Venous leg ulcers (VLUs) are one of the biggest challenges facing modern healthcare, impacting up to three percent of the world’s adult population1 and costing the NHS alone almost £2 billion to treat every year.2 VLUs mainly affect older adults and prevalence dramatically increases with age.3 Despite this widespread burden, there is no international consensus for gold standard treatment and management of VLUs.4
VLUs are slow to heal and difficult to treat with many patients experiencing recurrences within a year of healing. Patients therefore require frequent and intensive treatment to prevent VLU recurrence and ensure improved quality of life. However, adherence and concordance to treatment is low – estimated to be between 12-52 precent.5
There have been few improvements over the last 30 years in the adherence to VLU treatment.6 This was significantly exacerbated by COVID-19 where wound clinics were closured and scaled back to stop the spread of the virus, leaving patients to manage their ulcers independently at home.
Understanding the burden
VLUs are chronic skin ulcers that affect the gaiter area. They are caused by damaged or blocked veins in the leg either due to trauma, deep vein thrombosis, varicose veins, or oedema, limiting and preventing backflow of blood to the heart. This triggers a build-up of blood in the lower leg causing ulceration.7
VLUs have significant impacts on quality of life, such as extreme pain and an impeded ability to walk or sleep. In some cases, the wound may itch, puss and release an unpleasant smell, which can cause distress, discomfort and embarrassment for patients.8 This burden continues until the wound heals, though healing is typically slow: only 53 percent heal within one year9 and some never heal at all. Recurrence rates are estimated at 57 percent by one year10 leaving many patients suffering with VLU on an ongoing basis.
Adherence to VLU treatment has significant positive impacts on healing. If treated appropriately, VLUs can heal in four months3 as opposed to years or not at all. Early intervention can also avoid recurrences: early endovenous ablation – a procedure to close off varicose veins – is reported to accelerate VLU healing and reduce recurrences.11
Identifying issues with adherence
Gold standard for VLU treatment recommends compression therapy, typically involving medically prescribed compression bandaging or stockings applied by a clinically trained wound specialist. Compression therapy reduces vein distension activating the calf muscle to pump blood back to the heart and reduce oedema.12 Compression bandaging comes in various forms, including two-, three- and four-layer and will depend on what is required for optimal healing as well as the patient’s preferences for comfort.
Despite compression therapy being an effective form of treatment when appropriately applied, adherence to compression therapy is low. Non-adherence is multidimensional and can be impacted by various demographic, socio-economic, financial, and climatic factors13, making management of healing extremely difficult. A particularly elderly patient may have limited mobility, and so cannot walk to promote blood flow to optimise healing. A patient with low health literacy or cognitive skills may not understand, and subsequently be able to act on, healthcare advice provided by professionals.14 Frequently, such issues overlap making the source of non-adherence difficult to identify.
Patient concordance can also be impacted by pain and discomfort caused by compression therapy15, variations in application and removal of stockings, as well as relationships with healthcare advisors and lack thereof. In fact, multiple studies describe the importance of building good relationships or ‘partnerships’ between patients and healthcare professionals in the healing of VLUs.16 Emotional elements of care, such as empathy and honesty from healthcare professionals, are also believed to contribute to positive medical outcomes.17
Navigating barriers brought on by Covid-19
The scaling back of wound clinics during Covid-19 has made healthcare delivery for VLU more challenging. As wound patients are typically above the age of 70, putting them at a greater risk of developing complications with Covid-19, minimising the spread of the virus was prioritised by healthcare systems over conditions deemed ‘non-urgent’ such as chronic wounds.
For some wound patients, the delivery of VLU care also shifted to teleconsultation, via phone or video calling, requiring patients to treat their wounds independently at home. However, remote care lacks the ability to practically demonstrate to patients how to correctly bandage a wound. Even where patients build a knowledge base to dress a wound, it is possible that not enough pressure will be applied to best support recovery, optimising comfort over healing efficiency. The National Institute for Health and Care Excellence (NICE) recommends that: “the use [of compression bandages] calls for an expert knowledge of the elastic properties of the products and experience in the technique of providing careful graduated compression.”
Difficulties with application and removal of compression stockings are reported to negatively impact healing18 which can expose patients to recurrences and infections. Patients becoming their own primary care increase these risks.
Innovating wound care, improving adherence
Driving up concordance to VLU treatment, particularly in the context of patient self-management, can be improved with the support of medical technology (MedTech). Wearable devices that are simple to use, comfortable to wear, and easy to self-administer have the potential to significantly transform the VLU care pathway – in particular devices that can be used alongside compression and alone in patients initially unable to tolerate, or who might struggle to correctly self-apply, compression bandaging.
Clinical data has proven that increased blood flow to the wound bed can enhance oxygen and nutrient delivery, significantly helping to heal leg ulcers – with wounds closing in a matter of weeks, as opposed to months or not at all.19 A key contributor to the data is MedTech innovation with the advent of medical devices that are able to contract lower limb muscles to increase blood flow, transporting oxygenation blood to the surface of the skin – devices that are comfortable to wear, easy to apply and easy to self-manage.
This speaks to data that also demonstrates that giving patients greater control over their healthcare can positively impact wound healing. A study by Lindsay et al20 found that involving and engaging patients in their health and wound care improves outcomes, strengthens individual well-being and contributes to cohesive and effective treatment of leg ulcers.
Breaking barriers with MedTech
Despite a dedicated commitment to standard of care clinical practice and extensive research exploring the reasons for low-adherence to VLU treatment plans, the ability to resolve the situation remains a constant challenge to healthcare systems. As the ageing population continues to grow, healthcare systems expect rates of VLUs to rise, exacerbating what is already a widespread, expensive issue. Unless healthcare systems can find solutions to improve VLU compression adherence and reduce the rates of recurrence, the cost of treatments will continue to increase, while patient outcomes will not improve.
Going forward, the need to understand patients’ personal preferences remains crucial – listening to how patients would like to approach treatment and incorporating this into care plans. Taking the time to educate patients on ways they can help themselves and building patient/care provider relationships. Each remain critical to wound healing success. The paradigm shift driven by greater patient engagement though, also needs to be supported by MedTech innovation; devices able to activate the calf muscle pumps to increase and transport oxygenated blood, with all its inherent benefits, to the surface of the wound bed and surrounding skin, plus devices that can allow more impactful delivery of compression in the patients’ hands and of course remote monitoring. These adjunctive therapies provide huge potential to enhance patient self-management and motivation, leading to accelerated wound healing and better patient outcomes.