Patient compliance with venous leg ulcer treatment
Department of General and Vascular Surgery
Darent Valley Hospital
Kent – UK
Lower-limb venous ulceration is a common affliction, affecting particularly the elderly population, which significantly reduces quality of life. Compression treatment, in the form of hosiery, bandaging, or intermittent pneumatic compression devices (IPC) is regarded as standard in the management of venous leg ulceration (VLU). This article reviews the literature on patient compliance with such compression modalities, a factor often not paid much attention to clinical practice.
Chronic lower-limb ulceration affects approximately 1% of the population.1,2 The majority of these ulcers are of venous etiology3 but a variety of other causes have been identified which might coexist.4,5 The prevalence increases to more than 2% in those aged over 80 years6 with demographic studies suggesting a significant increase over the next 85 years.7 VLU is a considerable source of morbidity reducing patients’ quality of life8 and is estimated to cost the UK National Health System £300 to £600 million per year.9
The majority of VLUs are managed in the community and district nurses spend up to half of their time treating VLUs3 because leg ulceration is characterized by a cyclical pattern of healing and recurrence10 with recurrence rates ranging between 45% and 70%.3,11,12 Therefore, community leg ulcer clinics have been established in order to deliver specialized treatment in the form of weekly application of high compression bandaging, which improves the healing rate.13,14 Healed ulcer groups have also been suggested in the past, once healing of the ulcer has been achieved, mainly to educate patients, thus increasing their compliance with compression hosiery and in turn reducing the incidence of ulcer recurrence.15,16
PATIENTS’ COMPLIANCE WITH COMPRESSION TREATMENT
The goals of treating VLUs include counteracting the effects of venous hypertension and reduction of edema in order to heal and prevent ulcer recurrence. Edema is a significant problem, and the simplest way to reduce this is bedrest combined with leg elevation.17,18 Regular daily elevation above the heart level has been shown to improve swelling and venous microcirculation19 but this might be difficult for patients suffering from arthritis or heart failure.
Compression therapy is the oldest form of effective treatment for VLUs, as described by Hippocrates.20 The most effective method of compression remains an issue of controversy, but in general there are three forms of compression applied in clinical practice: inelastic, elastic, and intermittent pneumatic compression (IPC).
Two main prototypes of inelastic bandages are available: a short-stretch bandage (eg, Comprilan, Beiersdorf) which is favored in mainland Europe, and the traditional Unna boot, a moist zinc oxide-impregnated paste bandage used mainly in the USA.21 Such rigid bandages apply low resting but high working (walking) pressures, and require a patient who is not only mobile but also available; in particular the Unna boot requires frequent application because of its limited absorptive capacity for highly exudative wounds, which leads to a foul smell and might affect patients’ compliance with such bandages.22
Elastic compression therapy can be subdivided into compression hosiery and bandaging. Compression stockings utilize locally graduated pressure on the calf muscle and have been effective not only in treating23,24 but also in preventing recurrence of venous ulcers.25 Compression hosiery can be divided into three classes (British standard, I: 14-17 mm Hg, II: 18-24 mm Hg, III: 25-35 mm Hg at ankle), each class utilizing different pressure gradients with their own recommended indications for their use. A common problem related to compression hosiery is patient compliance and adherence to treatment protocols. 26,27 Patients’ compliance to treatment with stockings can be affected by skin allergies (Elastane, Nylon, or Lycra contained within hosiery), cosmetic considerations, ill-fitting stockings causing pressure necrosis, patients’ agerelated dexterity, or any other disability which might cause difficulty in applying the stockings.28,29,30 All of the above potential problems can be rectified, eg, patch tests can be performed to identify allergies31 and if positive the use of a cotton lining under the stockings can overcome this problem. Accurate measurement of the calf is important to ensure that the type of compression hosiery chosen fits well and various aids are available from manufacturers which help patients with the application of stockings but occasionally assistance from a relative or carer needs to be organized.32
Furthermore, pain caused by venous ulcers can be severe and needs to be addressed appropriately, which in turn can improve patients’ compliance with compression stockings.33 Patients require two pairs (one to wear and one to wash) and a new pair is needed in approximately 4 to 6 months as they wear out10 which means that costs have to be kept low by companies in order not to deter patients from buying them.
Awareness of all the above factors which can influence compliance will contribute to a successful treatment of VLUs, and in some cases it should be remembered that a lower level of compression is better than none.34
There are a variety of bandages available and they can be divided into multilayer or single-layer bandage systems.35 The Charing Cross four-layer bandage which is widely used in the UK achieves venous ulcer healing rates of 69% at 12 weeks.13 These multilayer bandages are designed to apply 40 mm Hg pressure at the ankle graduating to 17 mm Hg at the knee sustainable for a week.21 Multilayer systems might be more expensive than single-layer bandages, but in the long run they work out cheaper as they achieve higher and faster healing rates.10,21 Patients find the four-layer system comfortable and the onceweekly changing regimen less disruptive to their lives than other systems.35,36 Nevertheless, on occasions it is required to change the bandage two or three times a week because of the excessive exudates, and address patients’ discomfort with adequate analgesia.33 The main disadvantage of the four-layer compression system is that a certain expertise is needed, with most nurses having to complete a course on management of leg ulcers [ENB N18] with additional training days to practise adequate application.37 Nurses who specifically promote the delivery of four-layer high compression treatment achieve higher healing rates compared with results obtained by community nurses.38 Long-term continuation of compression in form of hosiery following healing of VLUs is the most effective preventive method for recurrence39 and patients’ compliance has been a concern.15,25 Previous studies demonstrated that adherence to compression therapy reduces the recurrence rates.40,41
Compliance in general with treatment has already been identified as a problem; eg, 50% to 60% of patients are not compliant with taking their medication42 and it has been shown that the noncompliance rate increases in particular with long-term treatment where the aim is preventive.43 Patients’ nonadherence with compression hosiery is a complex issue, as it is difficult to measure44 and affected by multiple factors as mentioned earlier.
Intermittent pneumatic compression devices (IPC)
IPC is a compression pump device designed to squeeze the leg intermittently, thus reducing venous stasis by promoting venous blood flow45 and increasing systemic fibrinolytic activity.46 This pump system has been demonstrated in earlier studies to aid venous ulcer treatment in combination with bandages, but unfortunately all these studies are characterized by small numbers.47,48,49 These trials confirmed that patients’ compliance was good, with compression regimens varying from hourly sessions weekly to 4 hours per day within a home setting. IPC might have a role to play in papatients with reduced mobility and difficult-to-heal ulcers.50
Venous ulceration can be the result of isolated superficial venous incompetence, but most studies have demonstrated that deep venous reflux alone or in conjunction with superficial insufficiency are the main causes of VLU.51,52 Superficial venous surgery is regarded as controversial in the presence of deep venous reflux53,54 but is indicated in patients with isolated superficial venous incompetence.55Conservative management in form of compression treatment will therefore remain the cornerstone for VLUs, and compliance of patients with such modalities to achieve healing or avoid recurrence will remain a major concern to doctors and nurses treating patients with lower-limb venous ulcers. Compliance is a complex issue based on patient’s attitude, their motivation and ownership of the problem27 which requires education, supervision, and support so that patients become responsible for their own care, thus in turn increasing adherence to compression therapy.
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