Leg-ulcer care in the community, before and after implementation of an evidence-based service

Automated devices for identifying peripheral arterial disease in people with leg ulceration: an evidence synthesis and cost-effectiveness analysis

Background

Peripheral artery disease is a common condition caused by narrowing/blockage of the arteries, resulting in reduced blood supply. Peripheral artery disease is associated with an increased risk of vascular complications, but early treatment reduces mortality and morbidity. Leg ulcers are long-lasting wounds, usually treated by compression therapy. Compression therapy is not suitable for people with peripheral artery disease, as it can affect the arterial blood supply. In clinical practice, people with peripheral artery disease are identified by measurement of the ankle-brachial pressure index using a sphygmomanometer and manual Doppler device. However, this method can be uncomfortable for people with leg ulcers and automated devices have been proposed as a more acceptable alternative. The objective of this appraisal was to summarise the clinical and cost-effectiveness evidence on the use of automated devices to detect peripheral artery disease in people with leg ulcers.

Methods

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Clinical effectiveness

To identify reports of relevant studies, we searched major electronic databases and scrutinised the information supplied by the manufacturers of the automated devices under investigation. Due to the lack of evidence on people with leg ulcers, we considered evidence from studies of any design assessing automated devices versus an acceptable reference device in any population receiving ankle-brachial pressure index assessment. We summarised information on diagnostic accuracy of the automated devices and level of agreement with the reference device. For each device, when data permit, we pooled data across studies by conducting random-effects meta-analyses using a Hierarchical Summary Receiving Operating Characteristics model.

Cost-effectiveness

An economic model comprising a decision tree (24 weeks) and Markov models to capture lifetime costs and quality-adjusted life-years associated with venous, arterial and mixed aetiology disease in leg ulcer patients. Analyses were conducted from a United Kingdom National Health Service and Personal Social Services perspective. Costs and quality-adjusted life-years were discounted at 3.5% per year. Deterministic and several probabilistic analyses were used to capture uncertainty surrounding a range of optimistic and pessimistic assumptions about the impact of automated tests on health outcomes (ulcer healing and requirement for invasive management of arterial disease).

Results

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Clinical effectiveness

From the 116 records retrieved by the electronic searches, we included 24 studies evaluating five devices (BlueDop Vascular Expert, BOSO ABI-System 100, Dopplex Ability, MESI ankle-brachial pressure index MD and WatchBP Office ABI). Two studies assessing people with leg ulcers found that automated devices often gave higher ankle-brachial pressure index readings than manual Doppler (underestimation of arterial disease). In the 22 studies involving people without leg ulcers, automated devices generally demonstrated good specificity and moderate specificity. Meta-analysis of 12 studies showed a pooled sensitivity of 64% (95% confidence interval 57% to 71%) and a pooled specificity of 96% (95% confidence interval 92% to 98%) for detection of peripheral artery disease.

Cost-effectiveness

Automated devices cost less than manual Doppler to deliver. However, increased risks of invasive treatment requirements for inappropriately compressed arterial/mixed ulcers due to false-negative results, and increased healing times due to delayed compression of false-positive test results mean that in most scenarios manual Doppler was less costly and had slightly higher quality-adjusted life-years than automated devices. Results are highly uncertain, dependent on many assumptions and should be interpreted cautiously.

Limitations and conclusions

The limited evidence identified for each automated device, especially in people with leg ulcers, and its clinical heterogeneity precludes any firm conclusions on the diagnostic performance and cost-effectiveness of these devices in clinical practice.

Study registration

This study is registered as PROSPERO CRD42022327588.

Funding

This award was funded by the National Institute for Health and Care Research (NIHR) Evidence Synthesis programme (NIHR award ref: NIHR135478) and is published in full in Health Technology Assessment; Vol. 28, No. 37. See the NIHR Funding and Awards website for further award information.

Principles of extramural health care for chronic wounds in China

Development of extramural health care for chronic wounds is still in its infancy in China, and thus it is urgent and vital to establish a correct concept and practicable principles. The authors reviewed recent domestic and international literature and summarized the following treatment procedures and principles for extramural health care of chronic wounds. (1) The patient needs to do self-assessment of the wound by using available simple methods; (2) The patient consult with professional physicians or nurses on wound care to define the severity and etiology of the non-healing wound; (3) Professionals evaluate the existing treatment strategies; (4) Etiological treatments are given by professionals; (5) Patients buy needed dressings via the more convenient ways from pharmacies, e-commerce platform or others; (6) Professionals provide a standardized and reasonable therapeutic plan based on the patient's wound conditions; (7) Both professionals and the patient pay attention to complications to prevent adverse outcomes; (8) Professionals strengthen the public education on wound care and integrated rehabilitation. This review expected to provide new perspectives on the therapeutic strategies for chronic wounds in an extramural setting.

Accelerating the Implementation of Evidence-Based Practice in Physical Medicine and Rehabilitation

Over the last three decades, a substantial number of studies were published with the purpose of improving the effectiveness and efficiency of rehabilitation clinical practice. Clinicians and researchers face considerable challenges in successfully implementing these research findings into routine clinical practice. Knowledge translation includes the synthesis, dissemination, exchange and ethically sound application of knowledge to improve health, provide more effective health services and products, and strengthen the healthcare system. An aim of knowledge translation research is to identify strategies to accelerate implementation of evidence into practice. A recent citation analysis on a commonly used knowledge translation framework, the Knowledge-to-Action Framework, identified implementation activities performed in physical medicine and rehabilitation. While this citation analysis describes activities performed and outcomes assessed while conducting knowledge translation projects, successful knowledge translation also requires a robust social and physical infrastructure. In this commentary, we offer several observations that appear related to the increased likelihood of implementation success. Funders, higher education institutions, healthcare payers, and healthcare organizations contribute to successful implementation and must embrace their roles in implementation. Administrators, clinicians, and consumers of physical medicine and rehabilitation also have essential roles in knowledge translation.

Implementation strategies used to implement nursing guidelines in daily practice: A systematic review

OBJECTIVES

Research specifically addressing implementation strategies regarding nursing guidelines is limited. The objective of this review was to provide an overview of strategies used to implement nursing guidelines in all nursing fields, as well as the effects of these strategies on patient-related nursing outcomes and guideline adherence. Ideally, the findings would help guideline developers, healthcare professionals and organizations to implement nursing guidelines in practice.

DESIGN

Systematic review. PROSPERO registration number: CRD42018104615.

DATA SOURCES

We searched the Embase, Medline, PsycINFO, Web of Science, Cochrane, CINAHL and Google Scholar databases until August 2019 as well as the reference lists of relevant articles.

REVIEW METHODS

Studies were included that described quantitative data on the effect of implementation strategies and implementation outcomes of any type of a nursing guideline in any setting. No language or date of publication restriction was used. The Cochrane Effective Practice and Organisation of Care taxonomy was used to categorize the implementation strategies. Studies were classified as effective if a significant change in either patient-related nursing outcomes or guideline adherence was described. Strength of the evidence was evaluated using the 'Cochrane risk of bias tool' for controlled studies, and the 'Newcastle-Ottawa Quality Assessment form' for cohort studies.

RESULTS

A total of 54 articles regarding 53 different guideline implementation studies were included. Fifteen were (cluster) Randomized Controlled Trials or controlled before-after studies and 38 studies had a before-after design. The topics of the implemented guidelines were diverse, mostly concerning skin care (n = 9) and infection prevention (n = 7). Studies were predominantly performed in hospitals (n = 34) and nursing homes (n = 11). Thirty studies showed a positive significant effect in either patient-related nursing outcomes or guideline adherence (68%, n = 36). The median number of implementation strategies used was 6 (IQR 4-8) per study. Educational strategies were used in nearly all studies (98.1%, n = 52), followed by deployment of local opinion leaders (54.7%, n = 29) and audit and feedback (41.5%, n = 22). Twenty-three (43.4%) studies performed a barrier assessment, nineteen used tailored strategies.

CONCLUSIONS

A wide variety of implementation strategies are used to implement nursing guidelines. Not one single strategy, or combination of strategies, can be linked directly to successful implementation of nursing guidelines. Overall, thirty-six studies (68%) reported a positive significant effect of the implementation of guidelines on patient-related nursing outcomes or guideline adherence. Future studies should use a standardized reporting checklist to ensure a detailed description of the used implementation strategies to increase reproducibility and understanding of outcomes.

Quality indicators for a community-based wound care centre: An integrative review

The purpose of this review was to identify the role and contribution of community-based nurse-led wound care as a service delivery model. Centres increasingly respond proactively to assess and manage wounds at all stages - not only chronic wound care. We conducted an integrative review of literature, searching five databases, 2007-2018. Based on inclusion and exclusion criteria, we systematically approached article selection and all three authors collaborated to chart the study variables, evaluate data, and synthesise results. Eighteen studies were included, representing a range of care models internationally. The findings showed a need for nurse-led clinics to provide evidence-based care using best practice guidelines for all wound types. Wound care practices should be standardised across the particular service and be integrated with higher levels of resources such as investigative services and surgical units. A multi-disciplinary approach was likely to achieve better patient outcomes, while patient-centred care with strong patient engagement was likely to assist patients' compliance with treatment. High-quality community-based wound services should include nursing leadership based on a hub-and-spoke model. This is ideally patient-centred, evidence-based, and underpinned by a commitment to developing innovations in terms of treatment modalities, accessibility, and patient engagement.

Evaluation of the Clarity and Completeness of Reporting in Orthopedic Clinical Practice Guidelines

Background

Clinical practice guidelines (CPGs) can positively affect the quality of patient care offered by physicians because they decrease variability in clinical practice and may help reduce unnecessary testing, promoting a more responsible use of resources. Building on existing framework for reporting guideline development, including the work of the Enhancing the Quality and Transparency of Health Research Network, the Reporting Items for Practice Guidelines in Healthcare (RIGHT) Working Group created a 2016 checklist of 35 items considered essential for high-quality reporting of CPGs.

Objectives

To evaluate how many previously published CPGs in orthopedic surgery met the RIGHT criteria and assess how improvements can be made in future orthopedic CPGs based on any found deficiencies.

Methods

All 18 CPGs published before January 1, 2018, by the American Academy of Orthopedic Surgeons (AAOS) are publicly available on orthoguidelines.org. Two authors downloaded each file and both of those authors independently scored each CPG using piloted abstraction RIGHT checklist forms.

Results

Of the 35 RIGHT criteria outlined in 22 checklist items, 23 (65.7%) were met across all AAOS guidelines, 6 (17.1%) were not met by any of the AAOS guidelines, and 6 (17.2%) were met by some of the AAOS guidelines.

Conclusion

Overall, the AAOS guidelines addressed many important recommendations within the RIGHT checklist. Assessing adherence to the RIGHT checklist can help ensure that future guidelines are more effectively communicated, hopefully assisting end users in efficient implementation and increasing the level of evidence-based patient care.

Optimization of home care nurses in Canada: A scoping review

Nurses are among the largest providers of home care services thus optimisation of this workforce can positively influence client outcomes. This scoping review maps existing Canadian literature on factors influencing the optimisation of home care nurses (HCNs). Arskey and O'Malley's five stages for scoping literature reviews were followed. Populations of interest included Registered Nurses, Registered/Licensed Practical Nurses, Registered Nursing Assistants, Advanced Practice Nurses, Nurse Practitioners and Clinical Nurse Specialists. Interventions included any nurse(s), organisational and system interventions focused on optimising home care nursing. Papers were included if published between January 1, 2002 up to May 15, 2015. The review included 127 papers, including 94 studies, 16 descriptive papers, 6 position papers, 4 discussion papers, 3 policy papers, 2 literature reviews and 2 other. Optimisation factors were categorised under seven domains: Continuity of Care/Care; Staffing Mix and Staffing Levels; Professional Development; Quality Practice Environments; Intra-professional and Inter-professional and Inter-sectoral Collaboration; Enhancing Scope of Practice: and, Appropriate Use of Technology. Fragmentation and underfunding of the home care sector and resultant service cuts negatively impact optimisation. Given the fiscal climate, optimising the existing workforce is essential to support effective and efficient care delivery models. Many factors are inter-related and have synergistic impacts (e.g., recruitment and retention, compensation and benefits, professional development supports, staffing mix and levels, workload management and the use of technology). Quality practice environments facilitate optimal practice by maximixing human resources and supporting workforce stability. Role clarity and leadership supports foster more effective interprofessional team functioning that leverages expertise and enhances patient outcomes. Results inform employers, policy makers and relevant associations regarding barriers and enablers that influence the optimisation of home care nursing in nursing, intra- and inter-professional and inter-organisational contexts.

Computer-Assisted Wound Assessment and Care Education Program in Registered Nurses: Use of an Interactive Online Program by 418 Registered Nurses

PURPOSE

The purpose of this descriptive study was to evaluate use of a previously validated, online, interactive wound assessment and wound care clinical pathway in a group of RNs. Specific aims were to (a) evaluate the proportions of correct, partially correct, and incorrect algorithmic decisions and dressing selections, (b) compare response rates between nurses who are and who are not wound care certified, and (c) evaluate its ease of use, educational value, and applicability in clinical practice.

DESIGN

Descriptive study.

SUBJECTS AND SETTING

Participants were recruited using convenience and snowball sampling methods. Four hundred eighteen nurses completed all 15 assessments; nearly half held a bachelors' degree in nursing (189, 45%), more than two-thirds worked in an inpatient acute care settings (277, 68%), and 293 (70%) were not certified in wound care.

METHODS

After providing written informed consent and completing the participant demographics form, participants assessed 15 photographs of wounds with accompanying moisture descriptions and completed an algorithm and dressing selection for each. All responses were anonymously collected by the program. Existing, retrospective, program data were also downloaded and data from nurses who completed all assessments were extracted and analyzed. Descriptive statistics were used to analyze all variables. Selection outcomes and survey responses between nurses who were and who were not wound care certified were compared using a 2-sample Student t test assuming unequal variances. Individual responses for the first 6 wounds were compared to the last 6 wounds using a paired t test.

RESULTS

The mean (M) proportions of fully or partially correct (operationally defined as safe but not fully correct) algorithm and dressing choice were 81% (SE: 0.88, 95% confidence level: 1.73) and 78.1% (SE: 0.70, 95% confidence level: 1.39), respectively. Wound care-certified nurses had higher mean algorithm scores than those who were not certified (M: 89.2%, SE: 1.27 vs M: 77.8%, SE: 1.10, P < .001). Most incorrect/partially correct choices were attributable to incorrect necrotic tissue assessment (n = 845, 58%). The difference between fully correct first 6 and last 6 algorithm choices was statistically significant (M: 310, SE: 0.02 vs M: 337, SE: 9.32, P = .04). On a Likert scale of 1 (not at all) to 5 (very), average scores for ease of program and algorithm use, educational value, and usefulness for clinicians ranged from M: 4.14, SE: 0.08 to M: 4.22, SE: 0.08.

CONCLUSIONS

Results suggest that the algorithm is valid and has potential educational value. Initial evaluation also suggests that program refinements are needed. Evaluation of participant responses indicated potential problems with the definitions used for necrotic tissue or assessment knowledge deficits. Results also substantiate the importance of instructional design and testing online education programs. More research is needed to uncover potential gaps in nurses' wound care knowledge that may hamper evidence-based practices adoption and the need to develop effective, evidence-based education-delivery techniques.

"Wounds Home Alone"-Why and How Venous Leg Ulcer Patients Self-Treat Their Ulcer: A Qualitative Content Study

BACKGROUND

Venous leg ulcers (VLUs), the most common type of leg ulcerations, have long healing times and high recurrence rates; reimbursement rules and a general shortage of nursing staff have put self-treatment into focus. The study aimed to investigate why and how patients with VLUs self-treat their ulcers.

METHODS

Patients with VLUs (N = 32) were selected by criterion sampling for a multicentric qualitative study using semi-structured interviews. The interviews were analyzed via inductive qualitative content analysis.

RESULTS

More than two-thirds of participants sometimes self-treated VLU and one quarter changed their prescribed treatment. Experiences were expressed through four themes as follows: (a) current local VLU therapy; (b) VLU self-treatment; (c) patient education; and (d) psychosocial issues. The main reasons for self-treatment were a lack of healthcare resources, reimbursement restrictions, and dissatisfaction with conventional treatment together with insufficient knowledge about the wound-healing process and possible side effects. No educational materials were provided for patients or caregivers. Many patients adopted homemade remedies.

CONCLUSION

Patients with VLUs practice self-care due to limited healthcare availability, a low awareness of the causes of their condition, and the effects of therapy on VLU healing. Future educational intervention is needed to enhance self-treatment.

Patient and Public Engagement in Integrated Knowledge Translation Research: Are we there yet?

PLAIN ENGLISH SUMMARY

There have been many attempts to improve how healthcare services are developed and delivered. Despite this, we know that there are many gaps and differences in practice and that these can lead to poor patient outcomes. In addition, there are also concerns that research is being undertaken that does not reflects the realities or needs of those using healthcare services, and that the use of research findings in practice is slow. As such, shared approaches to research, such as integrated knowledge translation, are being used.Integrated knowledge translation (IKT) is a research approach that brings together researchers, along with other stakeholders that have knowledge about a particular healthcare issue. Stakeholders may include healthcare providers and policy-makers. More recently, there has been a growing awareness of the need to include patients and members of the public within research processes. These collaborative and patient-oriented research approaches are seen as a way to develop research that tackles ongoing gaps in practice and reflect the insights, needs and priorities of those most affected by health research outcomes. Despite great support, little is known about how these major research approaches are connected, or how they may bring about improvements in the development and use of research evidence. In this paper, we examine how IKT and patient engagement processes are linked, as well as exploring where differences exist. Through this, we highlight opportunities for greater patient engagement in IKT research and to identify areas that need to be understood further.

ABSTRACT

Healthcare organizations across the world are being increasingly challenged to develop and implement services that are evidence-based and bring about improvement in patient and health service outcomes. Despite an increasing emphasis upon evidence-based practice, large variations in practice remain and gaps pervade in the creation and application of knowledge that improves outcomes. More collaborative models of health research have emerged over recent years, including integrated knowledge translation (IKT), whereby partnerships with key knowledge users are developed to enhance the responsiveness and application of the findings. Likewise, the meaningful engagement of patients, in addition to the inclusion of patient-reported outcomes and priorities, has been hailed as another mechanism to improve the relevance, impact and efficiency of research.Collectively, both IKT and patient engagement processes provide a vehicle to support research that can address health disparities and improve the delivery of effective and responsive healthcare services. However, the evidence to support their impact is limited and while these approaches are inextricably connected through their engagement focus, it is unclear how IKT and patient engagement processes are linked conceptually, theoretically, and practically. In this paper, we will begin to critically examine some of the linkages and tensions that exist between IKT and patient-engagement for research and will examine potential opportunities for IKT researchers as they navigate and enact meaningful partnerships with patients and the public.

Chronic wounds in Australia: A systematic review of key epidemiological and clinical parameters

Chronic wounds are a significant problem in Australia. The health care-related costs of chronic wounds in Australia are considerable, equivalent to more than AUD $3.5 billion, approximately 2% of national health care expenditure. Chronic wounds can also have a significant negative impact on the health-related quality of life of affected individuals. Studies have demonstrated that evidence-based care for chronic wounds improves clinical outcomes. Decision analytical modelling is important in confirming and applying these findings in the Australian context. Epidemiological and clinical data on chronic wounds are required to populate decision analytical models. Although epidemiological and clinical data on chronic wounds in Australia are available, these data have yet to be systematically summarised. To address these omissions and clarify the state of existing evidence, we conducted a systematic review of the literature on key epidemiological and clinical parameters of chronic wounds in Australia. A total of 90 studies were selected for inclusion. This paper presents a synthesis of the evidence on the prevalence and incidence of chronic wounds in Australia, as well as rates of infection, hospitalisation, amputation, healing, and recurrence.

Economic Evaluations of Guideline-Based Care for Chronic Wounds: a Systematic Review

OBJECTIVES

The aim of this study was to review all published economic evaluations of guideline-based care for chronic wounds and to assess how useful these studies are for decision making in health services.

METHODS

Embase, PubMed, Scopus, Health Technology Assessment (HTA) and National Health Service Economic Evaluation Database (NHS EED) were searched on April 16th, 2018. We included studies that evaluated the economic impact and health outcomes associated with implementing evidence-based guidelines as a bundle of care for the prevention and/or treatment of chronic wounds. Information was extracted from each eligible study and organized by the type of chronic wound. The quality of published economic evaluation studies was assessed using the Consolidated Health Economic Evaluation Reporting Standards (CHEERS).

RESULTS

A total of 24 economic evaluation studies met the inclusion criteria, of which 12 applied decision analytic models. The compliance with the CHEERS checklist ranged between 43 and 83%.

LIMITATIONS

We may have missed some economic evaluation studies despite the use of broad search terms. The quality assessment was conducted based on judgment. Using the CHEERS checklist may reflect the way evaluations were reported rather than conducted.

CONCLUSIONS AND IMPLICATIONS OF KEY FINDINGS

We found that guideline-based care may be cost-saving or cost-effective in most circumstances. The quality and usefulness of reviewed studies for decision making were variable. Better information and higher-quality economic evaluations will increase decision makers' confidence to promote guideline-based care.

SYSTEMATIC REVIEW REGISTRATION NUMBER

PROSPERO CRD42017051859.

Cost-effectiveness analysis of guideline-based optimal care for venous leg ulcers in Australia

BACKGROUND

Venous leg ulcers (VLUs) are expensive to treat and impair quality of life of affected individuals. Although improved healing and reduced recurrence rates have been observed following the introduction of evidence-based guidelines, a significant evidence-practice gap exists. Compression is the recommended first-line therapy for treatment of VLUs but unlike many other developed countries, the Australian health system does not subsidise compression therapy. The objective of this study is to estimate the cost-effectiveness of guideline-based care for VLUs that includes public sector reimbursement for compression therapy for affected individuals in Australia.

METHODS

A Markov model was designed to simulate the progression of VLU for patients receiving guideline-based optimal prevention and treatment, with reimbursement for compression therapy, and then compared to usual care in each State and Territory in Australia. Model inputs were derived from published literature, expert opinion, and government documents. The primary outcomes were changes to costs and health outcomes from a decision to implement guideline-based optimal care compared with the continuation of usual care. Sensitivity analyses were performed to test the robustness of model results.

RESULTS

Guideline-based optimal care incurred lower total costs and improved quality of life of patients in all States and Territories in Australia regardless of the health service provider. We estimated that providing compression therapy products to affected individuals would cost the health system an additional AUD 270 million over 5 years but would result in cost savings of about AUD 1.4 billion to the health system over the same period. An evaluation of unfavourable values for key model parameters revealed a wide margin of confidence to support the findings.

CONCLUSIONS

This study shows that guideline-based optimal care would be a cost-effective and cost-saving strategy to manage VLUs in Australia. Results from this study support wider adoption of guideline-based care for VLUs and the reimbursement of compression therapy. Other countries that face similar issues may benefit from investing in guideline-based wound care.

Wound centres-how do we obtain high quality? The EWMA wound centre endorsement project

OBJECTIVE

Different types of multidisciplinary concepts for treating non-healing wounds have been developed. However, there is insufficient evidence on the quality of multidisciplinary wound centres, and a limited number of evaluation systems have so far been developed. The lack of an international wound centre evaluation/certification system is the basis for the European Wound Management Association (EWMA) Wound Centre Endorsement Project. The project aims to describe the minimum requirements for a wound management centre. These requirements have been defined as a basis for evaluation and endorsement of wound centres inside as well as outside a hospital setting (in- and outpatient clinics).

METHOD

The endorsement programme focused on wound centre characteristics such as: target population; types of centres; and choice of model used. The method used to develop the EWMA wound centre endorsement programme was an evaluation of the quality of the different types of established wound centres across and outside Europe. Criteria and procedures for endorsement of wound centres were developed and pilot projects were performed outside Europe in two in-patient centres in China and one outpatient centre in Brazil.

RESULTS

The EWMA endorsement procedure includes the following steps: initial application; review of centre data provided via the application form and follow-up dialogue; visit to the wound centre; final report and endorsement; and re-endorsement. A follow-up visit was arranged in connection with the re-endorsement. Experiences from the pilot studies have so far indicated that the endorsement process is not only a quality declaration, but may also result in positive developments, such as increased visibility, increased patient flow, increased healing rates, and decreased amputation rate.

CONCLUSION

Development of endorsement systems focusing on the minimum requirements for a wound management centre is required to support the development of high-quality wound centres which provide health-care services according to recent evidence of current best practice. The EWMA Wound Centre Endorsement Project is the first international programme of its kind and this may, in the future, support the establishment of international collaboration and knowledge sharing about the development and maintenance of high-quality wound centres.

What is the effect of exercise on wound healing in patients with venous leg ulcers? A systematic review

Standard best practice for the treatment of venous leg ulcers (VLUs) is compression bandaging of the lower leg to reduce hydrostatic pressure. There is considerable variation in reported healing rates when using this gold-standard approach; therefore, a systematic and robust evaluation of other interventions is required. Exercise interventions, in addition to standard compression therapy, could improve wound-healing time and prevent their recurrence. We have conducted a systematic review to examine the effects of exercise on wound characteristics, including time to heal, size and recurrence, pain, quality of life, adverse events, and economic outcomes. This review was registered with PROSPERO 2016:CRD42016046407. A systematic search of Ovid Medline, Ovid EMBASE, Ovid CINAHL, The Cochrane Library, PsycINFO, Web of Science, and PEDro was conducted on January 30, 2017, for randomised control trials to examine the effects of exercise on time to heal, size and recurrence, pain, quality of life, adverse events, and economic outcomes. Six studies met the inclusion criteria, but all had design flaws leading to biases, most commonly performance and selective reporting bias. Three studies compared a progressive resistance exercise programme (PREG) plus compression with compression alone for a period of 12 weeks. Low-quality evidence indicates the following: possibly no difference in the proportion of ulcers healed (risk ratio [RR] 1.14, 95% CI 0.71 to 1.84, I² 36%; 3 trials, 116 participants); probably no difference in quality of life (mean difference [MD] 3 points better on 100 point scale with exercise, 95% CI -1.89 to 7.89, 1 trial, 59 participants); possible increase in the risk of adverse events with exercise (OR 1.32, 95% CI 0.95 to 1.85, 1 RCT, 40 participants); and no difference in ankle range of motion and calf muscle pump. Evidence was downgraded due to susceptibility to bias and imprecision. Recurrence, pain, and economic outcomes were not measured in these trials, and time to healing was measured but not fully reported in 1 trial. We are uncertain of the effects of other interventions (community-based exercise and behaviour modification, ten thousand steps, supervised vs unsupervised exercise) due to the availability of low- or very low-quality evidence only from single trials. The review highlights the need for further research, with larger sample sizes, to properly address the significance of the effect of exercise on VLU wound characteristics.

The impact of team based interprofessional comprehensive assessments on the diagnosis and management of diabetic foot ulcers: A retrospective cohort study

Background

Diabetic foot ulcers (DFU) are increasingly prevalent, and associated with significant morbidity, mortality, and cost. An interprofessional approach to DFU management is critical given the etiological complexity involved. This study aimed to assess the impact of an interprofessional team approach on DFU diagnosis and management for a cohort of patients receiving treatment in an Ontario Canada home care setting.

Methods

A retrospective cohort study of patients attending a large regional Community Care Access Centre (CCAC) between February 11, 2013-September 30, 2014 was conducted. Following CCAC referral, patients were assessed by an interprofessional team at the Toronto Regional Wound Healing Centre (TRWHC). Those aged > 18 years with a DFU of > 6 weeks duration were included. The primary outcome was the precision of the initial diagnosis relating to DFU etiology (i.e. neuropathic, ischemic or mixed etiology). Secondary outcomes included wound healing, and infection parameters. Analysis was completed with STATA 13.1 (College Stn., TX) of pre-determined outcomes with 2 sided α of 0.05.

Results

A total of 308 patients were screened, and 49 patients (67.3% male) of mean age 64.2 years (SD 13.7) with a diagnosis of DFU > 6 weeks duration were included for analysis. Of these, 95% were referred with unspecified DFU, and were reclassified to a precise diagnosis relating to etiology, including neuropathy, ischemia or neuroischemic etiology following TRWHC assessment (p < 0.001). For secondary outcomes post-assessment, healability assessment was conducted for a greater proportion of patients (100% versus 44%, p < 0.001). Infection was identified in a greater number of patients (p = 0.04), and of the 35 patients, 94.5% had deep and surrounding infection, and 88.0% were initiated on systemic antibiotics. Vascular insufficiency was diagnosed in an additional 14.3% of the cohort (p = 0.03). Offloading/footwear assessment was conducted in all patients compared with 30.6% prior to referral (p < 0.001) Dressing change frequency decreased significantly following TRWHC assessment (pre: 4.31/week; post: 3.54/week; p = 0.03). Pain scores decreased (2.18 to 1.67) on the numerical rating scale but this was not statistically significant at the final TRWHC assessment. Notably, 36.7% (18/49) reported improved quality of life by the second TRWHC encounter.

Conclusions

Interprofessional care teams are associated with improved diagnostic acumen and wound healing outcomes over conventional community care services. Initiatives including best practice interprofessional diabetic foot care pathways are recommended with timely vascular management of ischemia, treatment of deep and surrounding infection as well as the availability of foot care and footwear.

A large cluster randomized trial of outcome-based pathways to improve home-based wound care

BACKGROUND

Although not always recognized as a pressing health care problem, wounds are a common, complex and costly condition. The burden of treating wounds is growing rapidly due to increasing health care costs, an aging population and a sharp rise in the incidence of diabetes and obesity worldwide. The Integrated Client Care (ICC) Project was a multi-year initiative to develop and test a new, integrated model of wound care within the home care sector in Ontario, Canada to improve health outcomes for patients and decrease system costs.

METHODS

Cluster randomized trial, with allocation of intervention randomized at the cluster level (14 home care centers) and analysis of outcomes based on individual-level data (patients). Primary analysis was an intention-to-treat (ITT) analysis. Two wound types, diabetic foot ulcers and pilonidal sinus, were selected as tracer conditions to assess the impact of the intervention on two different patient populations. Time to successful discharge from home care was analyzed using multivariable Cox proportional hazards regression. Hazard ratios (HRs) and 95% confidence intervals (CIs) are presented.

RESULTS

A total of 12,063 diabetic foot ulcer patients and 1954 pilonidal sinus patient records were available for analysis. No appreciable differences were observed between patients in the control and intervention arms for either of the primary or secondary analyses in either condition group. In the diabetic foot ulcer group, 72.7% patients in the control arm and 73.6% patients in the intervention arm were discharged in the follow-up period (HR 1.05; 95% CI 0.94 to 1.17). In the pilonidal sinus group, 91.0% patients in the control arm and 89.0% patients in the intervention arm were discharged in the follow-up period (HR 0.96; 95% CI 0.82 to 1.12).

CONCLUSION

As implemented, the ICC intervention was not effective, most likely due to failure of implementation, and is, therefore, not ready for widespread implementation in Ontario. Significant work remains to be done to correct the implementation process so that the concept of outcome-based health care can be properly evaluated.

TRIAL REGISTRATION

ClinicalTrials.gov, ID: NCT01573832 . Registered on 12 January 2012.

Nurses' knowledge on diabetic foot ulcer disease and their attitudes towards patients affected: A cross-sectional institution-based study

AIMS AND OBJECTIVES

To assess nurses' knowledge on diabetic ulcer disease and their attitudes towards patients suffering from it and to identify factors which influence them.

BACKGROUND

Diabetic wound care is an evolving specialty with the rising prevalence of diabetes foot complications. As nurses play a key role in wound care, their knowledge and attitudes are important in providing optimum care to patients.

DESIGN

Descriptive cross-sectional survey design.

METHODS

The study was conducted in three teaching hospitals. Data were collected using a pretested, validated, self-administered questionnaire from purposively recruited, voluntarily participating nurses (n = 200) who were in diabetic wound care practice for ≥1 year.

RESULTS

Lack of formal wound care training was reported by 91.2%. Mean knowledge score was 77.9 (range 53.3-100 on a scale from 0-100) with 57.8% of nurses obtaining ≥80%. Nurses demonstrated an overall positive attitude towards caring for diabetic ulcer patients (median = 41, range 23-50 on a scale from 10-50). However, the study identified deficits in core knowledge and some negative attitudes such as insensitivity to pain. Statistically significant associations were seen between nurses' knowledge and duration of nursing, wound care experience and the type of unit they are attached to. In-service education (77.2%) and knowledge sharing with peers (77.9%) were the most popular knowledge-updating sources. Although 98.6% of nurses were interested in wound care, only 8.3% wished to engage in research. No correlation was observed between nurses' knowledge and attitudes.

CONCLUSION

Gaps in core knowledge and negative attitudes may be attributed to inadequate training, suboptimal update of knowledge and lack of interest in wound care research.

RELEVANCE TO CLINICAL PRACTICE

Wound care training should be made mandatory to improve quality of care given by nurses to patients with diabetic ulcers. Continuous professional development, evidence-based practices and wound care research should be encouraged.

Evidence and evidence gaps in therapies of nasal obstruction and rhinosinusitis

Therapeutic decisions in otorhinolaryngology are based on clinical experience, surgical skills, and scientific evidence. Recently, evidence-based therapies have gained increased attention and importance due to their potential to improve the individual patient's treatment and their potential at the same time to reduce treatment costs. In clinical practice, it is almost impossible to stay ahead of the increasing mass of literature and on the other hand critically assess the presented data. A solid scientific and statistical knowledge as well as a significant amount of spare time are required to detect systematic bias and other errors in study designs, also with respect to assessing whether or not a study should be part of an individual therapeutic decision. Meta-analyses, reviews, and clinical guidelines are, therefore, of increasing importance for evidence-based therapy in clinical practice. This review is an update of the availability of external evidence for the treatment of nasal obstruction and rhinosinusitis. It becomes evident that both groups of diseases differ significantly in the availability of external evidence. Furthermore, it becomes obvious that surgical treatment options are normally based on evidence of significantly lower quality than medical treatment options.

Health-related quality of life at healing in individuals with chronic venous or mixed-venous leg ulceration: a longitudinal assessment

AIMS

To identify factors associated with longitudinal changes in health-related quality of life in community-dwelling individuals with venous or mixed-venous leg ulcers.

BACKGROUND

Most care focuses primarily on healing; this research may additionally lead to strategies to improve quality of life.

DESIGN

Data from four studies (2000-2009) were combined (2012) to examine quality of life in community-dwelling individuals referred for care of chronic leg wounds.

METHODS

Data collection occurred at baseline, 3, 6, 9 and 12 months or at healing and included a comprehensive clinical assessment and measures of pain (McGill), functional autonomy (EQ-5D^™ ) and quality of life (SF-12^TM ). Physical Component Summary and Mental Component Summary scores (SF-12^TM ) were categorized by whether or not there was an improvement (≥3 points) over time. Multivariable logistic regression modelling was used to identify factors associated with improvement.

RESULTS/FINDINGS

Mean age of this sample (n = 519) was 67·5 years, 55·9% were women. Median time to healing was 70 days. Mean Physical Component Summary score increased from 37·0-41·5; factors associated with improvement included independent mobility, family history, problems with usual activities, fewer comorbidities and higher baseline pain. Mean Mental Component Summary score improved from 50·5-53·7; factors associated with improvement included anxiety or depression at baseline and living with others.

CONCLUSION

Chronic leg ulceration has a substantial, negative impact on health-related quality of life. Ascertaining characteristics associated with changes in quality of life will contribute to the development of comprehensive strategies for prevention, care and improved quality of life.

Improved wound management at lower cost: a sensible goal for Australia

Chronic wounds cost the Australian health system at least US$2·85 billion per year. Wound care services in Australia involve a complex mix of treatment options, health care sectors and funding mechanisms. It is clear that implementation of evidence-based wound care coincides with large health improvements and cost savings, yet the majority of Australians with chronic wounds do not receive evidence-based treatment. High initial treatment costs, inadequate reimbursement, poor financial incentives to invest in optimal care and limitations in clinical skills are major barriers to the adoption of evidence-based wound care. Enhanced education and appropriate financial incentives in primary care will improve uptake of evidence-based practice. Secondary-level wound specialty clinics to fill referral gaps in the community, boosted by appropriate credentialing, will improve access to specialist care. In order to secure funding for better services in a competitive environment, evidence of cost-effectiveness is required. Future effort to generate evidence on the cost-effectiveness of wound management interventions should provide evidence that decision makers find easy to interpret. If this happens, and it will require a large effort of health services research, it could be used to inform future policy and decision-making activities, reduce health care costs and improve patient outcomes.

Epidemiology and health care situation of chronic wounds in Germany

Chronic wounds are of great socioeconomic importance. Usually they are associated with a long, complicated and burdensome course of disease and require high nursing and medical expenses. The quality of life of patients with chronic wounds is substantially impaired. This article provides a systematic overview of current studies on the morbidity and the health care situation of patients with chronic wounds, especially in patients with leg ulcers in Germany.

Analyses based on routine data of statutory health insurances show higher incidence and prevalence rates, for example of patients with leg ulcers, compared with previously regional surveys. The quality of care is inadequate, particularly in diagnostics and therapy of patients with leg ulcers. To date, there is undersupply and a lack of execution and deficient knowledge about the compression treatment in patients with venous leg ulcers.

Thus, there is need for further action in order to establish better implementation of guidelines in the management of patients with chronic wounds.

Cost analysis of one of the first outpatient wound clinics in the Netherlands

OBJECTIVE

To perform, from an insurance perspective, a cost analysis of one of the outpatient community wound care clinics in the Netherlands, the Knowledge Centre in Wound Care (KCWC) at Venray.

METHOD

This study involved a cost analysis based on an observational cohort study with a one-year pre-admission and a one-year post-admission comparison of costs. Patients were included when they first consulted the outpatient wound care clinic. Participants were all insured by the same health insurance company, Coöperatie Volksgezondheidszorg (VGZ). A standard six-step procedure for performing cost studies was used to calculate the costs. Given the skewed cost data, non-parametric bootstrapping was used to test for statistical differences.

RESULTS

There were 172 patients included in this study. The difference in costs related to wound care between the year before and the year after initial admission to the wound clinic amounted to an average reduction of €2621 (£1873) per patient in the base case analysis. The categories 'general practitioner', 'hospital care', 'mental health care' and 'transport' scored lower, indicating lower costs, in the year after admission to the wound clinic.

CONCLUSION

In this study, only the reimbursement data of patients of one health insurance company, and specifically only those made under the 2006 Dutch Health Insurance Act, were available. Because of the observational design, definitive conclusions cannot be made regarding a demonstrated reduction of costs in the year post admission. Nevertheless, this study is a first attempt of a cost analysis of an equipped outpatient wound clinic as an innovative way of responding to the increasing number of chronic wounds in the Netherlands. The calculations show that savings in wound care are possible.

DECLARATION OF INTEREST

A possible conflict of interest should be mentioned. First author AALM Rondas, PhD student at Maastricht University, is working at the KCWC wound clinic at Venray in the Netherlands as a physician. However, the research data were provided externally by Coöperatie Volksgezondheidszorg (VGZ) and checked by the academic co-authors, none of whom have a conflict of interest. The authors have no financial or commercial interest to declare.

Prospective study on the treatment of lower-extremity chronic venous and mixed ulcers using tissue-engineered skin substitute made by the self-assembly approach

BACKGROUND

Despite present optimal standard treatment of lower-extremity ulceration, a high incidence of recurrence and treatment failure is observed. The objective of this project was to evaluate the effect of a self-assembled skin substitute (SASS) made by tissue engineering as a temporary cutaneous dressing in the treatment of hard-to-heal chronic ulcers.

PATIENTS AND METHODS

The prospective uncontrolled case study includes patients suffering from venous or mixed ulcers lasting more than 6 months and unresponsive to compression therapy, with an Ankle Brachial Index greater than 0.5. Compression therapy was combined with the weekly application of SASS, produced from the patient's own skin cells, until healing. A weekly follow-up recorded wound size, skin aspect, pain, drainage, and percentage of wound healing. Photographs were also taken to assess ulcer evolution.

RESULTS

Fourteen ulcers present on 5 patients were treated. A mean of 6.7 SASS depositions by ulcer was required for healing. Two ulcers developed a minor wound infection, which was treated with oral antibiotics; another 2 ulcers recurred, and 1 healed with a second course of treatment, whereas 1 ulcer had a small recurrence treated with local wound care.

CONCLUSION

The authors' study suggests that the SASS used as a biological dressing is a promising treatment for hard-to-heal chronic venous and mixed ulcers that are unresponsive to compression therapy.

Adaptation, evaluation, and updating of guidelines: article 14 in Integrating and coordinating efforts in COPD guideline development. An official ATS/ERS workshop report

INTRODUCTION

Professional societies, like many other organizations, have recognized the need to use more rigorous processes to ensure that health care recommendations are informed by the best available research evidence. This is the last of a series of 14 articles that methodologists and researchers from around the world have prepared to advise guideline developers in respiratory and other diseases on how to achieve this. We updated a review of the literature on guideline adaptation, evaluation, and updating, focusing on four key questions.

METHODS

In this review we addressed the following questions. (1) Which high-quality guidelines on chronic obstructive pulmonary disease (COPD) are available? (2) How should guidelines be adapted to the user's context and culture? (3) How should the use of guidelines be evaluated in clinical practice? and (4) How should guidelines be efficiently kept up-to-date? We did not conduct systematic reviews ourselves. We relied on a literature review published in 2006 and on a manual produced by the ADAPTE Collaboration to inform our judgments, as well as our collective experience and workshop discussions.

RESULTS AND DISCUSSION

Guideline adaptation can be seen as an alternative to de novo development and as part of an implementation process, taking into consideration the user's own context. A systematic approach should be followed to ensure high quality of the resulting guidance. On the topic of COPD, many guidelines are available. Guidelines of the Global Initiative for Chronic Obstructive Lung Disease and of the American Thoracic Society and European Respiratory Society are particularly well-suited for adaptation. The adaptation process includes (1) definition of specific questions that need to be answered by the guideline; (2) assessment of guideline quality; (3) assessment of the clinical content, validity, acceptability, applicability, and transferability of the recommendations; and (4) decisions about adoption or adaptation of the recommendations. The use of the guidelines in practice can be measured with performance indicators. Adverse effects of strict adherence to guideline recommendations should be prevented, in particular when the improvement of patient outcomes is unclear. COPD guidelines should be updated at least every 2 years. Collaboration between COPD guideline developers is recommended to prevent duplication of effort.

Health service pathways for patients with chronic leg ulcers: identifying effective pathways for facilitation of evidence based wound care

BACKGROUND

Chronic leg ulcers cause long term ill-health for older adults and the condition places a significant burden on health service resources. Although evidence on effective management of the condition is available, a significant evidence-practice gap is known to exist, with many suggested reasons e.g. multiple care providers, costs of care and treatments. This study aimed to identify effective health service pathways of care which facilitated evidence-based management of chronic leg ulcers.

METHODS

A sample of 70 patients presenting with a lower limb leg or foot ulcer at specialist wound clinics in Queensland, Australia were recruited for an observational study and survey. Retrospective data were collected on demographics, health, medical history, treatments, costs and health service pathways in the previous 12 months. Prospective data were collected on health service pathways, pain, functional ability, quality of life, treatments, wound healing and recurrence outcomes for 24 weeks from admission.

RESULTS

Retrospective data indicated that evidence based guidelines were poorly implemented prior to admission to the study, e.g. only 31% of participants with a lower limb ulcer had an ABPI or duplex assessment in the previous 12 months. On average, participants accessed care 2-3 times/week for 17 weeks from multiple health service providers in the twelve months before admission to the study clinics. Following admission to specialist wound clinics, participants accessed care on average once per week for 12 weeks from a smaller range of providers. The median ulcer duration on admission to the study was 22 weeks (range 2-728 weeks). Following admission to wound clinics, implementation of key indicators of evidence based care increased (p < 0.001) and Kaplan-Meier survival analysis found the median time to healing was 12 weeks (95% CI 9.3-14.7). Implementation of evidence based care was significantly related to improved healing outcomes (p < 0.001).

CONCLUSIONS

This study highlights the complexities involved in accessing expertise and evidence based wound care for adults with chronic leg or foot ulcers. Results demonstrate that access to wound management expertise can promote streamlined health services and evidence based wound care, leading to efficient use of health resources and improved health.

Specialized community-based care: an evidence-based analysis

BACKGROUND

Specialized community-based care (SCBC) refers to services that manage chronic illness through formalized links between primary and specialized care.

OBJECTIVES

The objectives of this evidence-based analysis (EBA) were as follows: to summarize the literature on SCBC, also known as intermediate care to synthesize the evidence from previous Medical Advisory Secretariat (now Health Quality Ontario) EBAs on SCBC for heart failure, diabetes, chronic obstructive pulmonary disease (COPD), and chronic wounds to examine the role of SCBC in family practice

RESULTS

PART 1: SYSTEMATIC REVIEW OF INTERMEDIATE CARE: Seven systematic reviews on intermediate care since 2008 were identified. The literature base is complex and difficult to define. There is evidence to suggest that intermediate care is effective in improving outcomes; however, the effective interventions are still uncertain. PART 2: SYNTHESIS OF EVIDENCE IN INTERMEDIATE CARE MORTALITY: Heart failure Significant reduction in patients receiving SCBC COPD Nonsignificant reduction in patients receiving SCBC HOSPITALIZATION: Heart failure Nonsignificant reduction in patients receiving SCBC COPD Significant reduction in patients receiving SCBC EMERGENCY DEPARTMENT VISITS: Heart failure Nonsignificant reduction in patients receiving SCBC COPD Significant reduction in patients receiving SCBC DISEASE-SPECIFIC PATIENT OUTCOMES: COPD Nonsignificant improvement in lung function in patients receiving SCBC Diabetes Significant reduction in hemoglobin A1c (HbA1c) and systolic blood pressure in patients receiving SCBC Chronic wounds Significant increase in the proportion of healed wounds in patients receiving SCBC QUALITY OF LIFE: Heart failure Trend toward improvement in patients receiving SCBC COPD Significant improvement in patients receiving SCBC PART 3: INTERMEDIATE CARE IN FAMILY PRACTICE--EVIDENCE-BASED ANALYSIS: Five randomized controlled trials were identified comparing SCBC to usual care in family practice. Inclusion criteria were 1) the presence of multiple chronic conditions, and 2) interventions that included 2 or more health care professions. The GRADE quality of the evidence was assessed as low for all outcomes due to the inconsistency and indirectness of the results.

LIMITATIONS

This review did not look at disease-specific studies on intermediate care in family practice.

CONCLUSIONS

Specialized community-based care effectively improves outcomes in patients with heart failure, COPD, and diabetes. The effectiveness of SCBC in family practice is unclear.

A home-based progressive resistance exercise programme for patients with venous leg ulcers: a feasibility study

This study aimed to assess the feasibility of a home-based exercise programme and examine the effects on the healing rates of venous leg ulcers. A 12-week randomised controlled trial was conducted investigating the effects of an exercise intervention compared to a usual care group. Participants in both groups (n = 13) had active venous ulceration and were treated in a metropolitan hospital outpatients clinic in Australia. Data were collected on recruitment from medical records, clinical assessment and questionnaires. Follow-up data on progress in healing and treatments were collected fortnightly for 12 weeks. Calf muscle pump function data were collected at baseline and 12 weeks from recruitment. Range of ankle motion data were collected at baseline, 6 and 12 weeks from recruitment. This pilot study indicated that the intervention was feasible. Clinical significance was observed in the intervention group with a 32% greater decrease in ulcer size (P = 0·34) than the usual care group, and a 10% (P = 0·74) improvement in the number of participants healed in the intervention group compared to the usual care group. Significant differences between groups over time were observed in calf muscle pump function parameters [ejection fraction (P = 0·05), residual volume fraction (P = 0·04)] and range of ankle motion (P = 0·01). This pilot study is one of the first to examine and measure clinical healing rates for participants involved in a home-based progressive resistance exercise programme. Further research is warranted with a larger multi-site study.

Roadmap for a participatory research-practice partnership to implement evidence

Background: Our research team has undertaken implementation of evidence in the form of practice guideline recommendations for populations in hospital, community, and long-term care settings with diverse provider and patient populations (people with chronic wounds, e.g., pressure and leg ulcers, heart failure, stroke, diabetes, palliative care, cancer, and maternity care). Translating evidence into clinical practice at the point of care is a complex and often overwhelming challenge for the health system as well as for individual practitioners.

Purpose: To ensure that best available evidence is integrated into practice, “local evidence” needs to be generated and this process accomplishes a number of things: it focuses all involved on the “same page,” identifies important facilitating factors as well as barriers, provides empirical support for planning, and in itself is a key aspect of implementation. In doing this work, we developed a roadmap, the Queen’s University Research Roadmap for Knowledge Implementation (QuRKI) that outlines three major phases of linked research and implementation activity: (1) issue identification/clarification; (2) solution building; and (3) implementation, evaluation, and nurturing the change.

In this paper, we describe our practical experience as researchers working at point-of-care and how research can be used to facilitate the implementation of evidence. An exemplar is used to illustrate the fluid interplay of research and implementation activities and present the range of supporting research.

Implications: QuRKI serves as a guide for researchers in the formation of a strategic alliance with the practice community for undertaking evidence-informed reorganization of care. Using this collaborative approach, researchers play an integral role in focusing on, and using evidence during all discussions. We welcome further evaluation of its usefulness in the field.

Evidence, research, and clinical practice: a patient-centered framework for progress in wound care

Traditional criteria used in selecting wound care interventions are being slowly replaced with an evidence-based practice approach. The value of such an approach for providing optimal care has been established, but the definition of evidence-based care and the process used to generate evidence continue to evolve. For example, the role of studies developed to demonstrate efficacy, randomized controlled trials, the value of effectiveness studies designed to evaluate outcomes in real world practice, and the use of disease-oriented (interim) study outcomes for wound care research, such as reduces wound fluid or improves granulation tissue formation, have been topics of international conversations and consensus documents. In addition, the use in some clinical studies and most systematic study reviews of ingredient or characteristic-based categories to group products that may not share a common operational definition of how they function has led to a high variability in outcomes, resulting in inconclusive or low-level evidence. These concerns and debates, along with their influence on practice, may cast doubt on the value of evidence-based practice guidelines for some clinicians, slowing their rate of implementation, and extending the discussion about definitions of evidence-based care and the relative merits of various research designs. At the same time, amid growing concerns about medical device safety, clinicians must answer 3 questions about an intervention and its related products or devices in order to provide safe and effective care: (1) Can it work? (2) Does it work? (3) Is it worth it? Reviewing current knowledge about wound care, wound treatment modalities, and the basic principles of research within the existing framework of questions to be answered suggests a clear path toward obtaining much-needed evidence. In wound care, using clearly defined processes to study patient-centered outcomes (eg, quality of life, complete healing) and only product groupings that meet an operational definition of functioning (eg, moisture-retentive) will help clinicians decide whether an intervention can work and does work and whether the value of the clinical and economic benefits is greater than the potential harm and cost.

The Canadian Bandaging Trial: Evidence-informed leg ulcer care and the effectiveness of two compression technologies

BACKGROUND

OBJECTIVE

To determine the relative effectiveness of evidence-informed practice using two high compression systems: four-layer (4LB) and short-stretch bandaging (SSB) in community care of venous leg ulcers.

DESIGN AND SETTING

Pragmatic, multi-centre, parallel-group, open-label, randomized controlled trial conducted in 10 centres. Cognitively intact adults (≥18 years) referred for community care (home or clinic) with a venous ulceration measuring ≥0.7cm and present for ≥1 week, with an ankle brachial pressure index (ABPI) ≥0.8, without medication-controlled Diabetes Mellitus or a previous failure to improve with either system, were eligible to participate.

METHODS

Consenting individuals were randomly allocated (computer-generated blocked randomization schedule) to receive either 4LB or SSB following an evidence-informed protocol. Primary endpoint: time-to- healing of the reference ulcer.

SECONDARY OUTCOMES

recurrence rates, health-related quality of life (HRQL), pain, and expenditures.

RESULTS

424 individuals were randomized (4LB n = 215; SSB n = 209) and followed until their reference ulcer was healed (or maximum 30 months). An intent-to-treat analysis was conducted on all participants. Median time to ulcer healing in the 4LB group was 62 days [95% confidence interval (CI) 51 to 73], compared with 77 days (95% CI 63 to 91) in the SSB group. The unadjusted Kaplan-Meier curves revealed the difference in the distribution of cumulative healing times was not significantly different between group (log rank χ2 = 0.001, P = 0.98) nor ulcers recurrence (4LB, 10.1%; SSB, 13.3%; p = 0.345). Multivariable Cox Proportional Hazard Modeling also showed no significant between-bandage differences in healing time after controlling for significant covariates (p = 0.77). At 3-months post-baseline there were no differences in pain (no pain: 4LB, 22.7%; SSB, 26.7%; p = 0.335), or HRQL (SF-12 Mental Component Score: 4LB, 55.1; SSB, 55.8; p = 0.615; SF-12 Physical Component Score: 4LB, 39.0; SSB, 39.6; p = 0.675). The most common adverse events experienced by both groups included infection, skin breakdown and ulcer deterioration.

CONCLUSIONS

The Canadian Bandaging Trial revealed that in the practice context of trained RNs using an evidence-informed protocol, the choice of bandage system (4LB and SSB) does not materially affect healing times, recurrence rates, HRQL, or pain. From a community practice perspective, this is positive news for patient-centred care allowing individual/family and practitioner choice in selecting compression technologies based on circumstances and context.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT00202267.

Implementing health research through academic and clinical partnerships: a realistic evaluation of the Collaborations for Leadership in Applied Health Research and Care (CLAHRC)

BACKGROUND

The English National Health Service has made a major investment in nine partnerships between higher education institutions and local health services called Collaborations for Leadership in Applied Health Research and Care (CLAHRC). They have been funded to increase capacity and capability to produce and implement research through sustained interactions between academics and health services. CLAHRCs provide a natural 'test bed' for exploring questions about research implementation within a partnership model of delivery. This protocol describes an externally funded evaluation that focuses on implementation mechanisms and processes within three CLAHRCs. It seeks to uncover what works, for whom, how, and in what circumstances.

DESIGN AND METHODS

This study is a longitudinal three-phase, multi-method realistic evaluation, which deliberately aims to explore the boundaries around knowledge use in context. The evaluation funder wishes to see it conducted for the process of learning, not for judging performance. The study is underpinned by a conceptual framework that combines the Promoting Action on Research Implementation in Health Services and Knowledge to Action frameworks to reflect the complexities of implementation. Three participating CLARHCS will provide in-depth comparative case studies of research implementation using multiple data collection methods including interviews, observation, documents, and publicly available data to test and refine hypotheses over four rounds of data collection. We will test the wider applicability of emerging findings with a wider community using an interpretative forum.

DISCUSSION

The idea that collaboration between academics and services might lead to more applicable health research that is actually used in practice is theoretically and intuitively appealing; however the evidence for it is limited. Our evaluation is designed to capture the processes and impacts of collaborative approaches for implementing research, and therefore should contribute to the evidence base about an increasingly popular (e.g., Mode two, integrated knowledge transfer, interactive research), but poorly understood approach to knowledge translation. Additionally we hope to develop approaches for evaluating implementation processes and impacts particularly with respect to integrated stakeholder involvement.

Evidence-based medicine in otolaryngology, part 1: The multiple faces of evidence-based medicine

Evidence-based medicine, with its capacity to improve patient outcomes, has grown prominent throughout the medical field. Otolaryngology is at a crucial stage in the expansion of evidence-based medicine, with its impact seen in many arenas. As the evidence continues to shape our field, we hope to serve our otolaryngology community through this invited series, which is dedicated to the exposition of evidence-based medicine and its applications. This first installment examines evidence-based medicine itself and its multiple interpretations, including a purist view, a population-based view, and a view centered on the individual. Strengths and weaknesses of each are discussed, as well the potential for unification and evolution of these concepts. We also place evidence-based medicine in the context of the mindset of traditional medicine and anticipate future developments.

Moving knowledge to action through dissemination and exchange

OBJECTIVE

The objective of this article is to discuss the knowledge dissemination and exchange components of the knowledge translation process that includes synthesis, dissemination, exchange, and ethically sound application of knowledge. This article presents and discusses approaches to knowledge dissemination and exchange and provides a summary of factors that appear to influence the effectiveness of these processes. It aims to provide practical information for researchers and knowledge users as they consider what to include in dissemination and exchange plans developed as part of grant applications.

STUDY DESIGN AND SETTING

Not relevant.

RESULTS AND CONCLUSIONS

Dissemination is targeting research findings to specific audiences. Dissemination activities should be carefully and appropriately considered and outlined in a dissemination plan focused on the needs of the audience who will use the knowledge. Researchers should engage knowledge users to craft messages and help disseminate research findings. Knowledge brokers, networks, and communities of practice hold promise as innovative ways to disseminate and facilitate the application of knowledge. Knowledge exchange or integrated knowledge translation involves active collaboration and exchange between researchers and knowledge users throughout the research process.

Community-based care for chronic wound management: an evidence-based analysis

In August 2008, the Medical Advisory Secretariat (MAS) presented a vignette to the Ontario Health Technology Advisory Committee (OHTAC) on a proposed targeted health care delivery model for chronic care. The proposed model was defined as multidisciplinary, ambulatory, community-based care that bridged the gap between primary and tertiary care, and was intended for individuals with a chronic disease who were at risk of a hospital admission or emergency department visit. The goals of this care model were thought to include: the prevention of emergency department visits, a reduction in hospital admissions and re-admissions, facilitation of earlier hospital discharge, a reduction or delay in long-term care admissions, and an improvement in mortality and other disease-specific patient outcomes.OHTAC approved the development of an evidence-based assessment to determine the effectiveness of specialized community based care for the management of heart failure, Type 2 diabetes and chronic wounds.PLEASE VISIT THE MEDICAL ADVISORY SECRETARIAT WEB SITE AT: www.health.gov.on.ca/ohtas to review the following reports associated with the Specialized Multidisciplinary Community-Based care series.Specialized multidisciplinary community-based care series: a summary of evidence-based analysesCommunity-based care for the specialized management of heart failure: an evidence-based analysisCommunity-based care for chronic wound management: an evidence-based analysisPlease note that the evidence-based analysis of specialized community-based care for the management of diabetes titled: "Community-based care for the management of type 2 diabetes: an evidence-based analysis" has been published as part of the Diabetes Strategy Evidence Platform at this URL: http://www.health.gov.on.ca/english/providers/program/mas/tech/ohtas/tech_diabetes_20091020.htmlPLEASE VISIT THE TORONTO HEALTH ECONOMICS AND TECHNOLOGY ASSESSMENT COLLABORATIVE WEB SITE AT: http://theta.utoronto.ca/papers/MAS_CHF_Clinics_Report.pdf to review the following economic project associated with this series:Community-based Care for the specialized management of heart failure: a cost-effectiveness and budget impact analysis.

OBJECTIVE

The objective of this evidence-based review is to determine the effectiveness of a multidisciplinary wound care team for the management of chronic wounds.

CLINICAL NEED

CONDITION AND TARGET POPULATION Chronic wounds develop from various aetiologies including pressure, diabetes, venous pathology, and surgery. A pressure ulcer is defined as a localized injury to the skin/and or underlying tissue occurring most often over a bony prominence and caused, alone or in combination, by pressure, shear, or friction. Up to three fifths of venous leg ulcers are due to venous aetiology. Approximately 1.5 million Ontarians will sustain a pressure ulcer, 111,000 will develop a diabetic foot ulcer, and between 80,000 and 130,000 will develop a venous leg ulcer. Up to 65% of those afflicted by chronic leg ulcers report experiencing decreased quality of life, restricted mobility, anxiety, depression, and/or severe or continuous pain. MULTIDISCIPLINARY WOUND CARE TEAMS: The term 'multidisciplinary' refers to multiple disciplines on a team and 'interdisciplinary' to such a team functioning in a coordinated and collaborative manner. There is general consensus that a group of multidisciplinary professionals is necessary for optimum specialist management of chronic wounds stemming from all aetiologies. However, there is little evidence to guide the decision of which professionals might be needed form an optimal wound care team.

EVIDENCE-BASED ANALYSIS METHODS

LITERATURE SEARCH

A literature search was performed on July 7, 2009 using OVID MEDLINE, MEDLINE In-Process and Other Non-Indexed Citations, OVID EMBASE, Wiley Cochrane, Centre for Reviews and Dissemination/International Agency for Health Technology Assessment, and on July 13, 2009 using the Cumulative Index to Nursing & Allied Health Literature (CINAHL), and the International Agency for Health Technology Assessment (INAHTA) for studies pertaining to leg and foot ulcers. A similar literature search was conducted on July 29' 2009 for studies pertaining to pressure ulcers. Abstracts were reviewed by a single reviewer and, for those studies meeting the eligibility criteria, full-text articles were obtained. Reference lists were also examined for any additional relevant studies not identified through the search. Articles with an unknown eligibility were reviewed with a second clinical epidemiologist and then a group of epidemiologists until consensus was established.

INCLUSION CRITERIA

Randomized controlled trials and Controlled clinical Trials (CCT)Systematic review with meta analysisPopulation includes persons with pressure ulcers (anywhere) and/or leg and foot ulcersThe intervention includes a multidisciplinary (two or more disciplines) wound care team.The control group does not receive care by a wound care teamStudies published in the English language between 2004 and 2009 EXCLUSION CRITERIA: Single centre retrospective observational studies

OUTCOMES OF INTEREST

Proportion of persons and/or wounds completely healedTime to complete healingQuality of LifePain assessment

SUMMARY OF FINDINGS

Two studies met the inclusion and exclusion criteria, one a randomized controlled trial (RCT), the other a CCT using a before and after study design. There was variation in the setting, composition of the wound care team, outcome measures, and follow up periods between the studies. In both studies, however, the wound care team members received training in wound care management and followed a wound care management protocol. In the RCT, Vu et al. reported a non-significant difference between the proportion of wounds healed in 6 months using a univariate analysis (61.7% for treatment vs. 52.5% for control; p=0.074, RR=1.19) There was also a non-significant difference in the mean time to healing in days (82 for treatment vs. 101 for control; p=0.095). More persons in the intervention group had a Brief Pain Inventory (BPI) score equal to zero (better pain control) at 6 months when compared with the control group (38.6% for intervention vs. 24.4% for control; p=0.017, RR=1.58). By multivariate analysis a statistically significant hazard ratio was reported in the intervention group (1.73, 95% CI 1.20-1.50; p=0.003). In the CCT, Harrison et al. reported a statistically significant difference in healing rates between the pre (control) and post (intervention) phases of the study. Of patients in the pre phase, 23% had healed ulcers 3 months after study enrolment, whereas 56% were healed in the post phase (P<0.001, OR=4.17) (Figure 3). Furthermore, 27% of patients were treated daily or more often in the pre phase whereas only 6% were treated at this frequency in the post phase (P<0.001), equal to a 34% relative risk reduction in frequency of daily treatments. The authors did not report the results of pain relief assessment. The body of evidence was assessed using the GRADE methodology for 4 outcomes: proportion of wounds healed, proportion of persons with healed wounds, wound associated pain relief, and proportion of persons needing daily wound treatments. In general, the evidence was found to be low to very low quality.

CONCLUSION

The evidence supports that managing chronic wounds with a multidisciplinary wound care team significantly increases wound healing and reduces the severity of wound-associated pain and the required daily wound treatments compared to persons not managed by a wound care team. The quality of evidence supporting these outcomes is low to very low meaning that further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate.

The lived experience of community nurses treating clients with leg ulcers

Chronic leg ulceration impacts negatively on the quality of life of the sufferer and has financial implications for the economy. Government health policy aims to tackle long-term conditions and restructure services from acute to community care. Community nurses play a pivotal role in managing and co-ordinating care to leg ulcer patients, yet their personal experience in this clinical situation is poorly explored. This qualitative study aims to gain an understanding of community nurses' personal experience of treating clients with leg ulcers; this is necessary to develop leg ulcer services which are effective, efficient and client-centred.

Nurse clinic versus home delivery of evidence-based community leg ulcer care: a randomized health services trial

BACKGROUND

International studies report that nurse clinics improve healing rates for the leg ulcer population. However, these studies did not necessarily deliver similar standards of care based on evidence in the treatment venues (home and clinic). A rigorous evaluation of home versus clinic care is required to determine healing rates with equivalent care and establish the acceptability of clinic-delivered care.

METHODS

Health Services RCT was conducted where mobile individuals were allocated to either home or nurse clinic for leg ulcer management. In both arms, care was delivered by specially trained nurses, following an evidence protocol.

PRIMARY OUTCOME

3-month healing rates.

SECONDARY OUTCOMES

durability of healing (recurrence), time free of ulcers, HRQL, satisfaction, resource use. Data were collected at base-line, every 3 months until healing occurred, with 1 year follow-up. Analysis was by intention to treat.

RESULTS

126 participants, 65 randomized to receive care in their homes, 61 to nurse-run clinics. No differences found between groups at baseline on socio-demographic, HRQL or clinical characteristics. mean age 69 years, 68% females, 84% English-speaking, half with previous episode of ulceration, 60% ulcers at inclusion < 5 cm2 for < 6 months. No differences in 3-month healing rates: clinic 58.3% compared to home care at 56.7% (p = 0.5) or in secondary outcomes.

CONCLUSION

Our findings indicate that organization of care not the setting where care is delivered influences healing rates. Key factors are a system that supports delivery of evidence-based recommendations with care being provided by a trained nursing team resulting in equivalent healing rates, HRQL whether care is delivered in the home or in a community nurse-led clinic.

TRIAL REGISTRATION

ClinicalTrials.gov Protocol Registration System: NCT00656383.

Evaluation of the impact of restructuring wound management practices in a community care provider in Niagara, Canada

The burden of chronic wounds is substantial, and this burden is set to increase as the population ages. The challenge for community health services is significant. Wound care is labour intensive, and demand for services is set to increase at a time when the availability of nursing resources is likely to be severely limited. In March 2005, the Niagara community health care provider implemented a radical reorganisation of wound management practices designed to ensure that available resources, particularly nurse time, were being used in the most efficient way. An evaluation of the impact of the reorganisation has shown improvements in clinical practice and better patient outcomes. The use of traditional wound care products reduced from 75% in 2005 to 20% in 2007 in line with best practice recommendations, and frequency of daily dressing changes reduced from 48% in 2005 to 15% in 2007. In a comparison of patients treated in 2005 and 2006, average time to healing was 51.5 weeks in 2005 compared with 20.9 weeks in 2006. Total treatment cost was lower in 2006 by $10,700 (75%) per patient. Overall, improvements in wound management practice led to a net saving of $3.8 million in the Niagara wound care budget.