Venous leg ulcer management in Australian primary care: Patient and clinician perspectives

Development of a core outcome set for use in research evaluations of interventions for venous leg ulceration: International eDelphi consensus

INTRODUCTION

Venous leg ulceration (VLU) is a chronic, recurring condition with associated pain, malodour, impaired mobility and susceptibility to infection which in turn significantly impacts an individual's health-related quality of life. Randomised controlled trials (RCTs) aim to determine the efficacy of interventions to improve outcomes. To be useful, these outcomes should be consistently and fully reported across RCTs. A core outcome set (COS) is an agreed-upon standardised set of outcomes which should be, at a minimum, reported in all RCTs for a given indication including that of VLU.

AIM

To gain consensus on which outcome domains and outcomes should be considered as core and therefore included in all RCTs of interventions in VLU treatment.

METHOD

Two sequential, two round e-Delphi surveys were completed. The first gained consensus on core outcome domains and the second on core outcomes within those domains. Participants included: people with direct experience of having VLUs and their carers, healthcare professionals whose practice included VLU care and researchers within wound care (clinical, academic, industry).

RESULTS

Five outcome domains; healing, pain, quality of life, resource use and adverse events, and 11 outcomes were rated as core by participants. The patient and not the limb or ulcer was the preferred unit of analysis for reporting.

RECOMMENDATIONS

We recommend investigators report on all five outcome domains, regardless of the type of intervention being evaluated. Future research is needed to identify measurement methods for the 11 identified outcomes. We also recommend investigators follow the CONSORT guidelines (http://www.consort-statement.org/).

Associations between self-care advice and healing time in patients with venous leg ulcer- a Swedish registry-based study

BACKGROUND

Venous leg ulcers take time to heal. It is advocated that physical activity plays a role in healing, and so does the patient's nutritional status. Additionally, malnutrition influences the inflammatory processes, which extends the healing time. Therefore, the staff's advising role is important for patient outcomes. Thus, this study aimed to investigate the associations between given self-care advice and healing time in patients with venous leg ulcers while controlling for demographic and ulcer-related factors.

METHODS

The sample consisted of patients registered in the Registry of Ulcer Treatment (RUT) which includes patient and ulcer-related and healing variables. The data was analyzed with descriptive statistics. Logistic regression models were performed to investigate the influence of self-care advice on healing time.

RESULTS

No associations between shorter healing time (less than 70 days) and the staff´s self-care advice on physical activity was identified, whilst pain (OR 1.90, CI 1.32-2.42, p < 0.001) and giving of nutrition advice (OR 1.55, CI 1.12-2.15, p = 0.009) showed an association with longer healing time.

CONCLUSIONS

Neither self-care advice on nutrition and/or physical activity indicated to have a positive association with shorter healing time. However, information and counseling might not be enough. We emphasize the importance of continuously and systematically following up given advice throughout ulcer management, not only when having complicated ulcers.

Experiences of patients living with venous leg ulcers: A qualitative meta-synthesis

BACKGROUND

Venous Leg Ulcer is characterized by a prolonged course, delayed healing and high recurrence rate. Bringing challenges to patient treatment and care.Patients need to control the negative behavioral factors that affect wound healing and recurrence, which seriously affect their quality of life.

OBJECTIVE

To integrate qualitative research related to the disease experience and feelings of patients with Venous Leg Ulcer and provide references for optimizing patient intervention measures.

METHODS

We searched databases including Pubmed, CINAHL, EMBASE, Web of Science, PsycINFO, The Cochrane library, ProQuest, CNKI and Wan Fang Data from 2000 to February 2023 to collect qualitative studies on the experiences of patients living with venous leg ulcers. We used the Australian JBI evidence-based healthcare center qualitative research quality evaluation standard to evaluate the quality of literature. After quality assessment, meta-synthesis was used to summarize and explain the results.

RESULTS

Sixteen studies were eligible for inclusion, and the total number of included individuals was 146. The perceptions of individuals with Venous Leg Ulcer synthesized three overarching themes and their subthemes: disease cognition (Understanding the cause of VLU,Understanding of VLU treatment, Recognition of VLU recurrence); physical experience (Pain symptoms, Other symptoms); and psychological and social experience (psychological impact, health education, economic burden, social relations, response strategies, doctor-patient/nurse-patient relationship).

CONCLUSION

The lives of patients with venous leg ulcers are influenced by various complex and diverse factors. Healthcare professionals must recognize the patient's emotional needs, establish a multidimensional support system, and promote wound healing through patient self-adjustment.

Análise de custo-efetividade do tratamento com terapia compressiva na cicatrização de úlceras venosas

Objetivo: analisar a custo-efetividade e calcular a razão de custoefetividade incremental do tratamento compressivo multicamadas em relação ao inelástico (bota de Unna e curto estiramento) de acordo com a literatura atual. Método: estudo quantitativo sobre custo-efetividade por meio de modelagem com auxílio do software TreeAge® para a construção da árvore de decisão. Os pressupostos anunciados foram obtidos pelo uso de dados secundários de literatura para estimativa do custo e efetividade dos parâmetros assumidos. Para tal, foi realizada uma revisão sistemática de literatura com metanálise. Resultados: a árvore de decisão, após Roll Back mostrou que a terapia multicamadas dominou as alternativas no caso-base, representando custo intermediário por aplicação, porém, com a maior efetividade. O gráfico da análise de custo-efetividade também mostrou uma dominância estendida da bota de Unna em relação à bandagem de curto estiramento. A análise de sensibilidade mostrou que a bandagem multicamadas permanece como alternativa mais custo-efetiva, dentro do limiar de disposição para pagar. Conclusão: a alternativa com maior custo-efetividade foi a bandagem multicamadas, considerada padrão ouro na literatura. A segunda alternativa mais custo-efetiva foi a bota de Unna, terapia mais utilizada no Brasil.

Cost-effectiveness analysis of the treatment with compressive therapy in the healing of venous ulcers

Objective: to analyze the cost-effectiveness and calculate the incremental cost-effectiveness ratio of multilayer compressive treatment in relation to inelastic (Unna boot and short stretch) therapy according to the current literature. Method: quantitative study about cost-effectiveness through modeling with the aid of TreeAge® software for construction of the decision tree. The anticipated assumptions were obtained by using secondary literature data to estimate the cost and effectiveness of the assumed parameters. A systematic literature review with meta-analysis was performed for this end. Results: the decision tree after Roll Back showed that the multilayer therapy dominated the alternatives in the base case, representing an intermediate cost per application, although with the highest effectiveness. The cost-effectiveness analysis graph also showed extended dominance of the Unna boot in relation to the short stretch bandage. The sensitivity analysis showed that multilayer bandage remains a more cost-effective alternative, within the threshold of willingness to pay. Conclusion: the most cost-effective alternative was multilayer bandage, considered the gold standard in the literature. The second most cost-effective alternative was the Unna boot, the most used therapy in Brazil.

Patients 'acceptance' of chronic wound-associated pain - A qualitative descriptive study

Chronic wound-associated pain negatively impacts the quality of life of individuals and their families. To date, little research exists that has explored collectively how individuals describe wound pain, strategies they use to manage pain, and the perceived effectiveness of such strategies. Therefore, qualitative, semi-structured interviews were carried out between June and August 2021 with 13 individuals to gain a deeper understand of the experience and impact of chronic wound-associated pain in this population. Data were analyzed following Braun and Clarke's approach for reflexive thematic analysis using MAXQdA®. Two themes and subthemes were identified. Theme 1 reflects participants' characterization of pain and how wound-associated pain affected their daily life and how they learned to accept it. Participants felt functionally impaired. In theme 2, participants described how they accepted to live with such a pain even though they received support to manage their chronic wound-associated pain, especially during the dressing-changes. Patients depended on their health care professionals and family support networks to cope with the pain. Coping with pain is exhausting contributing to poorer quality of life. Health care professionals should be aware of wound-associated pain during dressing changes. Patients recommended the need for further research on dressings and not drugs to manage pain.

Ulcerated skin evaluation by electrical impedance measurements

In the presented study, the transdermal results from the areas surrounding the ulcerated skin areas were compared with those obtained from healthy skin tissue. The analysis of electrical parameters, such as the slope of the Nyquist plot, min. IM, min. RE, min. f, Imagine part index, Phase index, Real part index, and Magnitude index were conducted. Electrical parameters have been measured in the group without lower leg ulceration and in the group with lower leg ulcers. On the basis of the statistical analysis, it was determined that these parameters may be effective in the evaluation of the skin. In fact, the skin surrounding the ulceration was characterised by different values of electrical parameters as compared with healthy skin tissue. A statistically significant difference was found in the electrical parameters obtained for the healthy leg skin and the skin surrounding the ulceration. This study was to investigate the applicability of electrical parameters in the evaluation of the skin in lower leg ulcers. The electrical parameters can be used as an effective tool in assessing the condition of the skin, both healthy and surrounding the ulcerations. The most useful parameters in assessing skin condition using electrical parameters include min. IM, min. RE, min. f, Imagine part index, Phase index, and Magnitude index.

Patient experiences of people with leg ulcers during the COVID-19 pandemic

BACKGROUND

The COVID-19 pandemic affected the care of people with chronic leg ulcers (CLUs).

AIMS

To understand how people with CLUs perceived illness, health care and the public health emergency during the second wave of the COVID-19 pandemic.

METHODS

Twenty people attending a wound care clinic in Northern Italy participated in semi-structured interviews and a thematic analysis was conducted using the software Atlas.ti 9.

FINDINGS

Results show that most of the participants evaluated their healthcare experience as positive but differed in their perceptions of the changes brought about by the pandemic according to their varied illness experiences and perceived social support. Participants were grouped in four trajectories that provided insight into the construction of personalised support strategies for people with CLUs.

CONCLUSION

These results may help inform healthcare interventions and policies in the care of long-term conditions such as CLUs during a widespread emergency in future.

Cost-effectiveness analysis of the treatment with compressive therapy in the healing of venous ulcers

OBJECTIVE

to analyze the cost-effectiveness and calculate the incremental cost-effectiveness ratio of multilayer compressive treatment in relation to inelastic (Unna boot and short stretch) therapy according to the current literature.

METHOD

quantitative study about cost-effectiveness through modeling with the aid of TreeAge® software for construction of the decision tree. The anticipated assumptions were obtained by using secondary literature data to estimate the cost and effectiveness of the assumed parameters. A systematic literature review with meta-analysis was performed for this end.

RESULTS

the decision tree after Roll Back showed that the multilayer therapy dominated the alternatives in the base case, representing an intermediate cost per application, although with the highest effectiveness. The cost-effectiveness analysis graph also showed extended dominance of the Unna boot in relation to the short stretch bandage. The sensitivity analysis showed that multilayer bandage remains a more cost-effective alternative, within the threshold of willingness to pay.

CONCLUSION

the most cost-effective alternative was multilayer bandage, considered the gold standard in the literature. The second most cost-effective alternative was the Unna boot, the most used therapy in Brazil.

Planning exercise interventions as an adjunct treatment in managing venous leg ulcers: A qualitative study of nurses’ perspectives

OBJECTIVE

To explore clinicians' perspectives regarding strategies to support exercise interventions for people with venous leg ulcers.

DESIGN

1:1 interview was guided by the Behaviour Change Wheel (BCW) to collect thoughts from clinicians with experiences in managing venous leg ulcers.

SETTINGS

Clinical nurses in metropolitan/regional Victoria, Australia.

PARTICIPANTS

A convenience sample of 21 nurses (mean clinical experience 14 years) was recruited.

METHODS

We conducted semi-structured remote interviews. Transcripts were coded and analysed using a theory-driven thematic analysis, and interventions to support the implementation of exercise interventions were mapped across the BCW.

RESULTS

Strategies related to capability, opportunity and motivation components from the BCW were identified. The strategies reported to be important included: i) education of patients and family members; ii) the provision of consistent and clear exercise advice; iii) setting realistic and meaningful goals in light of challenges encountered by patients; iv) flexibility in how exercise programmes were organised/structured, particularly to facilitate rapid adoption; and v) clinician education.

CONCLUSIONS

In-depth qualitative interviews of nurses working with people with venous leg ulcers in Australia revealed multifactorial issues that potentially affect prescription of care regarding physical exercise. In order to improve and standardise future clinical practice, a clear focus of future research should address such issues.

How health literacy relates to venous leg ulcer healing: A scoping review

BACKGROUND

The level of personal health literacy of patients with venous leg ulcers is likely to affect their ability to self-manage their condition impacting on their adherence to treatment and influences healing and recovery outcomes.

OBJECTIVES

To scope existing research that examined the level of health literacy in venous leg ulcer patients, to identify how this may link to self-management behaviours (particularly physical activity and compression adherence), and venous leg ulcer healing outcomes.

METHODS

This scoping review was based on the PRISMA-ScR six-stage framework. We searched MEDLINE, EMBASE, the Cochrane Library, PsycInfo and Health, Open Grey, and Google Scholar for publications examining general and specific health literacy in those with venous leg ulcers and for those examining any potential links of health literacy with self-management/healing generally, published between 2000-2020. This search was guided by a published protocol; studies that described other types of ulcers or did not examine health literacy were excluded. After applying inclusion and exclusion criteria the initial search identified 660 articles.

RESULTS

We included five articles. Four studies used randomised controlled trials or experimental designs to test the effect of specific health literacy interventions on venous leg ulcer knowledge, compression therapy use, or healing outcomes. One study was a cross- sectional survey with qualitative elements, assessing health literacy in venous leg ulcer patients. Broadly, the research suggested that health literacy was suboptimal amongst those with venous leg ulcers, and health literacy interventions had limited effects on improving key venous leg ulcer specific outcomes.

CONCLUSION

This review provides a synthesis of extant literature examining health literacy in patients with venous leg ulcers. We identified a dearth of literature investigating the value of general and specific health literacy interventions in this space. Most importantly, no recent research on general health literacy and venous leg ulcers was identified, despite strong theoretical utility to do so. The few studies identified largely indicated that targeting health literacy of patients with venous leg ulcers is a viable area of research and intervention, encouraging future researchers and clinicians to consider patient health literacy in venous leg ulcer management.

Exploring healthcare provider and patient perspectives on current outpatient care of venous leg ulcers and potential interventions to improve their treatment: a mixed methods study in the ulcus cruris care project

Background

The project "Ulcus Cruris Care" aims to improve primary care for patients with venous leg ulcer (VLU) in General Practitioner (GP) practices using a complex intervention comprised of educational components, standardized treatment recommendations, computer-assisted documentation, and case management by non-physician medical assistants (MAs). Prior to implementing and testing the intervention components in general practices, in-depth exploration of current outpatient treatment of VLU patients and relevant implementation determinants was pursued.

Methods

A mixed-methods study explored views of GPs, MAs, and patients regarding current VLU outpatient care and the planned intervention components to identify potential implementation determinants. Data were collected through semi-structured guide-based telephone interviews (n = 29) and a survey questionnaire (n = 28). Interviews were transcribed verbatim. Analysis was inductive initially and finalized in a deductive-inductive approach based on domains of the Theoretical Domains Framework to support structuring of relevant implementation determinants. Survey data were analyzed descriptively.

Results

Current VLU outpatient care was described as frequently tailored to individual wounds and gradient. In general, workload was shared by GPs (diagnostics, counselling) and MAs (wound care). All care providers were aware of compression therapy, yet not all of them considered it essential for VLU care. Standardized operating procedures and educational components including e-learning were considered supportive. Stronger involvement of non-physician assistants was seen as opportunity to optimize VLU care. Concerns were identified regarding integration of software-supported case management into daily practice routines and regarding potential limitations in decision-making autonomy when using standard operating procedures.

Conclusions

Findings in this study emphasize a need for educational interventions addressing VLU care providers as well as patients, particularly with regards to compression therapy. The conception of the planned intervention appears to be adequate and a structured guideline-based case management might be a promising approach for optimization of VLU treatment.

Investigating Quality of Life Instrument Measurement Properties for Adults with Active Venous Leg Ulcers: A Systematic Review

The primary objective of this systematic review was to identify which quality of life instruments have been applied in published studies of patients with active venous leg ulcers. Our secondary objective was to map the measurement properties of each identified quality of life instrument and to inform future recommendations for clinical practice and research. We searched CINAHL, Ovid Medline, Ovid Emcare and ProQuest to identify studies published from 1 January 2000 to 31 July 2021. Eleven studies that utilised quality of life instruments in adults with active venous leg ulcers met the inclusion criteria. Thirteen quality of life instruments were identified as some studies utilised both generic and condition‐specific quality of life instruments. Six out of nine (6/9) instruments were rated ‘very good’ of methodological quality on internal consistency; 1/7 studies rated ‘adequate’ on reliability; 2/4 rated ‘adequate’ on content validity; 3/6 studies rated ‘adequate’ on structural validity; 5/6 rated ‘adequate’ on hypotheses testing for construct and 2/6 studies rated ‘adequate’ on responsiveness. There is limited evidence of measurement properties of quality of life instruments for people with active venous leg ulcers. The Venous Leg Ulcer Quality of Life Questionnaire (VLU‐QoL) could be provisionally recommended for use although from our review it is clear further studies to assess VLU‐QoL measurement properties are needed to inform future recommendations for clinical practice and research.

Effects of physical activity as an adjunct treatment on healing outcomes and recurrence of venous leg ulcers: A scoping review

Healing time is protracted and ulcer recurrence is common in patients with venous leg ulcers. Although compression is the mainstay treatment, many patients do not heal timely. Physical activity may be a clinically effective adjunct treatment to compression to improve healing outcomes. This scoping review provides a broad overview of the effect of physical activity as an adjunct treatment to compression on wound healing and recurrence. We followed the six-step framework developed by Arksey and O'Malley. We searched electronic databases and trial registration websites for relevant studies and ongoing trials. Two authors independently screened and selected articles. Findings were presented in a descriptive statistical narrative summary. We consulted and presented our findings to the wound consumer group to ensure the relevance of our study. Physical activity interventions in 12 out of the 16 eligible studies consisted of only one component, eight studies were resistance exercises, three studies reported ankle and/or foot range of motion exercises, and one study reported aerobic/walking exercises. The remaining four studies involved multicomponent exercise interventions. Resistance exercise combined with ankle and/or foot range of motion exercise minimised ulcer size on day 12 (intervention group: 4.55 ± 1.14 cm² vs. control group: 7.43 ± 0.56 cm² ) and improved calf muscle pump performance on day 8 (ejection fraction: 40%-65%; residual volume fraction: 56%-40%). We identified one study that reported ulcer recurrence rate with no clinical difference in the intervention group versus the control group (i.e., 12% in intervention vs. 5% in control). Our review identified that resistance exercise was the most common type of physical activity intervention trialled in the published literature. Resistance exercise combined with ankle and/or foot range of motion exercise appears to be effective adjunct treatments; however, the overall evidence is still relatively weak as most programmes had a short intervention period which limited clinical outcomes.

Patient Explanation of Adherence and Non-Adherence to Venous Leg Ulcer Treatment: A Qualitative Study

The aim of this study was to understand which factors influence patients’ adherence to venous leg ulcer treatment recommendations in primary care. We adopted a qualitative study design, conducting phone interviews with 31 people with venous leg ulcers in Melbourne, Australia. We conducted 31 semi-structured phone interviews between October and December 2019 with patients with clinically diagnosed venous leg ulcers. Participants recruited to the Aspirin in Venous Leg Ulcer Randomized Control Trial and Cohort study were invited to participate in a qualitative study, which was nested under this trial. We applied the Theoretical Domains Framework to guide the data analysis. The following factors influenced patients’ adherence to venous leg ulcer treatment: understanding the management plan and rationale behind treatment (Knowledge Domain); compression-related body image issues (Social Influences); understanding consequences of not wearing compression (Beliefs about Consequences); feeling overwhelmed because it’s not getting better (Emotions); hot weather and discomfort when wearing compression (Environmental Context and Resources); cost of compression (Environmental Context and Resources); ability to wear compression (Beliefs about Capabilities); patience and persistence (Behavioral Regulation); and remembering self-care instructions (Memory, Attention and Decision Making). The Theoretical Domains Framework was useful for identifying factors that influence patients’ adherence to treatment recommendations for venous leg ulcers management. These factors may inform development of novel interventions to optimize shared decision making and self-care to improve healing outcomes. The findings from this article will be relevant to clinicians involved in management of patients with venous leg ulcers, as their support is crucial to patients’ treatment adherence. Consultation with patients about VLU treatment adherence is an opportunity for clinical practice to be targeted and collaborative. This process may inform guideline development.