Lower Extremity Ulcers

Lower extremity ulcerations contribute to significant morbidity and economic burden globally. Chronic wounds, or those that do not progress through healing in a timely manner, are estimated to affect 6.5 million people in the United States alone causing, significant morbidity and economic burden of at least an estimated $25 billion annually. Owing to the aging population and increasing rates of obesity and diabetes mellitus globally, chronic lower extremity ulcers are predicted to increase. Here, we explore the pathophysiology, diagnosis, and management of the most (and least) commonly seen lower extremity ulcers.

Human Wound and Its Burden: Updated 2020 Compendium of Estimates

Significance: Chronic wounds impact the quality of life (QoL) of nearly 2.5% of the total population in the United States and the management of wounds has a significant economic impact on health care. Given the aging population, the continued threat of diabetes and obesity worldwide, and the persistent problem of infection, it is expected that chronic wounds will continue to be a substantial clinical, social, and economic challenge. In 2020, the coronavirus disease (COVID) pandemic dramatically disrupted health care worldwide, including wound care. A chronic nonhealing wound (CNHW) is typically correlated with comorbidities such as diabetes, vascular deficits, hypertension, and chronic kidney disease. These risk factors make persons with CNHW at high risk for severe, sometimes lethal outcomes if infected with severe acute respiratory syndrome coronavirus 2 (pathogen causing COVID-19). The COVID-19 pandemic has impacted several aspects of the wound care continuum, including compliance with wound care visits, prompting alternative approaches (use of telemedicine and creation of videos to help with wound dressing changes among others), and encouraging a do-it-yourself wound dressing protocol and use of homemade remedies/substitutions. Recent Advances: There is a developing interest in understanding how the social determinants of health impact the QoL and outcomes of wound care patients. Furthermore, addressing wound care in the light of the COVID-19 pandemic has highlighted the importance of telemedicine options in the continuum of care. Future Directions: The economic, clinical, and social impact of wounds continues to rise and requires appropriate investment and a structured approach to wound care, education, and related research.

Cost-effectiveness of three adjunct cellular/tissue-derived products used in the management of chronic venous leg ulcers

OBJECTIVES

Determine the cost-effectiveness of three topically applied cellular/tissue-derived products (CTPs) used as adjunct therapies to standard care in the management of venous leg ulcers (VLUs).

METHODS

A three-state Markov model derived from the medical literature was developed to estimate the comparative cost-effectiveness of three CTPs in relation to VLU standard care. CTPs evaluated in the study included extracellular matrix (ECM), human skin equivalent (HSE), and living skin equivalent (LSE). The three Markov states included unhealed, healed, and death. A 1-year time horizon was used to determine the number of ulcer-free weeks and the expected costs of therapies. The payer perspective was taken in the analysis and only the direct costs of care were considered. Sensitivity analyses were performed to gauge model parameter uncertainty.

RESULTS

The expected costs for standard care, ECM, HSE, and LSE VLU therapy were $6,132, $6,732, $10,638, and $11,237, while the expected outcomes were 24, 31, 29, and 27 ulcer-free weeks, respectively. ECM was economically dominant among the three CTPs. In the base case of ECM versus standard care, the incremental cost-effectiveness ratio for ECM therapy was $86 per ulcer-free week. Sensitivity analysis did not alter ECM dominance. Clinic visits and home health utilization exhibited the greatest influence on cost.

CONCLUSIONS

ECM is the most cost-effective CTP when used in the management of VLUs as an adjunct to standard care. These findings suggest that VLU standard care therapy with ECM can yield potential cost savings and produce better outcomes than do other CTPs.

Cost-effective use of silver dressings for the treatment of hard-to-heal chronic venous leg ulcers

AIM

To estimate the cost-effectiveness of silver dressings using a health economic model based on time-to-wound-healing in hard-to-heal chronic venous leg ulcers (VLUs).

BACKGROUND

Chronic venous ulceration affects 1-3% of the adult population and typically has a protracted course of healing, resulting in considerable costs to the healthcare system. The pathogenesis of VLUs includes excessive and prolonged inflammation which is often related to critical colonisation and early infection. The use of silver dressings to control this bioburden and improve wound healing rates remains controversial.

METHODS

A decision tree was constructed to evaluate the cost-effectiveness of treatment with silver compared with non-silver dressings for four weeks in a primary care setting. The outcomes: 'Healed ulcer', 'Healing ulcer' or 'No improvement' were developed, reflecting the relative reduction in ulcer area from baseline to four weeks of treatment. A data set from a recent meta-analysis, based on four RCTs, was applied to the model.

RESULTS

Treatment with silver dressings for an initial four weeks was found to give a total cost saving (£141.57) compared with treatment with non-silver dressings. In addition, patients treated with silver dressings had a faster wound closure compared with those who had been treated with non-silver dressings.

CONCLUSION

The use of silver dressings improves healing time and can lead to overall cost savings. These results can be used to guide healthcare decision makers in evaluating the economic aspects of treatment with silver dressings in hard-to-heal chronic VLUs.

Burden of venous leg ulcers in the United States

OBJECTIVE

To estimate the annual incremental per-patient and overall payer burden (2012USD) of venous leg ulcers (VLU) in the US.

METHODS

Beneficiaries with and without VLU were identified using two de-identified insurance claims databases: aged 65+ from a 5% random sample of Medicare beneficiaries (2007-2010: n ∼ 2.3 million); and aged 18-64 from a privately-insured population (2007-2011: n ∼ 8.4 million). The index date was selected as the date of a VLU claim with no other VLU diagnoses in the preceding 12 months for the VLU cohort and as the date of a random medical claim for the non-VLU patients. These groups were matched using propensity scores to account for differences in demographics, comorbidities, resource utilization, and costs in the 12 month pre-index period. Medical resource use and costs incurred during the 12 month follow-up period were calculated for both payers. Drug costs and indirect work-loss due to disability and medically-related absenteeism were estimated for the privately-insured sample only. Annual VLU incidence rates were also estimated for both payers.

RESULTS

Data for 58,672 matched VLU/non-VLU pairs of Medicare and 22,476 matched pairs of privately-insured patients were analyzed. Relative to matched non-VLU patients, VLU patients used more medical resources and incurred annual incremental medical costs of $6391 in Medicare ($18,986 vs $12,595), and $7030 ($13,653 vs $6623) in private insurance ($7086 including drug costs). Compared with non-VLU patients, privately-insured VLU patients had more days missed from work (14.0 vs 10.0), resulting in 29% higher work-loss costs (comparisons significant at p < 0.0001). The average annual incidence rate of VLU was 2.2% in Medicare and 0.5% in private insurance.

LIMITATIONS

Findings did not account for out-of-pocket payments or other indirect costs (e.g., lost productivity), and relied on accuracy of diagnosis and procedure codes contained in claims data.

CONCLUSION

These findings suggest an annual US payer burden of $14.9 billion.

Strategy for the treatment of chronic leg wounds: a new model in Poland

AIM

The aim of the present study was to implement and evaluate a system of care for patients with chronic leg ulceration (CLU) in Poland.

METHODS

All patients within two defined geographical areas in Poland were identified for inclusion in the study. A model of care was developed based on guidelines, including the appropriate education of health professionals treating patients, access to non-invasive methods to determine the ulcer aetiology, compression therapy in those with proven venous ulceration.

RESULTS

In total 309 patients were identified with CLU at the start of the study (120 men, 189 women). Both regions had a similar profile of patients having a median (IQR) duration of ulceration of 96 (30-168) months. Most (75.7%) patients were assessed using clinical signs and symptoms alone, with a mean (SD) number of treatments per week at 1.8 (1.9) visits. Two years after implementation, the numbers of patients had reduced to 205 (86 men, 119 women) a reduction of 33%. Post implementation more patients were treated at home (49.3% versus 19.5%) with a corresponding reduction in those seen at health centres (35.6% versus 63.3%). The mean (SD) number of visits was reduced to 1.3 (0.7). During implementation the healing rate at 30 weeks improved from 73.3% to 82.9%, with a corresponding reduction in amputations from 6.3% to 2.1%. While the cost per patient was higher post-implementation, the overall cost of treating patients within the service reduced from €3847 to €2913 per week.

CONCLUSION

The development and implementation of an evidence based system of care for patients with CLU in Poland is both clinically and cost effective. This may be used as a model for other regions of Poland.

Activated charcoal dressing in malodorous leg ulcers

Leg ulcers are commonly associated with malodour. Reduction of malodour in foul smelling ulcers is an adjuvant therapy in the management of ulcers. We report two patients with leg ulcer who got benefited with activated charcoal dressing for malodour.

Collaboration in wound prevention and treatment

Wound prevention and treatment is a global issue for health professionals, patients and policy makers alike. The need to avoid duplication of effort and to harness knowledge and experience has led to the recent publication of International Pressure Ulcer Guidelines (European Pressure Ulcer Advisory Panel, 2009), while the fourth World Union of Wound Healing Societies conference is only two years away. These global initiatives show that with goodwill and shared goals, common ground in wound healing can be found across nations and their various healthcare systems. There are many examples of this kind of collaborative working – from the excellent position papers produced by the European Wound Management Association and the World Union of Wound Healing Societies, through to commercially supported initiatives such as the consensus document Pressure ulcer prevention: prevalence and incidence in context. Medical Education Partnership (2008). These provide clear guidance on several of the most challenging issues in wound prevention and healing.

Larval therapy for leg ulcers (VenUS II): randomised controlled trial

OBJECTIVE

To compare the clinical effectiveness of larval therapy with a standard debridement technique (hydrogel) for sloughy or necrotic leg ulcers.

DESIGN

Pragmatic, three armed randomised controlled trial.

SETTING

Community nurse led services, hospital wards, and hospital outpatient leg ulcer clinics in urban and rural settings, United Kingdom.

PARTICIPANTS

267 patients with at least one venous or mixed venous and arterial ulcer with at least 25% coverage of slough or necrotic tissue, and an ankle brachial pressure index of 0.6 or more.

INTERVENTIONS

Loose larvae, bagged larvae, and hydrogel.

MAIN OUTCOME MEASURES

The primary outcome was time to healing of the largest eligible ulcer. Secondary outcomes were time to debridement, health related quality of life (SF-12), bacterial load, presence of meticillin resistant Staphylococcus aureus, adverse events, and ulcer related pain (visual analogue scale, from 0 mm for no pain to 150 mm for worst pain imaginable).

RESULTS

Time to healing was not significantly different between the loose or bagged larvae group and the hydrogel group (hazard ratio for healing using larvae v hydrogel 1.13, 95% confidence interval 0.76 to 1.68; P=0.54). Larval therapy significantly reduced the time to debridement (2.31, 1.65 to 3.2; P<0.001). Health related quality of life and change in bacterial load over time were not significantly different between the groups. 6.7% of participants had MRSA at baseline. No difference was found between larval therapy and hydrogel in their ability to eradicate MRSA by the end of the debridement phase (75% (9/12) v 50% (3/6); P=0.34), although this comparison was underpowered. Mean ulcer related pain scores were higher in either larvae group compared with hydrogel (mean difference in pain score: loose larvae v hydrogel 46.74 (95% confidence interval 32.44 to 61.04), P<0.001; bagged larvae v hydrogel 38.58 (23.46 to 53.70), P<0.001).

CONCLUSIONS

Larval therapy did not improve the rate of healing of sloughy or necrotic leg ulcers or reduce bacterial load compared with hydrogel but did significantly reduce the time to debridement and increase ulcer pain.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN55114812 and National Research Register N0484123692.

Cost effectiveness analysis of larval therapy for leg ulcers

OBJECTIVE

To assess the cost effectiveness of larval therapy compared with hydrogel in the management of leg ulcers.

DESIGN

Cost effectiveness and cost utility analyses carried out alongside a pragmatic multicentre, randomised, open trial with equal randomisation. Population Intention to treat population comprising 267 patients with a venous or mixed venous and arterial ulcers with at least 25% coverage of slough or necrotic tissue.

INTERVENTIONS

Patients were randomly allocated to debridement with bagged larvae, loose larvae, or hydrogel.

MAIN OUTCOME MEASURE

The time horizon was 12 months and costs were estimated from the UK National Health Service perspective. Cost effectiveness outcomes are expressed in terms of incremental costs per ulcer-free day (cost effectiveness analysis) and incremental costs per quality adjusted life years (cost utility analysis).

RESULTS

The larvae arms were pooled for the main analysis. Treatment with larval therapy cost, on average, pound96.70 (euro109.61; $140.57) more per participant per year (95% confidence interval - pound491.9 to pound685.8) than treatment with hydrogel. Participants treated with larval therapy healed, on average, 2.42 days before those in the hydrogel arm (95% confidence interval -0.95 to 31.91 days) and had a slightly better health related quality of life, as the annual difference in QALYs was 0.011 (95% confidence interval -0.067 to 0.071). However, none of these differences was statistically significant. The incremental cost effectiveness ratio for the base case analysis was estimated at pound8826 per QALY gained and pound40 per ulcer-free day. Considerable uncertainty surrounds the outcome estimates.

CONCLUSIONS

Debridement of sloughy or necrotic leg ulcers with larval therapy is likely to produce similar health benefits and have similar costs to treatment with hydrogel.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN55114812 and National Research Register N0484123692.

Dressings for venous leg ulcers: systematic review and meta-analysis

OBJECTIVE

To review the evidence of effectiveness of dressings applied to venous leg ulcers.

DESIGN

Systematic review and meta-analysis.

DATA SOURCES

Hand searches of journals and searches of electronic databases, conference proceedings, and bibliographies up to April 2006; contacts with dressing manufacturers for unpublished studies.

STUDIES REVIEWED

All randomised controlled trials that evaluated dressings applied to venous leg ulcers were eligible for inclusion. Data from eligible studies were extracted and summarised independently by two reviewers using a data extraction sheet. Methodological quality was assessed independently by two reviewers.

RESULTS

The search strategy identified 254 studies; 42 of these fulfilled the inclusion criteria. Hydrocolloids were no more effective than simple low adherent dressings used beneath compression (eight trials; relative risk for healing with hydrocolloid 1.02, 95% confidence interval 0.83 to 1.28). For other comparisons, insufficient evidence was available to allow firm conclusions to be drawn. None of the dressing comparisons showed evidence that a particular class of dressing healed more ulcers. Some differences existed between dressings in terms of subjective outcome measures and ulcer healing rates. The results were not affected by the size or quality of trials or the unit of randomisation. Insufficient data were available to allow conclusions to be drawn about the relative cost effectiveness of different dressings.

CONCLUSIONS

The type of dressing applied beneath compression was not shown to affect ulcer healing. The results of the meta-analysis showed that applying hydrocolloid dressings beneath compression produced no benefit in terms of ulcer healing compared with applying simple low adherent dressings. No conclusive recommendations can be made as to which type of dressing is most cost effective. Decisions on which dressing to apply should be based on the local costs of dressings and the preferences of the practitioner or patient.

Accurate diagnosis and effective treatment of leg ulcers reduce prevalence, care time and costs

OBJECTIVE

This long-term follow-up recorded the prevalence, aetiology and treatment of hard-to-heal leg and foot ulcers, and an estimated nurses' time spent providing care, for the years 1994-2005.

METHOD

A questionnaire was sent to all district and community nurses in the county of Blekinge, Sweden, during one week in 1994, 1998, 2004 and 2005. Calculating the costs of hard-to-heal leg and foot ulcer care was not a primary aim, but the reduction in prevalence and time spent on wound management suggested it was important to illustrate the economic consequences of these changes over time.

RESULTS

Estimated prevalence of hard-to-heal leg and foot ulcers reduced from 0.22% in 1994 to 0.15% in 2005. Treatment time decreased from 1.7 hours per patient per week in 1994 to 1.3 hours in 2005. Annual costs of leg and foot ulcer care reduced by SEK 6.96 million in the study area from 1994 to 2005.

CONCLUSION

Improved wound management was demonstrated; leg and foot ulcer prevalence and treatment time were reduced. The results could be attributed to an increased interest in leg and foot ulcer care among staff, which was maintained by repeated questionnaires, continuous education, establishment of a wound healing centre in primary care and wound management recommendations from a multidisciplinary group. The improved ulcer care reduced considerably the annual costs of wound management in the area.

Static magnets prevent leg ulcer recurrence: savings for the NHS?

The objectives of this survey were to examine the effectiveness of a static magnet device--4UlcerCare--in preventing recurrence of leg ulcers after healing. Two hundred and eighty-nine randomly selected purchasers of 4UlcerCare were telephoned and asked to complete a short questionnaire. Our focus was on the 211 respondents who had ulcers that had already healed. The average age of subjects was 70.6 years and sex distribution was 55% female to 45% male. Mean duration of leg ulcers before using 4UlcerCare was 4.4 years. Sixty-five per cent of those surveyed had had ulcer recurrence before using 4UlcerCare, with a mean of 2.41 episodes of ulceration. This was close to the expected recurrence rate in the population of 67%. Using 4UlcerCare daily, these respondents' ulcers had healed within an average of 3.57 months. The survey took place an average of 19.94 months after healing. The manufacturers advise wearing 4UlcerCare daily post-healing, and of those respondents that had, none had suffered any recurrence. Extrapolating these results across the health economy, an estimate has been made of a potential pound153.7 million per year saving on leg ulcer care to the NHS.

Cost effectiveness of using carboxymethylcellulose dressing compared with gauze in the management of exuding venous leg ulcers in Germany and the USA

OBJECTIVE

To assess the cost effectiveness of using carboxymethylcellulose dressing (CMCD; Aquacel Hydrofiber) compared to gauze in the management of exuding venous leg ulcers in Germany and the USA.

DESIGN AND SETTING

This was a modelling study performed from the perspective of payers (i.e. the sickness funds in Germany and the community sector in the USA).

METHODS

Clinical outcomes attributable to managing exuding venous leg ulcers were obtained from the published literature in the English language. These data were combined with resource utilisation estimates derived from a panel of clinicians enabling us to construct two decision models depicting the management of venous leg ulcers with CMCD or gauze over 18 weeks in Germany and the USA. The models were used to estimate the cost effectiveness of CMCD compared to gauze in the management of exuding venous leg ulcers in both countries.

MAIN OUTCOME MEASURES AND RESULTS

Starting treatment with CMCD instead of gauze in both Germany and the USA is expected to heal 30% of ulcers within 18 weeks compared to 13% with gauze (p = 0.003). The healthcare cost of starting treatment with CMCD or gauze in Germany is expected to be Euro2020 and Euro 2654 respectively at 18 weeks. Additionally, the healthcare cost of starting treatment with CMCD or gauze in the USA is expected to be $3797 and $5288 respectively at 18 weeks. Hence, using CMCD instead of gauze is expected to increase the probability of healing within 18 weeks by 130% and reduce healthcare costs by at least 24%. The healthcare cost of managing CMCD-treated patients was less than that of gauze-treated patients in both countries due to decreased nursing and physician costs associated with a lower frequency of CMCD dressing changes compared to gauze dressing changes. If it were assumed that treatment with gauze in both countries heals 30% of ulcers within 18 weeks (i.e. is identical to CMCD), then the expected healthcare cost of using gauze would be reduced by only 3% (from Euro2654 to Euro2562 in Germany and from $5288 to $5148 in the USA).

CONCLUSION

Within the limitations of our model, starting management of an exuding venous leg ulcer with CMCD instead of gauze is the cost effective strategy in both Germany and the USA. Moreover, the purchase price of a leg ulcer dressing should not be used as an indication of the cost effectiveness of a given method of care.

Economic analysis of VenUS I, a randomized trial of two bandages for treating venous leg ulcers

BACKGROUND

The study investigated the cost-effectiveness of four-layer and short-stretch compression bandages for treating venous leg ulcers.

METHODS

Cost-effectiveness and cost-utility analyses were performed using patient-level data collected alongside the VenUS I leg ulcer study. The perspective for the economic analysis was that of the UK National Health Service (NHS) and Personal Social Service. The time horizon for the analysis was 1 year after recruitment. Health benefit was measured as differences in ulcer-free days and quality-adjusted life years (QALYs).

RESULTS

The mean healing time for ulcers treated with four-layer bandages was 10.9 (95 per cent confidence interval (c.i.) -6.8 to 29.1) days less than that for ulcers treated with short-stretch bandages. Mean average difference in QALYs between compression systems was -0.02 (95 per cent c.i. -0.08 to 0.04). The four-layer bandage cost a mean of pound 227.32 (95 per cent c.i. pound 16.53 to pound 448 .30) less per patient per year than the short-stretch bandage.

CONCLUSION

On average, four-layer bandaging was associated with greater health benefits and lower costs than short-stretch bandaging.

Unexpected Economics of Ulcer Care Protocols

The cost of managing chronic ulcers, both venous leg and decubiti (sacral pressure), was reviewed using 36 randomized, controlled studies with a focus on saline, hydrocolloid, and a human skin construct. When one includes the labor intensiveness of dressing changes three to four times per day, the application of hydrocolloid dressings becomes the most cost-effective.

Balancing cost-effectiveness with quality in tissue viability

The 21st century has seen an increase in the importance placed on the skills of healthcare practitioners. They now need to be able to demonstrate cost-effectiveness and balance it with quality in the delivery of care in the NHS. This emphasis is driven largely by the emergence of initiatives such as evidence-based practice, clinical governance and cost-effectiveness evaluations. The pressure to demonstrate cost-effective quality practices is becoming more and more prominent in the NHS. This article will discuss the practicalities and implications these pressures have on tissue viability and wound care providers.

Bilayered bioengineered skin substitute (Apligraf): a review of its use in the treatment of venous leg ulcers and diabetic foot ulcers

The bilayered bioengineered skin substitute (BBSS) [Apligraf] is used for the treatment of venous leg ulcers and diabetic foot ulcers. It has an epidermal layer formed from human keratinocytes and a dermal layer composed of human fibroblasts in a bovine type I collagen matrix. BBSS does not contain any antigen-presenting cells such as Langerhans cells, dermal dendritic cells, endothelial cells or leucocytes. In clinical trials, there was no evidence of clinical rejection and immunological tests indicated no humoral or cellular response to the keratinocytes or fibroblasts of BBSS. Further clinical trials are required to identify the exact mechanism of action of BBSS in chronic wounds. BBSS plus compression therapy was well tolerated and was superior in efficacy to compression therapy alone in a multicentre, randomised trial in patients with venous leg ulcers. At 6 months' follow-up, complete wound healing occurred in 63 versus 49% of patients and the median time to wound closure was 61 versus 181 days. In a subgroup of patients with hard-to-heal ulcers (>1 year's duration), wound healing was achieved in significantly more patients (47 vs 19%) and the median time to wound healing was significantly shorter (181 days vs not attained). In a multicentre, randomised trial, BBSS was well tolerated and effective in patients with full-thickness neuropathic diabetic foot ulcers. Ulcer healing occurred in significantly more patients (56 vs 38%) and the median time to wound healing was shorter (65 vs 90 days) with BBSS than with saline-moistened gauze at 12 weeks' follow-up. Patients in both groups also received standard diabetic foot care. The cost effectiveness of BBSS in patients with chronic ulcers has yet to be examined in well designed, prospective clinical trials. However, according to a modelled analysis incorporating data from a multicentre randomised trial, BBSS was cost effective in patients with hard-to-heal venous leg ulcers. The average annual medical cost of managing patients with ulcers of >1 year's duration was estimated to be 20,041 US dollars per patient treated with BBSS plus compression therapy and 27,493 US dollars per patient treated with compression therapy alone (1996 costs).

CONCLUSIONS

Clinical trials have shown that BBSS in conjunction with standard compression therapy was effective and well tolerated in patients with venous leg ulcers, especially patients with ulcers of >6 months' duration or that extended to the subcutaneous tissue. In addition, BBSS in conjunction with standard diabetic foot care was effective and well tolerated in patients with full-thickness neuropathic diabetic foot ulcers. BBSS represents a useful adjuvant to standard ulcer therapy in patients with venous leg ulcers or full-thickness neuropathic diabetic foot ulcers that do not respond to conventional ulcer therapy.

The role of hyperbaric oxygen therapy in ischaemic diabetic lower extremity ulcers: a double-blind randomised-controlled trial

OBJECTIVE

ischaemic lower-extremity ulcers in the diabetic population are a source of major concern because of the associated high risk of limb-threatening complications. The aim of this study was to evaluate the role of hyperbaric oxygen in the management of these ulcers.

METHOD

eighteen diabetic patients with ischaemic, non-healing lower-extremity ulcers were recruited in a double-blind study. Patients were randomly assigned either to receive 100% oxygen (treatment group) or air (control group), at 2.4 atmospheres of absolute pressure for 90 min daily (total of 30 treatments).

RESULTS

healing with complete epithelialisation was achieved in five out of eight ulcers in the treatment group compared to one out of eight ulcers in the control group. The median decrease of the wound areas in the treatment group was 100% and in the control group was 52% (p=0.027). Cost-effectiveness analysis has shown that despite the extra cost involved in using hyperbaric oxygen, there was a potential saving in the total cost of treatment for each patient during the study.

CONCLUSION

hyperbaric oxygen enhanced the healing of ischaemic, non-healing diabetic leg ulcers and may be used as a valuable adjunct to conventional therapy when reconstructive surgery is not possible.

Telemedicine: a new model of care

An estimated one per cent of the population will have a leg ulcer and prevalence increases markedly with age (Angle and Bergan, 1997). At any one time it is estimated that 100,000 patients have open leg ulcers that require treatment. This treatment is mainly repeat dressings over extended periods of time, carried out by community nurses. This is estimated to cost 600m Pounds each year in the UK (Logan, 1997). Improving healing time for leg ulcers and reducing recurrence leads to an improved quality of life for patients and their carers in addition to major cost savings for the NHS.

Current home care expenditures for persons with leg ulcers

OBJECTIVE

The purpose of this study was to gain a better understanding of the home care expenditures incurred in providing care to the population with leg ulcers.

DESIGN

The study was designed as a descriptive survey and was conducted over a 4-week period during March 1999.

SETTING AND SUBJECTS

Persons in a large Ontario urban center with an ulcer below the knee, including the foot, who were receiving nursing services in the home, were eligible for inclusion in the study.

INSTRUMENTS

A leg assessment tool, a supply usage form, and a visiting nurses log (all developed by the researchers for the study) were used to collect data.

METHODS

Home care nurses visited all clients and completed an in-depth assessment of their social, medical, and leg ulcer history. Legs were inspected, an ankle brachial pressure index score was determined, and ulcers were examined and measured. For each nursing visit, supply usage, travel and treatment times, and mileage were tracked.

RESULTS

During the study period, 2270 visits were made (mean treatment time = 26 minutes, mean travel time = 17 minutes) costing $80.62 (Canadian dollars). Supply costs were $21.06. The regional annual home care expenditures were conservatively estimated to be $1.3 million.

CONCLUSION

Costs could potentially be reduced by cutting the 40% visit time attributed to travel, decreasing the visit frequency to clients with minimal drainage, and attention to "best practice."

Community leg ulcer clinics vs home visits: which is more effective?

District nurses manage the care of the majority of patients with leg ulcers, but there have been reports of variations in the practice and effectiveness of treatment provided by district nurses (Audit Commission, 1999). Evidence-based health care aims to promote clinical and cost-effective care/treatment through the explicit, conscientious, and judicious use of the currently available best evidence from research to guide decisions (Sackett et al, 1996). Following the method of Griffiths (2002), a mini-systematic review was undertaken, to find out whether leg ulcer clinics provide more effective treatment to patients with leg ulcers than care provided in patients' homes by district nurses. Five databases were searched to find valid randomised controlled trials (RCTs) or systematic reviews to answer the question. The search was supplemented by hand searching of relevant publications. Only one trial met the inclusion criteria of the review. Although it concluded that leg ulcer clinics delivered improved outcomes the evidence provided was limited due to the comparison treatment being outdated, inadequate information regarding costs, and that as a relatively small isolated RCT it provided insufficient evidence to answer the question.

Evaluating the cost and efficacy of leg ulcer care provided in two large UK health authorities

OBJECTIVE

This prospective study investigated the cost and efficacy of leg ulcer care over a three-month period during 1993, 1994 and 1999. It compared two health authorities (Stockport and Trafford) whose populations totalled 540,000.

METHOD

All patients with active leg ulcers were invited to community leg ulcer clinics offering research-based innovations in care. Patients without significant arterial disease (ankle brachial pressure index less than 0.8) were treated with multilayer compression bandaging.

RESULTS

The 42% healing rate reported in the original Stockport study was maintained at 40% in 1999, although the 65% healing rate achieved by the leg ulcer clinics in 1993 was not replicated, with rates falling to 46%. Following the opening of community leg ulcer clinics in Trafford, healing rates rose from 20% to 42%. The annual expenditure on leg ulcer care in Stockport increased from 65,545.56 Pounds to 83,344.30 Pounds, while in Trafford the cost of care dropped from 151,375.35 Pounds to 53,176.76 Pounds between 1994 and 1999.

CONCLUSION

This study suggests that reductions in costs and improvements in healing rates can be sustained in a mature community leg ulcer clinic programme staffed by specialist leg ulcer nurses.

[Management of venous leg ulcer by French physicians, diversity and related costs: a prospective medicoeconomic observational study]

OBJECTIVES

The purpose of this study was to better ascertain how French physicians manage venous ulcers of the lower limbs. We explored the various therapeutic approaches used and their respective costs. Particular attention was focused on dressing prescriptions.

MATERIAL AND METHODS

A prospective medicoeconomic study was conducted. Eight hundred general practitioners and specialists throughout France were included and followed two patients each, one with a "new ulcer" (less than two weeks) and another with a "longstanding ulcer" (more than six weeks). Patients were followed to healing or for up to six months. An observation chart was completed at each visit. Data collected were characteristics of the ulcer at inclusion, assessment of the clinical course, and the nature and the volume of medical care prescribed. Corresponding costs (total cost for the society) were calculated on the basis of 1996 public prices for drugs and the French national health insurance quotations for ambulatory care. For hospital care, cost was calculated from the cost of stay for homogeneous patient groups.

RESULTS

Files established for 1,098 patients by 652 physicians could be assessed. Elderly female patients predominated in this population (mean age 72 years, 74% women). The length of the ulcer at inclusion was significantly correlated with its duration: 2.82 cm for new ulcers (52.6% of the cases) versus 5.03 cm for longstanding ulcers (47.3%). The mean number of consultations for all patients was 4.8 over a 29-day period. Mean cost resulting from these consultations was 5,827 FF per patient: 48% for care, 33 for drugs, 16% for hospitalizations, and 3% for work lay-off ). Cure was achieved in 77% of the cases within a mean delay of 3 months. Older ulcer was significantly associated with longer treatment (117 days for longstanding ulcers versus 80 days for new ulcers), lower cure rate (67% versus 86%) and higher cost (7 078 FF versus 4 669 FF). Dividing care methods between those using cleaning with compression or not showed that compression was prescribed in 76% of the cases at the inclusion consultation. This predominance of compression therapy did not preclude use of a variety of other therapeutic methods depending on the clinical and demographic situation of the patient. Cost varied accordingly with a mean ranging from 3 160 FF to 6 697 FF depending on the therapeutic attitude. The study also focused on the type and amount of dressings used. Dressings were prescribed for 56 patients in this series. It can be hypothesized that these patients already had dressings. Different indicators show that the absence of prescriptions for dressings concerned less severe and less costly ulcers (4 130 FF versus 5 918 FF for those with dressing prescriptions). Among the 1 042 patients for whom dressings were prescribed, 35% were for occlusive dressings, 29% for ointment dressings and also 24% for both occlusive and ointment dressings. The type was not specified in 55% of the cases. Mean cost for these different categories ranged from 4 921 to 7 019 FF.

An economic assessment of Apligraf (Graftskin) for the treatment of hard-to-heal venous leg ulcers

Several recent advances in wound care may offer promise for the treatment of hard-to-heal venous leg ulcers. One such treatment is Apligraf (Graftskin), a bilayered, living human skin construct. To assess the economic impact of Graftskin, a model was constructed to compare the annual medical costs and cost-effectiveness of treating hard-to-heal venous leg ulcers with Graftskin vs. compression therapy using Unna's boot. A semi-Markov model was used to describe the pattern of ulcer treatment, healing, and recurrence among patients with venous leg ulcers. Patients received 1 of 2 treatment regimens, Graftskin or Unna's boot, and were followed in the model for a 12-month period. The analysis was done from the perspective of a commercial health plan; therefore, only direct medical costs were included. Health care resource use included the primary therapeutic intervention, additional compression dressings, physician office visits, home health visits, laboratory tests and procedures, management of adverse events, and hospitalizations. The model estimated the annual medical cost of managing patients with hard-to-heal venous leg ulcers to be $20,041 for those treated with Graftskin and $27,493 for those treated with Unna's boot. In addition, treatment with Graftskin led to approximately 3 more months in the healed state per person per year than did treatment with Unna's boot. Because patients treated with Graftskin experienced improved healing compared with those treated with compression therapy using Unna's boot, they required fewer months of treatment for unhealed ulcers. As a result, the use of Graftskin for treating hard-to-heal venous leg ulcers resulted in lower overall treatment costs.

[Ambulatory skin grafting in leg ulcers: a feasibility study of 34 patients]

OBJECTIVES

Despite the advent of modern dressings, management of leg ulcers remains a long costly process, particularly if no etiological treatment is possible. Autologous skin grafting is more and more widely used in this indication. The aim of this open single center noncomparative study was to analyze the feasibility of ambulatory procedures for skin grafting and the incidence of ambulatory care in a medical nursing clinic as an alternative to traditional hospitalization on total cost in this pathological condition.

PATIENTS AND METHODS

Thirty-nine grafts were performed in 34 consecutive patients. No selection was made for etiology or duration of the leg ulcers. Three grafting techniques were used after debridement-cleansing: flap grafts for medium sized ulcers (29 cases), mesh grafts for large ulcers (6 cases) and patch grafts for small ulcers or ulcers with irregular contours (4 cases). The dressing was opened on day 5, nursing care was provided every 2 days and daily in case of infection. Percentage of healing was evaluated clinically on days 5, 15 and 30 then at months 3, 6 and 12. Photographs were taken.

RESULTS

Four patients were lost to follow-up and one died. Among the 34 grafts assessed at 6 months, we obtained total healing in 56 p. 100, 75 p. 100 healing in 6 p. 100, 50 p. 100 healing in 9 p. 100 and failure in 29 p. 100. Healing rates were those expected for arterial ulcers and necrotic angiodermas. For venous leg ulcers, the rate of total healing was only 30 p. 100 at 6 months and 43 p. 100 at 1 year. Outcome depended on duration of the lesion and not on the type of skin graft or patient age.

DISCUSSION

This prospective study reports outcome of ambulatory skin grafting in a large representative sample of patients with leg ulcers of various etiologies. The less favorable outcome for venous ulcers can be explained by the duration of the ulcerations and infection in these often neglected lesions. The risk of graft displacement, contact eczema, and infection must be recognized for early treatment. There were no cases with general complications. This ambulatory technique has the enormous advantage of limiting the risk of hospital-related problems in this elderly population and of reducing overall cost of care for leg ulcers, and finally of limiting the risk of recurrence by regular post-graft follow-up in a specialized center and by treatment of the causal disease.

Economic evaluation of the treatment of chronic wounds: hydroactive wound dressings in combination with enzymatic ointment versus gauze dressings in patients with pressure ulcer and venous leg ulcer in Germany

OBJECTIVE

The treatment costs for pressure ulcers and venous leg ulcers were estimated based on the hospital administrator's perspective in Germany.

DESIGN

A spreadsheet model using input data from various hospitals in Germany was developed.

INTERVENTIONS

Five currently used treatment strategies were analysed: gauze, impregnated gauze, calcium alginate and hydroactive wound dressing with enzymatic ointment.

PARTICIPANTS

All cases used for and in the analysis were treated in the inpatient setting (4 hospitals and 120 patients were included).

MAIN OUTCOME MEASURES AND RESULTS

The outcome distributions were calculated using the Monte Carlo method. For the whole treatment process, the attributable costs for the hospital were calculated for different cases (severity) and all treatment strategies (1997 values). The costs for treatment with gauze were the highest, whereas the costs for treatment with hydroactive wound dressings and enzymatic ointment were the lowest. The relation between personnel and material costs for gauze is approximately 95 to 5% and for hydroactive wound dressings 67 to 33%, respectively. The cost savings per case were between 1196 deutschmark (DM) and DM9826 using hydroactive wound dressings instead of gauze dressings (depending on the severity of the pressure ulcer), and between DM135 and DM677 for venous leg ulcers. The results were robust and did not change in any performed sensitivity analysis (parameter: 'personnel costs per minute', 'time required for changing a wound dressing', 'total number of wound dressing changes').

CONCLUSIONS

Despite the higher material costs of the hydroactive wound dressings in combination with enzymatic wound cleaning compared with other wound dressings, they should be recommended for the treatment of pressure ulcers and venous leg ulcers. This therapy alternative brings about significant reductions in total costs for hospitals because of significant reductions in personnel costs and the duration of treatment.

Treatment of leg ulcers with split skin grafts: early and late results

Sixty patients (mean age 73.5 years) with 88 leg ulcers that had not responded to conservative treatment had split skin grafts applied at the Department of Plastic Surgery, Linköping, Sweden. Of 51 venous leg ulcers 45 (88%) healed after a mean of 15 days (range 5-30); and 13 (62%) of the 21 arterial ulcers healed after a mean of 18 days (range 8-30). Additional skin grafting was done on nine of the venous and on three of the arterial ulcers. Twenty-two (49%) of the healed venous ulcers recurred after a mean of four months while only two (15%) of the healed arterial ulcers recurred after a mean of 10 months. At late follow up after a mean of four years 18 of the patients were dead and 10 had had the leg in question amputated. Of the 34 patients still alive who had not had amputations, 31 were investigated at open ward or interviewed by telephone and 23 patients were examined with colour duplex scan. Seven of these patients had open leg ulcers. At duplex scan six patients had no venous or arterial insufficiency that could cause a leg ulcer. Of 16 patients with venous insufficiency 10 patients had only an inadequate superficial system. The mean cost for treating one leg ulcer by skin grafting is estimated at SEK 89000 (US$11125). We conclude that leg ulcers often heal with skin grafting but that venous ulcers often recur. To reduce the recurrence rate we suggest a better preoperative aetiological evaluation and improved postoperative treatment with a compression bandage.

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

This paper reports the results of an analysis designed to estimate the expected annual cost per patient of treating venous leg ulcers, and to evaluate the relative cost-effectiveness of a systematic treatment regimen using a four-layer compression bandaging system (Profore) compared with usual care. A Markov model has been developed which simulates the transition of patients between health states (healed and unhealed) over a 52-week period. Healing rates used in the model are derived from those reported in the literature. By running the model for a cohort of 100 patients over 52 weeks it is possible to estimate expected outcomes and annual budgetary costs for alternative treatment regimens. Results suggest that, when compared with usual care, a systematic treatment regimen using Profore is unambiguously more cost-effective. Patient outcomes are improved and annual treatment costs reduced. An important implication is that failure to co-ordinate treatment policies and to use the most cost-effective treatments may result in substantial inefficiency in the use of NHS resources. This inefficiency could represent the equivalent of between 350,000 Pounds and 1.08 million Pounds annually for a typical health authority.

The cost-effectiveness of high compression

A recent systematic review1 indicated that compression bandaging was an effective treatment for venous leg ulceration. The economic evaluation by Carr et al in this issue (page 243-248) suggests that a compression regimen of four-layered bandaging is resource saving, in contrast to the results of a recent randomised trial.2

[Economic aspects of the treatment of leg ulcers using classical methods and modern bandages]

Costs of conventional and advanced treatments of leg ulcers are compared. Conventional treatment consisted in the application of calcaria solution and camphor ointment onto the wound and an indifferent pasta onto the surrounding skin. The advanced treatments included the use of the novel dressings Granuflex, Actisorb and Inadine. The latter treatments consider the sequence of healing phases and at the same time shorten the healing period by up one half. Comparisons of treatment costs have shown marked benefits of the novel dressings. The costs of complete healing of an ulcer with an area of 8 x 8 cm at the healing duration of 4 weeks were 503.48 CZK, 432.38 CZK and 329.62 CZK for Granuflex, Actisorb and Inadine, respectively. Direct costs of the conventional treatment of an ulcer with the same size were 863.28 CZK and the healing period extended to 6 weeks. The use of the novel dressing is apparently less expensive and affords more comfort to the patient.

[Medico-economic study of the management of leg ulcers of venous origin. Initial results]

PURPOSE

There is little data on the different techniques used in France to treat venous leg ulcers. Due to the lack of a well-accepted standard, it is most likely that therapeutic attitudes vary greatly. An assessment of the respective cost/benefit ratios would be most useful, but requires prior knowledge of the techniques used. We therefore conducted a survey of the main management schemes applied in France.

PATIENTS AND METHODS

A cross-sectional survey involved 800 investigators (85% general practitioners. 15% specialists: angiologists and dermatologists) throughout France. Each investigator was invited to include 2 patients with venous ulcerations of the leg. One patient was to have a long-standing ulceration (at least 6 weeks duration) and the other a new ulceration (less than 2 weeks duration). Patients were followed to cure or to study end-point six months after diagnosis. The clinical observations at inclusion are presented here for 247 patients with venous ulcerations.

RESULTS

The patient population showed a clear predominance and advanced age (mean 72 years). In half of the cases, the diagnosis was made at a home visit and in 20% of the cases at an office visit for a reason other than leg ulceration. History taking revealed a high frequency of varicose veins, osteoarthritis of the lower limbs and high blood pressure as well as a high rate of recurrence (60% for long-standing ulcerations). Treatments prescribed at the first visit were divided into 10 groups. The most frequently used methods were: cleansing, contention and general therapy (antibiotics, anticoagulants, antiaggregates, analgesics). General practitioners focused primary treatment on general therapies and local care while specialists used contention more often (more than 90%) and different skin treatments. These different treatment combinations were then grouped into 7 main types of therapeutic attitudes, differentiating between general practitioners and specialists. There were however three common elements found in the treatments applied by more than 50% of the physicians: cleansing (99%), combined with contention (64%) or a general therapy (56%).

CONCLUSION

The main observation was that contention is used at a relatively high percentage (77%). This survey must be continued with a larger number of inclusion visits and an analysis of follow-up visits in order to identify possible changes in therapeutic attitudes and the associated costs as a function of treatment duration and rate of cure within the 6 month period.

Leg ulceration in the sickle cell patient

BACKGROUND

The purpose of this study was to determine cost of care for leg ulcers in sickle cell patients and suggest an improved modality in ulcer care.

STUDY DESIGN

We performed a retrospective study of a group of sickle cell disease patients with leg ulcers.

RESULTS

Eighteen patients with a leg ulcer (duration: mean, 53.7 months), sickle cell disease, and a mean of 20.7 years of age had various modalities of treatment with the only consistency in healing being a commercial moist-wound dressing.

CONCLUSIONS

There is no consistency in the treatment of the sickle cell patient with a leg ulcer. Treatment with a moist dressing had the best results.

[Drug clinics. How I treat a cutaneous ulcer in outpatients]

Leg ulcers are the source of high social and economical costs in the domain of geriatric dermatology. The present review summarizes the indications of antiseptics and of sophisticated wound dressings including hydrogels, hydrocolloids, alginates, polyurethane foams and films, as well as formulations combatting the smelly aspects of ulcers.

Cost effectiveness of community leg ulcer clinics: randomised controlled trial

OBJECTIVES

To establish the relative cost effectiveness of community leg ulcer clinics that use four layer compression bandaging versus usual care provided by district nurses.

DESIGN

Randomised controlled trial with 1 year of follow up.

SETTING

Eight community based research clinics in four trusts in Trent.

SUBJECTS

233 patients with venous leg ulcers allocated at random to intervention (120) or control (113) group.

INTERVENTIONS

Weekly treatment with four layer bandaging in a leg ulcer clinic (clinic group) or usual care at home by the district nursing service (control group).

MAIN OUTCOME MEASURES

Time to complete ulcer healing, patient health status, and recurrence of ulcers. Satisfaction with care, use of services, and personal costs were also monitored.

RESULTS

The ulcers of patients in the clinic group tended to heal sooner than those in the control group over the whole 12 month follow up (log rank P=0.03). At 12 weeks, 34% of patients in the clinic group were healed compared with 24% in the control. The crude initial healing rate of ulcers in intervention compared with control patients was 1.45 (95% confidence interval 1.04 to 2. 03). No significant differences were found between the groups in health status. Mean total NHS costs were 878.06 pounds per year for the clinic group and 859.34 pounds for the control (P=0.89).

CONCLUSIONS

Community based leg ulcer clinics with trained nurses using four layer bandaging is more effective than traditional home based treatment. This benefit is achieved at a small additional cost and could be delivered at reduced cost if certain service configurations were used.

The effects of cadexomer iodine paste in the treatment of venous leg ulcers compared with hydrocolloid dressing and paraffin gauze dressing. Cadexomer Iodine Study Group

BACKGROUND

The aim was to examine cadexomer iodine paste in a comparative clinical trial.

METHODS

A 12-week, randomized, open, controlled, multicenter, multinational trial in patients with exudating, venous leg ulcers of cadexomer iodine paste (Iodosorb/Iodoflex), hydrocolloid dressing (Duoderm E, Granuflex E), or paraffin gauze dressing (Jelonet) was carried out. All patients used short-stretch compression bandages (Comprilan) throughout the study. The primary efficacy variable was a reduction in ulcer size (%), and the secondary end-point was the time taken to stop exudation, when the patient had completed the study according to the protocol. A total of 153 patients entered the study and were treated for 12 weeks or until cessation of exudation.

RESULTS

The mean reduction in ulcer size in all patients was 62% with cadexomer iodine vs. 41% and 24% for hydrocolloid and paraffin gauze (ns). Of those treated for 12 weeks (n = 51), ulcer area reduction was 66% for cadexomer iodine and 18% for hydrocolloid (p = 0.0127). For the whole material, the rate of healing (ulcer area reduction per week) was significantly higher for cadexomer iodine than for paraffin gauze (0.64 cm2/week vs. 0.19 cm2/week, p = 0.0353). The treatment costs were similar in all groups; however, when the costs were correlated with healing over a 12-week period, cadexomer iodine paste was found to be more cost effective than hydrocolloid dressing or paraffin gauze dressing.

CONCLUSIONS

This study shows that cadexomer iodine paste is an efficient, cost-effective and safe alternative to hydrocolloid dressing and paraffin gauze dressing for the treatment of venous leg ulcers.