Objectives: To identify the Critical Success Factors (CSFs) for implementing a value-based outcomes framework within a local authority adult social care reablement team, exploring the rationale, barriers, and implementation strategies. Design: A pragmatic, mixed-methods study, combining qualitative data from two semi-structured focus groups with quantitative data from an online staff survey. Setting: Torfaen County Borough Council reablement service, Wales, UK. Participants: 46 adult social care staff (including reablement workers, social workers, and team managers) responded to the survey. Two focus groups were conducted: one with reablement practitioners (n=9) and another with team managers and wider representatives (n=19). Results: Staff demonstrated strong support for person-centred outcomes but low awareness of Value-Based Healthcare (VBHC) principles (only 4% were familiar). Key barriers included resistance to change (34%), limited organisational capacity (34%), and financial constraints (17%). A central tension existed between frontline person-centred care and system-level efficiency pressures. Leadership was identified as the primary enabler (44% of respondents), alongside service user involvement in goal-setting (46%) and a phased implementation approach (15%). Digital systems were not perceived as a primary barrier or solution, with issues centring on the inconsistent use of existing tools rather than their absence. Conclusions: Implementing a value-based framework in social care is feasible but requires a tailored approach distinct from clinical models. Success is contingent on strong leadership to navigate cultural change, co-production with service users to define meaningful outcomes, and a modular implementation strategy to build momentum. Investment should focus on change management and process redesign rather than new digital infrastructure. This study provides a transferable framework for local authorities seeking to embed value-based care principles to demonstrate impact in an era of constrained budgets.

Abstract Objectives Value-Based Health Care (VBHC) increasingly guides health system redesign internationally. Despite the increasing availability of VBHC education, gaps remain between health professionals’ conceptual understanding of VBHC and their confidence to implement it in practice. This study assessed perceived learning needs and preferences of healthcare professionals across foundational topics essential to VBHC implementation. Design Cross-sectional online survey study Setting and participants The survey was distributed to the global VBHC community and yielded 518 responses. Most respondents were based in the UK and Ireland (51%) and 65% had more than 10 years of experience in the health sector. Participants represented a variety of professional backgrounds, including clinicians (34%), operational or executive managers and leaders (22%), and life sciences or procurement professionals (13%). Primary and secondary outcome measures Primary outcome measures included self-reported interest and confidence across 15 VBHC domains and the magnitude of the gap between them. Secondary outcomes included perceived implementation challenges and preferred VBHC learning approaches, including prior engagement with VBHC-related learning. Results Respondents identified substantial VBHC implementation challenges, including implementing outcome measurement (62.4%), conflicting priorities (57.7%), and resistance to change (56.8%). Interest in all VBHC domains was high (median >= 80/10), while confidence to implement remained substantially lower across most domains (median ti=50/100). The largest interest-confidence gaps were observed for reimbursement mechanisms, costing methodology, and overcoming implementation challenges. Interactive learning approaches, including in-person seminars/workshops (55.2%) and online masterclasses (53.9%) were preferred over self-directed formats. Conclusions This international survey identified consistent gaps between health professionals’ interest in VBHC and their confidence to implement key VBHC domains in practice. Addressing these gaps through advanced, targeted and contextual education may support more effective and sustainable VBHC implementation in practice.

Value-Based Procurement in healthcare: What is it, why now and how? Value-Based Procurement is no longer just an interesting idea: it is being used for healthcare procurement in many countries, including the UK. Value-Based Procurement is also a key enabler for Value-Based Healthcare. But what is it exactly, why is it important, and how is it done? Most health systems are under significant pressure from ageing populations, rising complexity of care and comorbidity, constrained budgets and shortages of staff for the current models of care delivery. Whilst costs are rising steeply, population and individual health outcomes are not rising in step: for example, in the UK, Healthy Life Expectancy is falling for the first time in generations1.

Innovating value in social care Learn here about innovating value in social care through leadership and artificial intelligence for outcome-driven transformation. Social care plays a vital role in supporting independence, safety and well-being, yet it lacks a coherent value framework comparable to those emerging in healthcare. Recent work on Value-Based Healthcare (VBHC) shows that artificial intelligence (AI) delivers system-level value only when aligned with leadership, data infrastructures and collaborative governance (Rees et al., 2025). Technology alone is insufficient; organisational and social capabilities determine whether AI moves beyond isolated pilots.

Purpose Outcome-based pricing models which consider domains of value not previously considered in healthcare, such as societal outcomes, are of increasing interest for healthcare systems. Societal outcomes can include family-reported outcome measures (FROMs), which measure the impact of disease upon the patient’s family members. The FROM-16 is a generic and easy-to-use family quality of life tool, but it has never been used in the context of patients undergoing advanced therapy medicinal product (ATMP) treatment. The use of potentially curative ATMPs is limited due their high cost and the low number of eligible patients. Using the FROM-16 to collect the impact on family of disease and treatment in ATMP patients may demonstrate additional value created by an ATMP intervention and strengthen the case for its use. Methods This feasibility study aimed to test the validity of the FROM-16 in family members of ATMP patients as a prelude for its use in ATMP value estimation. Patients and family members ( n = 24) were recruited from ATMP treatment centres in England and Wales. Family members completed the FROM-16 and were invited to a short debriefing interview. Results The FROM-16 showed high validity demonstrated by strong internal consistency (Cronbach’s alpha = 0.917) and intraclass correlation (0.803, 95%). Interviews identified that whilst the FROM-16 covered most areas of quality-of-life impact experienced by the participants, some explained that they also experienced other impacts upon their personal health and future outlook. Conclusion This feasibility study provides evidence that the FROM-16 could be used as part of a structured systematic approach to measure family quality of life impact in ATMP patients.

The UK NHS’s are all seeking sustainable, outcomes-driven care, adopting VBHC with its focus on better patients outcomes relative to cost: an approach underpinning the recent 10 year plan for England. A joint project between an International Biopharmaceutical Company and Swansea University explored effective collaboration for successful VBHC implementation. As healthcare systems around the globe deal with growing complexity, ageing populations, and escalating costs, the need for fundamental transformation has never been more urgent. In the UK, the National Health Service (NHS) faces similar pressures, prompting a renewed focus on delivering more sustainable, outcomes-driven care and has recently launched its 10 Year Health Plan for England with a vision of neighbourhood health centres, digital-first centres, and preventative care, and highlighted recently by the Health Innovation Southwest Network, CEO Jon Siddall that:

Health systems face rising demand and resource constraints, exacerbated by the SARS-CoV-2 ('COVID-19') pandemic. Value-based healthcare prioritizes achievement of outcomes that matter to patients at the lowest possible cost. The British Society for Surgery of the Hand guidance supports the performance of specific hand surgical procedures in a procedure room setting to safely increase capacity at a lower cost. In this study, this guidance was applied to all hand surgery procedures carried out over a 6-year period in a single country (Wales) to determine the volume of procedures potentially suitable for a procedure room setting (4500 cases/year). Standard costing methods were used to estimate financial and other resource savings associated with this change. Transferring suitable hand surgery procedures across Wales to a procedure room from a standard operating theatre would have reduced costs by more than £1 million/year ($1,500,000/€1,300,000) and released many hours of operating theatre time for alternative use.Level of evidence: IV.

ObjectiveTo examine if the weight of a child determines adverse events following oral antibiotics prescription.DesignPopulation respective cohort using linked general practice (GP), hospital data and linkage with the Welsh Demographic Service for demographic information. Data linkage was performed using Wales health data, extracted from the SAIL (Secure Anonymised Information Linkage) databank.InclusionChildren (0–12 years) prescribed oral antibiotics by their GP in Wales.ExposureAntibiotic prescription (penicillins, cephalosporins, macrolides, dihydropyrimidines, nitroimidazoles, nitrofurans, lincosamides).OutcomeAdverse event as defined by; patients’ death within 5 days, records of emergency admission within 5 days and GP records of adverse drug reactions or prescription of another antibiotic within 14 days.AnalysisLogistic regression of adverse events versus no adverse events at follow-up time.ResultsThere were 139 571 prescriptions of the selected antibiotics and 71 541 children (51.39% male) included with follow-up data of which there were 25 445 (18.23% of all prescriptions) children experienced adverse outcomes. There was higher odds of adverse events for lower weight children and those who were younger, female, of Asian origin or deprived.ConclusionThe findings support the hypothesis that smaller children for their age (eg, low weight, female, Asian) are more likely to experience adverse events following antibiotics prescription. This work suggests child weight, in addition to age, should be used when prescribing antibiotics to children in primary care.

To develop a sustainable, scalable methodology for the design of outcome-based agreements (OBAs) that works on the ground and dynamically overcomes historical challenges. Project IDEATE co-created solutions to known (and emergent) challenges via iterative workshops and real-world data analysis to develop and refine a hypothetical model for an OBA in a trusted research environment. A cross-disciplinary collaboration between National Health Service (NHS) Wales, industry and academia was developed. Data were collected from Welsh national datasets and used to construct a novel linked dataset. OBA scenarios, with different contract parameters, were analysed to assess impact on the proportion of contract payment due and the volatility of payments. An approved, in market, locally advanced and metastatic breast cancer treatment was selected as the test case. The total number of patients in the treatment cohort (2017–2020) was n = 99, and 286 in the control cohort (2014–2016). The final outcome variables selected were: (1) 1-year survival,( 2) intolerance to treatment (deferral), and (3) the total days disrupted by care. The primary scenario included all three outcomes measured at the population level and used a linear payment model. Volatility analyses demonstrated contract parameters can dramatically alter the contract output with greatest risk from a single, binary outcome contract design. The design of an OBA is a complex process that requires a multi-disciplinary approach. By assessing solutions to data, outcomes and contracting challenges, IDEATE provides a strong foundation for future success of OBAs in the UK. Outcome-based agreements (OBAs) are a way to pay for medicines if they help patient health in a specific way over time. These agreements can make it faster for people to get new medicines, but they also have challenges, like needing a lot of time and effort to manage them. A team from the NHS Wales, life sciences, and Swansea University created Project IDEATE to find a better way to design OBAs and solve some of these problems. Welsh datasets were used to create a new breast cancer dataset to test different OBAs and see how payments would change. A breast cancer treatment was used for the project. The project had 99 patients who got the medicine (2017–2020) and 286 patients who had breast cancer but did not get the medicine (2014–2016). Three health outcomes were measured: (1) living for one year after treatment, (2) patients needing to stop the medicine, and (3) days spent in care. The main OBA option we tested used all three health outcomes; the more the outcomes improved, the more the payments could go up until they hit the highest amount agreed. The analysis showed that the way an OBA is designed can make a big difference in how stable or risky it is, especially if one of the health outcomes has only two options. Project IDEATE showed that making an OBA can be hard, but when people from different fields work together, they can overcome many challenges and succeed.

Objective To evaluate the feasibility of recruiting participants diagnosed with atrial fibrillation (AF) taking oral anticoagulation therapies (OATs) and recently experiencing a bleed to collect health-related quality of life (HRQoL) information.Design Observational feasibility study. The study aimed to determine the feasibility of recruiting participants with minor and major bleeds, the most appropriate route for recruitment and the appropriateness of the patient-reported outcome measures (PROMs) selected for collecting HRQoL information in AF patients, and the preferred format of the surveys.Setting Primary care, secondary care and via an online patient forum.Participants The study population was adult patients (≥18) with AF taking OATs who had experienced a recent major or minor bleed within the last 4 weeks.Primary and secondary outcome measures Primary outcomes – PROMs: EuroQol 5 Dimensions-5 Levels, Perception of Anticoagulant Treatment Questionnaire, part 2 only (part 2), atrial fibrillation effect on quality of life. Secondary outcomes – Location of bleed, bleed severity, current treatment, patient perceptions of HRQoL in relation to bleeding events.Results We received initial expressions of interest from 103 participants. We subsequently recruited 32 participants to the study—14 from primary care and 18 through the AF forum. No participants were recruited through secondary care. Despite 32 participants consenting, only 26 initial surveys were completed. We received follow-up surveys from 11 participants (8 primary care and 3 AF forum). COVID-19 had a major impact on the study.Conclusions Primary care was the most successful route for recruitment. Most participants recruited to the study experienced a minor bleed. Further ways to recruit in secondary care should be explored, especially to capture more serious bleeds.Trial registration number The study is registered in the Clinicaltrials.gov database, NCT04921176.

Introduction:Healthcare systems face rising demand and unsustainable cost pressures. In response, health policymakers are adopting Value-Based Health Care (VBHC), targeting available resources to achieve the best possible patient outcomes at the lowest possible cost and actively disinvesting in care of low-value. This requires the evaluation of longitudinal clinical and patient reported outcome measures (PROMs) at an individual-level and population-scale, which can create significant data challenges. Achieving this through routinely collected electronic health record (EHR) data-linkage could facilitate the implementation of VBHC without an unacceptable data burden on patients or health systems and release time for higher-value activities.Objectives:Our study tested the ability to report an international, patient-centred outcome dataset (ICHOM-IBD) using only anonymised individual-level population-scale linked electronic health record (EHR) data sources, including clinical and patient-reported outcomes, in a cohort of patients with moderate-to-severe ulcerative colitis (UC), receiving biopharmaceutical therapies ("biologics") in a single, publicly funded, healthcare system.Results:We identified a cohort of 17,632 patients with UC in Wales and a cohort from two Health Boards of 447 patients with UC receiving biologics. 112 of these patients had completed 866 condition-specific PROMs during their biologics treatment. 44 out of 59 (74.6%) items in the ICHOM-IBD could be derived from routinely collected data of which a primary care source was essential for eight items and desirable for 21.Conclusions:We demonstrated that it is possible to report most but not all the ICHOM-IBD outcomes using routinely collected data from multiple sources without additional system burden, potentially supporting Value-Based Health Care implementation with population data science. As digital collection of PROMs and use of condition-specific registries grow, greater utility of this approach can be anticipated. We have identified that the availability of longitudinal primary and secondary care data linked with PROMs is essential for this to be possible.

Abstract BackgroundAdvance Therapeutic Medicinal Products (ATMPs) are a novel class of therapeutics to provide more effective treatment of conditions or diseases that have not responded to conventional treatment. However, ATMPs are generally very expensive, limiting their availability. Indicated conditions are usually chronic and severe and can have an impact beyond the patient themselves, impairing the lives of partners and other family members. This family impact is a major secondary burden of disease that is often ignored. The Family Reported Outcome Measure (FROM-16) is the first generic questionnaire designed to measure the impact of any chronic disease on the quality of life of family members or partners of patients. It is simple-to-use and non-burdensome for those completing it.We aim to validate the FROM-16 instrument in the setting of patients receiving ATMPs by recruiting family members to complete FROM-16 and Global Health Score questionnaire and undergo a semi-structured interview.MethodsUp to 30 patients of any age who are preparing for, or who have received, ATMP treatment and their family members aged 18 years or older, attending NHS providers within the Midland-Wales Advanced Therapy Treatment Centre will be recruited into this study. Family members will be asked to complete the FROM-16 and Global Health Score questionnaires, provide basic demographic information and complete a short semi-structured interview. The interview will provide data to contextualise the FROM-16 responses and allow construct and content validity to be assessed. Themes of experience will be identified from interview transcripts. The FROM-16 responses will be evaluated for total score, domain score, and individual item score. Reliability of responses between and within domains will be assessed by intraclass correlation. DiscussionCollecting FROM data reliably is important for demonstrating the wider impact of disease and the extended value of treatments. We hypothesise that collecting FROMs using the FROM-16 tool is a valid method to measure this impact in the setting of patients receiving ATMPs and if so, could provide evidence in future of the overall quality of life impact on the partners and family members of such patients and greater understanding of the wider societal value of these costly treatments. Trial RegistrationThis trial has been adopted onto the NIHR portfolio (I.D. 51376) and registered with www.ClinicalTrials.gov (#NCT05141318) in December 2021.

Background Oral anticoagulation therapies (OATs) are often prescribed in conjunction with medications to restore normal heart rate rhythm which can limit the risk of an atrial fibrillation (AF) related stroke and systemic thromboembolism. However, they are associated with the serious side effect of bleeding. Both clinically relevant nonmajor bleeding (CRNMB) and major bleeding while anticoagulated are believed to have a significant impact on patient quality of life (QoL). There is currently limited research into the effect bleeding has on QoL. The aim of this study is to evaluate the feasibility of identifying and recruiting patients diagnosed with AF, who are taking OATs and have recently experienced a bleed and collecting information on their QoL. Methods We will recruit a minimum of 50 patients to this cross-sectional, observational study. We will recruit from general practices, secondary care, and through an online AF forum. We will ask participants to complete three validated patient-reported outcome measures (PROMs), EQ5D, AFEQT, and PACT-Q, approximately 4 weeks following a bleed and again 3 months later. We will randomly select a subset of 10 participants (of those who agree to be interviewed) to undergo a structured interview with a member of the research team to explore the impact of bleeding on their QoL and to gain feedback on the three PROMs used. We will undertake a descriptive analysis of the PROMs and demographic data. We will analyse the qualitative interviews thematically to identify key themes. Discussion We aim to establish if it is possible to recruit patients and use PROMs to collect information regarding how patient QoL is affected when they experience either a clinically relevant non-major bleed (CRNMB) or major bleed while taking OATs for the management of AF. We will also explore the appropriateness, or otherwise, of the three identified PROMs for assessing quality of life following a bleed. PROMs Three PROMs were selected following a literature review of similar QoL studies and using the COnsensus-based Standards for the selection of health Measurement INstruments (COSMIN) checklist for comparison. A review of the current literature produced no suitable validated PROM to record QoL experiences in patients who have been diagnosed with AF and have experienced a bleed while anticoagulated. As such, the EQ5D, AFEQT, and PACT-Q (part 2) were deemed most appropriate for use in this feasibility study. Trial registration The trial has been adopted onto the NIHR Portfolio (ID no. 47771) and registered with www.ClinicalTrials.gov (no. NCT04921176) retrospectively registered in June 2021.

Purpose The UK Government-funded National Health Service (NHS) is experiencing significant pressures because of the complexity of challenges to, and demands of, health-care provision. This situation has driven government policy level support for transformational change initiatives, such as value-based health care (VBHC), through closer alignment and collaboration across the health-care system-life science sector nexus. The purpose of this paper is to evaluate the necessary antecedents to collaboration in VBHC through a critical exploration of the existing literature, with a view to establishing the foundations for further development of policy, practice and theory in this field. Design/methodology/approach A literature review was conducted via searches on Scopus and Google Scholar between 2009 and 2019 for peer-reviewed articles containing keywords and phrases “Value-based healthcare industry” and “healthcare industry collaboration”. Refinement of the results led to the identification of “guiding conditions” (GCs) for collaboration in VBHC. Findings Five literature-derived GCs were identified as necessary for the successful implementation of initiatives such as VBHC through system-sector collaboration. These are: a multi-disciplinarity; use of appropriate technological infrastructure; capturing meaningful metrics; understanding the total cycle-of-care; and financial flexibility. This paper outlines research opportunities to empirically test the relevance of the five GCs with regard to improving system-sector collaboration on VBHC. Originality/value This paper has developed a practical and constructive framework that has the potential to inform both policy and further theoretical development on collaboration in VBHC.

Background Atrial fibrillation (AF) is the most common cardiac arrhythmia. Oral anticoagulation therapies (OATs) are often prescribed in conjunction with medications to restore normal heart rate rhythm which can limit the risk of an AF-related stroke and systemic thromboembolism. However, they are associated with the serious side effect of bleeding. Both clinically relevant non-major bleeding (CRNMB) and major bleeding while anticoagulated are believed to have a significant impact on patient quality of life (QoL). There is currently limited research into the effect bleeding has on QoL. The aim of this study is to evaluate the feasibility of identifying and recruiting patients diagnosed with AF, who are taking OATs and have recently experienced a bleed and collecting information on their QoL. Methods We will recruit a minimum of 50 patients to this cross sectional, observational study. We will recruit from general practices, secondary care and through an online AF forum. We will ask participants to complete three validated patient-reported outcome measures (PROMs: EQ5D, AFEQT and PACT-Q), approximately four weeks following a bleed and again 3 months later. We will randomly select a subset of 10 participants (of those who agree to be interviewed) to undergo a structured interview with a member of the research team to explore the impact of bleeding on their QoL and to gain feedback on the three PROMs used. We will undertake a descriptive analysis of the PROMs and demographic data. We will analyse the qualitative interviews thematically to identify key themes. Discussion We aim to establish if it is possible to recruit patients and use PROMs to collect information regarding how patient QoL is affected when they experience either a CRNMB or major bleed, while taking OATs for the management of AF. We will also explore the appropriateness or otherwise of the three identified PROMs for assessing quality of life following a bleed. Trial registration The trial has been adopted onto the NIHR Portfolio (I.D. #47771) and registered with www.ClinicalTrials.gov (#NCT04921176) retrospectively registered in June 2021.

Objectives The aim was to outline the challenges of implementing outcomes-based contracts (OBCs) in Europe. Methods A scoping review was conducted, building on the searches of a previous systematic review and updating them for December 2017 until May 2021. The combined results were screened, based on inclusion and exclusion criteria. All identified studies published in the English language that described specific OBC schemes for medicines in European countries were included. Insights into the challenges of OBCs were extracted and analysed to develop a conceptual framework. Results Ten articles from the previous systematic review matched our inclusion criteria, along with 14 articles from electronic searches. Analysis of these 24 articles and classification of the challenges revealed that there are multiple barriers that must be overcome if OBCs that benefit all stakeholders are going to be adopted widely across Europe. These challenges were grouped according to five key themes: negotiation framework; outcomes; data; administration and implementation; and laws and regulation. Conclusions If the promise of OBCs is to be fully realised in Europe, there remain major challenges that need to be overcome by all stakeholders working in partnership. The overlapping and interconnected nature of these challenges highlights the complexity of OBC arrangements.

Background: Achilles tendinopathy is a common pathology that is considered difficult to treat. At a time of austerity in the NHS it is essential to have carefully designed pathways that are monitored in terms of cost and effectiveness. However, a paucity of evidence exists for what the "best value" dedicated "joined up" pathway of care is for this difficult condition. Objectives: Design, implement and evaluate the impact of a new therapist lead pathway for Tendon- Achilles Pain (TAP). Methods: Process mapping, driver diagrams, stakeholder analysis and a series of Plan-Do-Study-Act cycles were used to design and implement TAP. To assess the impact of TAP, data was compared on whole system measures for 46 patients treated with referral to the traditional service (without TAP) and 46 patients managed according to the newly designed pathway (with TAP). A cost analysis was also conducted. Results: A quality improvement approach led to the successful design and implementation of a therapist lead TAP. The impact of TAP included positive effects on patient satisfaction, a decrease in duplication of treatments, investigations and inappropriate reviews with consultants. No safety concerns were found. TAP was also 44,000 pound cheaper per annum than the previous service. Conclusion: Collaboration between orthopaedic and therapy services has resulted in a standardised pathway of care for patients with an Achilles tendinopathy. It has removed unwanted variation, provided an opportunity to monitor the outcomes of treatments and resulted in decreased cost for the health board.

Purpose. We report a technique of finite-element multidimensional modeling that was used to help with the planning of and the resection of an angiosarcoma in a single patient.Description. A patient was referred to our department with suspected aortic angiosarcoma. We visualized and reconstructed the computed tomography and magnetic resonance imaging scans of this patient to create finite-element multidimensional models of his diseased aorta.Evaluation. This technique and the multidimensional models were very helpful in assessing the tumor size and its extension. It also facilitated preoperative planning of the aortic resection and repair.Conclusion. Finite-element multidimensional modeling is a useful technique for preoperative planning of aortic operations in patients with angiosarcoma. (C) 2016 by The Society of Thoracic Surgeons

We present a case of successful artery only total nose replantation in an 18-month-old child, with 10 years of follow-up and full sensory recovery despite no nerve repair. The common absence of veins for anastomosis does not prevent successful replant, as demonstrated with the use of Hirudo medicinalis use in this unique case. We comprehensively review the literature of this rare and complex injury and advocate microsurgical replantation where possible over other methods of nasal reconstruction.

IntroductionSignificant controversy surrounds the effectiveness of negative pressure wound therapy although it has been in use for decades. Although many clinicians favor this modality in relation to its practicality, ease of use especially in complex wounds, it has faced the same challenges as other dressings in relation to evidence base of efficacy in relation to a number of outcome measures. In view of the current financial pressures on health care systems worldwide, this structured review systematically challenges the evidence for perioperative application of topical negative pressure (TNP) to split-thickness skin grafts (STSGs) through evidence-based critical appraisal, and extrapolate the mechanisms of action on the mechanisms through which TNP may aid wound healing. Weighted evidence-based recommendations regarding the impact of TNP on split skin graft quality and quantity of take as outcomes. MethodsPhase 1: Structured literature search. Phase 2: Retrieved articles were critically appraised for rigor and methodological validity by 3 independent authors, then stratified according to a validated “levels of evidence” framework. Graded “current best evidence” recommendations could therefore be proposed. ResultsOf the 220 studies retrieved in the initial search, 38 studies satisfied our quality of evidence criteria. Current best evidence supports 2 complementary trends explaining the mechanisms whereby STSG benefits from TNP. Active stimulation of epithelial mitosis: TNP creates mechanical stretch which stimulates multiple signaling pathways up-regulating growth- and mitosis-associated epithelial transcription factors. Topical negative pressure also promotes microcirculatory flow (graft and wound edge), stimulates angiogenesis and basement membrane integrity (grade C). Prevention of complications: significant reduction of graft lift-off by edema, exudates, subgraft hematoma, and reduction of shear when compared to traditional dressings (grade B). Topical negative pressure promotes significant qualitative improvement in the final STSG result studies (level 1B). The role of TNP in prevention of infection is, however, equivocal and further research is required. No evidence of harm from TNP application was reported. ConclusionsTopical negative pressure increases quantity and quality of split skin graft take compared to traditional bolster dressings. The advantages are increased in irregularly contoured, technically difficult wounds and suboptimal recipient wound beds where it seems to be the best modality currently available. Large-scale randomized clinical controlled trials remain scanty in all areas of wound dressing research including negative pressure therapy.