1
|
Lian Y, Anderson I, Stather P. Leg ulcer service provision in NHS hospitals. BRITISH JOURNAL OF NURSING (MARK ALLEN PUBLISHING) 2022; 31:S16-S20. [PMID: 35220735 DOI: 10.12968/bjon.2022.31.4.s16] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
AIM To explore the service provision for compression therapy for inpatients with leg ulcers in UK hospitals. METHODS An online survey was carried out to explore the service provision in hospital settings. It was distributed to Wounds UK National Conference delegates and to wound care specialist groups using social media. RESULTS The authors received 101 responses from health professionals in the UK. Of these, 67.3% reported there was no dedicated service for inpatients with leg ulceration and only 32% said compression therapy was provided in their hospitals. CONCLUSION This survey confirmed there is a significant shortfall in care provision for patients with leg ulcers in secondary care and highlighted the wide variations in service delivery in hospitals. Further research is needed to understand the reasons for these variations.
Collapse
Affiliation(s)
- Yaping Lian
- Tissue Viability Nurse Specialist, Tissue Viability Team, Cambridge University Hospitals NHS Foundation Trust, Cambridge
| | - Irene Anderson
- Professional Lead, Adult Nursing; Principal Lecturer Tissue Viability, and Associate Professor Learning and Teaching, University of Hertfordshire
| | - Philip Stather
- Consultant Vascular Surgeon, Norfolk and Norwich University Hospital, Norwich
| |
Collapse
|
2
|
Shi C, Dumville JC, Cullum N, Connaughton E, Norman G. Compression bandages or stockings versus no compression for treating venous leg ulcers. Cochrane Database Syst Rev 2021; 7:CD013397. [PMID: 34308565 PMCID: PMC8407020 DOI: 10.1002/14651858.cd013397.pub2] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
BACKGROUND Leg ulcers are open skin wounds on the lower leg that can last weeks, months or even years. Most leg ulcers are the result of venous diseases. First-line treatment options often include the use of compression bandages or stockings. OBJECTIVES To assess the effects of using compression bandages or stockings, compared with no compression, on the healing of venous leg ulcers in any setting and population. SEARCH METHODS In June 2020 we searched the Cochrane Wounds Specialised Register, the Cochrane Central Register of Controlled Trials (CENTRAL), Ovid MEDLINE (including In-Process & Other Non-Indexed Citations), Ovid Embase and EBSCO CINAHL Plus. We also searched clinical trials registries for ongoing and unpublished studies, and scanned reference lists of relevant included studies as well as reviews, meta-analyses and health technology reports to identify additional studies. There were no restrictions by language, date of publication or study setting. SELECTION CRITERIA We included randomised controlled trials that compared any types of compression bandages or stockings with no compression in participants with venous leg ulcers in any setting. DATA COLLECTION AND ANALYSIS At least two review authors independently assessed studies using predetermined inclusion criteria. We carried out data extraction, and risk-of-bias assessment using the Cochrane risk-of-bias tool. We assessed the certainty of the evidence according to GRADE methodology. MAIN RESULTS We included 14 studies (1391 participants) in the review. Most studies were small (median study sample size: 51 participants). Participants were recruited from acute-care settings, outpatient settings and community settings, and a large proportion (65.9%; 917/1391) of participants had a confirmed history or clinical evidence of chronic venous disease, a confirmed cause of chronic venous insufficiency, or an ankle pressure/brachial pressure ratio of greater than 0.8 or 0.9. The average age of participants ranged from 58.0 to 76.5 years (median: 70.1 years). The average duration of their leg ulcers ranged from 9.0 weeks to 31.6 months (median: 22.0 months), and a large proportion of participants (64.8%; 901/1391) had ulcers with an area between 5 and 20 cm2. Studies had a median follow-up of 12 weeks. Compression bandages or stockings applied included short-stretch bandage, four-layer compression bandage, and Unna's boot (a type of inelastic gauze bandage impregnated with zinc oxide), and comparator groups used included 'usual care', pharmacological treatment, a variety of dressings, and a variety of treatments where some participants received compression (but it was not the norm). Of the 14 included studies, 10 (71.4%) presented findings which we consider to be at high overall risk of bias. Primary outcomes There is moderate-certainty evidence (downgraded once for risk of bias) (1) that there is probably a shorter time to complete healing of venous leg ulcers in people wearing compression bandages or stockings compared with those not wearing compression (pooled hazard ratio for time-to-complete healing 2.17, 95% confidence interval (CI) 1.52 to 3.10; I2 = 59%; 5 studies, 733 participants); and (2) that people treated using compression bandages or stockings are more likely to experience complete ulcer healing within 12 months compared with people with no compression (10 studies, 1215 participants): risk ratio for complete healing 1.77, 95% CI 1.41 to 2.21; I2 = 65% (8 studies with analysable data, 1120 participants); synthesis without meta-analysis suggests more completely-healed ulcers in compression bandages or stockings than in no compression (2 studies without analysable data, 95 participants). It is uncertain whether there is any difference in rates of adverse events between using compression bandages or stockings and no compression (very low-certainty evidence; 3 studies, 585 participants). Secondary outcomes Moderate-certainty evidence suggests that people using compression bandages or stockings probably have a lower mean pain score than those not using compression (four studies with 859 participants and another study with 69 ulcers): pooled mean difference -1.39, 95% CI -1.79 to -0.98; I2 = 65% (two studies with 426 participants and another study with 69 ulcers having analysable data); synthesis without meta-analysis suggests a reduction in leg ulcer pain in compression bandages or stockings, compared with no compression (two studies without analysable data, 433 participants). Compression bandages or stockings versus no compression may improve disease-specific quality of life, but not all aspects of general health status during the follow-up of 12 weeks to 12 months (four studies with 859 participants; low-certainty evidence). It is uncertain if the use of compression bandages or stockings is more cost-effective than not using them (three studies with 486 participants; very low-certainty evidence). AUTHORS' CONCLUSIONS If using compression bandages or stockings, people with venous leg ulcers probably experience complete wound healing more quickly, and more people have wounds completely healed. The use of compression bandages or stockings probably reduces pain and may improve disease-specific quality of life. There is uncertainty about adverse effects, and cost effectiveness. Future research should focus on comparing alternative bandages and stockings with the primary endpoint of time to complete wound healing alongside adverse events including pain score, and health-related quality of life, and should incorporate cost-effectiveness analysis where possible. Future studies should adhere to international standards of trial conduct and reporting.
Collapse
Affiliation(s)
- Chunhu Shi
- Division of Nursing, Midwifery and Social Work, School of Health Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester Academic Health Science Centre, Manchester, UK
| | - Jo C Dumville
- Division of Nursing, Midwifery and Social Work, School of Health Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester Academic Health Science Centre, Manchester, UK
| | - Nicky Cullum
- Division of Nursing, Midwifery and Social Work, School of Health Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester Academic Health Science Centre, Manchester, UK
| | | | - Gill Norman
- Division of Nursing, Midwifery and Social Work, School of Health Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester Academic Health Science Centre, Manchester, UK
| |
Collapse
|
3
|
Scientific and Clinical Abstracts From WOCNext® 2021: An Online Event ♦ June 24-26, 2021. J Wound Ostomy Continence Nurs 2021; 48:S1-S49. [PMID: 37632236 DOI: 10.1097/won.0000000000000772] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
|
4
|
Asaf M, Salim N, Tuffaha M. Challenging the Use of Bandage Compression as the Baseline for Evaluating the Healing Outcomes of Venous Leg Ulcer-Related Compression Therapies in the Community and Outpatient Setting: An Integrative Review. DUBAI MEDICAL JOURNAL 2018. [DOI: 10.1159/000494217] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
|
5
|
Guest JF, Vowden K, Vowden P. The health economic burden that acute and chronic wounds impose on an average clinical commissioning group/health board in the UK. J Wound Care 2017; 26:292-303. [DOI: 10.12968/jowc.2017.26.6.292] [Citation(s) in RCA: 112] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- J. F. Guest
- Director of Catalyst, Visiting Professor of Health Economics, Catalyst Health Economics Consultants, Northwood, Middlesex, UK; Faculty of Life Sciences and Medicine, King's College, London, UK
| | - K. Vowden
- Nurse Consultant, Bradford Teaching Hospitals NHS Foundation Trust and University of Bradford, Bradford, UK
| | - P. Vowden
- Consultant Vascular Surgeon, Professor of Wound Healing Research, Bradford Teaching Hospitals NHS Foundation Trust and University of Bradford, Bradford, UK
| |
Collapse
|
6
|
Ashby RL, Gabe R, Ali S, Saramago P, Chuang LH, Adderley U, Bland JM, Cullum NA, Dumville JC, Iglesias CP, Kang'ombe AR, Soares MO, Stubbs NC, Torgerson DJ. 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. Health Technol Assess 2015; 18:1-293, v-vi. [PMID: 25242076 DOI: 10.3310/hta18570] [Citation(s) in RCA: 57] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
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.
Collapse
Affiliation(s)
- Rebecca L Ashby
- Department of Health Sciences, The University of York, York, UK
| | - Rhian Gabe
- Department of Health Sciences, The University of York, York, UK
| | - Shehzad Ali
- Department of Health Sciences, The University of York, York, UK
| | - Pedro Saramago
- Centre for Health Economics, The University of York, York, UK
| | | | - Una Adderley
- School of Healthcare, The University of Leeds, Leeds, UK
| | - J Martin Bland
- Department of Health Sciences, The University of York, York, UK
| | - Nicky A Cullum
- School of Nursing, Midwifery and Social Work, The University of Manchester, Manchester, UK
| | - Jo C Dumville
- Department of Health Sciences, The University of York, York, UK
| | | | | | - Marta O Soares
- Centre for Health Economics, The University of York, York, UK
| | | | | |
Collapse
|
7
|
O'Donnell TF, Passman MA, Marston WA, Ennis WJ, Dalsing M, Kistner RL, Lurie F, Henke PK, Gloviczki ML, Eklöf BG, Stoughton J, Raju S, Shortell CK, Raffetto JD, Partsch H, Pounds LC, Cummings ME, Gillespie DL, McLafferty RB, Murad MH, Wakefield TW, Gloviczki P. Management of venous leg ulcers: clinical practice guidelines of the Society for Vascular Surgery ® and the American Venous Forum. J Vasc Surg 2014; 60:3S-59S. [PMID: 24974070 DOI: 10.1016/j.jvs.2014.04.049] [Citation(s) in RCA: 384] [Impact Index Per Article: 38.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
|
8
|
Kota AA, Selvaraj AD, Premkumar P, Ponraj S, Agarwal S. Four layer dressing in the management of chronic venous ulcers in the outpatient setting of a tertiary hospital in India. ACTA ACUST UNITED AC 2014. [DOI: 10.1016/j.wndm.2014.04.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
|
9
|
Panca M, Cutting K, Guest J. Clinical and cost-effectiveness of absorbent dressings in the treatment of highly exuding VLUs. J Wound Care 2013; 22:3. [DOI: 10.12968/jowc.2013.22.sup3.s3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- M. Panca
- Catalyst Health Economics Consultants, Middlesex, UK
| | - K. Cutting
- Catalyst Health Economics Consultants, Middlesex, UK
| | - J.F. Guest
- Catalyst Health Economics Consultants, Middlesex, UK
- School of Biomedical Sciences, King's College, London, UK
| |
Collapse
|
10
|
Panca M, Cutting K, Guest J. Clinical and cost-effectiveness of absorbent dressings in the treatment of highly exuding VLUs. J Wound Care 2013; 22:109-10, 112-8. [DOI: 10.12968/jowc.2013.22.3.109] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- M. Panca
- Catalyst Health Economics Consultants, Middlesex, UK
| | - K. Cutting
- Buckinghamshire New University, Uxbridge, UK and Perfectus Medical, Daresbury, UK
| | - J.F. Guest
- Catalyst Health Economics Consultants, Middlesex, UK
- School of Biomedical Sciences, King's College, London, UK
| |
Collapse
|
11
|
Abstract
BACKGROUND Up to one percent of people in industrialised countries will suffer from a leg ulcer at some time. The majority of these leg ulcers are due to problems in the veins, resulting in an accumulation of blood in the legs. Leg ulcers arising from venous problems are called venous (or varicose or stasis) ulcers. The main treatment is the application of a firm compression garment (bandage or stocking) in order to aid venous return. There is a large number of compression garments available and it was unclear whether they are effective in treating venous ulcers and, if so, which method of compression is the most effective. OBJECTIVES To undertake a systematic review of all randomised controlled trials (RCTs) evaluating the effects on venous ulcer healing of compression bandages and stockings.Specific questions addressed by the review are:1. Does the application of compression bandages or stockings aid venous ulcer healing? 2. Which compression bandage or stocking system is the most effective? SEARCH METHODS For this second update we searched: the Cochrane Wounds Group Specialised Register (31 May 2012); the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library Issue 5, 2012); Ovid MEDLINE (1950 to May Week 4 2012); Ovid MEDLINE (In-Process & Other Non-Indexed Citations 30 May 2012); Ovid EMBASE (1980 to 2012 Week 21); and EBSCO CINAHL (1982 to 30 May 2012). No date or language restrictions were applied. SELECTION CRITERIA RCTs recruiting people with venous leg ulceration that evaluated any type of compression bandage system or compression stockings were eligible for inclusion. Eligible comparators included no compression (e.g. primary dressing alone, non-compressive bandage) or an alternative type of compression. RCTs had to report an objective measure of ulcer healing in order to be included (primary outcome for the review). SECONDARY OUTCOMES of the review included ulcer recurrence, costs, quality of life, pain, adverse events and withdrawals. There was no restriction on date, language or publication status of RCTs. DATA COLLECTION AND ANALYSIS Details of eligible studies were extracted and summarised using a data extraction table. Data extraction was performed by one review author and verified independently by a second review author. MAIN RESULTS Forty-eight RCTs reporting 59 comparisons were included (4321 participants in total). Most RCTs were small, and most were at unclear or high risk of bias. Duration of follow-up varied across RCTs. Risk ratio (RR) and other estimates are shown below where RCTs were pooled; otherwise findings refer to a single RCT.There was evidence from eight RCTs (unpooled) that healing outcomes (including time to healing) are better when patients receive compression compared with no compression.Single-component compression bandage systems are less effective than multi-component compression for complete healing at six months (one large RCT).A two-component system containing an elastic bandage healed more ulcers at one year than one without an elastic component (one small RCT).Three-component systems containing an elastic component healed more ulcers than those without elastic at three to four months (two RCTs pooled), RR 1.83 (95% CI 1.26 to 2.67), but another RCT showed no difference between groups at six months.An individual patient data meta-analysis of five RCTs suggested significantly faster healing with the four-layer bandage (4LB) than the short stretch bandage (SSB): median days to healing estimated at 90 and 99 respectively; hazard ratio 1.31 (95% CI 1.09 to 1.58).High-compression stockings are associated with better healing outcomes than SSB at two to four months: RR 1.62 (95% CI 1.26 to 2.10), estimate from four pooled RCTs.One RCT suggested better healing outcomes at 16 months with the addition of a tubular device plus single elastic bandage to a base system of gauze and crepe bandages when compared with two added elastic bandages. Another RCT had three arms; when one or two elastic bandages were added to a base three-component system that included an outer tubular layer, healing outcomes were better at six months for the two groups receiving elastic bandages.There is currently no evidence of a statistically significant difference for the following comparisons:⋅alternative single-component compression bandages (two RCTs, unpooled);⋅two-component bandages compared with the 4LB at three months (three RCTs pooled);⋅alternative versions of the 4LB for complete healing at times up to and including six months (three RCTs, unpooled);⋅4LB compared with paste bandage for complete healing at three months (two RCTs, pooled), six months or one year (one RCT for each time point);⋅adjustable compression boots compared with paste bandages for the outcome of change in ulcer area at three months (one small RCT);⋅adjustable compression boots compared with the 4LB with respect to complete healing at three months (one small RCT);⋅single-layer compression stocking compared with paste bandages for outcome of complete healing at four months (one small RCT) and 18 months (another small RCT);⋅low compression stocking compared with SSB for complete healing at three and six months (one small RCT);⋅compression stockings compared with a two-component bandage system and the 4LB for the outcome of complete healing at three months (one small, three-armed RCT); and,⋅tubular compression compared with SSB (one small RCT) for complete healing at three months. SECONDARY OUTCOMES 4LB was more cost-effective than SSB. It was not possible to draw firm conclusions regarding other secondary outcomes including recurrence, adverse events and health-related quality of life. AUTHORS' CONCLUSIONS Compression increases ulcer healing rates compared with no compression. Multi-component systems are more effective than single-component systems. Multi-component systems containing an elastic bandage appear to be more effective than those composed mainly of inelastic constituents. Two-component bandage systems appear to perform as well as the 4LB. Patients receiving the 4LB heal faster than those allocated the SSB. More patients heal on high-compression stocking systems than with the SSB. Further data are required before the difference between high-compression stockings and the 4LB can be established.
Collapse
Affiliation(s)
- Susan O'Meara
- Department of Health Sciences, University of York, York, UK.
| | | | | | | |
Collapse
|
12
|
Lazareth I, Moffatt C, Dissemond J, Padieu AL, Truchetet F, Beissert S, Wicks G, Tilbe H, Sauvadet A, Bohbot S, Meaume S. Efficacy of two compression systems in the management of VLUs: results of a European RCT. J Wound Care 2012; 21:553-4, 556, 558 passim. [DOI: 10.12968/jowc.2012.21.11.553] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- I. Lazareth
- Vascular Medicine Unit, Saint-Joseph Hospital, Paris, France
| | | | - J. Dissemond
- Head, Dermatology Department, University Hospital, Essen, Germany
| | | | - F. Truchetet
- Head, Dermatology Department, Beauregard Hospital, Thionville, France
| | - S. Beissert
- Dermatology Department, University Hospital, Münster, Germany
| | - G. Wicks
- Leg Ulcer Clinic, Wrafton House Surgery, Hatfield, UK
| | - H. Tilbe
- Trowbridge Community Hospital, Trowbridge, UK
| | - A. Sauvadet
- R–D Department, Laboratoires URGO, Chenôve, France
| | - S. Bohbot
- R–D Department, Laboratoires URGO, Chenôve, France
| | - S. Meaume
- Head, Geriatric Department, Rothschild Hospital, Paris, France
| |
Collapse
|
13
|
Guest J, Taylor R, Vowden K, Vowden P. Relative cost-effectiveness of a skin protectant in managing venous leg ulcers in the UK. J Wound Care 2012; 21:389-94, 396-8. [DOI: 10.12968/jowc.2012.21.8.389] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- J.F. Guest
- Catalyst Health Economics Consultants, Northwood, UK
- School of Biomedical Sciences, King's College, London, UK
| | - R.R. Taylor
- Catalyst Health Economics Consultants, Northwood, UK
| | - K. Vowden
- Bradford Teaching Hospitals NHS Foundation Trust and University of Bradford, UK
| | - P. Vowden
- Bradford Teaching Hospitals NHS Foundation Trust and University of Bradford, UK
| |
Collapse
|
14
|
Abstract
BACKGROUND Around one percent of people in industrialised countries will suffer from a leg ulcer at some time. The majority of these leg ulcers are due to problems in the veins, resulting in an accumulation of blood in the legs. Leg ulcers arising from venous problems are called venous (varicose or stasis) ulcers. The main treatment has been a firm compression garment (bandage or stocking) in order to aid venous return. There is a large number of compression garments available and it is unclear whether they are effective in treating venous ulcers and which compression garment is the most effective. OBJECTIVES To undertake a systematic review of all randomised controlled trials of the clinical effectiveness of compression bandage or stocking systems in the treatment of venous leg ulceration.Specific questions addressed by the review are:1. Does the application of compression bandages or stockings aid venous ulcer healing? 2. Which compression bandage or stocking system is the most effective? SEARCH STRATEGY For this update we searched the Cochrane Wounds Group Specialised Register (14/10/08); The Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library Issue 4 2008); Ovid MEDLINE (1950 to October Week 1 2008); Ovid EMBASE (1980 to 2008 Week 41) and Ovid CINAHL (1982 to October Week 1 2008). No date or language restrictions were applied. SELECTION CRITERIA Randomised controlled trials recruiting people with venous leg ulceration that evaluated any type of compression bandage system or compression hosiery were eligible for inclusion. Comparators included no compression (e.g. primary dressing alone, non-compressive bandage) or an alternative type of compression. Trials had to report an objective measure of ulcer healing in order to be included (primary outcome for the review). Secondary outcomes of the review included ulcer recurrence, costs, quality of life, pain, adverse events and withdrawals. There was no restriction on date, language or publication status of trials. DATA COLLECTION AND ANALYSIS Details of eligible studies were extracted and summarised using a data extraction table. Data extraction was performed by one review author and verified independently by a second review author. MAIN RESULTS Overall, 39 RCTs reporting 47 comparisons were included.Review question 1: there was reasonable evidence from seven RCTs that venous ulcers heal more rapidly with compression than without.Review question 2: findings from six trials of single-component compression suggested that this strategy was less effective than multi-component compression. Evidence from compression systems with two components (3 trials) and three components (4 trials) suggested better outcomes when an elastic component was included. Different versions of compression with four-components (based on the Charing Cross four-layer bandage system) have similar effectiveness (3 trials). Compression with four components (variants of the Charing Cross four-layer bandage) is more effective than multi-component compression that includes a short-stretch bandage (6 trials). It is difficult to determine the relative effectiveness of the four-layer bandage compared with paste bandage systems because of differences in the paste systems (5 trials). There was no difference in effectiveness between the adjustable compression boot and compression bandages (2 trials) or between single-layer compression stockings and paste bandages (2 trials). Two-layer stockings appeared more effective than the short-stretch bandage (2 trials). The relative effectiveness of tubular compression when compared with compression bandages was not clear from current evidence (2 trials).Three trials reported ulcer recurrence; because of sparseness of data and trials not being primarily designed to assess this outcome, firm conclusions could not be drawn. Although several trials included cost data, only one reported a rigorously conducted cost-effectiveness analysis with findings suggesting that the four-layer bandage was more cost-effective than multi-component compression comprising a short-stretch bandage. Seven trials assessed health-related quality of life and none observed significant differences between treatment groups. Several trials evaluated pain either as a stand-alone outcome, or as part of the assessment of adverse events. In general, the data did not indicate clear differences between treatment groups. It is possible that stockings could be associated with less pain than bandages but in view of scarcity of available data this requires further evaluation. Many of the trials reported adverse events and / or withdrawals. Overall, these outcomes appeared similar across different treatment groups. AUTHORS' CONCLUSIONS Compression increases ulcer healing rates compared with no compression. Multi-component systems are more effective than single-component systems. Multi-component systems containing an elastic bandage appear more effective than those composed mainly of inelastic constituents.
Collapse
Affiliation(s)
- Susan O'Meara
- Department of Health Sciences, University of York, Area 3 Seebohm Rowntree Building, Heslington, York, UK, YO10 5DD.
| | | | | |
Collapse
|
15
|
|
16
|
Benigni J, Lazareth I, Parpex P, Gerard J, Alves M, Vin F, Meaume S, Senet P, Allaert F, Sauvadet A, Bohbot S. Efficacy, safety and acceptability of a new two-layer bandage system for venous leg ulcers. J Wound Care 2007; 16:385-90. [DOI: 10.12968/jowc.2007.16.9.27866] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
| | - I Lazareth
- Vascular Unit, Saint Joseph Hospital, Paris, France
| | | | | | | | - F Vin
- Neuilly-sur-Seine, France
| | - S Meaume
- Charles Foix Hospital, Ivry-sur-Seine, France
| | - P Senet
- Rothschild Hospital, Paris, France
| | | | - A Sauvadet
- Research and Development, Laboratoires Urgo, Chenôve, France
| | - S Bohbot
- Research and Development, Laboratoires Urgo, Chenôve, France
| |
Collapse
|
17
|
Vowden P, Romanelli M, Peter R, Boström A, Josefsson A, Stege H. The effect of amelogenins (Xelma) on hard-to-heal venous leg ulcers. Wound Repair Regen 2006; 14:240-6. [PMID: 16808801 DOI: 10.1111/j.1743-6109.2006.00117.x] [Citation(s) in RCA: 52] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
With an aging population venous ulceration is likely to become an increasing problem. Despite improvements in care and the widespread introduction of compression bandaging, the mainstay of current management, a significant proportion of venous leg ulcers remain hard to heal. Therefore, a single-blinded, randomized multicenter study was performed to compare wound size reduction using amelogenin proteins (Xelma) formulated into a solution which forms a temporary extracellular matrix on contact with the wound bed. Propylene glycol alginate 7% served as a control. Patients were randomized to receive either amelogenin protein or control treatment. The investigational products were applied weekly under soft silicone secondary dressings for up to a maximum of 12 weeks. Compression therapy was maintained throughout the investigation. Wound size reduction was measured by tracing and all wounds were photographed. In total 123 patients were recruited, 62 patients in the amelogenin group, and 61 in the control group, respectively. Subgroup analyses were performed for ulcers with a size>10 cm2 at baseline and for ulcers of duration of >12 months. The wound size reduction was greatest in the group treated with amelogenin (33.8 vs. 25.6%, n=117), this difference being greatest for larger ulcers (25 vs. 7.9% for ulcers>10 cm(2), n=61) and those of long duration (29.3 vs. 10.9% for ulcers>12-month duration, n=61). We conclude that this product may be clinically useful in the treatment of these venous leg ulcers.
Collapse
Affiliation(s)
- Peter Vowden
- Vascular Unit, Bradford Royal Infirmary, Bradford, United Kingdom, and Department of Dermatology, University of Pisa, Italy.
| | | | | | | | | | | |
Collapse
|
18
|
Abstract
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.
Collapse
Affiliation(s)
- Kathryn R Vowden
- Bradford Teaching Hospitals NHS Foundation Trust & University of Bradford, Bradford, UK.
| | | |
Collapse
|
19
|
Abstract
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.
Collapse
Affiliation(s)
- Christine Moffatt
- Wolfson Institute for Health Sciences, Thames Valley University, London.
| |
Collapse
|
20
|
Smith J, Hill J, Barrett S, Hayes W, Kirby P, Walsh S, Gittins E, Whitehurst F, Cooper R. Evaluation of Urgotol plus K-Four compression for venous leg ulcers. ACTA ACUST UNITED AC 2004; 13:S20-8. [PMID: 15126972 DOI: 10.12968/bjon.2004.13.sup1.12536] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/01/2004] [Indexed: 11/11/2022]
Abstract
In this non-comparative clinical evaluation, 36 subjects with venous leg ulcers, 85% of which were indolent or deteriorating, were treated with Urgotul lipidocolloid wound dressing and the K-Four multilayer compression bandaging system for 12 weeks or to healing--whichever occurred first. Results show that Urgotul was an ideal dressing in combination with K-Four, being easy to apply (98.7%) and remove (98.1%), and largely pain-free (95.6%) and non-adherent (99.7%). In a patient group of "hard-to-heal" ulcers, 50% of the ulcers healed within the treatment period. Ulcers not healed after 12 weeks achieved almost 50% area reduction on average. The treatment combination proved safe, with only one of seven adverse events reported being probably related to the products used. This study supports the use of a combination of Urgotul dressing and K-Four compression to provide a "matched" treatment for venous leg ulcers.
Collapse
Affiliation(s)
- J Smith
- North Dorset Primary Care Trust, UK
| | | | | | | | | | | | | | | | | |
Collapse
|
21
|
Abstract
After a leg ulcer has healed, well-fitting compression stockings, patient education and regular check-ups are the basis for preventing recurrence. This article examines patterns in recurrence and subsequent healing among patients at an ulcer clinic.
Collapse
Affiliation(s)
- S Poore
- Wound Healing Unit, Department of Dermatology, Oxford Radcliffe Hospitals, Churchill, Oxford, UK
| | | | | |
Collapse
|
22
|
Vowden KR, Wilkinson D, Vowden P. The K-Four bandage system: evaluating its effectiveness on recalcitrant venous leg ulcers. J Wound Care 2001; 10:182-4. [PMID: 12964326 DOI: 10.12968/jowc.2001.10.5.26075] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
This evaluation examined the effectiveness of the K-Four (Parema) high compression bandage system on 50 patients with recalcitrant 'hard-to-heal' venous leg ulcers and relates the outcome to an earlier randomised study which compared three other four-layer bandage systems. Twelve-week healing rates were 53.2% in the current series, which included patients with poor mobility, large ulcers and long pretreatment ulcer duration, rising to 69.5% at 20 weeks. When account was taken of known risk factors for delayed ulcer healing, no significant difference could be identified between between either K-Four or the earlier evaluated bandages, which included the original Charing Cross system, where the overall healing rates were 64.5% and 80%, respectively, at 12 and 20 weeks. It would seem more likely that treatment outcome is related to patient risk factors for delayed healing and bandaging expertise than to the bandage system employed.
Collapse
Affiliation(s)
- K R Vowden
- Department of Vascular Surgery, Bradford Royal Infirmary, UK
| | | | | |
Collapse
|
23
|
Vowden K. The use of intermittent pneumatic compression in venous ulceration. BRITISH JOURNAL OF NURSING (MARK ALLEN PUBLISHING) 2001; 10:491-509. [PMID: 12066041 DOI: 10.12968/bjon.2001.10.8.5312] [Citation(s) in RCA: 20] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 04/01/2001] [Indexed: 11/11/2022]
Abstract
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.
Collapse
Affiliation(s)
- K Vowden
- Department of Vascular Surgery, Bradford Royal Infirmary, Bradford, UK
| |
Collapse
|
24
|
Lane C, Franks PJ. Nurses' evaluation of a new four-layer bandage system. J Wound Care 2001; 10:111-4. [PMID: 12964315 DOI: 10.12968/jowc.2001.10.4.26072] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
This small study was undertaken to evaluate a new four-layer bandage (4LB) system (Ultra Four, Robinson). The aim was to provide initial user information about the product and compare it with the previously used original Charing Cross 4LB system. Subjective evaluations of the comparative performance of the Ultra Four system were assessed using a weekly treatment questionnaire in 30 patients. Both patients and nurses commented on the usability of each individual layer and the overall performance of the new system over a period of up to 12 weeks or until healing. After 12 weeks 15/30 ulcers (50%) had healed. Using life table analysis, allowing for patients who failed to reach 12 weeks, the expected healing rate was 65%. The performance of each individual layer was considered similar to those of the Charing Cross 4LB in terms of wear and tear, slippage and ease of removal. However, there was an indication that the fourth layer provided superior wear and tear at the heel and better ease of application and ease of removal than the original. After one week of treatment the Ultra Four system was rated better than the original 4LB for wear and tear at the heel in 15/28 patients (54%), for overall wear and tear in 12/25 (48%), for ease of application in 9/27 (33%) and for ease of removal in 11/26 (42%). This study relied on the nurses' experience rather than a direct comparison between bandages. However, it does indicate that the relative performance of products may help nurses to make decisions when objective comparative data are not available.
Collapse
Affiliation(s)
- C Lane
- Trafford Healthcare Trust, Sale, UK
| | | |
Collapse
|
25
|
Abstract
The high treatment costs of inappropriate leg ulcer management are well referenced. Wide variations in practice have also been reported. A training programme for community nurses has been in place in Leicestershire and Rutland NHS Trust for five years. Its objective is to promote evidence-based leg ulcer management. The aim of this prospective audit was to assess and compare the effectiveness of the compression bandage systems used in the trust: the original Charing Cross system (August 1996 to September 1997) and Robinson's Ultra Four kit (October 1997 to December 1998). All patients with leg ulceration were assessed using the Leicestershire leg ulcer assessment form. This was submitted along with an audit tool to the tissue viability service in exchange for a 12-week supply of compression bandages. The audit form was resubmitted after each subsequent 12-week period until the patient either had healed or was withdrawn from the audit. Differences between the two groups in mobility, previous deep vein thrombosis, fixed ankle deformity, the male to female ratio, duration of ulcer and ulcer surface area were noted. Patients using the Ultra Four kit had faster healing times than those given the Charing Cross system, but this was not statistically significant. Cost comparisons between the previous dressing regimen and compression bandaging showed a significance difference (p < 0.001). There was also a significant reduction in nurse time (p < 0.001). The audit results showed that compression bandaging therapy was an effective method of achieving healing in patients with venous leg ulcers and that significant cost savings were made in terms of dressing cost and nurse time. Furthermore, there were potential benefits in continuing compression therapy for the group of non-healers.
Collapse
Affiliation(s)
- S Loftus
- Clinical Development Centre, Gorse Hill Hospital, Leicestershire and Rutland Healthcare NHS Trust, UK
| | | |
Collapse
|
26
|
Ballard K, McGregor F, Baxter H. An evaluation of the Parema four-layer bandage system. BRITISH JOURNAL OF NURSING (MARK ALLEN PUBLISHING) 2000; 9:1089-94. [PMID: 12785090 DOI: 10.12968/bjon.2000.9.16.5481] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
This article gives an overview of the treatment and causes of venous leg ulcers and focuses on a new four-layer bandage system (K-Four from Parema) which can be used in the treatment of these ulcers. The article features preliminary observations of this new system, which was used on 10 patients who had previously worn multilayer compression.
Collapse
Affiliation(s)
- K Ballard
- Tissue Viability Unit, Guy's Nuffield House, Guy's Hospital, London
| | | | | |
Collapse
|