Background:  Current prevalence estimates of chronic leg ulceration are frequently based on studies from the 1980s. During the last decade, major changes have occurred in the application of evidence-based practice to this condition.

Aim:  To determine the prevalence and cause of leg ulceration in a defined geographical population after 8 years of providing standardized evidence based protocols of care.

Design:  Prospective survey.

Methods:  Patients with leg ulceration of >4 weeks duration) within an integrated acute and community leg ulcer service were ascertained, interviewed and clinically assessed, using a standardized questionnaire on medical history, ulcer details and non-invasive vascular investigation to describe causes. Ulcers were classified by aetiology.

Results:  We identified 113 patients in a population of 252 000, giving a crude prevalence of 0.45/1000 (95%CI 0.37–0.54/1000): 0.34/1000 in men, 0.54/1000 in women. Rates were highly dependent on age, increasing to 8.29 (men) and 8.06/1000 (women) in those aged >85 years. Of the responders, 62/113 (55%) had their ulcer for >1 year. Uncomplicated venous ulceration was observed in only 59/138 (43%) ulcerated limbs; a further 21 had ulceration primarily due to arterial disease. Complex causes were present in 48 (35%) limbs, mostly venous disease in combination with diabetes (35%), lymphoedema (42%) and rheumatoid arthritis (26%).

Discussion:  Our prevalence of chronic leg ulceration is approximately one-third of that predicted by previous studies using similar methodologies in the 1980s. Patients with ulceration have more complex aetiologies than previously recognized, which may be a consequence of both increasing ulcer chronicity and age.

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Prevalence of leg ulceration in a London population

With an aging population venous ulceration is likely to become an increasing problem. Despite improvements in care and the widespread introduction of compression bandaging, the mainstay of current management, a significant proportion of venous leg ulcers remain hard to heal. Therefore, a single-blinded, randomized multicenter study was performed to compare wound size reduction using amelogenin proteins (Xelma) formulated into a solution which forms a temporary extracellular matrix on contact with the wound bed. Propylene glycol alginate 7% served as a control. Patients were randomized to receive either amelogenin protein or control treatment. The investigational products were applied weekly under soft silicone secondary dressings for up to a maximum of 12 weeks. Compression therapy was maintained throughout the investigation. Wound size reduction was measured by tracing and all wounds were photographed. In total 123 patients were recruited, 62 patients in the amelogenin group, and 61 in the control group, respectively. Subgroup analyses were performed for ulcers with a size>10 cm2 at baseline and for ulcers of duration of >12 months. The wound size reduction was greatest in the group treated with amelogenin (33.8 vs. 25.6%, n=117), this difference being greatest for larger ulcers (25 vs. 7.9% for ulcers>10 cm(2), n=61) and those of long duration (29.3 vs. 10.9% for ulcers>12-month duration, n=61). We conclude that this product may be clinically useful in the treatment of these venous leg ulcers.

The effect of amelogenins (Xelma) on hard-to-heal venous leg ulcers.

Objectives: The objectives of this study were to (1) determine how congruent community-provided leg ulcer care was with best practice for venous leg ulcers and (2) identify organizational and clinical factors associated with the provision of best practice for venous leg ulcers. Design: The practice variation study group was an audit of nursing agency client records to determine the provision of care. Setting and subjects: The study population was a home care cohort of persons with venous leg ulcers (n = 66) who received care from one Ontario home care nursing agency between March 1999 and November 1999. Instrument: The audit tool was developed with a checklist reflecting the common recommendations from 3 international practice guidelines, as well as organizational and clinical factors that may influence or reflect best practice. Results: Half of client records (35/66) included an identified etiology of the leg ulcer. An Ankle Brachial Pressure Index score was documented prior to the initiation of compression on fewer than half of the records (21/44). Regular ulcer measurement was done for 11% of the clients (7/64). Two thirds of the clients (44/66) were treated with compression. More than 60% of the clients (40/66) had been seen by either a dermatologist or a vascular surgeon. Topical antibiotics were prescribed for two thirds of clients (44/64). Fifteen percent of clients (10/66) were assessed for pain, and 17% (11/66) received some form of pain management. Documentation of client education specific to the leg ulcer was present on 3% of records (2/66). The mean number of different nurses providing leg ulcer care to each client was 19. A registered practical nurse was the classification of nurse assigned to 43.8% (29/66) of the clients. Conclusion: Several gaps were identified in the care provided. A standardized approach to care is needed that includes a comprehensive leg ulcer assessment to determine the ulcer etiology, determination of an Ankle Brachial Pressure Index score to screen for the presence of arterial disease, and compression for all clients who meet the criteria for venous disease. A reorganization of services is required, which includes an increased role for community nurses in leg ulcer assessment and management. Organizational and clinical factors influencing the delivery of best practice need to be identified and addressed. (J WOCN 2003;30:132-42.)

Venous leg ulcer care: How evidence-based is nursing practice?

Multiple factors affect the likelihood of a wound healing. One of these factors, wound duration, is well known to be related to healing rates, with numerous publications showing that older wounds are less likely to heal. However, disentangling the effect of this factor on wound healing rates is complex. Is this simply an observation of the obvious; wounds of longer duration will by definition be harder to heal? Or does time represent an independent factor, implying that should treatments be given earlier in the disease process, better outcomes may result? This review summarizes the available evidence of the effects of wound duration on healing rates and examines potential biological aberrations identified in chronic wounds, which may be significant in making chronic wounds difficult to heal. Wounds of longer duration are associated with excessive inflammation, fibroblast senescence, and alterations in wound bed flora, which appears to have a temporal relationship. Early and aggressive treatment of ulcers that fail to respond to standard care may well aid in reducing the burden of wounds that become chronic.

Wound duration and healing rates: Cause or effect?

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. 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. 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. 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. ClinicalTrials.gov Protocol Registration System: NCT00656383

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

An audit of clinical leg ulcer services was undertaken in South Bedfordshire and was followed by a process of implementation using research-based methods; a re-audit was conducted 18 months later. Using an adaptation of the Riverside model, patients were referred to community leg ulcer clinics. They were assessed using Doppler ultrasound; those with ABPI >0.8 were treated using a high-compression four-layer bandage system. Those with ABPI 0.6-0.8 were treated using reduced compression, and those with ABPI <0.6 were sent to their GP for referral for specialist opinion. In October 1993, the average cost of consumables for each patient was £8.53, and this rose to £10.14 in May 1995. However, patients treated in community clinics had a reduced cost of consumables of £7.91 compared with £10.78 for patients treated at home. There was also a corresponding reduction in weekly treatments and an overall reduction in nursing time to treat patients. In 111 patients (134 limbs) treated by high compression in the commu...

C J Moffett

Papers

Clinical audit and effective change in leg ulcer services.