With the level of spending on wound care in the billions of pounds, both the financial and health-related impact of venous leg ulcers cannot be understated. Dan Carradice (Hull York Medical School, Hull, UK) speaks to Venous News about the latest report by the All-Party Parliamentary Group on Vascular and Venous Disease, which articulates the extent of this important issue, and what can be done to improve care in the UK.
How did the report, “Venous Leg Ulcers: A Silent Crisis”, come about, and why are venous ulcers an important issue?
The thing to say first is that vascular disease is an unwitting victim of the widespread misunderstanding and misdirection of healthcare attention, and I think that this is true all the way from strategy and planning, down to individual patient care. It is clear that vascular disease is the most common cause of death in UK adults, the most common cause of limb loss, and results in a significant level of physical, mental and psychological morbidity across the country. Despite this, it has received precious little attention compared to other diseases, such as cancer, and when it is considered it is usually fragmented, with all attention limited to heart disease and stroke.
The predominant interest of those involved in the management of vascular disease is targeted towards arterial disease, and it is against this backdrop that venous disease sits in near silence. I think that this report came about because both patients and their carers are clamouring to be heard, while healthcare professionals are battling to improve care quality and outcomes. For this reason, we have been working with organisations such as Legs Matter, Lindsay Leg Club, and now MPs in the parliamentary group to produce this report, raising awareness of such an important condition.
In terms of the second part of the question, I think that this is an important issue because lower limb venous reflux is one of the most common causes of disease in adults, with a prevalence of about 40-50% in adults overall. It is difficult to know how many people have active venous leg ulcers, as they are frequently misdiagnosed, but at least 200,000 people seek help for these ulcers annually. There are another 420,000 leg wounds treated every year which never receive a formal diagnosis, and we also have some detailed epidemiological studies which estimate a prevalence of around 0.7%, which would equate to around 400,000 active ulcers in the UK.
What are some of the key reasons for the development of venous leg ulcers, and how do these wounds impact patients’ lives?
Venous leg ulcers are caused by high pressure in the veins (venous hypertension), which initiates an inflammatory condition within the skin and the soft tissues of the leg. This results in the breakdown of the skin. There are a range of causes for this increase in venous pressure, but the most important and common, by far, is reflux in the superficial veins of the legs. This, in turn, is also caused by an inflammatory condition in the vein walls, which results in a loss of valvular function.
Ulcers have a profound impact on patients’ lives; they can be painful, distressing and have been shown to significantly limit health-related quality of life, due to physical limitation, social isolation and psychological strain. One study I was involved with performed a detailed evaluation of objective health-related quality of life, which found that venous ulcers have a similar impact on patients as that of end-stage heart failure.
Is there enough awareness of the physical, social and psychological problems patients with venous leg ulcers experience?
Sadly, I think we are far from where we need to be. We know this from our own experience as clinicians, but the parliamentary group has also received testimony from multiple people who have been through this condition and suffered from a lack of awareness. Patients themselves do not understand the significance of their first ulcer when it does occur, as the underlying venous health issues and their implications are not well known.
Usually, they will go to see their GP and, if the GP does not know what the wound is, then the patient will try some antibiotics and perhaps try to dress it with a simple adhesive dressing or dermatological creams. In some cases, these patients spend years having such a dressing placed on the wound by a GP practice nurse and never receive access to a vascular specialist. In fact, 75% of patients with known ulcers never receive an appropriate assessment.
For those who are lucky to be diagnosed with a venous leg ulcer, it is still rare that they make the transition from primary to secondary care. Primary care usually involves the conservative management of wounds with dressings, and the quality of these dressings is often quite poor. When they are referred to hospital, some of the commissioning policies can make it challenging to treat them expeditiously, while the lack of investment in this area means that services fail to develop to the level required.
As part of the report, you wrote about geographical variation in the provision of venous treatments. Could you explain how this “postcode lottery” affects patients?
Geographical variation results in significant inequality of access to NHS services and a failure to deliver clinically- and cost-effective treatment recommended by the UK’s National Institute for Health and Care Excellence (NICE). This not only leads to poor healthcare, but also inefficient and inequitable use of NHS funding. Both the Government and NHS England are committed to reducing the level of inequality, and, as such, we need to focus on areas like this where inequality is prevalent.
We performed a study where we assessed the published policies of clinical commissioning groups (CCGs) across England, with regard to whether they allowed or prevented the application of NICE’s evidence-based guidelines for the treatment of this venous reflux. Only a third of CCGs had a policy which did not actively prevent the application of these guidelines and evidence-based treatment, while the others employed a range of restrictive or rationing mechanisms, leading to a wide variation in access to treatment. In total, over 90% of patients presenting with superficial reflux do not receive the recommended, evidence-based treatment.
What are the key findings of the report with regard to the current state of venous leg ulcer care in the UK?
I think we have found that there is a widespread lack of effective information and knowledge at multiple levels; the patient themselves, among community-based healthcare professionals and, to a degree, at the level of secondary care.
What we have also found is that there is a lack of awareness among commissioners, which has led to a drop in investment for treatment of these conditions and, in turn, a lack of infrastructure in secondary care to be able to deal with them. The All-Party Parliamentary Group actually did a piece of research focusing on the proportion of trusts who had a specific team for delivering this care, and they discovered that only half of the trusts they contacted had a team in place. In addition, significant elements of variation in access and the quality of treatment were found.
Looking ahead, what recommendations do you and your peers offer in the report to improve the quality of venous treatment for patients?
To sum up the most important points from the report, I think that education is a hugely important aspect and this needs to be integral, at both a policy-making level and the community level, as well as at a commissioner and secondary-care level. Moreover, there needs to be a separate arm for patients because they need to know that the longer it takes for these wounds to heal, the harder the task becomes. We have to make sure these patients realise that, by delaying care, they are reducing the ability of healthcare professionals to address this problem, so education is crucial.
The second key element relates to healthcare services; we need to have streamlined and agreed pathways for getting patients from the community into expert assessment, secondary care and, ultimately, expedited treatment. The only way we can do this is by ensuring that we have effective organisation and commissioning in this area of wound care, along with a strong emphasis on education.
We have a solid evidence base upon which we can dramatically improve the outcomes for these patients and enable health services to make considerable financial savings, even in the short-term. We simply need to overcome these practical hurdles and apply our knowledge and skills to transform care in this common and debilitating disease.
Dan Carradice is an academic vascular and endovascular surgeon at Hull York Medical School and Hull University Teaching Hospitals NHS Trust (Hull, UK). He is the clinical lead for vascular surgical services and is actively involved in leading research aiming to improve quality of life, and save life and limb.