Cost consequences due to reduced ulcer healing times - analyses based on the Swedish Registry of Ulcer Treatment

Quality registry improves the data of chronic ulcers: Validation of Tampere Wound Registry

Quality registries are potential tools for improving health care documentation, but the quality and completeness of each registry should be ensured. This study aimed to evaluate the completion rate (completeness) and accuracy of data, first contact-to-registration time (timeliness), and case coverage of the Tampere Wound Registry (TWR) to assess whether it can be reliably used in clinical practice and for research purposes. Data from all 923 patients registered in the TWR between 5 June 2018 and 31 December 2020 were included in the analysis of data completeness, while data accuracy, timeliness and case coverage were analysed in those registered during the year 2020. In all analyses values over 80% were considered good and values over 90% excellent. The study showed that the overall completeness of the TWR was 81% and overall accuracy was 93%. Timeliness achieved 86% within the first 24 h, and case coverage was found to be 91%. When completion of seven selected variables was compared between TWR and patient medical records, the TWR was found to be more complete in five out of seven variables. In conclusion, the TWR proved to be a reliable tool for health care documentation and an even more reliable data source than patient medical records.

A qualitative study of patients' experiences of living with hard-to-heal leg ulcers

BACKGROUND

Patients with hard-to-heal leg ulcers are often older and have underlying conditions that contribute to making wound healing more difficult. Hard-to-heal leg ulcers are often treated in primary care and form a large part of the district nurse's work.

AIM

To describe patients' experiences of living with hard-to-heal leg ulcers.

METHODS

This qualitative study undertook 18 interviews with patients in primary care with hard-to-heal leg ulcers.

FINDINGS

A total of three categories were identified: 'Living with changes in everyday life', 'Being dependent on care', and 'Experiencing and dealing with suffering'. The patients described limitations in physical activity and changes in social interaction. Suffering was described in different ways and also resulted in coping strategies.

CONCLUSIONS

Living with hard-to-heal leg ulcers affects the patient's everyday life physically and mentally. Knowledge about the complexity of patients' experiences can contribute to better care and increased quality of life in a difficult situation.

Still engaged – healthcare staff’s engagement when introducing a new eHealth solution for wound management: a qualitative study

Background

eHealth solutions have often been considered favourable for improved effectiveness and quality in healthcare services for wound management. Staff engagement related to organisational changes is a key factor for successful development and implementation of a new eHealth solution, like a digital decision support systems (DDSS). It is essential to understand the engagement process in terms of sustainability, wellbeing in staff and efficiency in a long-term perspective. The aim of this study was to describe healthcare staff’s engagement during a 6-month test of an eHealth solution (DDSS) for wound management.

Methods

A qualitative design, including interviews conducted with healthcare staff working with wound management within primary, community and specialist care (n = 11) on two occasions: at the introduction of the solution and after 6 months, when the test period was over. Data were interpreted with qualitative content analysis.

Results

Healthcare staff’s descriptions from a 6-month test of an eHealth solution for wound management can be summarised as Engaging through meaning, but draining. The analysis revealed a result with three subcategories: Having a shared interest is stimulating, Good but not perfect and Exciting, but sometimes exhausting. The staff described their engagement as sustained through feelings of meaningfulness when using the eHealth solution, but limited by feelings of exhaustion due to heavy workload and lack of support and understanding from others.

Conclusions

The results indicate that the healthcare staff who tested the eHealth solution described themselves as individuals who easily become engaged when an idea and efforts felt meaningful. The staff needed resources to nourish engagement in their new role when implementing eHealth in the clinical everyday work of wound management. Allocating time and support are important to consider when planning for sustainable implementation of eHealth solutions in healthcare organisations.

Development of a model to predict closure of chronic wounds in Germany: Claims data analysis

Patients with chronic leg ulcer, pressure ulcer, or diabetic foot ulcer suffer from significant disease burden. With a view to improving healthcare provision sustainably, a predictive model of time to closure (time-to-event analysis) based on claims data was developed. To identify potential predictors of wound closure, clinical information absent from statutory health insurance (SHI) data was modelled. In patients with leg ulcers, age of the patient (hazard ratios [HR] 0.99), increasing number of comorbidities (HR 0.94), inpatient stays (HR 0.74), and treatment by a specialised wound care professional (HR 1.18) were significant predictors of time to closure (adjusted model). In almost all models, the number of inpatient stays and of comorbidities predicted a lower probability of healing. In addition, the age and the sex of the patient were found to be significant predictors in some models (leg ulcer: HR 0.99; pressure ulcer: HR 0.99). Increasing number of comorbidities and inpatient stays were predictors for closure time in all models. Since these predictors may give an indication of wound severity, further clinical information should be considered in future models, as also indicated by the moderate values of the c-statistics. This requires future data linkage between SHI and primary studies (eg, registers).

Pain and analgesics in patients with hard-to-heal ulcers: using telemedicine or standard consultations

OBJECTIVE

To compare consultations carried out via video with those performed in person for patients with painful, hard-to-heal ulcers, with a focus on ulcer pain and pain treatment. A further aim was to investigate predictors for pain and pain treatment.

METHOD

This was a register-based, quasi-experimental study based on data from the Swedish Registry of Ulcer Treatment (RUT). A total of 100 patients with hard-to-heal ulcers diagnosed via video consultation were compared with 1888 patients diagnosed in person with regard to pain assessment, intensity and treatment. Ulcer pain intensity was assessed by the visual analogue scale (VAS). Normally distributed variables (age, VAS) were compared between consultation groups using Student's t-test. Non-normally distributed variables (ulcer size, ulcer duration) were compared using the Mann-Whitney U-test, except for healing time, which was analysed with a log-rank test. Categorical variables (gender, ulcer aetiology and prescribed analgesics) were compared using Pearson's chi-square test (χ²). A p value of less than 0.05 was considered to indicate statistical significance. Predictors for pain and pain treatment were analysed in multiple regression analyses.

RESULTS

The results showed a high presence of pain; 71% of patients with pain reported severe ulcer pain. There was no significant difference in ability to assess pain by VAS in the group diagnosed via video consultation (90%) compared with the group diagnosed in person (86%) (χ², p=0.233). A significantly higher amount of prescribed analgesics was found for patients diagnosed via video (84%) compared with patients diagnosed by in-person assessment (68%) (χ², p=0.044). Predictors for high-intensity pain were female gender or ulcers due to inflammatory vessel disease, while the predictors for receiving analgesics were older age, longer healing time and being diagnosed via video consultation.

CONCLUSION

To identify, assess and treat ulcer pain is equally possible via video as by in-person consultation. The results of this study confirm that patients with hard-to-heal ulcers suffer from high-intensity ulcer pain, with a discrepancy between pain and pain relief. Further well-designed randomised controlled studies are necessary to understand how best to deploy telemedicine in ulcer pain treatment.

General practitioners' knowledge of leg ulcer treatment in primary healthcare: an interview study

Aim:

To describe general practitioners’ (GPs’) knowledge and the development of their knowledge regarding leg ulcer treatment when treating patients with leg ulceration at primary healthcare centers.

Background:

Earlier research regarding GPs’ knowledge of leg ulcer treatment in a primary healthcare context has focused primarily on the assessment of wounds and knowledge of wound care products. Less is known about GPs’ understandings of their own knowledge and knowledge development regarding leg ulceration in the everyday clinical context. This study, therefore, sets out to highlight these aspects from the GPs’ perspective.

Methods:

Semi-structured interviews were conducted with 16 individual GPs working at both private and county council run healthcare centers. The data were analyzed inductively using a thematic analysis.

Results:

Four themes were identified. ‘Education and training’ describe the GPs’ views regarding their knowledge and knowledge development in relation to leg ulcer treatment. ‘Experience’ refers to GPs’ thoughts about the importance of clinical experience when treating leg ulcers. ‘Prioritization’ describes the issues GPs raised around managing the different knowledge areas in their clinical work. ‘Time constraints’ explore the relationship between GPs’ sense of time pressure and their opportunities to participate in professional development courses.

Conclusions:

The study shows that the GPs working in primary healthcare are aware of the need for ongoing competence development concerning leg ulceration. They describe their current knowledge of leg ulcer treatment as insufficient and point to the lack of relevant courses that are adapted for their level of knowledge and the limited opportunities for clinical training.

Pain and analgaesics in patients with hard-to-heal ulcers: using telemedicine or standard consultations

OBJECTIVE

To compare consultations carried out via video with those performed in person for patients with painful, hard-to-heal ulcers, with a focus on ulcer pain and pain treatment. A further aim was to investigate predictors for pain and pain treatment.

METHOD

This was a register-based, quasi-experimental study based on data from the Swedish Registry of Ulcer Treatment (RUT). A total of 100 patients with hard-to-heal ulcers diagnosed via video consultation were compared with 1888 patients diagnosed in person with regard to pain assessment, intensity and treatment. Ulcer pain intensity was assessed by the visual analogue scale (VAS). Normally distributed variables (age, VAS) were compared between consultation groups using Student's t-test. Non-normally distributed variables (ulcer size, ulcer duration) were compared using the Mann-Whitney U-test, except for healing time, which was analysed with a log-rank test. Categorical variables (gender, ulcer aetiology and prescribed analgesics) were compared using Pearson's chi-square test (χ²). A p value of less than 0.05 was considered to indicate statistical significance. Predictors for pain and pain treatment were analysed in multiple regression analyses.

RESULTS

The results showed a high presence of pain; 71% of patients with pain reported severe ulcer pain. There was no significant difference in ability to assess pain by VAS in the group diagnosed via video consultation (90%) compared with the group diagnosed in person (86%) (χ², p=0.233). A significantly higher amount of prescribed analgesics was found for patients diagnosed via video (84%) compared with patients diagnosed by in-person assessment (68%) (χ², p=0.044). Predictors for high-intensity pain were female gender or ulcers due to inflammatory vessel disease, while the predictors for receiving analgesics were older age, longer healing time and being diagnosed via video consultation.

CONCLUSION

To identify, assess and treat ulcer pain is equally possible via video as by in-person consultation. The results of this study confirm that patients with hard-to-heal ulcers suffer from high-intensity ulcer pain, with a discrepancy between pain and pain relief. Further well-designed randomised controlled studies are necessary to understand how best to deploy telemedicine in ulcer pain treatment.

Bayesian Regression Model for a Cost-Utility and Cost-Effectiveness Analysis Comparing Punch Grafting Versus Usual Care for the Treatment of Chronic Wounds

Punch grafting is a traditional technique used to promote epithelialization of hard-to-heal wounds. The main purpose of this observational study was to conduct a cost-utility analysis (CUA) and a cost-effectiveness analysis (CEA) comparing punch grafting (n = 46) with usual care (n = 34) for the treatment of chronic wounds in an outpatient specialized wound clinic from a public healthcare system perspective (Spanish National Health system) with a three-month time horizon. CUA outcome was quality-adjusted life years (QALYs) calculated from EuroQoL-5D, whereas CEA outcome was wound-free period. One-way sensitivity analyses, extreme scenario analysis, and re-analysis by subgroups were conducted to fight against uncertainty. Bayesian regression models were built to explore whether differences between groups in costs, wound-free period, and QALYs could be explained by other variables different to treatment. As main results, punch grafting was associated with a reduction of 37% in costs compared to usual care, whereas mean incremental utility (0.02 ± 0.03 QALYs) and mean incremental effectiveness (7.18 ± 5.30 days free of wound) were favorable to punch grafting. All sensitivity analyses proved the robustness of our models. To conclude, punch grafting is the dominant alternative over usual care because it is cheaper and its utility and effectiveness are greater.

The characteristics and impact of hard-to-heal wounds: results of a standardised survey

The effective management of hard-to-heal wounds has increasingly important implications for those who provide wound care services within healthcare systems. The burden of wounds in the population continues to grow, as does the demand for wound care, against a backdrop of cost constraints and increasing expectations. The need to improve both outcomes and efficiency in wound care is therefore paramount and the time taken to heal wounds is an important factor in determining both. Survey methodology was used to collect data across 10 community wound care providers in the UK, Ireland, Finland, Norway and Denmark between February and August 2017. This allowed for analysis of wounds and their characteristics, dressing selection and nursing practice across a typical wound caseload. Data from 1057 wounds demonstrates that the characteristics and consequences of hard-to-heal wounds are different from improving wounds. However, wounds are, in general, treated in the same way, irrespective of whether they are hard-to-heal or improving, suggesting that the healing status of a wound is not a major factor in treatment selection. Early intervention to return hard-to-heal wounds to a healing trajectory may be a useful approach to improving efficiency in wound care.

Stratification of chronic and complex wounds according to healing characteristics: a retrospective study

OBJECTIVE

Wound risk-stratified analyses are clinically relevant as they can assist in identifying hard-to-heal wounds. The aim of the study is to develop risk categories for wound healing based on a limited number of reliably recordable clinical data.

METHOD

This retrospective study used observational data. The primary outcome measure was wound healing at the end of treatment and the secondary outcome measure was the time to wound healing. A stratification model using regression analyses was developed to assign the patients to risk categories for wound healing and the time-to-heal.

RESULTS

The study cohort comprised of 540 patients. The most common wound diagnoses were diabetic ulcers, wounds in irradiated areas and wound dehiscence after surgery. Average wound duration before starting treatment at the wound centre was 11.7 months. Healing was achieved in 382 (71%) wounds, after an average treatment time of 4.4 months. A total of four risk categories for wound healing were developed by combining wound diagnosis (favourable versus unfavourable) and duration (<3 months versus >3 months). These risk categories demonstrated healing percentages ranging from 69-97% (p=0.0004) and mean time-to-healing varying from 2.7-5.9 months (p=0.01).

CONCLUSION

Using two clinical wound variables, diagnosis and duration, stratification categories were identified with significant associations with wound healing outcomes. Longer wound duration and unfavourable diagnoses, when combined into unfavourable risk categories, were associated with a lower percentage of wound healing and a longer treatment time until healing.

General practitioners' perceptions of their role and their collaboration with district nurses in wound care

Aim

To explore the perceptions of general practitioners (GPs) regarding their role and their collaboration with district nurses (DNs) in the management of leg ulcers in primary healthcare.

Background

Earlier research regarding the treatment of leg ulcers in a primary care context has focussed primarily on wound healing. Less is known about GPs’ understandings of their role and their collaboration with DNs in the management of leg ulcers. Since the structured care of patients with leg ulcers involving both GP and DN is currently rather uncommon in Swedish primary care, this study sets out to highlight these aspects from the GP’s perspective.

Methods

Semi-structured individual interviews with 16 GPs including both private and county council run healthcare centres. Thematic analysis was used to analyse the data.

Results

Four themes were identified. The first theme: ‘role as consultant and coordinator’ shows how the GPs perceived their role in wound care. In the second theme: ‘responsibility for diagnosis’ the GPs’ views on responsibility for wound diagnosis is presented. The third theme: ‘desire for continuity’ is based on the GPs’ desire for continuity concerning various aspects. In the fourth theme: ‘collaboration within the organisation’ the importance of the organisation for collaboration between GPs and DNs is presented.

Conclusions

The GP’s often work on a consultation-like basis and feel that they become involved late in the patients’ wound treatment. This can have negative consequences for the medical diagnosis and, thereby, lead to a prolonged healing time for the patient. Shortcomings regarding collaboration are mainly attributed to organisational factors.

Comparing video consultation with inperson assessment for Swedish patients with hard-to-heal ulcers: registry-based studies of healing time and of waiting time

OBJECTIVES

To investigate differences in ulcer healing time and waiting time between video consultation and inperson assessment for patients with hard-to-heal ulcers.

SETTING

Patients treated at Blekinge Wound Healing Centre, a primary care centre covering the whole of Blekinge county (150 000 inhabitants), were compared with patients registered and treated according to the Registry of Ulcer Treatment, a Swedish national web-based quality registry.

PARTICIPANTS

In the study for analysing ulcer healing time, the study group consisted of 100 patients diagnosed through video consultation between October 2014 and September 2016. The control group for analysing healing time consisted of 1888 patients diagnosed through inperson assessment during the same period. In the study for analysing waiting time, the same study group (n=100) was compared with 100 patients diagnosed through inperson assessment.

PRIMARY AND SECONDARY OUTCOME MEASURES

Differences in ulcer healing time were analysed using the log-rank test. Differences in waiting time were analysed using the Mann-Whitney U test.

RESULTS

Median healing time was 59 days (95% CI 40 to 78) in the study group and 82 days (95% CI 75 to 89) in the control group (P<0.001). Median waiting time was 25 days (range: 1-83 days) in the study group and 32 days (range: 3-294 days) for patients diagnosed through inperson assessment (P=0.017). There were no significant differences between the study group and the control group regarding age, gender or ulcer size.

CONCLUSIONS

Healing time and waiting time were significantly shorter for patients diagnosed through video consultation compared with those diagnosed through inperson assessment.

Treatment of chronic ulcers

Chronic ulcers (CUs) are a major cause of morbidity and mortality with increasing prevalence, in part due to the ageing population, and an increase of risk factors such as diabetes and obesity. CUs are caused by numerous diseases including venous dysfunction, diabetes mellitus, infections, peripheral neuropathy, pressure, and atherosclerosis. The current standard therapy for CUs includes compression, surgical débridement, infection control, and adequate wound dressings. As a high percentage of CUs do not adequately heal or quickly relapse with standard treatments, additional therapeutic approaches are pursued, termed “advanced wound care therapies”. Here, an overview on commonly applied therapies lacking significant evidence for wound healing is reviewed, followed by therapies with significant evidence supporting the routine use in the treatment of CUs, and a short outlook in a possible future wound treatment landscape.

To give a résumé, the presented literature reveals that most of the commonly applied topical and advanced ulcer treatments largely lack solid scientific evidence for the induction or acceleration of wound healing. Surprisingly only “classical” treatments such as wound cleansing, débridement and compression have significant evidence. Novel approaches such as bilayered skin reconstructs, cell suspensions or extracorporal shock waves seem promising. Considering the increasing number of ulcer patients, there is a strong need for further basic research to fully understand all factors involved in wound development and healing of the various ulcer pathophysiologies, and the urgent need for prospective clinical trials comparing the various treatment options.

District nurses' experiences of caring for leg ulcers in accordance with clinical guidelines: a grounded theory study

This qualitative study used the grounded theory method to investigate district nurses' experiences of caring for leg ulcers in accordance with clinical guidelines at seven primary health care centres in Stockholm, Sweden. Group interviews were conducted with 30 nurses. The results describe how district nurses strive to stay on track in order to follow clinical guidelines and remain motivated despite prolonged wound treatment and feelings of hopelessness. Three main obstacles to following the guidelines were found. District nurses used compensating strategies so the obstacles would not lead to negative consequences. If the compensating strategies were insufficient, perceived prolonged wound treatment and feelings of hopelessness could result. District nurses then used motivating strategies to overcome these feelings of hopelessness. Sometimes, despite the motivating strategies, treatment in accordance with guidelines could not be achieved. With some patients, district nurses had to compromise and follow the guidelines as far as possible.

Wound management for the 21st century: combining effectiveness and efficiency

Treatment of wounds of different aetiologies constitutes a major part of the total health care budget. It is estimated that 1·5-2 million people in Europe suffer from acute or chronic wounds. These wounds are managed both in hospitals and in community care. The patients suffering from these wounds report physical, mental and social consequences of their wounds and the care of them. It is often believed that the use of wound dressings per se is the major cost driver in wound management, whereas in fact, nursing time and hospital costs are together responsible for around 80-85% of the total cost. Healing time, frequency of dressing change and complications are three important cost drivers. However, with the use of modern, advanced technology for more rapid wound healing, all these cost drivers can be substantially reduced. A basic understanding of the terminology and principles of Health Economics in relation to wound management might therefore be of interest.

Treating patients with venous leg ulcers in the acute setting: part 1

Leg ulcers present with a variety of aetiologies, sometimes in combination. The most common aetiology is venous, with treament involving compression, elevation and exercise; the most common treatment setting is the community. However, people with leg ulcers do sometimes require admission to hospital for conditions and situations which may, or may not, be ulcer-related. There is a lack of contemporary evidence on the experience of inpatients and insufficient analysis of the impact on healing and complications to the lower limb when patients with leg ulcers and compression therapy are admitted to hospital. Admission to hospital presents an ideal opportunity for a focus on leg care and potentially enhancing healing rates of patients. The reality for patients with venous leg ulceration being treated with compression therapy is that this does not continue if they are admitted to hospital as inpatients-having been interrupted for MRSA screening and skin assessment, often no-one is available to reinstate the therapy. This article highlights key issues in the ongoing care of these patients and offers suggestions for basic management until a more acceptable and evidence-based solution can be found. Part 2 will deal with the preparation for discharge and options for the treatment of patients who are not already in the care of community services.

Assessing and comparing the quality of wound centres: a literature review and benchmarking pilot

Multidisciplinary wound centres are currently facing an increase in both the incidence of wounds and the complexity of care. This has resulted in rising costs and increased interest in the effectiveness of treatments. Little evidence is available regarding optimal wound centre organisation and effectiveness; therefore, measuring the quality of wound centres has become more important. This study aims to assess the evidence concerning quality by describing the state of the art of wound centres and organisational effectiveness by developing indicators of quality and by assessing their suitability in a pilot study. A multi-method approach was used: a literature review performed resulted in the development of an indicator list that was consequently subjected to expert review, and a benchmark study was completed comparing eight wound centres in the Netherlands. We thus provide a description of the relevant state-of-the-art aspects of wound centre organisation, which were multidisciplinary collaborations and standardisation of the organisation of care. In literature, significant patient-related effects were observed in improved healing rates and decreased costs. A total of 48 indicators were selected. The indicator list was tested by a benchmark study pilot. In practice, the outcome indicators were especially difficult to generate. Six indicators regarding structure, three regarding process and five regarding outcome proved feasible to measure and improve quality of wound centres.

Impact of UK NICE clinical guidelines 168 on referrals to a specialist academic leg ulcer service

Background

Leg ulcers are a common cause of morbidity and disability and result in significant health and social care expenditure. The UK National Institute for Health and Care Excellence (NICE) Clinical Guideline (CG)168, published in July 2013, sought to improve care of patients with leg ulcers, recommending that patients with a break in the skin below the knee that had not healed within two weeks be referred to a specialist vascular service for diagnosis and management.

Aim

Determine the impact of CG168 on referrals to a leg ulcer service.

Methods

Patients referred with leg ulceration during an 18-month period prior to CG168 (January 2012–June 2013) and an 18-month period commencing six months after (January 2014–June 2015) publication of CG168 were compared.

Results

There was a two-fold increase in referrals (181 patients, 220 legs vs. 385 patients, 453 legs) but no change in mean age, gender or median-duration of ulcer at referral (16.6 vs. 16.2 weeks). Mean-time from referral to specialist appointment increased (4.8 vs. 6 weeks, p = 0.0001), as did legs with superficial venous insufficiency (SVI) (36% vs. 44%, p = 0.05). There was a trend towards more SVI endovenous interventions (32% vs. 39%, p = 0.271) with an increase in endothermal (2 vs. 32 legs, p = 0.001) but no change in sclerotherapy (24 vs. 51 legs) treatments. In both groups, 62% legs had compression. There was a reduction in legs treated conservatively with simple dressings (26% vs. 15%, p = 0.0006).

Conclusions

Since CG168, there has been a considerable increase in leg ulcer referrals. However, patients are still not referred until ulceration has been present for many months. Although many ulcers are multi-factorial and the mainstay of treatment remains compression, there has been an increase in SVI endovenous intervention. Further efforts are required to persuade community practitioners to refer patients earlier, to educate patients and encourage further investment in chronically underfunded leg ulcer services.