Prevalence of Chronic Wounds in Quebec Home Care: An Exploratory Study

    Chronic wound care is an important clinical challenge, especially for home care professionals. People eligible for home care services often experience progressive loss of autonomy either because of age-related issues or other medical conditions (eg, paraplegia, diabetes, vascular disease) that put them at high risk for developing chronic wounds.¹ The rising number of seniors and disabled people points toward a major explosion in the number of chronic wounds in the future.² Moreover, the reduction in postsurgical stay in hospitals, combined with the prohibitive price of wound dressings and sophisticated treatment modalities, could delay healing time in patients with chronic wounds, especially if home health and/or family cannot provide care and support.³

    In the 1990s, the number of pressure ulcers in the US was estimated to be 2.1 million, leading to more than $1.3 billion in national expenses.² These data reflect only one type of ulcer. Additional data from American hospitals estimate the number of patients with chronic wounds is approximately 5 million, generating $20 billion in healthcare costs.⁴

    In Canada, little information is available about the number of individuals suffering from chronic wounds and no national chronic wound prevalence or incidence records exist.⁵ This information is crucial for proper assessment of the related healthcare costs.^5,6 Prevailing opinion is that chronic wound research is frequently conducted by private companies to test their new products; patients receiving home care are rarely selected for participation in these research projects.⁵ The lack of home care patients in these studies may restrict applicability of the results to this population.

    In Quebec, home care services are provided by local community service centers (CLSC) recently integrated into a larger network of health center and social services (CSSS). The purpose of this exploratory study was to evaluate the feasibility of collecting information on the prevalence of chronic wounds in vulnerable patients receiving home care services using a survey and cross-sectional data.

Method

    Cross-sectional data were collected over two 30-day periods — May 2003 and September 2003 (the latter for CLSCs not able to participate in the first round). All 149 CLSCs in Quebec offering home care services were invited to participate. Surveys were mailed to home care department heads. Research team members contacted non-respondents 1 week after the surveys were sent. When required, several attempts were made via telephone or email to contact potential respondents to ensure the largest survey response possible. Reasons for non-participation were recorded.

    Nursing personnel were asked to complete a questionnaire for every patient under their care with a chronic wound. Each patient was entered in the database only once. The home care department head also was asked to complete a questionnaire that addressed general service center statistics.

    Data and variables. The two different questionnaires (one for home program leaders, one for nurses) were available in a paper format and electronic version (Microsoft ACCESS). The questionnaires were pre-tested among five nurses to determine time necessary for completion (15 to 20 minutes); no modifications to the questionnaire were made. The home care program leader questionnaire included questions about the number of patients receiving home care services, the use of a wound care protocol (yes/no), staff training in wound care (yes/no) and, if yes, proportion of staff that received the training.

    A more elaborate questionnaire that comprised three sections was sent to nurses. The first section pertained to patient information (eg, age and gender) and included questions on risk factors for chronic wounds based on the Braden^6,7 scale for mobility, nutrition, and incontinence and the Norton’s scale⁸ for mental condition. Also included were questions about associated health problems that may affect healing, such as neurological disorders (cerebrovascular accident, multiple sclerosis, spinal cord injury), rheumatoid arthritis, kidney failure, peripheral vascular system (venous and arterial insufficiency, chronic swelling of the lower extremities), endocrine system (diabetes), gastrointestinal system (hepatic cirrhosis), nutrition disorders (cachexia, obesity), and cancer.⁹

    The second section gathered information on the most severe type of wound. Pressure ulcers were described according to Shea’s¹⁰ classification (Stage I to Stage IV) which is the basis of the National Pressure Ulcer Advisory Panel (NPUAP), Agency for Health Care Policy and Research (AHCPR), and Canadian Association of Wound Care (CAWC) recommended four-stage classification system to describe depth of tissue damage.⁸ Diabetic ulcers were described according to Wagner’s¹¹ classification (Stage 0 to Stage V). No grading/classification system exists for venous ulcers. Nurses were asked to describe observed healing progress in the last 3 months, including any complications, as follows: no change, deteriorating, good evolution (if progressive debridement and granulation buds developed as expected), or fluctuating. Complications listed included cellulitis, pain, hemorrhage, local infection, systemic infection, lymphangitis, osteomyelitis.⁹ The classifications were thoroughly defined in the appendix. Pictures were added to the electronic version to further assist respondents in accurately classifying wound types.

    The third section of the questionnaire was related to wound treatments other than dressings. A list was provided and participants selected those relevant to the most severe wound described. Examples of specific approaches, treatments, or devices included repositioning, exercise, pressure-relief or pressure-reduction support surfaces, and compression therapy (eg, compression wraps, compression stockings, sequential pumps, and special equipment such as mattress replacement and cushion products). Respondents also were provided space for comments or concerns about chronic wound care.

    A period prevalence measure, defined as the number of cases with a chronic wound present in the general population within a specified time frame (1 month), divided by the number of persons at risk in the same population during the same period, was used to establish prevalence rate.^12,13

    Statistical analysis. The analysis was carried out using the Statistical Package for Social Scientists (SPSS version 10.0, Chicago, Ill). A descriptive analysis of the general data was followed by an analysis per center. A bivariate analysis was performed using chi-square tests for categorical variables and t-tests for continuous variables. The alpha level was set at 0.05 for all statistical tests. Qualitative data such as participants’ comments were categorized and tabulated.

Results

    Sample. Of the 149 CLSCs invited to participate, 52 responded (35%). Regions with a CLSC participation rate >50% were Laval, Northern Quebec, Côte–Nord, Bas-St-Laurent, Abitibi-Témiscaminque, and Terre-Cries-de-la-Baie-James.

    Questionnaire obstacles.
    Time. According to nursing staff queried, the primary reason for not participating was lack of time. The questionnaire was thought to be too long. Many centers said staff workload did not allow working time to participate. Although all centers have computers and email, nurses did not take advantage of the electronic questionnaire that would have taken less time to complete.

    Accuracy. The number of patients having a chronic wound was computed by adding the number of patients provided voluntarily by each nurse who agreed to participate. Cases were probably underdeclared. Reliable coding of wounds by the home care authority (CLSC) did not exist. Without this information, validating the actual number of patients with a chronic wound per center was not possible (the numerator of the prevalence fraction).

    Patient characteristics. Four-hundred-and-eighty-eight (488) patients with chronic wounds were described by the participating centers. Patient mean age was 68.5 years; 227 (46.5%) were 76 years or older. Slightly more than half (265, 54.4%) were women. Of the total sample, 17.2% currently smoked, 15% had occasional urinary incontinence, 20% were permanently incontinent of urine, and 15% experienced fecal incontinence. The nurses rated the nutritional status of these patients as poor (4%) and probably inadequate (24%). Table 1 shows patient mobility level, mental state, and degree of cooperation with recommended preventive measures.

    Wound characteristics. The 488 patients had 887 wounds; 395 (81%) had one or two wounds, 54 (11%) had three or four, wounds, and 39 (8%) had five or more wounds. Prevalence of chronic wounds among participating centers was 1.4% (range 0.1% to 7.5%). These values are likely an underestimation of the true prevalence.

    Nurses were asked to describe the most severe wounds in subjects with multiple wounds. The mean duration of wounds was 26.8 months (range 0 to 180 months, median 12 months). The most frequent wound types were pressure ulcers, followed by venous ulcers and diabetic foot wounds (see Figure 1). Figure 2 shows the location of these wounds.

    Of the 170 pressure ulcers, 76 (44.6%) were Stage III (see Table 2). Approximately 50% of diabetic foot ulcers were grade II (see Table 2) — that is, the subcutaneous part of the skin was destroyed, possibly exposing tendons and ligaments — and 25.6% were grade III, indicating an abscess or osteomyelitis.

    Approximately 60% of wounds were not showing signs of improvement or were getting worse; 226 (46.4%) had had a complication within the last 3 months (see Table 3).

    Wound treatment other than dressings. Therapeutic surfaces are often used in the home care setting for the prevention and treatment of pressure ulcers (see Figure 3). Other therapeutic modalities are used for specific types of wounds (see Table 4). In this study, it was found that certain modalities were not necessarily appropriate for the type of ulcer. For instance, compression treatments (16.7%) and walking casts (3.3%) were used in patients with arterial disease, which is contraindicated.¹⁴ Inappropriate use might be explained by an error in choosing treatment, coding a therapeutic modality that addressed a wound other than the one described, or answering the questionnaire.

    Home care treatment team. Dressings usually were changed by the visiting nurse (see Table 5). In 50% of the cases, dressings were replaced two to four times a week. Only 2.5% of dressing changes were performed by the patient or family. A chronic wound protocol was used by 48% of participating centers; 57% of these centers report having trained between 75% and 100% of the staff.

    Despite the fact that most patients (94%) were reported to have a family doctor, only 37.7% of these physicians were involved in, or responsible for, the wound treatment plan (see Table 6). Patients with diabetic or arterial ulcers were referred to specialists more often than patients with pressure ulcers.

    Staff concerns. Qualitative responses included a variety of concerns. Nurses indicated a need for increased education and integrated services. Difficulties specific to the home care environment included poor cooperation from the family, poor patient hygiene, and difficulties moving patients whose mobility is severely impaired. Also mentioned were reduced accessibility to specialized resources (human or technical) and the negative influence of divergent professional opinions on the treatment plan.

    Due to the chronic aspect of wound care, questions often are raised about the long-term effects of providing care and the best possible approach to motivate caring professionals and prevent desperation and discouragement among patients and their loved ones. Although not always possible, nurses believe that the same caring team should remain with the patient to ensure continuity and best results.

    Leader concerns. Program leaders’ main concerns were similar to those of nurses: poor access to home care providers and complex wound specialists; inconsistencies of chronic wound treatments between nurses and between centers; inability to improve the patient’s environment when support and care are lacking; inability to communicate cost-effective treatment options to the patient and among care providers; and insufficient budget allocated to training programs.

    Staff in certain centers did not know if treatment protocols were available. Some individuals wondered if cultivating a few wound care experts would be preferable to training everyone. The current medical approach was criticized as being too traditional, ineffective, and not proactive. Two proposed solutions were to 1) implement conference call access to various resources and 2) create a network of virtual specialists via the Internet, using the patient’s wound pictures.

Discussion

    Relevance of prevalence studies. Chronic wounds take time to heal and are expensive to treat. Patients referred to home care services have increasingly complex and extensive needs. Current demographic and financial trends indicate a growing need for trained health professionals who will be required to handle increasingly complex chronic wounds and are able to function as team players.¹⁵ At this time, taking a comprehensive look at the current situation and initiating a process to address both service levels and financial support, which are limited, are critical.

    Lack of data may explain why chronic wounds are currently not a recognized health problem countrywide.⁵ No published prevalence data on chronic wounds is currently available in Quebec. Prevalence and incidence data could help clinicians, institutions, and decision makers better evaluate the preventive measures in use as well as subsequently considered treatment plans. Moreover, medical resources are costly and additional information could help leaders make accurate decisions on the type of equipment to purchase, increase prevention efforts, or improve wound treatments while fine-tune staffing requirements. Additional information could prove useful when implementing appropriate prevention programs.¹⁵

    Literature regarding chronic wound prevalence reveals that comparing results between studies is difficult. Methods, such as measurements, target populations, and prevalence definitions, vary.¹² In this study, the denominator of the prevalence fraction is the number of functionally dependent individuals receiving home care support. This target population is at higher risk of developing a wound than the general public. The decision to use this population was based on the potential use of information by various institutions offering home care services. Other analysts, reviewing regional wound prevalence for budgetary purposes, may have to use the general population as their denominator. When reviewing studies, these methodological issues have to be examined in order to better understand and evaluate the internal and external validity of results and conclusion. Fletcher¹⁶ clearly explains the challenges and pitfalls associated with accurately defining chronic wound prevalence.

    Despite these limits, data comparison is useful and meaningful when it originates from a single environment and a single methodology. For example, researchers in a British community used the same method and the same territory from the 1980s to demonstrate that the prevalence was reduced one third as a result of various chronic wound care initiatives.¹⁷ This is an example of useful results emerging from prevalence studies.

Lessons Learned

    The results of this study confirm that the prevalence of chronic wounds in those receiving home care is difficult to assess in Quebec. Overloaded work schedules limited study participation and the absence of a computerized database compiling chronic wounds precluded validating the number of cases (the numerator of the prevalence definition). In this pilot study, cases were hardly declared — that is, untrained, overburdened staff were asked to report data, which most likely impeded participation and underreporting. In addition, limited financial and personnel support to assess prevalence kept the participation rate low. Nevertheless, an underestimated overall prevalence of 1.4% with prevalence rates per CLSC of up to 7.5% is not very different from other reported prevalence data. The Ottawa-Carleton regional leg ulcer project conducted several studies, including a prevalence study in a home care setting. The regional prevalence rate per 1,000 population over 25 was 1.8¹⁸ Considering that the study clients (with wounds) represented 6% of the agency’s clients, this figure represents the prevalence of lower limb ulcers among a population comparable to this study group. Another Canadian study reported the impact of implementing practice standards and interventions to define and improve home wound care outcomes.¹⁹ The proportion of patients with at least one wound was reduced from 82.9% in 1999 to 39.1 % in 2002. However, the criteria that rendered that population eligible to receive services from these home care agencies were not described. Therefore, these figures cannot be compared with current data.

    Some improvement opportunities identified during this exploratory study will be useful when contemplating designing and implementing another prevalence study. For instance, the time required to complete questionnaires should be reduced as much as possible. The “lack of time” factor seems to have affected both the participation level in most centers and the number of reported cases, skewing the results. However, using medical charts to extract information and excluding nurses’ participation would not yield valuable results because essential risk factor information is not systematically recorded in the medical files.

    Another important issue to consider before conducting another prevalence study is the validity of the numerator of the prevalence fraction. Researchers must be certain that the number of patients suffering from chronic wounds can be ascertained. This experience revealed that obtaining this number was affected by the nurses’ time and ability to recall information. This study found that several home care nurses only bring a medical summary when visiting patients and often do not have access to the full wound history. During a personnel shift change, a new nurse may experience difficulties in accurately assessing wound progress. In reviewing the literature, a standard data collection tool for patients with chronic wounds under care could be an interesting solution.^4,12,20 No participating center used such a system.

    For nurses to embrace a new system, it must be perceived as useful and effective. Computerized files could address this concern by allowing nurses to read and enter new descriptive data while on site. Should a laptop be unavailable, the nurse could simply print out the patient’s history, wound evolution, and wound description before the visit. A computer data collection tool could help medical follow-up and improve communication between patient care team members. Using such a tool could reduce the number of personnel required for future studies and increase data accuracy.

    Alblaza⁴ explored use of a computerized tool and recommends using remote medicine to improve communication among various experts. Nurses could email information and digital pictures of the wound directly to a team of experts. The treatment plan, in turn, could be sent back via Internet. This system could prove useful to patients with mobility issues and/or who have difficulty with travel. It also addresses concerns of various professionals, as observed in this study, regarding access barriers to specialized resources. However, this system could facilitate documentation of prevalence if all chronic wounds are entered, not just wounds without favorable resolution.

Clinical Observations

    The need for training, development, and support of health professionals is confirmed by the results of this study. Although the majority of patients had a family doctor, only one third of these professionals was involved in wound care. The lack of exposure or experience may explain the high referral rate to other specialized professionals. Multiple commentaries from nurses and their program leaders confirm these needs.

    The median duration of wounds (26.8 months with a median of 12 months) is longer than noted in other studies and cause for concern. More than 50% of the wounds were present for more than 1 year; similar data also were reported in the literature.^21-24 Other studies show a mean duration of 1 month to 12 years and a median of 6 to 8 months.^17,21,25 As the duration range varies in some cases, the median is a more appropriate measure. The long median ulcer duration in this study may be explained by the target population. Patients followed at home tend to be older, less mobile, and have more comorbid conditions. In fact, most other prevalence study populations were in acute care or outpatient facilities, less functionally dependent, and had fewer risk factors for delayed healing, as compared to patients in the current study. Moreover, current data are inherently biased toward more severe wounds because they were the focus of this study. The nurses, however, might also have selected patients with a more complex profile.

    Another result related to duration is evolution of the wound. In a large proportion (60%) of wounds presented in this study, healing was reported as “worsened or stalled.” Several additional factors may explain the longer healing process of wounds treated at home — ie, patient repositioning, eating habits, and support staff accessibility. Other challenges may be related to nurse shift changes, limited access to specialized medical services, and inability to obtain certain types of dressings or equipment needed for treatment or prevention. The long duration of wounds and lack of improvement underscores the need for the development of wound prevention and treatment programs. Results of a study where patients benefited from a pressure ulcer prevention program in a hospital setting shows that incidence can be reduced by 10% to 20%.²⁰

    Program leaders’ concerns were similar to those of nurses and can be summarized as follows: poor access to home care providers and chronic wound specialists; inconsistency of chronic wound treatment among nurses and centers; restrictions regarding improving patient environment; inability to communicate cost-effective treatment options; and insufficient budget allocated to training programs.

Conclusion

    Home wound care providers face important challenges. Convincing decision makers of the need to address these challenges requires clear information. Therefore, developing and implementing standardized wound prevalence data collection tools is necessary.

    Certain basic conditions must be met before a meaningful prevalence study can be initiated. Improved computer systems and redesigned data-capturing processes would help ensure information accuracy.
Chronic wounds, like other chronic health problems, will continue to increase in the decades ahead. Clinicians need to improve communication and information exchange to effectively address the challenges associated with caring for chronic wounds. Obtaining and applying data regarding wound prevalence and appropriate treatment are key to successful wound prevention and care.

Acknowledgment

    The authors are grateful to CLSC-CHSLD du Marigot (J-P Fraser) for providing financial support and Julie Laberge et Marjolaine Hamon for clerical assistance.

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