Limitations of Daily Living Activities in Patients With Venous Stasis Ulcers Undergoing Compression Bandaging: Problems With

Disclosure: Dr. Fife is Chief Medical Officer for Intellicure Inc. David Walker is President and CEO of Intellicure Inc. 

Ulcers caused by chronic venous insufficiency constitute 70%–90% of all lower extremity ulcers.^1,2 For more than 2 decades, compression bandaging has remained the gold standard of therapy,³ although only 50%–60% of venous stasis ulcers (VSUs) typically heal within 6 months and recurrence is common.^4,5 High-technology products hold promise in accelerating ulcer healing for some patients,⁶ but do not address the fundamental problem—venous insufficiency.Compression will most likely not help those patients who have significant concomitant arterial disease. Nevertheless, until significant advances are made in this area, compression bandaging is likely to remain a standard clinical guideline.⁷
Medicare and insurance companies only cover the cost of compression stockings if an active ulcer is present, but not to prevent the formation of venous ulcers, even though the lifetime cost per quality-adjusted life year saved is < $60 000.⁸ Further, at least 1 regional Medicare carrier has suggested restricting reimbursement for the cost of compression bandaging at wound care centers, indicating that patients should be able to self bandage.⁹ This brief study sought to estimate how many patients with VSUs within a wound care setting would be unable to self bandage based on an activities of daily living (ADL) analysis.

Materials and Methods

Intellicure Inc (The Woodlands, Tex) maintains a research consortium agreement with its Level-4 electronic health record software users and permits an analysis of wound care visits in a HIPAA-compliant fashion. The dataset consisted of 7251 patients with all types of wounds (N = 16,856), which produced 119,134 patient encounters at 29 wound care facilities. Standard query language was used to ascertain: A) how many patients had ADL information; B) how many of these patients had VSUs (ICD-9 code 454.x); C) what percentage of these patients required assistance with ADLs or ambulation; and D) what types of limitations these patients had.

Results

Fourteen facilities used ADL assessments, and 547 patients with VSUs were identified with ADL data. The ADL results are shown in Table 1.

Discussion

Fifty-five percent of patients with VSUs required assistance with ADL. Out of this group,between one-third and one-half reported separate problems concerning ambulation, dressing, and toileting. If a patient cannot dress him or herself or has a problem toileting, it is likely that the person will have problems applying a compression bandage, presuming that he or she has the knowledge to do so,which is a separate issue. Thus, more than half of these patients are unlikely to be able to participate in the necessary therapy to treat their venous stasis ulcers unless the help of family members or healthcare professionals is available.
The original dataset was collected as part of routine care among wound center patients and was not collected with self-bandaging assessments in mind.This reduces any potential “bias” in data collection that would favor the results of this brief analysis. Furthermore, because of the broad geographic cross-section of wound centers that are represented by this analysis, the authors believe that this is a reliable estimate that can be extrapolated to larger populations.
Since no data collection was directed at the specific question of self-bandaging, there is no way to determine self-bandaging ability among patients whose ADLs are reportedly normal. Patients who do not require assistance with dressing and toileting may not be able to achieve body positions that would permit self-bandaging. Thus, there is no way to estimate what percentage of the remaining patients would be unable to perform this task. As a result, this brief analysis represents the most conservative estimation of self-bandaging abilities, and it is likely that a much higher proportion of patients would be unable to actually perform self-bandaging.

Conclusion

Due to continually increasing pressure to reduce reimbursement for compression bandaging, these results suggest that there will be major implications for wound care. In 1998,McGuckin and Kerstein¹⁰ estimated that the annual cost of treating VSUs to the US healthcare system was $2.5 to $3.5 billion. If patients cannot afford the costs of basic compression bandaging and cannot self bandage, costs to the healthcare system and patients alike will ultimately rise as ulcers become far less likely to heal. Additionally, the quality-of-life for such patients will remain low. Iglesias et al¹¹ estimated the utility value of untreated VSUs at 0.6 and healing ulcers at 0.7—a considerable difference.