Eliciting patients' preferences for elastic compression stocking therapy after deep vein thrombosis: potential for improving compliance

Budget Impact of Three Improvement Targets for Compression Therapy for Patients with Deep Venous Thrombosis in The Netherlands

BACKGROUND AND OBJECTIVE

Compression therapy following deep venous thrombosis in the Netherlands is suboptimal. We assessed the budget impact of targeted care improvements.

METHODS

We calculated the per-patient and population healthcare resource use and costs concerning 26,500 new patients each year in the Netherlands for the current pathways in region North Holland (divided into two parts: NH-A and NH-B) and region Limburg. Next, we assessed the impact of three improvement targets: optimizing initial compression therapy, early consultation of an occupational therapist, and tailored duration of elastic compression stocking therapy. Inputs were based on interview (n = 30) and survey data (n = 114), literature, and standard prices. The robustness of the results was tested by sensitivity analyses.

RESULTS

The current per-patient costs for a 2-year episode were €1046 (NH-A), €947 (NH-B), and €1256 (Limburg). The improvements led to direct savings for region Limburg (€4.7 million). Population costs increased in the first year for NH-A (+ €3.5 million) and NH-B (+ €6.4 million), and decreased in the second and third year resulting in a cost reduction for NH-A (- €2.2 million) but not for NH-B (+ €0.6 million). Workload for occupational therapists and internists in North Holland increased, and workload for home care nurses decreased in all regions.

CONCLUSIONS

This study provides a detailed insight into current costs and healthcare resource use associated with compression therapy and the potential impact of implementing three improvement targets. We showed that the improvements resulted in considerable cost savings within 3 years after implementation for region NH-A and Limburg.

[Medical compression stockings for chronic venous diseases and lymphedema : Scientific evidence and results of a patient survey on quality of care]

BACKGROUND AND AIMS

Medical compression stockings (MCS) are indicated for chronic venous insufficiency (CVI) of all stages and are an indispensable component in lymphedema therapy. In all, 8% of the German population has been prescribed MCS by a physician-more women than men (12% vs. 5%), and especially persons aged 60 years and older (17%). Patient adherence is relevant for successful treatment with MCS. We examined MCS use from the patient's perspective.

PATIENTS AND METHODS

This study examined the quality of care through structured interviews with 414 representative users in 2019. Findings are discussed taking into consideration scientific evidence on the efficacy of MCS.

RESULTS

Venous conditions are the most common reason for prescription (44%), followed by lymphedema (22%) or multiple indications (27%). Patients generally wear MCS daily and on average 11 h/day. In all, 89% of patients were satisfied or very satisfied with MCS, whereby efficacy was dependent on the indication. This reflects the extensive scientific evidence on the clinical efficacy of MCS. An important factor for patient adherence is physician training and education.

CONCLUSION

MCS are well accepted by patients. When prescribing them, practical aspects such as donning and doffing, recommended wearing time and frequency, and the mechanism of action of MCS should be clearly communicated.

Using the Functional Resonance Analysis Method to explore how elastic compression therapy is organised and could be improved from a multistakeholder perspective

OBJECTIVES

Elastic compression stocking (ECS) therapy is an important treatment for patients with deep venous thrombosis (DVT) and chronic venous insufficiency (CVI). This study aimed to provide insight into the structure and variability of the ECS therapy process, its effects on outcomes, and to elicit improvement themes from a multiple stakeholder perspective.

DESIGN

Thirty semi-structured interviews with professionals and patients were performed. The essential functions for the process of ECS therapy were extracted to create two work-as-done models using the Functional Resonance Analysis Method (FRAM). These findings were used to guide discussion between stakeholders to identify improvement themes.

SETTING

Two regions in the Netherlands, region Limburg and region North-Holland, including an academic hospital and a general hospital and their catchment region.

PARTICIPANTS

The interviewees were purposely recruited and included 25 healthcare professionals (ie, general practitioners, internists, dermatologists, nurses, doctor's assistants, occupational therapists, home care nurses and medical stocking suppliers) and 5 patients with DVT or CVI.

RESULTS

Two FRAM models were created (one for each region). The variability of the functions and their effect on outcomes, as well as interdependencies between functions, were identified. These were presented in stakeholder meetings to identify the structure of the process and designated variable and uniform parts of the process and its outcomes. Ultimately, six improvement themes were identified: dissemination of knowledge of the entire process; optimising and standardising initial compression therapy; optimising timing to contact the medical stocking supplier (when oedema has disappeared); improving the implementation of assistive devices; harmonising follow-up duration for patients with CVI; personalising follow-up and treatment duration in patients with DVT.

CONCLUSIONS

This study provided a detailed understanding of how ECS therapy is delivered in daily practice by describing major functions and variability in performances and elicited six improvement themes from a multistakeholder perspective.

Compression stockings to prevent postthrombotic syndrome: Literature overview and presentation of the CELEST trial

Postthrombotic syndrome (PTS) is a burdensome and costly complication of deep vein thrombosis (DVT) that develops in 20%-40% of patients within 2 years after proximal DVT. In the absence of effective curative treatment, management of PTS relies on its prevention after DVT. The effectiveness of elastic compression stockings (ECS) to prevent PTS is uncertain. We present an overview of published studies assessing the efficacy of ECS to prevent PTS and present the protocol for the CELEST clinical trial. While previous open-label randomized trials have reported a 50% risk reduction in PTS in patients treated with >30 mm Hg ankle pressure ECS, a large double-blind trial reported no effect of ECS. We discuss the main potential limitations of these trials, including a placebo effect and suboptimal compliance to ECS. We present the protocol of the CELEST double-blind randomized trial comparing 2 years of high strength (ankle pressure 35 mm Hg) versus lower strength (ankle pressure 25 mm Hg) ECS in the prevention of PTS after a first acute symptomatic, unilateral, proximal DVT. The use of lower-strength ECS than that used in previous studies should favor compliance. CELEST may provide important evidence about the efficacy of ECS in the prevention of PTS after DVT. The results will be interpreted in the light of results from recent clinical trials assessing ECS for PTS prevention that reported that the duration of ECS use should be tailored to the individual, if ECS are efficacious in the prevention of PTS.

Patient values and preferences regarding VTE disease: a systematic review to inform American Society of Hematology guidelines

Values and preferences relate to the importance that patients place on health outcomes (eg, bleeding, having a deep venous thrombosis) and are essential when weighing benefits and harms in guideline recommendations. To inform the American Society of Hematology guidelines for management of venous thromboembolism (VTE) disease, we conducted a systematic review of patients' values and preferences related to VTE. We searched Medline, Embase, Cochrane Central Register of Controlled Trials, PsycINFO, and the Cumulative Index to Nursing and Allied Health Literature from inception to April of 2018 (PROSPERO-CRD42018094003). We included quantitative and qualitative studies. We followed Grading of Recommendations Assessment, Development and Evaluation (GRADE) guidance for rating the certainty and presenting findings for quantitative research about the relative importance of health outcomes and a grounded theory approach for qualitative thematic synthesis. We identified 14 quantitative studies (2465 participants) describing the relative importance of VTE-related health states in a widely diverse population of patients, showing overall small to important impact on patients' lives (certainty of the evidence from low to moderate). Additionally, evidence from 34 quantitative studies (6424 participants) and 15 qualitative studies (570 participants) revealed that patients put higher value on VTE risk reduction than on the potential harms of the treatment (certainty of evidence from low to moderate). Studies also suggested a clear preference for oral medication over subcutaneous medication (moderate certainty). The observed variability in health state values may be a result of differences in the approaches used to elicit them and the diversity of included populations rather than true variability in values. This finding highlights the necessity to explore the variability induced by different approaches to ascertain values.

O cotidiano de idosos com insuficiência venosa que usam meia elástica de compressão

Objetivo: Compreender o cotidiano de idosos com insuficiência venosa que usam meia elástica de compressão. Métodos: Pesquisa fenomenológica que entrevistou 13 idosos atendidos em Unidades Básicas de Saúde no estado de Minas Gerais, entre novembro de 2017 e janeiro de 2018. Os depoimentos foram organizados em categorias e discutidos segundo o referencial da fenomenologia social de Alfred Schütz e literatura temática. Resultados: Emergiram das entrevistas as categorias que explicitam a perspectiva dos participantes sobre seu dia a dia com a meia elástica de compressão: “alívio dos principais sintomas da insuficiência venosa”, “adversidades que permeiam o uso das meias elásticas de compressão” e “uso de meia elástica de compressão em longo prazo”. Conclusão: Para os idosos com insuficiência venosa crônica, o uso da meia elástica de compressão promove alívio dos sintomas, porém requer ajuda para calçar e descalçar e provoca sensação de calor e desconforto nos membros inferiores. Os idosos esboçaram a expectativa de continuar usando a meia elástica em longo prazo com vistas a controlar a recidiva de úlcera varicosa. Valorizar as adversidades relacionadas ao uso desse dispositivo de compressão poderá auxiliar esses idosos a ampliar sua autonomia e capacidade funcional comprometidas pela insuficiência venosa.

Everyday life of elderly with venous insufficiency, who use elastic compression socks

Objective: To comprehend every day of older people with venous insufficiency, who use elastic compression socks. Methods: Phenomenological research that interviewed 13 elderly attended Basic Health Units in the state of Minas Gerais, between November 2017 to January 2018. The depositions were organized in categories and discussed according to the Alfred Schütz social phenomenology and theme literature. Results: Emerged from the interviews that make explicit the perspective of the participants regarding their everyday activities with compression elastic socks: “main symptoms of the venous insufficiency relieved”, “adversities that permeate the use of elastic compression socks” and “long term use of compression elastic socks”. Conclusion: For elderly people with chronic venous insufficiency, the use of elastic compression socks promotes relieve of the symptoms; however, it demands help to put them on and take them off and provokes heat sensation and discomfort in the limbs. The elderly showed the expectation to continue the long term use of the elastic sock aiming at avoiding the relapse of varicose ulcer. To validate the adversities related to the use of this compression device may help the elderly to broaden their autonomy and functional capacity, which may be compromised by venous insufficiency.

Prevention and treatment of the post-thrombotic syndrome

Post thrombotic syndrome (PTS) is a common chronic complication of deep vein thrombosis of the leg (DVT). Treatment options are limited therefore emphasis is placed on its prevention. Several risk factors have been recognized, but were so far not used for risk stratification or translation into prediction models. Early interventions did not yet result in more successful preventive treatment strategies; for the acute phase of DVT there is equipoise on the value of elastic compression, as well as on catheter directed thrombolysis. There are no drugs specifically targeted at PTS prevention. The use of anticoagulant medication such as direct oral anticoagulants (DOACs) might decrease PTS incidence, but this needs to be corroborated. Both research into more effective treatment options as well as future PTS management may benefit from a uniform diagnostic strategy and the use of prediction rules to better allocate treatment and thereby increase treatment efficacy.

Control of lower extremity edema in patients with diabetes: Double blind randomized controlled trial assessing the efficacy of mild compression diabetic socks

AIMS

Persons with diabetes frequently present with lower extremity (LE) edema; however, compression therapy is generally avoided for fear of compromising arterial circulation in a population with a high prevalence of peripheral arterial disease. This double blind randomized controlled trial (RCT) assessed whether diabetic socks with mild compression could reduce LE edema in patients with diabetes without negatively impacting vascularity.

METHODS

Eighty subjects with LE edema and diabetes were randomized to receive either mild-compression knee high diabetic socks (18-25mmHg) or non-compression knee high diabetic socks. Subjects were instructed to wear the socks during all waking hours. Follow-up visits occurred weekly for four consecutive weeks. Edema was quantified through midfoot, ankle, and calf circumferences and cutaneous fluid measurements. Vascular status was tracked via ankle brachial index (ABI), toe brachial index (TBI), and skin perfusion pressure (SPP).

RESULTS

Seventy-seven subjects (39 controls and 38 mild-compression subjects) successfully completed the study. No statistical differences between the two groups in terms of age, body mass index, gender, and ethnicity. Repeated measures analysis of variance and Sidak corrections for multiple comparisons were used for data analyses. Subjects randomized to mild-compression diabetic socks demonstrated significant decreases in calf and ankle circumferences at the end of treatment as compared to baseline. LE circulation did not diminish throughout the study with no significant decreases in ABI, TBI or SPP for either group.

CONCLUSIONS

Results of this RCT suggest that mild compression diabetic socks may be effectively and safely used in patients with diabetes and LE edema.

Medical Treatment for Postthrombotic Syndrome

Deep vein thrombosis (DVT) is a prevalent disease. About 20 to 30% of patients with DVT will develop postthrombotic syndrome (PTS) within months after the initial diagnosis of DVT. There is no gold standard for diagnosis of PTS, but clinical signs include pitting edema, hyperpigmentation, phlebectatic crown, venous eczema, and varicose veins. Several scoring systems have been developed for diagnostic evaluation. Conservative treatment includes compression therapy, medications, lifestyle modification, and exercise. Compression therapy, the mainstay and most proven noninvasive therapy for patients with PTS, can be prescribed as compression stockings, bandaging, adjustable compression wrap devices, and intermittent pneumatic compression. Medications may be used to both prevent and treat PTS and include anticoagulation, anti-inflammatories, vasoactive drugs, antibiotics, and diuretics. Exercise, weight loss, smoking cessation, and leg elevation are also recommended. Areas of further research include the duration, compliance, and strength of compression stockings in the prevention of PTS after DVT; the use of intermittent compression devices; the optimal medical anticoagulant regimen after endovascular therapy; and the role of newer anticoagulants as anti-inflammatory agents.