How medical technology can enhance patient self-management in wound care

Successful medical recovery often relies on a patient’s ability to independently manage and actively improve their own health condition. However, self-management can be complex, especially in the case of chronic wound care – such as leg ulcers – where regular input and consultation is required from healthcare professionals, particularly general practice nurses

Chronic wounds are one of the most adverse healthcare issues facing modern medicine and represent a silent epidemic across the globe. Roughly 2% of people will develop a chronic wound in their lifetime in the developed world,1 and prevalence increases with age.² Chronic wounds are classified as skin ulcerations – typically around the gaiter area – that do not show signs of healing within 30 days.³

VENOUS LEG ULCERS: PREVALENCE AND BURDEN

Venous leg ulcers (VLUs) are the most prevalent type of leg ulcer impacting up to 3% of the world’s adult population.⁴ They are often caused by continuous venous hypertension or chronic venous insufficiency.⁵

The risk of developing a VLU increases with age, with prevalence doubling among those older than 65 years.⁶ VLUs can take months to heal, while some fail to heal at all. Even if a wound has healed, the chance of recurrence is high.⁷ It is therefore essential for healthcare professionals and patients to collaborate to ensure the recommended standard of care is fully understood, implemented and working for each individual patient.

Although most VLU cases are not considered life threatening, living with a VLU has significant negative impacts to the quality of life of patients and those who care for them. They can be extremely painful and impede a patient’s ability to walk, move and sleep at night. This ongoing pain combined with a lack of mobility and sleep can lead to deteriorated mental health and further physical health consequences, such as involuntary weight loss.⁸

THE TRUE IMPACT OF INFECTION

As a direct result, many VLU sufferers, especially those with hard to heal wounds, can also find themselves battling infection. A study conducted by Bui et al found that in a group 636 patients with mixed leg ulcers (75% venous) 15.9% developed clinical infection within 12 weeks.⁹ In some cases, the wound may itch, discharge pus and release an unpleasant smell, which can cause distress, discomfort and embarrassment for patients.¹⁰ If left untreated, infected wounds can lead to septicaemia and even limb amputation.¹¹

Beyond the mental and physical burden of wound infection, combating VLU infection places a ‘unique economic burden on healthcare systems’. According to a case-control study from Melikian et al,12 which studied VLU patients in the United States, active infection of the wound was the most frequent cause for inpatient treatment, responsible for 61% of inpatient admissions with the need for intravenous antibiotics.

Nine of 78 patients with a VLU (11.5%) followed for at least one year had a minimum of one inpatient admission for infection. Within that infected cohort, 44% had an unhealed ulcer at the end of the one-year follow up period, compared with just 13% in the non-infected group. When compared with the 69 patients without infection, the total cost of treating infected patients ($27,408) was nearly three times greater than non-infected ($11,088).

There were an estimated 3.8 million patients with a wound managed by the NHS in 2017-2018, of which 15% were VLUs and a further 9% leg ulcers that are uncharacterised. An estimated 59% of chronic wounds healed if there was no evidence of infection compared with 45% if there was a definite or suspected infection. Annual levels of resource use attributable to wound management included 54.4 million district/community nurse visits, 53.6 million healthcare assistant visits and 28.1 million practice nurse visits. 13

TREATMENT OF VLUS

These studies clearly emphasise the importance of preventing infection in patients with VLUs due to its major impact on both medical resources and costs, as well as on ulcer healing and patient health.^12,13 Adequate treatment of wounds is therefore crucial in reducing infections, improving patient outcomes and saving healthcare systems money.

Standard for VLU treatment is compression therapy, typically involving medically prescribed compression bandaging or stockings applied by a clinically trained wound specialist. Compression therapy comes in various forms, including two-layer, four-layer, compression bandaging, hosiery kits and compression wraps, and will depend on what is required for optimal healing as well as the patient’s preferences for comfort. They work by reducing vein distension by compressing the calf muscles to pump blood back to the heart.¹⁴ The increase in blood flow is clinically proven to deliver oxygenated blood to the wound bed to promote healing.¹⁴ Compression therapy also reduces oedema and is anti-stasis for VTE prevention.

IMPROVING ADHERENCE AND CONCORDANCE

However, there is no international consensus for gold standard treatment and management despite the widespread burden of VLUs, and there have been few improvements over the last 30 years in the adherence to VLU treatment.^15,16 Compression therapy is an effective form of treatment when appropriately applied. However, due to the slow healing nature of VLUs, many patients struggle with adherence to standard of care and experience recurrences within a year of healing. Adherence and concordance to treatment are reported to be low overall – estimated to be between 12-52%.¹⁷

Adherence is multidimensional and can be impacted by various demographic, socio-economic, financial, and climatic factors,18 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.¹⁹ 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 therapy,20 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.²¹ Emotional elements of care, such as empathy and honesty from healthcare professionals, are also believed to contribute to positive medical outcomes.

THE COST OF CHRONIC WOUND CARE

The burden of chronic wounds extends far beyond the physical and mental suffering they cause patients. Chronic wounds have long been associated with significant healthcare costs; the wound care burden represents the third highest expense for the NHS, costing approximately £8.3 billion annually. Of these costs, £2.7 billion and £5.6 billion were spent on managing healed and unhealed wounds, respectively.¹³

These costs are relative to the intensive treatment and regular consultation and therapy required throughout the treatment of wounds. Each wound must be cleaned and dressed, often by a qualified general practice nurse, and then redressed and monitored over time to examine progress. Altogether, this consumes large portions of healthcare systems’ time and money.

A study by Drew et al found that between 15 and 20% of wound costs derive from material costs, such as dressings and medical gloves, while 30-35% is spent on nursing time. Patient hospitalisation accounts for more than 50% of the overall spend on wound care.²² Quick diagnosis and effective care pathways are even more important in reducing the number of hospitalisations.

These costs can be further exacerbated by patient adherence and concordance to prescribed venous leg ulcer compression therapy, extending the cost and time it can take to heal an ulcer.²³ Patients can also be required for regular follow-ups with their local surgery in order to monitor how well the VLU is healing, spending more time and money in the process.

ENABLING SELF-MANAGEMENT IN THE HOME

General practice nurses are an integral part of providing care for VLU patients by applying dressings in the clinic, with some needing to be reapplied as many as three times a week. These nurses play a crucial role in supporting the community nurse teams with the care of VLU patients, who are unable to change or reapply their own dressings and bandages. However, general practice nurses don’t often specialise in wound healing compared with specialist community wound care nurses and are more commonly involved in managing wound care, which can be problematic.

A potential solution that can benefit the patient and healthcare system is to facilitate patient self-management and shared care. Reducing the time spent by both general practice nurses and wound care specialists in treating patients can save time, money and resources while empowering patients and their families to take control of their health and contribute to their own outcomes.

Tackling self-management

Patient self-management typically involves maintaining a healthy diet, exercising regularly, managing dosages of prescriptions, or monitoring vital signs like weight and blood pressure. For wound patients, exercising to promote blood flow is not always possible, particularly for elderly patients with mobility issues. Cleaning and dressing their own wounds requires a level of medical knowledge and skill that general practice nurses work to demonstrate in those patients with good health literacy and/or family support.

Even where patients build the knowledge to dress a wound independently, it is possible that not enough pressure will be applied to best support recovery. For VLUs, this can have significant negative impacts on the healing process. The British National Formulary (BNF) states: ‘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.’24 With patient self-management this becomes more troublesome and risks wounds not healing properly or healing more slowly – in some cases doing more harm than good.

INNOVATION FACILITATING SELF-MANAGEMENT IN THE HOME SETTING

Innovation in medical technology (MedTech) is placing patient self-care and shared-care within general practices.

A recent example is a medical technology that is clinically proven to increase blood flow to the wound bed, significantly accelerating the rate of VLU healing by more than double, when used in combination with compression therapy.²⁵ By design, the innovation needed to be safe, well tolerated and easy to use and self-apply.

This advanced wound care innovation is a wearable medical device, the size of a small wristwatch and warn at the knee. It works by delivering painless electrical shocks once every second, to stimulate blood flow back towards the heart, at a rate equivalent to 60% of walking. It can significantly enhance patient adherence and concordance to the standard of care and empower patients to both self-care, without disruption to daily routines, and to share their care with family members and healthcare professionals.

CONCLUSION

VLUs represent a significant financial cost and emotional burden. With many general practice nurses spending huge amounts of time treating patients, innovation in MedTech is required and well placed to drive better patient outcomes. The lasting benefit of advanced innovations and adjunctive wound therapies – those able to accelerate healing and promote self-care or shared care – is reduced health system costs and a reduction in nursing time, through fewer follow-up appointments and home visits. MedTech innovations are modernising standard of care through evidence-based clinical efficiency for better patient outcomes.

REFERENCES

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