Volume 27 Number 2

Key messages

• Despite WHO declaring chronic wounds an epidemic in 2010, incidence and prevalence have only increased.
• With increased life expectancy, and ever increasing diabetes in the general population, healthcare budget pressures due to chronic wound costs are projected to rise explosively.
• Both the FDA and the EWMA advocate for more innovative, more efficacious chronic wound management strategies to not only reduce the burden for patients, but also on health care budgets.
• Currently, European HCP signal strong medical unmet needs regarding patient chronic wound treatments; 66% see significant health inequality and limited access to care.
• Furthermore, 71% of wound care HCP experience reimbursement challenges affecting medical treatment availability, while 80% see insufficient reimbursement, limiting chronic wound treatment of their patients.

Introduction

According to the 2024 report by the European Innovation Partnership on Active and Healthy Ageing (EIP-AHA), the number of Europeans aged over 65 years is projected to double over the next 50 years, while the population aged over 80 years is expected to almost triple.¹ However, increased life expectancy does not necessarily equate to a healthier, more active, or independent life. EIP-AHA estimates, that approximately 20% of life years will be spent in poor health.^1,2 Chronic wounds are prevalent at all ages, with the majority occurring among older populations, and thus representing a substantial individual and societal burden.

At a patient level, chronic wounds can lead to infection, pain, functional impairment, disability and even limb amputation, resulting in a marked decline in quality of life.³ On a policy and administrative level, chronic wounds represent a strong, noteworthy economic burden on public health systems. In 2022, the US Food and Drug Administration (FDA) wrote that more than 6.5 million individuals are affected by chronic wounds annually in the US, a figure expected to rise further with increasing obesity and diabetes prevalence.^4–6 In a recent retrospective study in the Lancet, the NCD Risk Factor Collaboration (NCD-RisC) shared the pooled data analysis of 1108 population-representative studies, and concluded that an estimated 828 million adults globally were living with diabetes in 2022, more than quadruple the 198 million reported in 1990.^7,8 This increase was found in 131 countries for women and in 155 countries for men. Alarmingly, the study also highlights that in many low- and middle-income countries, the availability and quality of diabetes care have not kept pace with the rising prevalence. The authors therefore advocate for expansion of health insurance and primary care services, along with dedicated diabetes programmes that prioritise early detection and effective management.⁷

Although diabetic foot ulcers (DFUs) represent only one subset of chronic wounds, they underscore the magnitude of the unmet medical need. Epidemiological data suggest that between 10% and 15% of individuals with diabetes will develop a foot ulcer during their lifetime, with approximately 20% experiencing inadequate arterial perfusion to the lower limb.⁹ Furthermore, individuals with diabetes are over ten times more likely to undergo non-traumatic lower limb amputation compared to non-diabetic individuals.⁹ Given the figure of 828 million adults with diabetes, this translates to an estimated 124 million individuals at risk for hard-to-heal diabetic foot ulcers. The urgency implied by this number increases further upon consideration of the epidemiological findings of Martinengo et al¹⁰ that not DFU, but chronic leg ulcers demonstrate the highest point prevalence among chronic wounds within healthcare system. This underscores the scale of the challenge and reaffirms the assessment in 2010 by WHO that: “Chronic wounds are a global epidemic”.¹¹

The COVID-19 pandemic provides a recent and compelling illustration of this dual dynamic, demonstrating how a single global health crisis can both strain public resources and drive rapid expansion within the pharmaceutical and biotechnology sectors. According to Reuters, western pharmaceutical manufacturers generated an estimated USD 100 billion (EUR 95 billion) in revenue from COVID-19 vaccines and treatments in 2022 alone.¹² Against this backdrop, the economic burden of chronic wounds has emerged as an increasing concern for healthcare policymakers. In a 2022 analysis, FDA stated that more than US$25 billion (EUR 24 billion) is spent annually in the US on the treatment of chronic wounds.⁴ A subsequent study by Freedman et al revised this estimate upward one year later to US$30 billion (EUR 28 billion).¹³ Comparable results have been found in Europe. Guest et al calculated that the management of chronic wounds and associated comorbidities costs the British National Health Service (NHS) approximately GBP 5.3 billion per year (US$6.7 billion, EUR 6.4 billion), while only a modest reduction of 2% to 15% was found when costs attributable to comorbidities were excluded.^14–17 District nurse visits were identified as the primary cost driver, accounting for 52% or more of total patient management expenses.¹⁶ In Sweden, Öien et al analysed data from the Swedish Registry of Ulcer Treatment and found that staff-related costs represented approximately 87% of total expenditures associated with chronic wound care.¹⁸ Importantly, the implementation of innovative, more effective therapeutic strategies was shown to reduce total treatment costs by up to 38%, primarily due to shorter healing times.¹⁸ More recently, in 2023, Hwang confirmed this cost-saving potential, and reported cost avoidance of 93.5% with DFU cases, and of 85.9% with venous stasis ulcer cases when patients were referred to specialised care units earlier.¹⁹ Despite a growing body of epidemiological and economic evidence, a critical gap remains in understanding of how front-line wound care professionals perceive current challenges, resource constraints and strategic priorities in the everyday European wound care practice. Such perspectives are essential for translating economic data into actionable policies, optimising resource allocation, and guiding the implementation and availability of newer, innovative therapies.

The present survey by the European Wound Management Association (EWMA) aimed to capture the views of healthcare professionals (HCPs) directly involved in patient wound management across Europe, with the objective of identifying practical needs, barriers, and opportunities for advancing evidence-informed wound care policy and practice.

Material and methods

A cross-sectional, descriptive survey was conducted by EWMA between November 2024 and January 2025. The survey targeted HCPs involved in wound care and was distributed to EWMA registered members, as well as to 54 EWMA partner, national wound management organisations across Europe. The survey design was selected for its low threshold effectiveness in gathering practice-based insights from large, geographically dispersed professional populations in a time-efficient and cost-effective manner.²⁰

The questionnaire, developed in English, consisted of 31 items, 30 multiple choice questions and one open-ended item. It explored key topics, including current clinical practice, challenges in wound care delivery, application of guidelines and standards, access to care, unmet needs, and expectations for the future of wound care. In the latter section, participants were invited to comment not only on emerging wound care technologies, but also on broader health system-related concerns. The open-ended item encouraged respondents to suggest specific actions that could improve future wound care. EWMA partner organisations were given the option to disseminate either the original English version, or a translated version of the questionnaire in their respective national languages. Participation in the survey was voluntary. During the data collection period, multiple reminder communications were sent out by the EWMA secretariat to encourage participation. Formal ethics approval was not required for this type of non-interventional research. Completion and submission of the survey were considered as provision of informed consent.

The survey was constructed and executed using the SurveyMonkey Matrix/Rating Scale Question model.²¹ Sampling was based on voluntary participation among the entire EWMA membership and affiliated partner organisations. Descriptive statistical analysis was performed to summarise results. Absolute and relative frequencies (counts and percentages) were calculated for all closed ended, multiple-choice items. Data were pooled and analysed using SQLite (v3.46.1-7) and R (v4.5.1-1). No inferential statistical analysis was conducted, as the primary objective of the survey was exploratory and descriptive in nature. Where appropriate, results were summarised in graphical form.

Results

Survey completion and respondent characteristics

After database closure and data cleaning, 176 fully completed questionnaires were available for analysis. Response rates varied by country, with Italy providing the largest share of responses (39%, n=60). Seven percent of participants reported working primarily outside Europe, while 14% chose not to disclose their country of practice. No significant differences were identified between responses from Italy and those from other countries. The average item non-response rate (the skip rate) was 25% with the lowest skip rate (≤7%) recorded for items related to current wound care practice, clinical challenges, and unmet medical needs. The highest skip rate was associated with the open-ended question (90%). A descriptive summary of respondent profiles is provided in Table 1. Among physicians, 77% reported working in hospital settings, compared to 51% of nurses. None of the participating physicians were employed exclusively in home care, whereas 16% of nurses reported home care-only practice. Nurses more frequently reported treating venous leg ulcers (52.6% versus 36.9%) and pressure ulcers (54.4% versus 32.3%), while physicians reported greater involvement with mixed ulcers (35.4% versus 19.3%). Regarding therapeutic autonomy, 97% of physicians indicated independent decision making for wound care treatment compared to 67% of nurses. Country-level comparisons were not statistically meaningful due to limited sample sizes.

 

Table 1. Summary of 2024 EWMA State of Affairs Questionnaire respondent profiles

 

Anticipated challenges in wound care

When respondents were asked to rate anticipated challenges in wound care for the next 5–10 years, the most frequently selected concerns were rising wound care patient numbers (90%), increasing healthcare cost pressures (93%), and shortages of qualified wound care professionals (87%, Figure 1). In their current clinical setting, 92% rated the lack of qualified staff as “extremely” or “very” important, while 91% highlighted insufficient staff training and education as a key concern. Additional frequently reported challenges included inadequate interdisciplinary coordination (91%), suboptimal diagnostic and referral procedures in primary care (88%), and insufficient coordination between wound care centres or units (82%). Streamlining clinical protocols and workflows was prioritised by 80% of respondents (Figure 1).

 

Figure 1. Responses to the question: How important are these challenges in current wound management?

 

Barriers to effective wound management

Asked to identify the most significant limiting factors in current wound care delivery, 75% selected workforce capacity and training deficiencies (Figure 2). Other prominent barriers included dysfunctional patient pathways (69%), demographic and disease-related burdens (ageing population and chronic illness; 67%), and infection control and antimicrobial resistance (66%).

 

Figure 2. Responses to the question: Which factors most limit wound management?

 

Limited access to wound care and health inequalities among their wound care patients were observed by 66% of respondents. Only 9% reported facing no economic barriers affecting access to advanced wound care treatments. In contrast, 71% reported significant or very significant economic constraints affecting care delivery to their patients.

Regarding reimbursement systems, 56% considered their national or regional reimbursement framework for wound care to be inadequate, with 25% even rating it as very inadequate. Among physicians, 29% assessed reimbursement conditions as very inadequate, compared to 18% of nurses. Reimbursement for advanced wound therapies specifically was reported as limited by 83% of respondents (22% partial limitation, 61% strong limitation). Similar constrains were also noted with regard to overall product coverage (81%) and access to wound care therapy generally (78%, see Figure 3).

 

Figure 3. Responses to the question: How do reimbursement challenges limit access to wound care products or technologies in your country or region?

 

Unmet clinical needs

Survey responses highlighted several unmet medical needs in daily wound care practice. The most frequently reported was the inability to tailor treatment to individual patient needs (42%, Figure 4) Other reported needs included insufficient resources for outpatient care (34%), lack of effective wound monitoring tools (33%), and diagnostic limitations (30%). Nurses reported more frequently a lack of pain and discomfort reducing products than physicians as a substantial unmet need (29% versus 8.5%).

 

Figure 4. Responses to the question: What clinical needs remain unmet in your wound care practice?

 

Policy priorities and implementation conditions

Respondents identified increased investment in wound care research and development, as well as improved funding frameworks, as key policy priorities for improving future wound management in Europe (Figure 5).

 

Figure 5. Responses to the question: To what extent would the following policy actions positively impact the advancement of wound management in Europe?

 

When asked to identify the most critical conditions for implementation innovative wound care solutions, cost-effectiveness was selected by 88% of respondents as a primary condition (i.e. 49% extremely important, 39% very important). Other important factors included ease of use and training requirements (87%) and evidence of improved clinical outcomes (84%, Figure 6).

 

Figure 6. Responses to the question: How important are the various factors to incentivise the adoption of new wound care technologies within your organisation?

 

Potential of future wound care innovation

When asked to assess the potential of innovative wound care technologies over the next five years, 98% of respondents highlighted bioactive and regenerative therapies, which were rated as having some (23%), great (39%), or extreme potential (34%, Figure 7). For telemedicine and remote monitoring, 96% expressed some (16%), great (48%), or extreme potential (33%). Nearly half of all respondents (49%) reported experience with, or ongoing use of digital health tools in their clinical practice, while 51% reported no current usage. Physicians reported higher use of digital health tools than nurses (50.9% versus 39.5%), whereas nurses more frequently rated digital integration as extremely important (36.8% versus 18.6%). New wound dressings and materials, as well as AI-based wound assessment tools, were perceived as having comparatively lower potential (16%, Figure 7). Although the number of free-text entries with suggested actions to address European wound care challenges was low (9.6%), it was possible to detect some communality in the received replies. Most suggested by physicians specifically are more and better wound treatment guidelines, followed by a need for focussed wound care advocacy with policy makers and payers, more wound care resources, and better reimbursement. Furthermore, both physicians and nurses called strongly for wound care to be instituted as a well defined, separate discipline/specialisation, and for better wound care education and training. Noteworthy mentions are to establish wound care registries, avoid wound care privatisation, and address antimicrobial resistance actively.

Discussion

This cross-sectional survey provides an overview of the perspectives of European wound care professionals regarding key clinical, organisational and systemic challenges in the management of chronic wounds. The results reveal widespread concern about increasing patient demand, limited resources and persistent access barriers. These issues have been documented in literature previously, but seem to remain inadequately addressed in everyday clinical practice. Although the WHO labelled the prevalence and incidence of chronic wounds in a global epidemic in 2010, the situation since then has not improved, but grown even larger in size. For example, as Guest et al report in their 2020 BMJ update, the annual prevalence of wounds in the UK increased by 71% in the 5 years between 2012/2013 and 2017/2018, accompanied by a substantial increase in resource use and patient management cost of 48% in real terms.²² The complex, multifactorial nature of chronic wounds likely contributes to this observed persistent growth in clinical and economic burden, affecting not only healthcare providers, but also policy makers, regulators, payers, and ultimately patients and their families. Reflecting this challenge, FDA has acknowledged publicly the national health burden of chronic wounds and committed itself to aid advancing product development for non-healing wounds.⁴

Although the 2024 EWMA Questionnaire offers only a snapshot of current everyday professional observations, its results underscore a collective expectation of increasing pressures for the years ahead. On a macro-level, reported concerns align with economic projections from the European Commission’s Economic & Budgetary projections for the EU Member States (2022-2070) report.²³ Here, the Ministries of Finance of the various Member States forecast substantial rises in healthcare and long-term care expenditures due to population ageing. For example, Germany projects a health and long-term care cost increase of approximately EUR 23.2 billion by 2070. Other European countries forecast similar increases, with EUR 26.3 billion in France, EUR 12.0 billion in Italy, and EUR 28.3 billion in Spain. Current expenditure data already illustrate and evidently confirm this trajectory. For 2022, Eurostat reported that Germany recorded the highest healthcare spending among EU countries with EUR 489 billion (12.6% of GDP), followed by France (EUR 314 billion; 11.9% of GDP), Italy (EUR 176 billion; 9.0% of GDP), and Spain (EUR 131 billion; 9.7% of GDP).²⁴

Demographic projections further reinforce this observed trend. The European Commission observes in their 2023 report The Impact of Demographic Change that on 1 January 2021, 20.8% of the EU population was aged 65 or older.²⁵ By 2050, this will be about 30%, and combined with a decreasing population of young people in the EU, this will result in a ratio of fewer than two working age adults for each elderly person, and an increasing trend of old-age dependency up to 56.7%.²⁵ In their 2023 World Social Report, the United Nations came to a similar conclusion, predicting that the proportion of the world’s population of 60 years or older will nearly double between 2015 and 2050.²⁶

At the same time, the financial world already hedges their positions. Rating agencies warn that worsening demographics are already hitting credit ratings of governments.²⁷ Moody’s, Standard and Poor’s, and Fitch all say the rise in borrowing costs impacts growth due to changes in working age populations, impacts the public finances and availability of pensions, and, as also observed by the EWMA Questionnaire respondents, increases healthcare costs firmly. In January 2023, Standard and Poor’s even went as far as to predict that roughly half of the world’s largest economies will have been downgraded to junk by 2060, if no measures are taken to ease the costs of ageing populations.²⁷

Consistent with these demographic and economic forecasts, 90% of survey respondents identified an expanding patient burden, driven by ageing populations and multi-morbidity as a primary challenge. These perceptions are supported by epidemiological projections estimating a sharp rise in the incidence and prevalence of chronic wounds in ageing societies.²⁸ Workforce shortages and insufficient training were perceived as critical limitations to effective wound care delivery, with over 90% of respondents rating them as extremely or very important. This aligns with prior findings from an Australian study showing that wound care is often performed by generalists with limited specialist training, particularly in community settings.²⁹ The reported deficiencies in interdisciplinary coordination and referral pathways echo observations from previous studies in which fragmented care processes have been linked to treatment delays and suboptimal outcomes.³⁰

Economic constraints emerged as a major structural barrier. Only 9% of respondents reported having no financial restrictions affecting wound care access, while 71% cited significant or very significant economic limitations. Reimbursement for advanced therapies was perceived as limited or strongly limited by 83% of participants. These results are consistent with previous research highlighting considerable variation in reimbursement frameworks for wound care across Europe, leading to unequal access to products and services.^31,32 The greater dissatisfaction with reimbursement among physicians (28.8%) compared to nurses (18.4%) may reflect differences in prescribing authority and administrative burden. Notably, respondents emphasised the inability to tailor treatment to individual wound types and patient conditions (42%) as the most important unmet clinical need. This reinforces earlier calls in literature for more personalised, stratified approaches to wound management, particularly for complex wounds, such as diabetic foot ulcers and mixed aetiology leg ulcers.³³ The higher reported lack of pain and discomfort reducing products by nurses also aligns with the known discrepancy between clinician and patient priorities in chronic wound care, where symptom burden is often under-addressed.³⁴

Support for innovation was high across the sample. Similar to the FDA and EWMA Innovation Alliance, the queried European wound healing professionals also see new innovative therapeutic approaches as essential for wound care.^4,35,36 Important here, however, is that respondents indicated that these new and innovative approaches should signify more than just the next iteration of an already available dressing (92%), and be guided by robust clinical evidence (84%) and ease-of-use (87%). These priorities are consistent with recommendations from health technology assessment bodies, objectives of the recently introduced European Health Technology Assessment legislation, and align with findings from studies on barriers to innovation adoption in healthcare.^37–39 However, the results also suggest that innovation alone is ineffective when availability and reimbursement are lacking. This echoes conclusions from prior analyses of advanced wound care product diffusion in Europe.⁴⁰ Hence, it is concerning to find that only 18% of wound care professionals on the ground judge reimbursement in their country/ region as adequate, and report to see strong health inequality and limited access to wound care in their everyday clinical wound care practice (66%).

Strengths and limitations

This report provides timely, practice-based insights into the challenges and needs of wound care professionals across Europe. Its main strength lies in the relevance of the topic, the diversity of respondents from multiple countries, and the comprehensive scope covering clinical, organisational, and economic aspects of wound care. More specifically, this report is timely and addresses a relevant topic: a growing public health concern—chronic wounds—in the context of ageing populations, rising diabetes rates and increasing health system pressures. Furthermore, its findings offer a real-world perspective by capturing the observations of wound care professionals from across Europe, offering a grounded view of clinical challenges and unmet needs in every day clinical practice. Also, with its comprehensive scope, it covers medical, economic, policy and systemic aspects of wound care, including staffing, training, access, reimbursement, and innovation, which is data driven, and include also policy relevant recommendations, which offers actionable insights concerning improvement of reimbursement systems, innovation uptake, and care coordination.

The main limitation of this study was the low response rate and representation bias, since the number of respondents (n=176) was modest and skewed geographically (for example 39% from Italy), potentially limiting the applicability of responses for Europe in general. Likewise, a high skip rate was found for some survey questions, most likely indicating a focus on, and strong involvement with some, but not all issues addressed by the survey. Unfortunately, the high non-response rates (up to 25%) to several specific questions reduced data completeness, especially when considering the 90% skip rate on the only free text question of the survey, which asked the medical professionals for their thoughts on the future of wound care. Finally, the survey clearly is a snapshot in time, and therefore unable to reveal or investigate any potential trends or changes over time.

Conclusion

The 2024 EWMA survey underscores that real, every day barriers to effective wound care for chronic wound patients extend beyond clinical management, and also encompasses organisational, financial and policy domains. Coordinated policy action is critical to enable delivery of evidence-based, cost-efficient wound care across Europe. Such a multi-stakeholder cooperation not only concerns health care professionals, inventors and the wound care industry, but also European politicians, regulators and healthcare insurers/ payers. All are called upon to work towards elevating the very real, and reportedly growing, unmet need that European wound patients experience every day.

Acknowledgement

The authors gratefully acknowledge all healthcare professionals who participated in the survey and generously shared their experiences and insight to help analyse the current state of care for patients with non-healing wounds. Special thanks are extended to Helmut Schröder-Mattliebe of the Klinik für Neurologie Köln-Merheim, Germany, for his invaluable assistance during the production of this manuscript.

Conflict of interest

The authors declare no conflicts of interest.

Funding

The authors received no funding for this study.

Author(s)

Edwin den Braber¹* MD PhD, Andrea Pokorná² RN PhD, Dimitri Beeckman³ RN PhD, Elena Conde Montero⁴ MD PhD, Jan Apelqvist⁵ MD, Sebastian Probst⁶ RN PhD,  Kirsi Isoherranen⁷ MD PhD
¹EWMA Innovation Alliance, Denmark
²Department of Health Sciences, Masaryk University, Czech Republic
³Skin Integrity Research Group (SKINT), University Centre for Nursing and Midwifery, Department of Public Health and Primary Care, Faculty of Medicine and Health Sciences, Ghent University, Belgium. Swedish Centre for Skin and Wound Research (SCENTR), School of Health Sciences, Faculty of Medicine and Health, Örebro University, Sweden
⁴Hospital Universitario Infanta Leonor, Madrid, Spain
⁵Department of Endocrinology University, Hospital of Skåne in Malmö and Division for Clinical Sciences University of Lund, Sweden
⁶Geneva School of Health Sciences, HES-SO University of Applied Sciences and Arts Western Switzerland, Geneva, Switzerland. Care Directorate, University Hospital Geneva, Switzerland. Faculty of Medicine Nursing and Health Sciences, Monash University, Australia. College of Medicine Nursing and Health Sciences, University of Galway, Ireland
⁷Helsinki University Hospital and Helsinki University, Dermatology Clinic and Helsinki Wound Healing Centre, Finland.

*Corresponding author email innovation@ewma.org

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