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Abstract
The literature suggests that leg ulcer clinics are more expensive than home visits, but are associated with faster healing times. Providing district nurses with better postgraduate education on wound care may make better use of this resource.
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Affiliation(s)
- L R Patton
- South Eastern Health and Social Care Trust, Northern Ireland, UK.
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53
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Keleher H, Parker R, Abdulwadud O, Francis K. Systematic review of the effectiveness of primary care nursing. Int J Nurs Pract 2009; 15:16-24. [PMID: 19187165 DOI: 10.1111/j.1440-172x.2008.01726.x] [Citation(s) in RCA: 89] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
This paper reports on a systematic review that sought to answer the research question: What is the impact of the primary and community care nurse on patient health outcomes compared with usual doctor-led care in primary care settings? A range of pertinent text-words with medical subject headings were combined and electronic databases were searched. Because of the volume of published articles, the search was restricted to studies with high-level evidence. Overall, 31 relevant studies were identified and included in the review. We found modest international evidence that nurses in primary care settings can provide effective care and achieve positive health outcomes for patients similar to that provided by doctors. Nurses are effective in care management and achieve good patient compliance. Nurses are also effective in a more diverse range of roles including chronic disease management, illness prevention and health promotion. Nevertheless, there is insufficient evidence about primary care nurses' roles and impact on patient health outcomes.
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Affiliation(s)
- Helen Keleher
- Department of Health Science, Monash University Peninsula Campus, Frankston, Victoria, Australia.
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54
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Guest J, Nagy E, Sladkevicius E, Vowden P, Price P. Modelling the relative cost-effectiveness of amelogenin in non-healing venous leg ulcers. J Wound Care 2009; 18:216, 218-24. [DOI: 10.12968/jowc.2009.18.5.42176] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- J.F. Guest
- Catalyst Health Economics Consultants, Northwood, UK
- Postgraduate Medical School, Surrey University, Guildford, UK
| | - E. Nagy
- Catalyst Health Economics Consultants, Northwood, UK
| | | | - P. Vowden
- Vascular Unit, Bradford Royal Infirmary, Bradford, UK
| | - P. Price
- Department of Wound Healing, School of Medicine, Cardiff University, Cardiff, UK
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55
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Abstract
BACKGROUND Around one percent of people in industrialised countries will suffer from a leg ulcer at some time. The majority of these leg ulcers are due to problems in the veins, resulting in an accumulation of blood in the legs. Leg ulcers arising from venous problems are called venous (varicose or stasis) ulcers. The main treatment has been a firm compression garment (bandage or stocking) in order to aid venous return. There is a large number of compression garments available and it is unclear whether they are effective in treating venous ulcers and which compression garment is the most effective. OBJECTIVES To undertake a systematic review of all randomised controlled trials of the clinical effectiveness of compression bandage or stocking systems in the treatment of venous leg ulceration.Specific questions addressed by the review are:1. Does the application of compression bandages or stockings aid venous ulcer healing? 2. Which compression bandage or stocking system is the most effective? SEARCH STRATEGY For this update we searched the Cochrane Wounds Group Specialised Register (14/10/08); The Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library Issue 4 2008); Ovid MEDLINE (1950 to October Week 1 2008); Ovid EMBASE (1980 to 2008 Week 41) and Ovid CINAHL (1982 to October Week 1 2008). No date or language restrictions were applied. SELECTION CRITERIA Randomised controlled trials recruiting people with venous leg ulceration that evaluated any type of compression bandage system or compression hosiery were eligible for inclusion. Comparators included no compression (e.g. primary dressing alone, non-compressive bandage) or an alternative type of compression. Trials had to report an objective measure of ulcer healing in order to be included (primary outcome for the review). Secondary outcomes of the review included ulcer recurrence, costs, quality of life, pain, adverse events and withdrawals. There was no restriction on date, language or publication status of trials. DATA COLLECTION AND ANALYSIS Details of eligible studies were extracted and summarised using a data extraction table. Data extraction was performed by one review author and verified independently by a second review author. MAIN RESULTS Overall, 39 RCTs reporting 47 comparisons were included.Review question 1: there was reasonable evidence from seven RCTs that venous ulcers heal more rapidly with compression than without.Review question 2: findings from six trials of single-component compression suggested that this strategy was less effective than multi-component compression. Evidence from compression systems with two components (3 trials) and three components (4 trials) suggested better outcomes when an elastic component was included. Different versions of compression with four-components (based on the Charing Cross four-layer bandage system) have similar effectiveness (3 trials). Compression with four components (variants of the Charing Cross four-layer bandage) is more effective than multi-component compression that includes a short-stretch bandage (6 trials). It is difficult to determine the relative effectiveness of the four-layer bandage compared with paste bandage systems because of differences in the paste systems (5 trials). There was no difference in effectiveness between the adjustable compression boot and compression bandages (2 trials) or between single-layer compression stockings and paste bandages (2 trials). Two-layer stockings appeared more effective than the short-stretch bandage (2 trials). The relative effectiveness of tubular compression when compared with compression bandages was not clear from current evidence (2 trials).Three trials reported ulcer recurrence; because of sparseness of data and trials not being primarily designed to assess this outcome, firm conclusions could not be drawn. Although several trials included cost data, only one reported a rigorously conducted cost-effectiveness analysis with findings suggesting that the four-layer bandage was more cost-effective than multi-component compression comprising a short-stretch bandage. Seven trials assessed health-related quality of life and none observed significant differences between treatment groups. Several trials evaluated pain either as a stand-alone outcome, or as part of the assessment of adverse events. In general, the data did not indicate clear differences between treatment groups. It is possible that stockings could be associated with less pain than bandages but in view of scarcity of available data this requires further evaluation. Many of the trials reported adverse events and / or withdrawals. Overall, these outcomes appeared similar across different treatment groups. AUTHORS' CONCLUSIONS Compression increases ulcer healing rates compared with no compression. Multi-component systems are more effective than single-component systems. Multi-component systems containing an elastic bandage appear more effective than those composed mainly of inelastic constituents.
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Affiliation(s)
- Susan O'Meara
- Department of Health Sciences, University of York, Area 3 Seebohm Rowntree Building, Heslington, York, UK, YO10 5DD.
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56
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Prevalencia de la heridas crónicas en una comarca de la provincia de Barcelona. ENFERMERIA CLINICA 2009; 19:4-10. [DOI: 10.1016/j.enfcli.2008.10.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2008] [Accepted: 10/21/2008] [Indexed: 11/24/2022]
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Harrison MB, Graham ID, Lorimer K, VandenKerkhof E, Buchanan M, Wells PS, Brandys T, Pierscianowski T. Nurse clinic versus home delivery of evidence-based community leg ulcer care: a randomized health services trial. BMC Health Serv Res 2008; 8:243. [PMID: 19036149 PMCID: PMC2630316 DOI: 10.1186/1472-6963-8-243] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2008] [Accepted: 11/26/2008] [Indexed: 12/03/2022] Open
Abstract
BACKGROUND International studies report that nurse clinics improve healing rates for the leg ulcer population. However, these studies did not necessarily deliver similar standards of care based on evidence in the treatment venues (home and clinic). A rigorous evaluation of home versus clinic care is required to determine healing rates with equivalent care and establish the acceptability of clinic-delivered care. METHODS Health Services RCT was conducted where mobile individuals were allocated to either home or nurse clinic for leg ulcer management. In both arms, care was delivered by specially trained nurses, following an evidence protocol. PRIMARY OUTCOME 3-month healing rates. SECONDARY OUTCOMES durability of healing (recurrence), time free of ulcers, HRQL, satisfaction, resource use. Data were collected at base-line, every 3 months until healing occurred, with 1 year follow-up. Analysis was by intention to treat. RESULTS 126 participants, 65 randomized to receive care in their homes, 61 to nurse-run clinics. No differences found between groups at baseline on socio-demographic, HRQL or clinical characteristics. mean age 69 years, 68% females, 84% English-speaking, half with previous episode of ulceration, 60% ulcers at inclusion < 5 cm2 for < 6 months. No differences in 3-month healing rates: clinic 58.3% compared to home care at 56.7% (p = 0.5) or in secondary outcomes. CONCLUSION Our findings indicate that organization of care not the setting where care is delivered influences healing rates. Key factors are a system that supports delivery of evidence-based recommendations with care being provided by a trained nursing team resulting in equivalent healing rates, HRQL whether care is delivered in the home or in a community nurse-led clinic. TRIAL REGISTRATION ClinicalTrials.gov Protocol Registration System: NCT00656383.
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Affiliation(s)
- Margaret B Harrison
- School of Nursing, Queen's University, 78 Barrie Street, Kingston, Ontario, Canada, K7L 3N6
| | - Ian D Graham
- School of Nursing, University of Ottawa, 550 Cumberland Street, Ottawa, Ontario, Canada, K1N 6N5
- Ottawa Health Research Institute, Clinical Epidemiology Institute, 1053 Carling Avenue, Ottawa, Ontario, Canada, K1Y 4E9
| | - Karen Lorimer
- Carefor Health and Community Services, 1200 St. Laurent Blvd., Ottawa, Ontario, Canada, K1K 3B8
| | | | - Maureen Buchanan
- School of Nursing, Queen's University, 78 Barrie Street, Kingston, Ontario, Canada, K7L 3N6
| | - Phil S Wells
- University of Ottawa, The Ottawa Hospital Dept. of Medicine, 1053 Carling Avenue, Ottawa, Ontario, Canada, K1Y 4E9
- Ottawa Health Research Institute, 725 Parkdale Ave., Ottawa, Canada, K1Y 4E9
| | - Tim Brandys
- Dept. of Surgery, 550 Cumberland St, Ottawa, Ontario, Canada, K1N 6N5
- University of Ottawa, 550 Cumberland Street, Ottawa, Ontario, Canada, K1N 6N5
| | - Tadeusz Pierscianowski
- Dept of Medicine, University of Ottawa, 550 Cumberland Street, Ottawa, Ontario, Canada, K1N 6N5
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58
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Howard DPJ, Howard A, Kothari A, Wales L, Guest M, Davies AH. The role of superficial venous surgery in the management of venous ulcers: a systematic review. Eur J Vasc Endovasc Surg 2008; 36:458-65. [PMID: 18675558 DOI: 10.1016/j.ejvs.2008.06.013] [Citation(s) in RCA: 64] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2008] [Accepted: 06/11/2008] [Indexed: 11/18/2022]
Abstract
BACKGROUND The complicated natural history of venous ulcers requires the continued development and improvement of treatments to ensure the most effective management. Compression therapy or surgical correction of superficial venous incompetence (SVI) are currently the main methods employed for the treatment for venous ulceration (VU). This review compares and summates the healing and recurrence rates for each treatment modality used over the last thirty years. METHODS Sixty-one articles investigating compression and superficial venous surgical treatments were obtained from a systematic search of electronic databases (Medline, Embase, The Cochrane Library, and Google Scholar) and then an expanded reference list review. Patient demographics, CEAP classification, patterns of venous insufficiency, type of intervention, length of follow up, healing and recurrence rates for venous ulceration was assessed. Inadequate data in seven reports led to their exclusion. Recent randomised controlled trials (RCTs) specifically comparing superficial surgery to compression therapy were reviewed and data from non-randomised and/or 'small' clinical studies prior to 2000 underwent summation analysis. RESULTS Five RCTs since 2000 demonstrate a similar healing rate of VU with surgery and conservative compression treatments, but a reduction in ulcer recurrence rate with surgery. The effect of deep venous incompetence (DVI) on the ulcer healing is unclear, but sub-group analysis of long-term data from the ESCHAR trial suggests that although surgery results in a less impressive reduction in ulcer recurrence in patients with DVI, these patients appear to still benefit from surgery due to the haemodynamic and clinical benefits that result. The RCTs also highlight that a significant proportion of VU patients are unsuitable for surgical treatment. Summation of data from earlier studies (before 2000), included twenty-one studies employing conservative compression alone resulted in an overall healing rate of 65% (range 34-95%) and ulcer recurrence of 33% (range 0-100%). In thirty-one studies investigating superficial venous surgery, the overall rate of ulcer healing was 81% (range 40-100%) with a post-operative recurrence rate of 15% (range 0-55%). The duration of follow up care in the surgical studies was approximately twice as long as in the conservative studies, which would lend to more reliable recurrence data. CONCLUSIONS Evidence from the current literature, would suggest that superficial venous surgery is associated with similar rates of ulcer healing to compression alone, but with less recurrence. The effects of post-operative compression and DVI on the efficacy of surgery are still unclear.
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Affiliation(s)
- D P J Howard
- Oxford Radcliffe Hospitals Trust, United Kingdom.
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59
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Rogers LC, Bevilacqua NJ, Armstrong DG. The use of marrow-derived stem cells to accelerate healing in chronic wounds. Int Wound J 2008. [PMID: 18179555 DOI: 10.1111/j.1742-481x.2007.00349] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Adult bone marrow-derived stem cells may aid the healing of chronic lower extremity wounds by transplanting a population of progenitor cells locally into the wound. We present results from three cases in which bone marrow aspirate containing marrow-derived cells was applied/injected locally into complex lower extremity chronic wounds of differing aetiologies. Our case series suggest that bone marrow aspirate, applied topically and injected into the wound periphery, may be a useful and potentially safe adjunct to wound simplification and ultimate closure.
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Affiliation(s)
- Lee C Rogers
- Amputation Prevention Center, Broadlawns Medical Center, Des Moines, IA, USA
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60
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Rogers LC, Bevilacqua NJ, Armstrong DG. The use of marrow-derived stem cells to accelerate healing in chronic wounds. Int Wound J 2008; 5:20-5. [PMID: 18179555 DOI: 10.1111/j.1742-481x.2007.00349.x] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
Adult bone marrow-derived stem cells may aid the healing of chronic lower extremity wounds by transplanting a population of progenitor cells locally into the wound. We present results from three cases in which bone marrow aspirate containing marrow-derived cells was applied/injected locally into complex lower extremity chronic wounds of differing aetiologies. Our case series suggest that bone marrow aspirate, applied topically and injected into the wound periphery, may be a useful and potentially safe adjunct to wound simplification and ultimate closure.
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Affiliation(s)
- Lee C Rogers
- Amputation Prevention Center, Broadlawns Medical Center, Des Moines, IA, USA
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62
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Abstract
Venous ulcers, sometimes termed varicose or stasis ulcers, are a consequence of damage to the valves in the veins of the legs, leading to raised venous pressure. They are characterized by a cyclical pattern of healing and recurrence. There is a need to have a thorough assessment of patients with leg ulcers by an appropriately experienced clinician to maximize the chance of healing the ulcer. The main treatment is the application of compression, either in the form of compression bandages or hosiery. Dressings are applied beneath the compression with a view to controlling exudate, comfort and to aid healing. There are a large number of dressing products and types available but the evidence to justify their use is poor. The main treatment for venous ulcers should therefore be the application of compression therapy with a simple, low adherent dressing.
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Affiliation(s)
- Simon Palfreyman
- Sheffield Vascular Institute, University of Sheffield, Sheffield
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63
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Gohel MS, Barwell JR, Taylor M, Chant T, Foy C, Earnshaw JJ, Heather BP, Mitchell DC, Whyman MR, Poskitt KR. Long term results of compression therapy alone versus compression plus surgery in chronic venous ulceration (ESCHAR): randomised controlled trial. BMJ 2007; 335:83. [PMID: 17545185 PMCID: PMC1914523 DOI: 10.1136/bmj.39216.542442.be] [Citation(s) in RCA: 240] [Impact Index Per Article: 14.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
OBJECTIVE To determine whether recurrence of leg ulcers may be prevented by surgical correction of superficial venous reflux in addition to compression. DESIGN Randomised controlled trial. SETTING Specialist nurse led leg ulcer clinics in three UK vascular centres. PARTICIPANTS 500 patients (500 legs) with open or recently healed leg ulcers and superficial venous reflux. INTERVENTIONS Compression alone or compression plus saphenous surgery. MAIN OUTCOME MEASURES Primary outcomes were ulcer healing and ulcer recurrence. The secondary outcome was ulcer free time. RESULTS Ulcer healing rates at three years were 89% for the compression group and 93% for the compression plus surgery group (P=0.73, log rank test). Rates of ulcer recurrence at four years were 56% for the compression group and 31% for the compression plus surgery group (P<0.01). For patients with isolated superficial reflux, recurrence rates at four years were 51% for the compression group and 27% for the compress plus surgery group (P<0.01). For patients who had superficial with segmental deep reflux, recurrence rates at three years were 52% for the compression group and 24% for the compression plus surgery group (P=0.04). For patients with superficial and total deep reflux, recurrence rates at three years were 46% for the compression group and 32% for the compression plus surgery group (P=0.33). Patients in the compression plus surgery group experienced a greater proportion of ulcer free time after three years compared with patients in the compression group (78% v 71%; P=0.007, Mann-Whitney U test). CONCLUSION Surgical correction of superficial venous reflux in addition to compression bandaging does not improve ulcer healing but reduces the recurrence of ulcers at four years and results in a greater proportion of ulcer free time. TRIAL REGISTRATION Current Controlled Trials ISRCTN07549334 [controlled-trials.com].
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Affiliation(s)
- Manjit S Gohel
- Cheltenham General Hospital, Cheltenham, Gloucester GL53 7AN
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64
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Palfreyman SJ, Tod AM, King B, Tomlinson D, Brazier JE, Michaels JA. Impact of intravenous drug use on quality of life for patients with venous ulcers. J Adv Nurs 2007; 58:458-67. [PMID: 17484747 DOI: 10.1111/j.1365-2648.2007.04251.x] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
AIM This paper is a report of a study to examine, from the perspective of patients, the impact of venous leg ulcers on health-related quality of life in current and former intravenous drug users and the general population. BACKGROUND Venous ulceration can be caused by intravenous drug use. There has been little examination on how this affects the quality of life of this group of patients and how they compare with other patients who have venous ulcers. METHOD A qualitative approach was adopted, using framework analysis. Semi-structured interviews with 19 participants who had a venous leg ulcer were conducted between August 2005 and February 2006. Interview audiotapes were analysed to identify recurring themes relating to the impact of venous leg ulcers on overall quality of life. FINDINGS A complex interaction between symptoms, social restriction and attribution of illness influenced the impact of venous leg ulcers. Smell and pain were the symptoms that had the most profound impacts. In addition to the physical and psychological consequences, participants' activities and social interactions were restricted. Intravenous drug users experienced more social isolation and difficulties in accessing treatment for their venous ulcers. CONCLUSION While leg ulcer services remain focused on the needs of older people, services for young intravenous drug users are unlikely to improve. A more coherent and earlier intervention, when the ulcers are not as difficult to treat, would decrease time and costs to the health service. The challenge is to find new ways of providing effective and accessible care to this growing population.
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Affiliation(s)
- Simon J Palfreyman
- Academic Vascular Unit, Coleridge House, Northern General Hospital, Sheffield, UK.
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65
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Abstract
Multidisciplinary wound care centers have proliferated as a result of an increasing need for care of nonhealing wounds. Information regarding types of wounds treated, length of treatment, compliance with treatment, and rates of healing was collected from a tertiary care hospital-based wound center over a 7-year period. Venous stasis ulcers were the most common type of wound treated (21%) and were also the most likely to heal. Pressure ulcers (20%), diabetic neuropathic ulcers (14%), ischemic ulcers (6%), and postsurgical wounds (6%) comprised the remainder of wounds treated. The success of treating wounds varied greatly with the wound's etiology. Despite the chronic nature of these wounds, most patients did not become long-term patients of the wound center. This study provides baseline outcome measures, which can serve as the basis for the comparison of treatment protocols and the development of prospective clinical trials.
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Affiliation(s)
- Alina D Sholar
- Department of Plastic Surgery, University of Tennessee College of Medicine-Chattanooga, Chattanooga, Tennessee 37403, USA
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66
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Franks PJ, Moody M, Moffatt CJ, Hiskett G, Gatto P, Davies C, Furlong WT, Barrow E, Thomas H. Randomized trial of two foam dressings in the management of chronic venous ulceration. Wound Repair Regen 2007; 15:197-202. [PMID: 17352751 DOI: 10.1111/j.1524-475x.2007.00205.x] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
A multicenter prospective randomized clinical trial was undertaken to compare two foam dressings (Allevyn Hydrocellular, Smith & Nephew and Mepilex, Molnlycke Health Care AB) in the management of chronic venous leg ulceration. Patients were also randomized to two compression bandage systems (4-layer vs. cohesive short stretch) as a factorial design. Those with causes of ulceration other than venous disease were excluded. In all, 156 patients met the entry criteria and were randomized from the 12 clinical centers with a median (range) ulcer size of 4.33 (0.33-123.10) cm(2). After 24 weeks a total of 100 (64.1%) patients had complete ulcer closure, 46 (29.5%) had withdrawn from the trial, nine (5.8%) remained unhealed and one patient died. Of the patients randomized to Mepilex, 50/75 (66.7%) had complete ulcer healing compared with 50/81 (61.7%) on Allevyn. The hazard ratio for healing after adjustment for bandage type and trial center was 1.48 (95% C.I. 0.87-2.54, p=0.15), which only marginally changed following adjustment for baseline variables, neither of which achieved statistical significance (p=0.16). Withdrawal rates were similar between groups (23, 30.7% Mepilex vs. 23, 28.4% Allevyn). Pain improved following treatment with both dressings (p<0.001), but with no difference between dressings.
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Affiliation(s)
- Peter J Franks
- Centre for Research & Implementation of Clinical Practice, Faculty of Health & Human Sciences, Thames Valley University, London, United Kingdom.
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67
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Gordon L, Edwards H, Courtney M, Finlayson K, Shuter P, Lindsay E. A cost-effectiveness analysis of two community models of care for patients with venous leg ulcers. J Wound Care 2006; 15:348-53. [PMID: 17001943 DOI: 10.12968/jowc.2006.15.8.26942] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
AIM To conduct a cost-effectiveness analysis based on data from a randomised controlled trial comparing traditional community home nursing with a community Leg Club model for chronic venous leg ulcer management in the south-east metropolitan area of Queensland, Australia. METHOD Participants were randomised to the Leg Club (n=28) or home visits (n=28). Data were obtained on resources/related costs incurred by the service provider, clients and carers, and the community. RESULTS From the collective perspective (service provider, clients and carers, and the community), at six months the incremental cost per healed ulcer was dollars AU515 (Euros 318) and the incremental cost per reduced pain score was dollars AU322 (Euros 199). For the service provider, Leg Club intervention resulted in cost savings and better health effects when compared with home nursing. CONCLUSION On both clinical and economic grounds, the Leg Club model appears to be more cost-effective than traditional home nursing for the treatment of chronic venous leg ulcers. However, clients and the local community contribute substantial financial and in-kind support to the operation of both services.
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Affiliation(s)
- L Gordon
- Institute of Health and Biomedical Innnovation School of Nursing, Queensland University of Technology, Brisbane, Australia.
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68
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Abstract
It is not uncommon to find that patients with venous leg ulcers have a reduced quality of life, but to prevent inappropriate management and thus contribute to the chronicity of these wounds, clinical practice must be based on sound evidence and application of research. The choice of compression options is fairly wide, but occasionally problems are encountered with tailoring a particular product to a patient. In this case study, a number of challenges were presented to the nursing team in implementing evidence-based practice and accommodating patient choice, but these were overcome and the patient's quality of life has significantly improved.
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Affiliation(s)
- Jenny Bentley
- Florence Nightingale School of Nursing and Midwifery, King's College London, UK
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69
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Rogalski C, Simon J, Paasch U. Gesundheitsökonomische Studien in der Dermatologie. Hautarzt 2006; 57:297-302. [PMID: 15971088 DOI: 10.1007/s00105-005-0982-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Because of reduced resources for health care, provision of modern effective dermatologic care for patients with German public health insurances has become more and more difficult. This survey is designed to aid in the assessment of published health economic studies as well as encourage participation in health economic evaluations. These studies should analyze and optimize the allocation of the available resources. Four main approaches can be used to calculate the incidental expenses; they differ in their methods of evaluation and assessment of health services. They all offer methods to calculate the anticipated costs and consequences. The methods include cost minimization analysis (CMA), cost effectiveness analysis (CEA), cost utility analysis (CUA) or cost benefit analysis (CBA). Many subgroups also exist. Important criteria for the evaluation of health economic trials and hints for the publication of the results are provided on the basis of the recommendations for health economic evaluations.
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Affiliation(s)
- C Rogalski
- Klinik für Dermatologie, Venerologie und Allergologie, Universitätsklinikum Leipzig.
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70
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Abstract
This review article examines the available evidence on both the primary and secondary prevention of venous ulceration, exploring both the individual, social and financial implications of system failures that allow patients to remain at increased risk of recurrent ulceration. The role of both venous disease assessment and corrective superficial venous surgery are discussed in the light of recently published randomised controlled studies on the role of superficial venous surgery as both an adjunct to ulcer healing and ulcer prevention.
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Affiliation(s)
- Kathryn R Vowden
- Bradford Teaching Hospitals NHS Foundation Trust & University of Bradford, Bradford, UK.
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71
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Satpathy A, Hayes S, Dodds SR. Measuring sub-bandage pressure: comparing the use of pressure monitors and pulse oximeters. J Wound Care 2006; 15:125-8. [PMID: 16550667 DOI: 10.12968/jowc.2006.15.3.26878] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
OBJECTIVE To test the use of low-cost sub-bandage pressure monitors and pulse oximeters as part of a quality-control measure for graduated compression bandaging in leg ulcer clinics. METHOD Twenty-five healthy volunteers (mean age 40 years) providing 50 limbs were bandaged with a four-layer compression bandaging system. The ankle systolic pressure (ASP) was measured using a pulse oximeter (Nellcor NBP-40) before applying the graduated compression bandages. Interface pressure was measured by placing pressure sensors on the skin at three points (2cm above the medial malleolus; the widest part of the calf; and a point midway between them) in the supine and standing positions. The ASP was measured again with the pulse oximeter after the bandage had been applied, and the effect of the bandage on the ASP was recorded. The actual pressure created by the bandage was compared with the required pressure profile. RESULTS Interface pressures varied with change of position and movement. With the operator blinded to the pressure monitors while applying the bandages, the target pressure of 35-40mmHg at the ankle was achieved in only 36% of limbs ([mean +/- 95% confidence interval]; 32.3 +/- 1.6mmHg [supine]; 38.4 +/- 2.4mmHg [standing position]). With the help of the pressure monitors, the target pressure was achieved in 78% of the limbs. There was no correlation between the pressure monitors and pulse oximeter pressures, demonstrating that the pulse oximeter is not a useful tool for measuring sub-bandage pressures. CONCLUSION The results suggest a tool (interface pressure monitors) that is easy to operate should be available as part of quality assurance for treatment, training of care providers and education.
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Affiliation(s)
- A Satpathy
- Surgical Research Fellow, Good Hope Hospital NHS Trust, Sutton Coldfield, UK.
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72
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Abstract
Uncommon presentations like vasculitis or other immunologic causes and malignancy account for about 1% to 2% of patients suffering from leg ulcers. We focus on such uncommon leg ulcers including: cutaneous vasculitis causing cutaneous ulceration, other immunologic or metabolic cutaneous lesions such as pyoderma gangrenosum and necrobiosis lipoidica, and ulcers based on neoplastic etiology. A short description on leg ulcers in the tropics is also included. The described uncommon presentations of leg ulcers are typically difficult to diagnose and treat; it is a specialist's job to take care of patients with these types of ulcers. Multidisciplinary specialized wound healing concepts integrated in the national health care system, as an accepted expert function, is the ideal way to organize the wound healing area. Such a system would result in an earlier diagnosis and more sufficient treatment for patients with uncommon presentations of leg ulcers.
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Affiliation(s)
- Finn Gottrup
- Department of Plastic and Reconstructive Surgery, University Center of Wound Healing, Odense University Hospital, Denmark.
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73
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Campbell WB, Thomson H, MacIntyre JB, Coward C, Michaels JA. Venous Ulcer Services in the United Kingdom. Eur J Vasc Endovasc Surg 2005; 30:437-40. [PMID: 16023387 DOI: 10.1016/j.ejvs.2005.05.035] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2004] [Accepted: 05/28/2005] [Indexed: 10/25/2022]
Abstract
OBJECTIVES To obtain comprehensive information about venous ulcer services throughout the United Kingdom (UK). DESIGN Questionnaire based survey. MATERIALS Questionnaire. METHODS Letters about venous ulcer services were sent to consultant vascular surgeons in all areas of the UK (total 181). Questionnaires were then directed to the appropriate clinician in each area. RESULTS Responses were received from 177 (98%) areas. Fifteen (8%) had no dedicated service. Completed questionnaires were returned for 112 (63%) areas. Fifty-six (54%) services were managed by acute hospitals, 29 (28%) by primary care (community) and 19 (18%) jointly. Doctors supervised services in 65 (64%) (vascular surgeons 49, dermatologists 12, both 4) and nurses in 31 (33%). New referrals per week were 1-50 based on audit (33%) or estimates (67%). Sixty-three (58%) services had no database. Written guidelines existed for 76% services (90% nurse-supervised and 64% doctor-supervised services--p<0.02). CONCLUSIONS Dedicated venous ulcer services have been shown to improve healing rates and quality of life. Although now present in most areas of the UK, their organisation varies considerably and many are not based in the community, near patients homes. This survey provides a benchmark for comparison with venous ulcer services in other countries.
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Affiliation(s)
- W B Campbell
- Department of Surgery, Royal Devon and Exeter Hospital, Peninsula Medical School, Exeter EX2 5DW, UK
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74
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Edwards H, Courtney M, Finlayson K, Lewis C, Lindsay E, Dumble J. Improved healing rates for chronic venous leg ulcers: pilot study results from a randomized controlled trial of a community nursing intervention. Int J Nurs Pract 2005; 11:169-76. [PMID: 15985095 DOI: 10.1111/j.1440-172x.2005.00521.x] [Citation(s) in RCA: 37] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Venous leg ulcers are a frequent source of chronic ill-health and a considerable cost to health-care systems. This paper reports pilot study results from a randomized controlled trial to determine the effectiveness of a community-based 'Leg Club' environment on improving healing rates of venous leg ulcers. Leg Clubs offer a setting where people with similar problems can socialize in a supportive, information-sharing environment. A sample of 33 clients with a below-knee venous leg ulcer were randomized to treatment, either in their own homes or in a community Leg Club. Treatment was provided to all participants, whether in the control group or intervention group, by a team of trained wound-care nurses following evidence-based assessment and treatment guidelines. Data were collected on admission to the study and at 12 weeks from admission. Results showed a significant improvement in healing in the intervention group compared to the control group, as measured by ulcer area size and Pressure Ulcer Scale for Healing scores. These results suggest that a community Leg Club environment provides benefits additional to wound care expertise and evidence-based care. Knowledge gained from this study provides evidence to guide service delivery and improve client outcomes.
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Affiliation(s)
- Helen Edwards
- School of Nursing, Centre for Health Research-Nursing, Queensland University of Technology, Victoria Park Road, Kelvin Grove, Queensland 4059, Australia
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75
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Ragnarson Tennvall G, Hjelmgren J. Annual costs of treatment for venous leg ulcers in Sweden and the United Kingdom. Wound Repair Regen 2005; 13:13-8. [PMID: 15659032 DOI: 10.1111/j.1067-1927.2005.130103.x] [Citation(s) in RCA: 84] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
The aim of this study was to estimate costs of treating venous leg ulcers in Sweden and the United Kingdom during 1 year and to quantify costs in different health states. The costs of treating four different types of venous leg ulcers were estimated for 52 weeks by a stochastic health economic model, which simulated resource use data obtained from prospectively collected patient data, expert panels in the two countries, and published scientific literature. The average cost of treating an ulcer varied between 1332 Euro and 2585 Euro in Sweden and from 814 Euro to 1994 Euro in the United Kingdom. Cost of treating large ulcers (>/= 10 cm(2)) of long duration (>/= 6 months) was highest in both countries. Frequency of dressing changes and duration of time for each dressing change were higher in Sweden than in the United Kingdom, resulting in higher total cost per patient in Sweden. An important factor for the total costs was time to heal. Other important variables influencing treatment costs were frequency and duration of dressing changes. Actions to reduce time used for dressing changes and the total time to healing are thus very important in reducing costs spent on treatment of venous leg ulcers in both countries.
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76
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Tyler P, Hollinworth H, Osborne R. The wearing of compression hosiery for leg problems other than leg ulcers. BRITISH JOURNAL OF NURSING (MARK ALLEN PUBLISHING) 2005; 14:S21-7. [PMID: 15976608 DOI: 10.12968/bjon.2005.14.sup2.18212] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Many people have leg problems other than ulceration. Practitioners from one primary care trust in Suffolk considered nursing assessment of these patients and the fitting of prescribed compression hosiery where appropriate as a health promotion initiative. However, ongoing assessment adds to heavy clinical demands on community practitioners. Engaging with people to take greater responsibility for their health, and recognition that practice should be underpinned by credible evidence, provided the backdrop to a two-staged retrospective audit. Results are based on the nursing records of 101 patients wearing prescribed compression hosiery other than for previous venous ulceration. It was concluded that following an initial detailed holistic assessment, including ankle brachial pressure index, those patients who meet identified characteristics can be empowered to return for reassessment only if there is a change in their health status, or skin changes to their legs. An information leaflet is considered critical to this strategy.
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77
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Kjaer ML, Sorensen LT, Karlsmark T, Mainz J, Gottrup F. Evaluation of the quality of venous leg ulcer care given in a multidisciplinary specialist centre. J Wound Care 2005; 14:145-50. [PMID: 15835223 DOI: 10.12968/jowc.2005.14.4.26760] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
OBJECTIVE To determine the quality of venous leg ulcer care given in a multidisciplinary, specialist wound-healing centre and to identify problem areas that might affect it. METHOD The case records of 90 consecutive patients with venous leg ulcers, diagnosed and treated at the Copenhagen Wound Healing Centre, Denmark, were retrospectively audited by a Scandinavian cross-sectional and multidisciplinary expert panel. Quality of care was audited in each case using implicit criteria. The experts then formulated key recommendations for good clinical practice for patients with venous leg ulcers. RESULTS Quality of care was satisfactory in 74 patients (82%). The one-year healing rate was 77% (69/90), with a three-month recurrence rate of 12% (11/90). Identified problem areas included the lack of systematic assessment of patients' suitability for surgery; lack of systematic, duplex-verified diagnoses of venous aetiology; and the lack of systematic examination of distal arterial pressure. The recommendations include the need for venous diagnosis, differential diagnosis, compression therapy, surgery, systemic treatment, access to venous leg ulcer care and better communication. CONCLUSION The quality of venous leg ulcer care given in this multidisciplinary centre was satisfactory.
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Affiliation(s)
- M L Kjaer
- Copenhagen Wound Healing Center, H:S Bispebjerg Hospital, University of Copenhagen, Denmark.
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78
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Walters SJ, Campbell MJ. The use of bootstrap methods for analysing Health-Related Quality of Life outcomes (particularly the SF-36). Health Qual Life Outcomes 2004; 2:70. [PMID: 15588308 PMCID: PMC543443 DOI: 10.1186/1477-7525-2-70] [Citation(s) in RCA: 62] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2004] [Accepted: 12/09/2004] [Indexed: 11/10/2022] Open
Abstract
Health-Related Quality of Life (HRQoL) measures are becoming increasingly used in clinical trials as primary outcome measures. Investigators are now asking statisticians for advice on how to analyse studies that have used HRQoL outcomes. HRQoL outcomes, like the SF-36, are usually measured on an ordinal scale. However, most investigators assume that there exists an underlying continuous latent variable that measures HRQoL, and that the actual measured outcomes (the ordered categories), reflect contiguous intervals along this continuum. The ordinal scaling of HRQoL measures means they tend to generate data that have discrete, bounded and skewed distributions. Thus, standard methods of analysis such as the t-test and linear regression that assume Normality and constant variance may not be appropriate. For this reason, conventional statistical advice would suggest that non-parametric methods be used to analyse HRQoL data. The bootstrap is one such computer intensive non-parametric method for analysing data. We used the bootstrap for hypothesis testing and the estimation of standard errors and confidence intervals for parameters, in four datasets (which illustrate the different aspects of study design). We then compared and contrasted the bootstrap with standard methods of analysing HRQoL outcomes. The standard methods included t-tests, linear regression, summary measures and General Linear Models. Overall, in the datasets we studied, using the SF-36 outcome, bootstrap methods produce results similar to conventional statistical methods. This is likely because the t-test and linear regression are robust to the violations of assumptions that HRQoL data are likely to cause (i.e. non-Normality). While particular to our datasets, these findings are likely to generalise to other HRQoL outcomes, which have discrete, bounded and skewed distributions. Future research with other HRQoL outcome measures, interventions and populations, is required to confirm this conclusion.
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Affiliation(s)
- Stephen J Walters
- Medical Statistics Group, School of Health and Related Research, University of Sheffield, UK
| | - Michael J Campbell
- Medical Statistics Group, School of Health and Related Research, University of Sheffield, UK
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79
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Gupta N, Gupta SK, Shukla VK, Singh SP. An Indian community-based epidemiological study of wounds. J Wound Care 2004; 13:323-5. [PMID: 15469216 DOI: 10.12968/jowc.2004.13.8.26657] [Citation(s) in RCA: 37] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
OBJECTIVE To establish the prevalence of wounds in a community, with an emphasis on chronic lower extremity wounds, and to identify the various aetiological factors involved. METHOD A cross-sectional study was conducted to screen the population of two nearby communities (one urban and one rural) in India for wounds. This involved conducting a door-to-door survey between July 2001 and February 2003. RESULTS The prevalence of wounds in the population studied (n = 6917) was 15.03 per 1000. The prevalences of acute and chronic wounds were 10.55 and 4.48 per 1000 of the population respectively. CONCLUSION The most common site for both acute and chronic wounds was the lower extremity. In contrast to Western studies, the most common aetiology for a chronic lower extremity wound was an untreated acute traumatic wound. This in turn highlights the need to establish community-based wound-care teams in India.
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Affiliation(s)
- N Gupta
- Institute of Medical Sciences, Banaras Hindu University, Varanasl, India
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80
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Dowsett C. Patient involvement must be a key aspect of choosing an appropriate regimen for leg ulcer management. J Wound Care 2004; 13:443-4. [PMID: 15575576 DOI: 10.12968/jowc.2004.13.10.26683] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
The final article in a six-part series on leg ulcers focuses on developing leg ulcer services in the community and stresses the importance of taking a holistic approach and the value of patient/carer education to promote concordance.
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Affiliation(s)
- C Dowsett
- Newham Primary Care Trust, London, UK.
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81
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Iglesias CP, Nelson EA, Cullum N, Torgerson DJ. Economic analysis of VenUS I, a randomized trial of two bandages for treating venous leg ulcers. Br J Surg 2004; 91:1300-6. [PMID: 15382101 DOI: 10.1002/bjs.4755] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
BACKGROUND The study investigated the cost-effectiveness of four-layer and short-stretch compression bandages for treating venous leg ulcers. METHODS Cost-effectiveness and cost-utility analyses were performed using patient-level data collected alongside the VenUS I leg ulcer study. The perspective for the economic analysis was that of the UK National Health Service (NHS) and Personal Social Service. The time horizon for the analysis was 1 year after recruitment. Health benefit was measured as differences in ulcer-free days and quality-adjusted life years (QALYs). RESULTS The mean healing time for ulcers treated with four-layer bandages was 10.9 (95 per cent confidence interval (c.i.) -6.8 to 29.1) days less than that for ulcers treated with short-stretch bandages. Mean average difference in QALYs between compression systems was -0.02 (95 per cent c.i. -0.08 to 0.04). The four-layer bandage cost a mean of pound 227.32 (95 per cent c.i. pound 16.53 to pound 448 .30) less per patient per year than the short-stretch bandage. CONCLUSION On average, four-layer bandaging was associated with greater health benefits and lower costs than short-stretch bandaging.
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Affiliation(s)
- C P Iglesias
- Department of Health Sciences, Seebohm Rowntree Building (Area 4), University of York, Heslington, York YO10 5DD, UK
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82
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Abstract
Accurate diagnosis of mixed aetiology leg ulcers depends on detailed assessment by a trained practitioner. This paper, the fourth in a six-part series on leg ulcers, describes how reduced compression bandaging can achieve successful outcomes.
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Affiliation(s)
- J Stevens
- Tissue Viability, Hounslow and North Surrey Primary Care Trusts, West Middlesex University Hospital Trust, UK.
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83
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Abstract
OBJECTIVE To investigate the impact of 'disease' and treatment on quality of life in patients with venous leg ulceration. METHOD Sixty-five patients with venous leg ulcers were recruited and treated. At study entry and exit or following complete wound closure, whichever occurred first, each patient was assessed using the SF-36 quality-of-life questionnaire. Data analysis included an investigation of the study population as whole, differences between patients whose ulcers did and did not heal and between gender and age. Health domain means for all patients were compared with age equivalent norms (AENs) at both entry and exit. RESULTS There was a significant improvement in the SF-36 domains of bodily pain, health transition, mental health and social functioning for all 65 patients. Patients whose ulcers healed also showed a statistically significant improvement in the vitality domain. Patients whose ulcers did not heal had statistically significant improved scores for bodily pain and health transition. At entry all SF-36 values, except for general health, were lower than the AENs. On exit, scores for bodily pain, general health and mental health were comparable with the AEN; values for the remaining five domains increased at exit. CONCLUSION The results highlight that good wound management and effective compression therapy can improve quality of life in patients with venous leg ulceration, whether or not the patient's leg ulcer healed following treatment.
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Affiliation(s)
- H Charles
- St Charles Hospital, Exmoor Street, London W10 6DZ
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84
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Affiliation(s)
- Deborah A Simon
- Academic Department of Surgery, Wythenshawe Hospital, Manchester M23 9LT
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85
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Persoon A, Heinen MM, van der Vleuten CJM, de Rooij MJ, van de Kerkhof PCM, van Achterberg T. Leg ulcers: a review of their impact on daily life. J Clin Nurs 2004; 13:341-54. [PMID: 15009337 DOI: 10.1046/j.1365-2702.2003.00859.x] [Citation(s) in RCA: 278] [Impact Index Per Article: 13.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND Current nursing care for leg ulcer patients often focuses on wound care and providing compression therapy. Nurses perceive leg ulcer patients as 'under-served' with regard to problems patients experience in daily life. An overview of patient problems is a first and essential step in the development of comprehensive nursing care. AIMS AND OBJECTIVES To gather information about the impact of leg ulcers on patient's daily life as described in quantitative and qualitative studies. DESIGN Systematic literature review. METHODS Medline and Cinahl databases were searched for venous leg ulcer studies, up to 2002; this was followed by the 'snowball method'. Studies were selected in accordance with preset criteria. RESULTS A total of 37 studies was included. All studies report that leg ulcers pose a threat to physical functioning. Furthermore, a negative impact on psychological functioning is reported and, to a lesser degree, on social functioning. Major limitations are pain and immobility, followed by sleep disturbance, lack of energy, limitations in work and leisure activities, worries and frustrations and a lack of self-esteem. Patients have a significantly poorer quality of life compared with healthy people. Finally, patients report problems with regard to follow-up treatment. CONCLUSIONS Having a leg ulcer has a major impact on a patient's life. There are indications of under-treatment of pain. RELEVANCE TO CLINICAL PRACTICE Keeping in mind that leg ulceration is notorious for its chronic character, the negative impact on patient's life implies that many patients suffer over longer periods of time. This emphasizes the need to focus on quality of life aspects in patient care. There is much to gain, especially concerning pain and mobility. The development of comprehensive care programmes is essential.
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Affiliation(s)
- Anke Persoon
- Department of Nursing Science, University Medical Centre St Radboud, Nijmegen, The Netherlands.
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86
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Kumar RN, Gupchup GV, Dodd MA, Shah B, Iskedjian M, Einarson TR, Raisch DW. Direct Health Care Costs of 4 Common Skin Ulcers in New Mexico Medicaid Fee-for-Service Patients. Adv Skin Wound Care 2004; 17:143-9. [PMID: 15194976 DOI: 10.1097/00129334-200404000-00015] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To determine health care costs associated with pressure ulcers, ulcers of the lower limbs, other chronic ulcers, and venous leg ulcers from the New Mexico Medicaid fee-for-service program perspective. DESIGN Retrospective analysis of claims database MAIN OUTCOME MEASURES Physician visit, hospital, and prescription costs were determined for New Mexico Medicaid patients with a primary and/or secondary diagnosis of 1 of 4 identified categories of skin ulcers from January 1, 1994, through December 31, 1998. Costs were determined in terms of mean and median annual cost per patient and total costs per year. Zero dollar claims were included within the cost calculations. All costs are expressed in 2000-dollar values. MAIN RESULTS Mean annual physician visit costs per patient ranged from $71 (standard deviation [SD] = $60) for venous leg ulcers in 1998 to $520 (SD = $1228) for pressure ulcers in 1996. Mean annual hospital costs per patient ranged from $266 (SD = $348) for other chronic ulcers in 1998 to $15,760 (SD = $30,706) for pressure ulcers in 1998. Mean annual prescription costs per patient ranged from $145 (SD = $282) for other chronic ulcers in 1998 to $654 (SD = $1488) for pressure ulcers in 1994. CONCLUSION The New Mexico Medicaid fee-for-service system incurred a total cost of approximately $11.6 million (in 2000 dollars) from 1994 through 1998 for the treatment of the 4 categories of skin ulcers studied. The data showed that the majority of wounds were coded as pressure ulcers, which had the highest associated costs.
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Affiliation(s)
- Ritesh N Kumar
- College of Pharmacy, University of Michigan, Ann Arbor, MI, USA
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87
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Simka M, Majewski E. The social and economic burden of venous leg ulcers: focus on the role of micronized purified flavonoid fraction adjuvant therapy. Am J Clin Dermatol 2003; 4:573-81. [PMID: 12862500 DOI: 10.2165/00128071-200304080-00007] [Citation(s) in RCA: 71] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
Chronic venous insufficiency (CVI) occurs in a relatively large proportion of the population and is associated with significant morbidity, high cost of healthcare, loss of productivity and reduced quality of life. Lower extremity ulcers related to CVI have been estimated to affect 0.2-1% of the population in developed countries. The prevalence of venous ulcers in the US is estimated at 500,000-600,000, and increases with age. Estimates of the annual incidence of leg ulcer in the UK and Switzerland are 3.5 and 0.2 per 1000 individuals, respectively. Treatment of venous ulcers can be expensive, leading to a large economic burden on health services in many countries. The annual cost of CVI is estimated to be more than 1 billion US dollars in the US and between pound 400-600 million in the UK. Current treatments for CVI include surgery, sclerotherapy, compressive therapy (conventional therapy) and adjuvant pharmacotherapy. Various pharmacological agents have been used as adjuvant therapy but in many cases there is no definitive evidence of their efficacy. Effective treatment programs for venous leg ulcers could substantially reduce the economic impact of CVI on health services. In controlled studies, micronized purified flavonoid fraction (MPFF) adjuvant therapy has been shown to increase significantly the number of healed venous leg ulcers and to reduce significantly the healing time of ulcers compared with conventional therapy alone, potentially leading to an improvement in patients' quality of life. The treatment of venous leg ulcers with MPFF was also found to reduce overall treatment costs compared with conventional therapy alone. In a retrospective cost-effectiveness analysis based on direct medical costs only, MPFF therapy improved the cost-effectiveness ratio by 45% compared with conventional therapy. If intangible costs, such as loss of quality of life were included, the difference in cost-effectiveness ratios is likely to be even greater in favor of MPFF. Sensitivity analyzes showed that even with a 20% increase in drug price the cost-effectiveness ratio for MPFF therapy was substantially better than that for conventional therapy (1061.8 US dollars vs 1871.9 US dollars per ulcer healed). Hence, the addition of MPFF adjuvant therapy to the treatment of venous leg ulcers would be effective and potentially cost saving.
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Affiliation(s)
- Marian Simka
- Out-Patient Department of Angiology, Pszczyna ul. Wodzislawska 78-43-200 Pszczyna, Poland.
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88
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Nemeth KA, Graham ID, Harrison MB. The measurement of leg ulcer pain: identification and appraisal of pain assessment tools. Adv Skin Wound Care 2003; 16:260-7. [PMID: 14581818 DOI: 10.1097/00129334-200309000-00017] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To identify and compare the psychometric, clinical sensibility, and pain-specific properties of leg ulcer pain assessment tools for use as a guide for clinicians and researchers. DESIGN Pain assessment tools were selected for appraisal based on 4 inclusion criteria: (1) designed specifically to measure either quality and/or intensity of pain, (2) used in at least 2 different diseases and/or pain-inducing interventions in adults, (3) generic, and (4) patient self-reporting. The tools were appraised against psychometric properties, clinical sensibility attributes, and pain-specific issues. Two reviewers independently reviewed each abstract, with a third reviewer resolving any disagreements. Then the first 2 reviewers independently assessed the selected tools using the predetermined appraisal criteria. RESULTS Of 54 identified pain assessment tools, 5 (the pain ruler, the numerical rating scale, the visual analogue scale, the verbal descriptor scale, and the short-form McGill Pain Questionnaire) met the inclusion criteria. Each tool met the appraisal criteria to varying degrees. CONCLUSIONS The use of a pain assessment tool to measure leg ulcer pain is recommended. Clinicians must decide independently which factors are most important when selecting a tool. Although a specific pain assessment approach cannot yet be recommended, a 2-step pain assessment process is most practical. To optimize pain management, further study is needed to ensure that leg ulcer pain is accurately and reliably assessed.
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Affiliation(s)
- Kathleen A Nemeth
- Thrombosis/Hemostasis Research Group, The Ottawa Hospital, Ottawa, Ontario, Canada
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89
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O'Brien JF, Grace PA, Perry IJ, Hannigan A, Clarke Moloney M, Burke PE. Randomized clinical trial and economic analysis of four-layer compression bandaging for venous ulcers. Br J Surg 2003; 90:794-8. [PMID: 12854102 DOI: 10.1002/bjs.4167] [Citation(s) in RCA: 56] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
BACKGROUND The aim of this study was to compare the cost-effectiveness of four-layer compression bandaging for venous leg ulcers with that of other available treatments. METHODS In this pragmatic trial, 200 patients with a venous leg ulcer were randomized either to four-layer bandaging (intervention group; n = 100) or to continue their usual system of care (control group; n = 100). The follow-up for each patient was 12 weeks. Analysis was by intention to treat; the main outcome measures were time to healing and cost to the health board per leg healed. RESULTS Baseline characteristics were well matched in the two groups. The Kaplan-Meier estimate of the healing rate at 3 months was 54 per cent with four-layer bandaging and 34 per cent in the control group. Throughout the 3 months, four-layer bandaging healed leg ulcers significantly earlier (P = 0.006). There was a significant reduction in the median cost per leg healed with four-layer bandaging (euro 210 versus euro 234; P = 0.040). CONCLUSION Four-layer bandaging is currently the most effective method of treating venous leg ulcers in a community setting.
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Affiliation(s)
- J F O'Brien
- Department of Vascular Surgery, Mid-Western Regional Hospital, Limerick, Ireland
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90
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Walters SJ, Brazier JE. What is the relationship between the minimally important difference and health state utility values? The case of the SF-6D. Health Qual Life Outcomes 2003; 1:4. [PMID: 12737635 PMCID: PMC155547 DOI: 10.1186/1477-7525-1-4] [Citation(s) in RCA: 320] [Impact Index Per Article: 15.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2003] [Accepted: 04/11/2003] [Indexed: 01/15/2023] Open
Abstract
BACKGROUND The SF-6D is a new single summary preference-based measure of health derived from the SF-36. Empirical work is required to determine what is the smallest change in SF-6D scores that can be regarded as important and meaningful for health professionals, patients and other stakeholders. OBJECTIVES To use anchor-based methods to determine the minimally important difference (MID) for the SF-6D for various datasets. METHODS All responders to the original SF-36 questionnaire can be assigned an SF-6D score provided the 11 items used in the SF-6D have been completed. The SF-6D can be regarded as a continuous outcome scored on a 0.29 to 1.00 scale, with 1.00 indicating "full health". Anchor-based methods examine the relationship between an health-related quality of life (HRQoL) measure and an independent measure (or anchor) to elucidate the meaning of a particular degree of change. One anchor-based approach uses an estimate of the MID, the difference in the QoL scale corresponding to a self-reported small but important change on a global scale. Patients were followed for a period of time, then asked, using question 2 of the SF-36 as our global rating scale, (which is not part of the SF-6D), if there general health is much better (5), somewhat better (4), stayed the same (3), somewhat worse (2) or much worse (1) compared to the last time they were assessed. We considered patients whose global rating score was 4 or 2 as having experienced some change equivalent to the MID. In patients who reported a worsening of health (global change of 1 or 2) the sign of the change in the SF-6D score was reversed (i.e. multiplied by minus one). The MID was then taken as the mean change on the SF-6D scale of the patients who scored (2 or 4). RESULTS This paper describes the MID for the SF-6D from seven longitudinal studies that had previously used the SF-36. CONCLUSIONS From the seven reviewed studies (with nine patient groups) the MID for the SF-6D ranged from 0.010 to 0.048, with a weighted mean estimate of 0.033 (95% CI: 0.029 to 0.037). The corresponding Standardised Response Means (SRMs) ranged from 0.11 to 0.48, with a mean of 0.30 and were mainly in the "small to moderate" range using Cohen's criteria, supporting the MID results. Using the half-standard deviation (of change) approach the mean effect size was 0.051 (range 0.033 to 0.066). Further empirical work is required to see whether or not this holds true for other patient groups and populations.
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Affiliation(s)
- Stephen J Walters
- Sheffield Health Economics Group, School of Health and Related Research, University of Sheffield, Regent Court, 30 Regent Street, Sheffield, S1 4DA, UK
| | - John E Brazier
- Sheffield Health Economics Group, School of Health and Related Research, University of Sheffield, Regent Court, 30 Regent Street, Sheffield, S1 4DA, UK
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91
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O'Brien JF, Clarke-Moloney M, Grace PA, Perry IJ, Burk PE. Leg Ulcers: A Cross-Sectional Survey of Management Practices and Treatment Costs in Ireland. Phlebology 2002. [DOI: 10.1177/026835550201700304] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Objective: To review the management and the cost of leg ulcers. Design: Cross-sectional survey based on a questionnaire completed by healthcare workers caring for patients with leg ulcers in a defined population. Setting: The Mid-Western Health Board area in Ireland with a population of 317069. Patients: All patients receiving healthcare for active leg ulceration. Results: Leg ulcers were recorded for 389 individuals and public health nurses primarily provided care (n = 283). Patients had open ulcers for a median period of 8 months (interquartile range: 3 months — 2 years) with almost half (n = 181) reporting previous episodes of ulceration. Fifty different dressing products were used to treat leg ulcers in the region. Only 52.2% (203/389) of patients had the aetiology of their leg ulcers properly investigated and evidence-based care was generally apparent in this group. Otherwise, care appeared haphazard and at times inappropriate. The estimated annual direct cost of dressing leg ulcers was £585 660. Conclusion: A regional strategy for managing leg ulcers needs to be clarified and implemented if practitioners are to incorporate evidence-based care into routine work.
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Affiliation(s)
- J. F. O'Brien
- Department of Vascular Surgery, The Limerick Regional General Hospital and St John's Hospital, Limerick
| | - M. Clarke-Moloney
- Department of Vascular Surgery, The Limerick Regional General Hospital and St John's Hospital, Limerick
| | - P. A. Grace
- Department of Vascular Surgery, The Limerick Regional General Hospital and The BioMedical Institute, University of Limerick
| | - I. J. Perry
- Department of Epidemiology and Public Health, Distillery House, University College Cork, Ireland
| | - P. E. Burk
- Department of Vascular Surgery, The Limerick Regional General Hospital and St John's Hospital, Limerick
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92
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Leg ulcers: A cross-sectional survey of management practices and treatment costs in Ireland. Phlebology 2002. [DOI: 10.1007/bf02638600] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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93
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Abstract
As the Journal of Wound Care celebrates its tenth anniversary, now is a good time to reflect on how our discipline has grown over the years. Here, Helena Baxter charts the advances in wound management that have made such a difference to our day-to-day practice and describes the exciting developments that lie ahead.
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Affiliation(s)
- H Baxter
- Hinchingbrooke Hospital, Huntingdon, UK.
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94
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Ruckley. Effect of a national community intervention programme on healing rates of chronic leg ulcer: Randomised controlled trial. Phlebology 2002. [DOI: 10.1007/bf02637185] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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95
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96
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Abstract
District nurses manage the care of the majority of patients with leg ulcers, but there have been reports of variations in the practice and effectiveness of treatment provided by district nurses (Audit Commission, 1999). Evidence-based health care aims to promote clinical and cost-effective care/treatment through the explicit, conscientious, and judicious use of the currently available best evidence from research to guide decisions (Sackett et al, 1996). Following the method of Griffiths (2002), a mini-systematic review was undertaken, to find out whether leg ulcer clinics provide more effective treatment to patients with leg ulcers than care provided in patients' homes by district nurses. Five databases were searched to find valid randomised controlled trials (RCTs) or systematic reviews to answer the question. The search was supplemented by hand searching of relevant publications. Only one trial met the inclusion criteria of the review. Although it concluded that leg ulcer clinics delivered improved outcomes the evidence provided was limited due to the comparison treatment being outdated, inadequate information regarding costs, and that as a relatively small isolated RCT it provided insufficient evidence to answer the question.
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97
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Samad A, Hayes S, Dodds S. Telemedicine: an innovative way of managing patients with leg ulcers. BRITISH JOURNAL OF NURSING (MARK ALLEN PUBLISHING) 2002; 11:S38-52. [PMID: 11979190 DOI: 10.12968/bjon.2002.11.sup1.12248] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 01/01/2002] [Indexed: 11/11/2022]
Abstract
The optimal management of patients with leg ulcers requires a multidisciplinary approach, with contributions from both community and hospital specialists to identify, investigate and treat the underlying causes, provide patient education, assess healing and dress the wounds, monitor outcome and prevent recurrence. However, current practice is impaired by the limited communication between community and hospital specialists. There are inconsistencies in methods of transferring and updating patient records between the hospital and the community, and this can lead to confusion over the diagnosis and appropriate management. Telemedicine, the electronic exchange of medical information at a distance, would appear to offer a way to establish an efficient and effective communication link between hospital and community specialists involved in the care of patients with leg ulcers. The authors of this article believe that modern information technology and the existing NHSnet information infrastructure could be employed to create such a link via electronic patient records.
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Affiliation(s)
- Ajai Samad
- Department of Vascular Surgery, Good Hope Hospital NHS Trust, West Midlands
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98
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McGuckin M, Waterman R, Brooks J, Cherry G, Porten L, Hurley S, Kerstein MD. Validation of venous leg ulcer guidelines in the United States and United Kingdom. Am J Surg 2002; 183:132-7. [PMID: 11918875 DOI: 10.1016/s0002-9610(01)00856-x] [Citation(s) in RCA: 87] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Venous leg ulcers account for 85% of all lower-extremity ulcers, with treatment costs of 3 billion dollars and loss of 2 million workdays per year. The purpose of this study was to validate the clinical efficacy and cost effectiveness of multidisciplinary guidelines for the diagnosis and treatment of venous leg ulcers. METHODS Eighty (40 retrospective, 40 prospective) patients from the United States and United Kingdom were enrolled. RESULTS United States patients were 6.5 times and United Kingdom 2 times more likely to heal if a guideline was followed (P <0.001). A significant decrease was noted in healing time for both the United States and United Kingdom (P <0.01), and the median cost decreased significantly when the guideline was followed (P <0.01). CONCLUSIONS Implementation of a guideline for diagnosis and treatment of venous leg ulcers resulted in improvement in diagnosis, decrease in healing time, and an increase in healing rates resulting in lower costs.
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Affiliation(s)
- Maryanne McGuckin
- School of Medicine, University of Pennsylvania, 422 Curie Blvd., Rm. 605A, Stellar Chance Building, Philadelphia, PA 19104-6021, USA.
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99
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Huang A, Edwards N, McWhinnie DL. Subfascial Endoscopic Perforator Surgery is More Cost-Effective Than Compression Bandaging for Healing Venous Ulcers. Phlebology 2001. [DOI: 10.1177/026835550101600206] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Objective: To determine whether subfascial endoscopic perforator surgery (SEPS) is more cost-effective than compression bandaging for healing venous ulcers. Design: Cost analyses based on theoretical patients supposing the two methods are equally effective in healing venous ulcers. Setting: District hospital. Patients: A theoretical population of 200 patients with unilateral leg ulceration due to incompetent perforating veins. Intervention: The cost of SEPS was calculated based on outpatient visits, investigations and surgery including complications, with varying failure and re-ulceration rates. The cost of compression bandaging was estimated from published data and compared with that of SEPS. Results: The average cost per patient undergoing SEPS was £723. In 100 patients with an operative failure rate of 2% and a 10% re-ulceration rate, the cost increased to £818/patient in the first year (£16/ulcer-free week). A re-ulceration rate of 35% increased the cost to £23/ulcer-free week. However, the cost of compression bandage was £33/ulcer-free week using the same model, with healing rates of 50–70% at 20–40 weeks and a recurrence rate of 18–30% at 30–40 weeks. Conclusion: In a theoretical model SEPS was more cost-effective in healing venous ulcers due to incompetent perforators compared with compression bandaging.
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Affiliation(s)
- A. Huang
- Department of Vascular Surgery, Milton Keynes General Hospital, Milton Keynes MK6 5LD, UK
| | - N. Edwards
- The NHS Confederation, London SW16 4ND, UK
| | - D. L. McWhinnie
- Department of Vascular Surgery, Milton Keynes General Hospital, Milton Keynes MK6 5LD, UK
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100
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Vowden KR, Vowden P. Knowledge is power. J Wound Care 2001; 10:97. [PMID: 12964311 DOI: 10.12968/jowc.2001.10.4.26308] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Only by setting up national benchmarking with detailed information on patients, treatments and outcomes will the care of chronic wounds improve
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Affiliation(s)
- K R Vowden
- Bradford Royal Infirmary, University of Bradford, UK
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