses varying drug prices or hospital costs demonstrated that A/S was consistently more cost-effective than I/C. Varying the clinical success rate 
    Output:
    
Conclusions Consistent identification of cost-effective and cost-saving interventions may help to reduce the DFU healthcare burden .