Evidence-based (S3) Guidelines for Diagnostics and treatment of venous leg ulcers - Answer to Dr Bertolini

Assessing the healthcare costs associated with venous leg ulcer compression bandages - A scoping review

AIM

To determine the monetary costs identified in economic evaluations of treatment with compression bandages among adults with venous leg ulcers (VLU).

METHOD

A scoping review of existing publications was conducted in February 2023. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were used.

RESULTS

Ten studies met the inclusion criteria. To place the costs of treatment into context, these are reported in conjunction with the healing rates. Three comparisons were made: 1.4 layer compression versus no compression (3 studies). One study reported that 4 layer compression was more expensive than usual care (£804.03 vs £681.04, respectively), while the 2 other studies reported the converse (£145 vs £162, respectively) and all costs (£116.87 vs £240.28 respectively). Within the three studies, the odds of healing were statistically significantly greater with 4 layer bandaging (OR: 2.20; 95% CI: 1.54-3.15; p = 0.001).; 2.4 layer compression versus other compression (6 studies). For the three studies reporting the mean costs per patient associated with treatment (bandages alone), over the treatment period, analysis identified a mean difference (MD) in costs for 4 layer vs comparator 1 (2 layer compression, short-stretch compression, 2 layer compression hosiery, 2 layer cohesive compression, 2 layer compression) of -41.60 (95% CI: 91.40 to 8.20; p = 0.10). The OR of healing for 4 layer compression vs comparator 1 (2 layer compression, short-stretch compression, 2 layer compression hosiery, 2 layer cohesive compression, 2 layer compression) is: 0.70 (95% CI: 0.57-0.85; p = 0.004). For 4 layer vs comparator 2 (2 layer compression) the MD is: 14.00 (95% CI: 53.66 to -25.66; p < 0.49). The OR of healing for 4 layer compression vs comparator 2 (2 layer compression) is: 3.26 (95% CI: 2.54-4.18; p < 0.00001). For comparator 1 (2 layer compression, short-stretch compression, 2 layer compression hosiery, 2 layer cohesive compression, 2 layer compression) vs comparator 2 (2 layer compression) the MD in costs is: 55.60 (95% CI: 95.26 to -15.94; p = 0.006). The OR of healing with Comparator 1 (2 layer compression, short-stretch compression, 2 layer compression hosiery, 2 layer cohesive compression, 2 layer compression) is: 5.03 (95% CI:4.10-6.17; p < 0.00001). Three studies presented the mean annual costs per patient associated with treatment (all costs). The MD is 172 (150-194; p = 0.401), indicating no statistically significant difference in costs between the groups. All studies showed faster healing rates in the 4 layer study groups. 3. Compression wrap versus inelastic bandage (one study). Compression wrap was less expensive than inelastic bandage (£201 vs £335, respectively) with more wounds healing in the compression wrap group (78.8%, n = 26/33; 69.7%, n = 23/33).

CONCLUSION

The results for the analysis of costs varied across the included studies. As with the primary outcome, the results indicated that the costs of compression therapy are inconsistent. Given the methodological heterogeneity among studies, future studies in this area are needed and these should use specific methodological guidelines to generate high-quality health economic studies.

Effect of educational interventions on wound healing in patients with venous leg ulceration: A systematic review and meta-analysis

Educational interventions for patients with venous leg ulceration (VLU) may promote adherence and self-management, however, their effect on wound healing is unclear. A systematic literature search was performed and randomised controlled trials with a focus on educational interventions were included. Wound healing was analysed by assessing wound healing rate, ulcer size, and the PUSH Score. Additional outcomes comprised pain, quality of life, and functional ability. The study protocol for this work is registered at PROSPERO 2020 (ID: CRD42021286152). Nine studies were included in this meta-analysis. The odds ratio for wound healing was 1.91 (95% CI, 0.99-3.67, P = .053) in favour of educational interventions compared to usual care. Ulcer size reduction was higher (MD: -7.22; 95% CI, -11.91 to -2.53, P = .003) in patients following educational interventions. Included studies also showed significant effects on pain, quality of life, and functional analysis, though no quantitative synthesis was feasible. The overall risk of bias showed some concerns. Educational interventions aim to actively involve patients in their treatment, thereby appearing to be able to have a positive impact on wound healing within 12 weeks. Consequently, integrating educational approaches to routine wound care may be a promising strategy to improve treatment of VLU.

Effectiveness of implementation strategies for venous leg ulcer guidelines: A systematic review

BACKGROUND

The aim of clinical practice guidelines (CPGs) is to improve patient care; however inconsistencies between recommended practice and what actually happens in clinical practice continues. Venous Leg Ulcers (VLUs) have a significant negative impact on patients' quality of life and it is acknowledged that managing people with venous leg ulcers is protracted and costly. The aim of this review is to identify the most effective strategies to implement clinical practice guidelines for the management of VLUs by health care professionals in the hospital, outpatient, home and community setting.

METHODS

A systematic review guided by methods from the Cochrane Effective Practice and Organisation of Care (EPOC) group was undertaken to identify implementation strategies for VLU clinical practice guidelines. Eligible studies were identified via systematic electronic searches of Medline, Embase, CINHAL and the Cochrane Library.

RESULTS

We identified 142 potential studies of which one randomised controlled trial met the inclusion criteria. Following an analysis of the included study, it is not possible to recommend one implementation strategy over another when implementing practice guidelines for people with VLUs.

CONCLUSION

We identified a limited evidence base for the effectiveness of implementation strategies for VLU CPGs. No one implementation strategy is better than another to facilitate VLU CPG implementation by health care professionals in hospital, outpatient, home or community settings.

Development of an accurate nursing program based on function in chronic venous leg ulcers: protocol for matching function status with nursing interventions using the Delphi survey

Objective

Venous leg ulceration (VLU) is one of the complications of lower extremity venous reflux and reflux disorder of severe diseases, with many adverse effects on patient’s work and life. Nowadays, more and more patients with VLU accept wound care in community setting. Clinical nurses generally take care of the patients based on their own experiences. Healing in VLU is an incredibly complex process, which puzzles even experts. The majority of general nurses do not have this level of expertise, especially those nurses serving in community. Function is the basis of nursing activities. Patients always show different clinical manifestations and self-care abilities due to various function states, which cannot be reflected completely by the existing nursing practice. How to describe nursing practice standardized in order to demonstrate the effectiveness of interventions and facilitate interdisciplinary communication is another urgent problem. Therefore, the aim of this project is to develop an accurate nursing program based on function in chronic venous leg ulcers, which can both satisfy the needs of patients and promote nursing revolution.

Methods

This study will use International Classification of Functioning Disability and Health as a framework to choose suitable functions and to filter function classification standards of chronic venous leg ulcers through evidence-based systematic research. Nursing interventions related to VLU are selected based on Nursing Interventions Classification, adding other nursing activities by methods of evidence-based systematic review and clinical observation. Then, nursing interventions and function status are matched through steering committee. Finally, the Delphi survey method is adopted to make nursing program native and scientific.

Conclusions

This study is expected to be very significant and meaningful in using standardized nursing terminology. The nursing program established could better meet the needs of both patients with chronic venous leg ulcers and clinical nurses, promoting the development of wound specialist and standardized nursing language.