Comparative cost-effectiveness of four-layer bandaging in the treatment of venous leg ulceration

A Systematic Review of Model-Based Economic Evaluations of Treatments for Venous Leg Ulcers

OBJECTIVE

The aim of this review was to identify, and assess the quality of, published model-based economic evaluations relating to treatments for patients with venous leg ulcers to help inform future decision-analytic models in this clinical area.

METHODS

A systematic literature search was performed on six electronic databases, from database inception until 21 May 2018. Search results were screened against predefined criteria by two independent reviewers. Data was then extracted from the included studies using a standardised form, whilst the decision-analytic model-specific Philips Checklist was used to assess quality and to inform model critique.

RESULTS

A total of 23 models were identified, 12 studies used a Markov modelling approach, five used decision trees and six studies did not detail the model type. Studies were predominantly from the National Health Service (NHS)/payer perspective, with only two taking a societal perspective. Interventions were wide ranging, but dressing technologies (11/23) were most common. The intervention studied was found to be dominant in 22/23 studies. The reporting quality of papers was mostly low, with evidence behind model structures, time horizons and data selection consistently underreported across the included papers.

CONCLUSIONS

This review has identified a sizeable literature of model-based economic evaluations, evaluating treatments for venous leg ulcers. However, the methods used to conduct such studies were generally poorly reported. In particular, the reporting of evidence surrounding the model structure, justification of the time horizon used and the rationale for selecting data inputs should be focused on in any future models developed.

Cost-Effectiveness: Seeking Value for Money in Lower Extremity Wound Management

This article discusses the different methods of evaluating cost in relation to the outcomes of treatment, and reviews the evidence of cost-effectiveness (CE) in the management of chronic leg ulceration. In essence, the CE argument revolves around the need to demonstrate outcomes of treatment in relation to particular levels of financial input by the health providers. High CE allows for either the same number of patients to be treatedmore efficiently (at a lower cost) ormore patients to be treated for the same financial input. Areview ofmedical and nursing databases (Medline, Embase, and Cinahl) identified studies of CE of dressing materials (n = 8), use of compression therapy (n = 4), and other treatments (n = 2). In addition, 5 research groups have undertaken studies to evaluate the relative CE of different systems of care. Overall conclusionsare that modern wound dressings provide a more costeffective alternative to saline gauze, whereas the evidence relating to the use of tissue-engineered skin is less clear. The use of compression bandaging is substantially more costeffective when compared with a system of care where compression is not systematically offered. The systems that offer compression are not only cost-effective but also lead to reductions in absolute cost. The evaluation of CE is likely to become an ever-increasing part of wound care evaluation as we strive to achieve greater efficiency in the use of scarce health resources.

VenUS IV (Venous leg Ulcer Study IV) - compression hosiery compared with compression bandaging in the treatment of venous leg ulcers: a randomised controlled trial, mixed-treatment comparison and decision-analytic model

BACKGROUND

Compression is an effective and recommended treatment for venous leg ulcers. Although the four-layer bandage (4LB) is regarded as the gold standard compression system, it is recognised that the amount of compression delivered might be compromised by poor application technique. Also the bulky nature of the bandages might reduce ankle or leg mobility and make the wearing of shoes difficult. Two-layer compression hosiery systems are now available for the treatment of venous leg ulcers. Two-layer hosiery (HH) may be advantageous, as it has reduced bulk, which might enhance ankle or leg mobility and patient adherence. Some patients can also remove and reapply two-layer hosiery, which may encourage self-management and could reduce costs. However, little robust evidence exists about the effectiveness of two-layer hosiery for ulcer healing and no previous trials have compared two-layer hosiery delivering 'high' compression with the 4LB.

OBJECTIVES

Part I To compare the clinical effectiveness and cost-effectiveness of HH and 4LB in terms of time to complete healing of venous leg ulcers. Part II To synthesise the relative effectiveness evidence (for ulcer healing) of high-compression treatments for venous leg ulcers using a mixed-treatment comparison (MTC). Part III To construct a decision-analytic model to assess the cost-effectiveness of high-compression treatments for venous leg ulcers.

DESIGN

Part I A multicentred, pragmatic, two-arm, parallel, open randomised controlled trial (RCT) with an economic evaluation. Part II MTC using all relevant RCT data - including Venous leg Ulcer Study IV (VenUS IV). Part III A decision-analytic Markov model.

SETTINGS

Part I Community nurse teams or services, general practitioner practices, leg ulcer clinics, tissue viability clinics or services and wound clinics within England and Northern Ireland.

PARTICIPANTS

Part I Patients aged ≥ 18 years with a venous leg ulcer, who were willing and able to tolerate high compression.

INTERVENTIONS

Part I Participants in the intervention group received HH. The control group received the 4LB, which was applied according to standard practice. Both treatments are designed to deliver 40 mmHg of compression at the ankle. Part II and III All relevant high-compression treatments including HH, the 4LB and the two-layer bandage (2LB).

MAIN OUTCOME MEASURES

Part I The primary outcome measure was time to healing of the reference ulcer (blinded assessment). Part II Time to ulcer healing. Part III Quality-adjusted life-years (QALYs) and costs.

RESULTS

Part I A total of 457 participants were recruited. There was no evidence of a difference in time to healing of the reference ulcer between groups in an adjusted analysis [hazard ratio (HR) 0.99, 95% confidence interval (CI) 0.79 to 1.25; p = 0.96]. Time to ulcer recurrence was significantly shorter in the 4LB group (HR = 0.56, 95% CI 0.33 to 0.94; p = 0.026). In terms of cost-effectiveness, using QALYs as the measure of benefit, HH had a > 95% probability of being the most cost-effective treatment based on the within-trial analysis. Part II The MTC suggests that the 2LB has the highest probability of ulcer healing compared with other high-compression treatments. However, this evidence is categorised as low to very low quality. Part III Results suggested that the 2LB had the highest probability of being the most cost-effective high-compression treatment for venous leg ulcers.

CONCLUSIONS

Trial data from VenUS IV found no evidence of a difference in venous ulcer healing between HH and the 4LB. HH may reduce ulcer recurrence rates compared with the 4LB and be a cost-effective treatment. When all available high-compression treatments were considered, the 2LB had the highest probability of being clinically effective and cost-effective. However, the underpinning evidence was sparse and more research is needed. Further research should thus focus on establishing, in a high-quality trial, the effectiveness of this compression system in particular.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN49373072.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 18, No. 57. See the NIHR Journals Library website for further project information.

A systematic review of cost-effectiveness analyses of complex wound interventions reveals optimal treatments for specific wound types

BACKGROUND

Complex wounds present a substantial economic burden on healthcare systems, costing billions of dollars annually in North America alone. The prevalence of complex wounds is a significant patient and societal healthcare concern and cost-effective wound care management remains unclear. This article summarizes the cost-effectiveness of interventions for complex wound care through a systematic review of the evidence base.

METHODS

We searched multiple databases (MEDLINE, EMBASE, Cochrane Library) for cost-effectiveness studies that examined adults treated for complex wounds. Two reviewers independently screened the literature, abstracted data from full-text articles, and assessed methodological quality using the Drummond 10-item methodological quality tool. Incremental cost-effectiveness ratios were reported, or, if not reported, calculated and converted to United States Dollars for the year 2013.

RESULTS

Overall, 59 cost-effectiveness analyses were included; 71% (42 out of 59) of the included studies scored 8 or more points on the Drummond 10-item checklist tool. Based on these, 22 interventions were found to be more effective and less costly (i.e., dominant) compared to the study comparators: 9 for diabetic ulcers, 8 for venous ulcers, 3 for pressure ulcers, 1 for mixed venous and venous/arterial ulcers, and 1 for mixed complex wound types.

CONCLUSIONS

Our results can be used by decision-makers in maximizing the deployment of clinically effective and resource efficient wound care interventions. Our analysis also highlights specific treatments that are not cost-effective, thereby indicating areas of resource savings. Please see related article: http://dx.doi.org/10.1186/s12916-015-0288-5.

The impact of providing product funding for compression bandaging and medical footwear on compression use, wound healing and quality of life

A study conducted in an Australian home nursing service sought to ascertain whether the provision of funding for compression bandaging and medical footwear would impact on compression therapy use, wound healing and quality of life (QoL) among people with venous leg ulcers. Clients (n = 120) were randomly allocated to evaluation funded or not evaluation funded groups, the former provided funding for compression bandaging and medical footwear. Outcome measures included the number of wounds healed, healing rate, compression use and QoL. Analysis included ttests and Kaplan-Meier Survival Analysis. An alpha level of 0·05 classified findings as significant. There were no significant differences between groups for rate or time to healing, wounds healed or compression use. The evaluation funded group were significantly more likely to receive medical footwear. Those with confirmed diagnosis and who received multilayer bandaging, irrespective of group, achieved healing rates significantly higher than those who wore other compression therapy. Factors other than cost intervened with the capacity to evaluate the impact of wound product subsidisation. Further exploration of how to best promote evidence-based practice and future research to evaluate clinically and cost-effective wound treatments in a range of health care settings is required.

Immediate Hemodynamic Effect of the Additional Use of the SCD EXPRESS™ Compression System in Patients with Venous Ulcers Treated with the Four-layer Compression Bandaging System

OBJECTIVES

To test the hypothesis that the SCD EXPRESS intermittent pneumatic compression applied in combination with a four-layer bandage in patients with venous ulcers increases popliteal vein volume flow and velocity.

DESIGN

Twenty limbs of 18 patients with venous leg ulcers were studied, median age 76 years. The Total Volume Flow (TVF) and the Peak Systolic Velocity (PSV) were recorded in the popliteal vein using duplex ultrasonography. Measurements were made (i) without bandage, (ii) with four layer bandage and (iii) following the application of the SCD Compression System on top of a four-layer bandage for at least 15 minutes.

RESULTS

The median VCSS was 17 (range, 12-22) while the median VSDS for reflux was 4.5 (range, 1-7.5). The median TVF was 71 mL/min (inter-quartile range 57-101) without bandage, 112 (IQR 89-148) with four-layer bandage and 291 (IQR 241-392) with the addition of the SCD System (P<.001, Wilcoxon signed ranks test). The median PSV was 8.4 cm/sec (IQR 6.8-14) without bandage, 13 (9.0-19) with four-layer bandage and 27 (21-31) with the addition of the SCD System (P<.001, Wilcoxon signed ranks test). Both TVF and PSV increased slightly with the addition of the four-layer bandage. However, with the addition of the SCD System these parameters increased three fold.

CONCLUSIONS

The SCD EXPRESS Compression System accelerates venous flow in the legs of patients with venous ulcers already treated with a four-layer bandage. The combination of four-layer compression with the SCD System on healing venous ulcers needs to be tested by a clinical effectiveness study.

Cost-effective faster wound healing with a sustained silver-releasing foam dressing in delayed healing leg ulcers--a health-economic analysis

The aim of this analysis was to examine the cost-effectiveness of Contreet Foam (A) in comparison with three other commonly used venous leg ulcer treatment protocols: Aquacel Ag (B), Actisorb Silver (C) and Iodoflex (D). A health-economic analysis reflecting the UK treatment practice and cost structure was performed. The analysis was set up to assess the cost of relative wound area reduction over a 4-week treatment period. The model was validated by a UK expert panel consisting of four wound care specialists. To assure that the 4-week model had a realistic link to cost-effectiveness of complete wound healing, a Markov analysis was also performed. Sensitivity analyses were carried out to ensure validity. Protocol A and C proved to be the most effective treatments. The mean relative reduction in wound area after 4 weeks of treatment was 50.2% (protocol A), 23.9% (protocol B), 44.6% (protocol C) and 36.0% (protocol D). Cost-effectiveness ratios showed that protocol A proved to be the most cost-effective treatment, and protocol B the least. The cost per percentage reduction in wound area was 9.50 UK pounds for protocol A, compared to 16.50-17.60 UK pounds for the other treatment options. The cost-effectiveness of complete healing (Markov analysis) and sensitivity analyses confirmed these results. Using Contreet Foam instead of the other dressing alternatives may imply savings of 2.2-4.4 million UK pounds per year to the National Health Service.

Giving information on compression to patients with venous leg ulcers

Venous leg ulceration is a common condition that is more likely to affect the elderly (Alexander House Group, 1992; Coupe and Walukiewicz, 2000) and often has a psychological, as well as physical, impact on the individual (Charles, 1995). Many of those affected are cared for within the community (Maylor, 2002) and may become isolated because of the difficulties caused by their condition (Charles, 1995). Compression bandaging therapy has been shown as an effective treatment for venous leg ulcers (Loftus and Wheatley, 2000) but the bandages must be worn continually during treatment and therefore need to be socially and psychologically acceptable if the patient is to be happy with the treatment regimen (Pudner, 1998). Nurses need to be competent in the care of leg ulcers so that pain and discomfort are minimized and patients need to be willing to accept the treatment given.

Preventing venous ulcer recurrence: a review

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.

Setting up a community nurse-led healed leg ulcer clinic

Chronic obstructive pulmonary disease (COPD) is a progressive, smoking-related, chronic disease that eventually impacts on every area of the lives of the patient and his/her family and carers. The nature of the disease - chronic, irreversible airflow obstruction - limits the impact of drug therapy, particularly as the disease progresses. Increasing breathlessness on exertion saps confidence, reduces self-esteem and produces dependence. In addition, frequent exacerbations utilize health service resources. Non-pharmacological approaches, such as pulmonary rehabilitation, together with lifestyle advice that enables patients to help themselves manage exacerbations, maintain independence and quality of life and make the most of life with COPD can benefit both patients and the health service.

Four-layer bandaging: from concept to practice

The 4-layer bandage was originally designed to provide sustained leg compression to patients with venous leg ulcers. Since then, the practice of 4-layer bandaging has become widespread in the United Kingdom. Ulcer healing rates vary for a number of reasons. This review, by a member of the original design team, seeks to discuss reasons of varying success and offers advice for its appropriate usage.

The cost-effectiveness of wound management protocols of care

A European cost-effectiveness study has been conducted using published clinical trial data from multinational studies on chronic venous leg ulcers and pressure sores. Data relevant to UK chronic wound management practice have been extracted and are presented here. A total of 15 pressure sore studies involving 519 wounds, and 12 leg ulcer studies involving 843 ulcers were used in a pooled analysis. The study objectives included the calculation of comparative costs in pound sterling for three different treatment protocols for each wound type. The protocols have been adapted for UK clinical practice in both hospital and community settings and are based on primary dressings and nurse time costs, wound cleansing and debridement, the use of fillers, and compression as appropriate. The focus of the study has been the cost-effectiveness comparison (as measured by cost per healed wound) of two modern dressings - Granuflex(R) hydrocolloid dressing and Apligraf(R) skin replacement - and traditional gauze dressings in the treatment of venous leg ulcers and, in the case of pressure sores, comparison of Granuflex(R) Comfeel(R) hydrocolloid dressings and traditional saline gauze dressings. The choice of dressings studied was dictated by the available published literature. The construction of treatment protocols and assumptions on treatments otherwise missing from published papers has been achieved through the use of an expert panel. Results show Granuflex(R) to be 50% more cost-effective, at 422 pounds per healed wound, than Comfeel(R) (643 pounds) and 500% more so than saline gauze (2548 pounds) in the treatment of pressure sores. Granuflex(R) at 342 pounds was also more cost-effective than gauze (541 pounds) or Apligraf(R) (6741 pounds) in the treatment of venous leg ulcers. These data will provide a valuable adjunct to published clinical evidence, offering further information upon which carers can base their choice of wound dressing.

Treatment of an atypical leg ulcer: pyoderma gangrenosum

Mrs B was referred to the Skin and Woundcare Department at the start of January 2002 with a chronic non-healing ulcer to her lower right leg proximal to the medial aspect of her right knee. The ulcer was diagnosed as pyoderma gangrenosum, a condition which Mrs B had suffered from previously. Assessment and management of this atypical ulcer are discussed. Once the progression of the lesion was halted, conservative treatment could be undertaken, and led to a successful outcome.

The use of intermittent pneumatic compression in venous ulceration

Even with the application of four-layer bandaging, the recommended treatment for venous leg ulceration, patients with reduced mobility have delayed ulcer healing. Intermittent pneumatic compression (IPC) has an established role in deep vein thrombosis prophylaxis and has been shown to influence fibrinolysis, tissue oxygenation, oedema and venous return. It has also been suggested, but not yet proven, that IPC may improve the healing of venous leg ulcers. An extensive review of the literature has demonstrated that the use of this treatment on patients with reduced mobility has not been previously studied; yet, analysis of difficult-to-heal ulcer patients would indicate that this method of treatment may be appropriate and requires further study.

Evaluating a superabsorbent hydropolymer dressing for exuding venous leg ulcers

A new hydropolymer dressing was compared with an alginate dressing in a multicentre, prospective, controlled, randomised, stratified, open label trial of 113 patients with exuding venous leg ulcers. The study aimed to evaluate the performance of the dressings in terms of their ability to handle exudate, patient and user acceptability and cost-effectiveness. Patients were stratified according to volume of wound exudate (moderate/heavy) and randomised to the hydropolymer dressing or the alginate plus a secondary dressing. A statistically significant difference between treatment groups was observed in mean wear time, with a longer wear time observed in the hydropolymer group (3.91 days) compared with the alginate group (3.09 days, p = 0.001). In terms of patient and user acceptability, all 10 overall evaluations made by both patient and investigator were markedly in favour of the hydropolymer dressing (p < 0.001 to p = 0.020). The use of the hydropolymer dressing for patients with moderate to heavily exuding venous leg ulcers has statistically significant advantages over the alginate dressing in terms of wear time and investigator and patient acceptability. It is anticipated that this reduction in dressing frequency will translate into a cost-effective wound treatment.

Chronic Venous Insufficiency

Chronic venous insufficiency of the lower extremities is a complicated disorder that affects the productivity and well-being of millions of people worldwide. Management requires careful differential diagnosis and a systematic long-term multidisciplinary care effort directed toward realistic goals within the context of the patient's lifestyle. Optimal therapy requires control of abnormal venous physiology combined with adjunctive treatments to correct secondary skin ulceration, infection, and lymphedema. Fundamental management tools are limb elevation, simple dressings, antibiotics, and elastic compression garments. Patients with large leg ulcers may benefit from split-thickness skin grafting. Other selected patients may benefit from ligation and stripping of superficial veins or subfascial interruption of perforating veins. New endoscopic methods have dramatically reduced morbidity from subfascial perforator surgery. Surgery directed at correcting valvular reflux and venous occlusion is possible in highly selected patients.

Comparison of the healing rates and complications of three four-layer bandage regimens

This randomised controlled study compares the healing rates, complications and patient and staff acceptability of three four-layer bandage regimens for leg ulcers. A total of 149 patients were recruited into the study, of whom 50 received the original Charing Cross system (CX4L), 50 a modified Charing Cross system (Parema) and 49 a commercially available kit, Robinson Ultra Four (Robinson). No significant difference was found in the healing rates of the three systems. Overall 12 weeks' healing was 65%, while the 20-week healing rates for the individual systems were 87% (CX4L), 84% (Parema) and 83% (Robinson). Analysis of known risk factors for delayed healing showed that no bandaging system had an advantage over the others. Staff familiarity resulted in an initial preference for the CX4L but there was no bandage preference by the end of the study. The data suggest that none of the systems has an advantage over the others and that cost savings can be made by pursuing a competitive pricing policy.