Economic evaluation of compression stockings for the prevention of venous leg ulcer recurrence in Ontario.

OBJECTIVE: Approximately between 1.5 and 3.0 per 1000 people are affected by venous leg ulcers (VLUs). The treatment and management of VLUs is costly and recurrence is a major concern. There is evidence that compression stockings can reduce the rate of re-ulceration compared with no compression. We present the first cost-effective analysis of compression stockings in preventing recurrence of VLUs from the perspective of the Ontario healthcare system. METHOD: A cost-utility analysis with a five-year time horizon was conducted. Use of compression stockings was compared with usual care (no compression stockings). We simulated a hypothetical cohort of 65-year-old patients with healed VLUs, using a state-transition model. Model input parameters were obtained mainly from the published literature. We estimated quality-adjusted life years (QALYs) gained and direct medical costs. We conducted various sensitivity analyses. RESULTS: Compared with usual care, compression stockings were associated with higher costs and increased QALYs. Cost-utility analysis showed that the incremental cost-effectiveness ratio of compression stockings was $23,864 per QALY gained compared with no compression stockings. The most influential drivers of cost-effectiveness were the utility value of healed VLUs, cost of stockings, number of stocking replacements, monthly prevention cost and the risk of VLU recurrence. CONCLUSION: Compared with usual care, compression stockings were cost-effective in preventing VLUs, using a willingness-to-pay threshold of $50,000. These observations were consistent even when uncertainty in model inputs and parameters were considered.

Round-knit or flat-knit compression garments for maintenance therapy of lymphedema of the leg? - Review of the literature and technical data.

To date, there have been no studies comparing flat-knit and round-knit compression garments for maintenance therapy of lymphedema of the leg. According to expert opinion, flat-knit fabrics are generally recommended for this purpose. Given the differences in the clinical presentation of lymphedema in terms of disease stage and location as well as patient adherence, and, last but not least, for economic reasons, it seems questionable whether all patients with lymphedema of the leg actually do require flat-knit compression garments. Considering technical aspects, published data and our own clinical experience, it seems reasonable that the choice of compression stockings be based on clinical findings and not on the diagnosis. Typical indications for flat-knit garments include significant differences in leg circumference as well as deep skin folds and edema of the toes/forefoot. However, there are also patients with lymphedema who benefit from round-knit fabrics with a high degree of stiffness. In any case, prior to maintenance therapy, it is essential to adequately decongest the legs using compression bandages and/or adaptive compression systems.

Clinical and cost-effectiveness of compression hosiery versus compression bandages in treatment of venous leg ulcers (Venous leg Ulcer Study IV, VenUS IV): a randomised controlled trial.

BACKGROUND: Drawbacks exist with the standard treatment (four-layer compression bandages) for venous leg ulcers. We have therefore compared the clinical effectiveness and cost-effectiveness of two-layer compression hosiery with the four-layer bandage for the treatment of such ulcers. METHODS: We undertook this pragmatic, open, randomised controlled trial with two parallel groups in 34 centres in England and Northern Ireland. The centres were community nurse teams or services, family doctor practices, leg ulcer clinics, tissue viability clinics or services, and wound clinics. Participants were aged 18 years or older with a venous leg ulcer and an ankle brachial pressure index of at least 0·8, and were tolerant of high compression. We randomly allocated participants (1:1) to receive two-layer compression hosiery or a four-layer bandage, using a remote randomisation service and prevalidated computer randomisation program. Participants were stratified by ulcer duration and ulcer area with permuted blocks (block sizes four and six). The primary endpoint was time to ulcer healing, with a maximum follow-up of 12 months. Although participants and health-care providers were not masked to treatment allocation, the primary endpoint was measured by masked assessment of photographs. Primary analysis was intention to treat with Cox regression, with adjustment for ulcer area, ulcer duration, physical mobility, and centre. This trial is registered with the ISRCTN register, number ISRCTN49373072. FINDINGS: We randomly allocated 457 participants to the two treatment groups: 230 to two-layer hosiery and 227 to the four-layer bandage, of whom 453 (230 hosiery and 223 bandage) contributed data for analysis. Median time to ulcer healing was 99 days (95% CI 84-126) in the hosiery group and 98 days (85-112) in the bandage group, and the proportion of ulcers healing was much the same in the two groups (70·9% hosiery and 70·4% bandage). More hosiery participants changed their allocated treatment (38·3% hosiery vs 27·0% bandage; p=0·02). 300 participants had 895 adverse events, of which 85 (9·5%) were classed as serious but unrelated to trial treatment. INTERPRETATION: Two-layer compression hosiery is a viable alternative to the four-layer bandage-it is equally as effective at healing venous leg ulcers. However, a higher rate of treatment changes in participants in the hosiery group than in the bandage group suggests that hosiery might not be suitable for all patients. FUNDING: NIHR Health Technology Assessment programme (07/60/26).

A Cost-effectiveness Analysis of Surgery, Endothermal Ablation, Ultrasound-guided Foam Sclerotherapy and Compression Stockings for Symptomatic Varicose Veins.

OBJECTIVE: The aim was to investigate the cost-effectiveness of interventional treatment for varicose veins (VV) in the UK NHS, and to inform the national clinical guideline on VV, published by the National Institute of Health and Care Excellence. DESIGN: An economic analysis was constructed to compare the cost-effectiveness of surgery, endothermal ablation (ETA), ultrasound-guided foam sclerotherapy (UGFS), and compression stockings (CS). The analysis was based on a Markov decision model, which was developed in consultation with members of the NICE guideline development group (GDG). METHODS: The model had a 5-year time horizon, and took the perspective of the UK National Health Service. Clinical inputs were based on a network meta-analysis (NMA), informed by a systematic review of the clinical literature. Outcomes were expressed as costs and quality-adjusted life years (QALYs). RESULTS: All interventional treatments were found to be cost-effective compared with CS at a cost-effectiveness threshold of £20,000 per QALY gained. ETA was found to be the most cost-effective strategy overall, with an incremental cost-effectiveness ratio of £3,161 per QALY gained compared with UGFS. Surgery and CS were dominated by ETA. CONCLUSIONS: Interventional treatment for VV is cost-effective in the UK NHS. Specifically, based on current data, ETA is the most cost-effective treatment in people for whom it is suitable. The results of this research were used to inform recommendations within the NICE guideline on VV.

Microfine toe caps: an innovative and cost-saving solution.

This article discusses the use of Microfine toe caps (Haddenham, UK) for the treatment of digit swelling. It will discuss the indications and contraindications of the device and offers some case studies where toe caps have been used in clinical practice. The use of the Microfine toe cap offers an alternative to toe bandaging, has many different applications and can be safe and time-saving to apply when used appropriately following a full and holistic assessment.

Stockings or bandages for leg-ulcer compression?

BACKGROUND: Four-layer bandaging is the standard treatment for venous leg ulcers but is bulky and can restrict mobility. Two-layer compression stockings have recently been marketed but their clinical and cost effectiveness were unknown. AIM: To compare the clinical and cost effectiveness of four-layer bandaging with two-layer compression stockings. METHOD: In a pragmatic, open, randomised controlled trial 454 participants were randomly allocated two-layer compression stockings or four-layer bandages and followed for up to 12 months after healing. RESULTS: The median time to ulcer healing was almost identical (stockings group: 99 days, bandaging group: 98 days). More patients allocated stockings changed treatment but ulcer recurrence rates were higher in the bandaging group. Stockings cost 302 sterling pounds less per participant per year and had more than 95% probability of being the most cost-effective treatment. CONCLUSION: Two-layer compression stockings are a viable, cost-effective alternative to four-layer bandaging but may not be suitable for all patients.

Compression for venous leg ulcers.

BACKGROUND: Up to one percent of people in industrialised countries will suffer from a leg ulcer at some time. The majority of these leg ulcers are due to problems in the veins, resulting in an accumulation of blood in the legs. Leg ulcers arising from venous problems are called venous (or varicose or stasis) ulcers. The main treatment is the application of a firm compression garment (bandage or stocking) in order to aid venous return. There is a large number of compression garments available and it was unclear whether they are effective in treating venous ulcers and, if so, which method of compression is the most effective. OBJECTIVES: To undertake a systematic review of all randomised controlled trials (RCTs) evaluating the effects on venous ulcer healing of compression bandages and stockings.Specific questions addressed by the review are:1. Does the application of compression bandages or stockings aid venous ulcer healing? 2. Which compression bandage or stocking system is the most effective? SEARCH METHODS: For this second update we searched: the Cochrane Wounds Group Specialised Register (31 May 2012); the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library Issue 5, 2012); Ovid MEDLINE (1950 to May Week 4 2012); Ovid MEDLINE (In-Process & Other Non-Indexed Citations 30 May 2012); Ovid EMBASE (1980 to 2012 Week 21); and EBSCO CINAHL (1982 to 30 May 2012). No date or language restrictions were applied. SELECTION CRITERIA: RCTs recruiting people with venous leg ulceration that evaluated any type of compression bandage system or compression stockings were eligible for inclusion. Eligible comparators included no compression (e.g. primary dressing alone, non-compressive bandage) or an alternative type of compression. RCTs had to report an objective measure of ulcer healing in order to be included (primary outcome for the review). SECONDARY OUTCOMES of the review included ulcer recurrence, costs, quality of life, pain, adverse events and withdrawals. There was no restriction on date, language or publication status of RCTs. DATA COLLECTION AND ANALYSIS: Details of eligible studies were extracted and summarised using a data extraction table. Data extraction was performed by one review author and verified independently by a second review author. MAIN RESULTS: Forty-eight RCTs reporting 59 comparisons were included (4321 participants in total). Most RCTs were small, and most were at unclear or high risk of bias. Duration of follow-up varied across RCTs. Risk ratio (RR) and other estimates are shown below where RCTs were pooled; otherwise findings refer to a single RCT.There was evidence from eight RCTs (unpooled) that healing outcomes (including time to healing) are better when patients receive compression compared with no compression.Single-component compression bandage systems are less effective than multi-component compression for complete healing at six months (one large RCT).A two-component system containing an elastic bandage healed more ulcers at one year than one without an elastic component (one small RCT).Three-component systems containing an elastic component healed more ulcers than those without elastic at three to four months (two RCTs pooled), RR 1.83 (95% CI 1.26 to 2.67), but another RCT showed no difference between groups at six months.An individual patient data meta-analysis of five RCTs suggested significantly faster healing with the four-layer bandage (4LB) than the short stretch bandage (SSB): median days to healing estimated at 90 and 99 respectively; hazard ratio 1.31 (95% CI 1.09 to 1.58).High-compression stockings are associated with better healing outcomes than SSB at two to four months: RR 1.62 (95% CI 1.26 to 2.10), estimate from four pooled RCTs.One RCT suggested better healing outcomes at 16 months with the addition of a tubular device plus single elastic bandage to a base system of gauze and crepe bandages when compared with two added elastic bandages. Another RCT had three arms; when one or two elastic bandages were added to a base three-component system that included an outer tubular layer, healing outcomes were better at six months for the two groups receiving elastic bandages.There is currently no evidence of a statistically significant difference for the following comparisons:⋅alternative single-component compression bandages (two RCTs, unpooled);⋅two-component bandages compared with the 4LB at three months (three RCTs pooled);⋅alternative versions of the 4LB for complete healing at times up to and including six months (three RCTs, unpooled);⋅4LB compared with paste bandage for complete healing at three months (two RCTs, pooled), six months or one year (one RCT for each time point);⋅adjustable compression boots compared with paste bandages for the outcome of change in ulcer area at three months (one small RCT);⋅adjustable compression boots compared with the 4LB with respect to complete healing at three months (one small RCT);⋅single-layer compression stocking compared with paste bandages for outcome of complete healing at four months (one small RCT) and 18 months (another small RCT);⋅low compression stocking compared with SSB for complete healing at three and six months (one small RCT);⋅compression stockings compared with a two-component bandage system and the 4LB for the outcome of complete healing at three months (one small, three-armed RCT); and,⋅tubular compression compared with SSB (one small RCT) for complete healing at three months. SECONDARY OUTCOMES: 4LB was more cost-effective than SSB. It was not possible to draw firm conclusions regarding other secondary outcomes including recurrence, adverse events and health-related quality of life. AUTHORS' CONCLUSIONS: Compression increases ulcer healing rates compared with no compression. Multi-component systems are more effective than single-component systems. Multi-component systems containing an elastic bandage appear to be more effective than those composed mainly of inelastic constituents. Two-component bandage systems appear to perform as well as the 4LB. Patients receiving the 4LB heal faster than those allocated the SSB. More patients heal on high-compression stocking systems than with the SSB. Further data are required before the difference between high-compression stockings and the 4LB can be established.

The impact of providing product funding for compression bandaging and medical footwear on compression use, wound healing and quality of life.

A study conducted in an Australian home nursing service sought to ascertain whether the provision of funding for compression bandaging and medical footwear would impact on compression therapy use, wound healing and quality of life (QoL) among people with venous leg ulcers. Clients (n = 120) were randomly allocated to evaluation funded or not evaluation funded groups, the former provided funding for compression bandaging and medical footwear. Outcome measures included the number of wounds healed, healing rate, compression use and QoL. Analysis included ttests and Kaplan-Meier Survival Analysis. An alpha level of 0·05 classified findings as significant. There were no significant differences between groups for rate or time to healing, wounds healed or compression use. The evaluation funded group were significantly more likely to receive medical footwear. Those with confirmed diagnosis and who received multilayer bandaging, irrespective of group, achieved healing rates significantly higher than those who wore other compression therapy. Factors other than cost intervened with the capacity to evaluate the impact of wound product subsidisation. Further exploration of how to best promote evidence-based practice and future research to evaluate clinically and cost-effective wound treatments in a range of health care settings is required.

Eliminating Hospital-Acquired Pressure Injuries Caused by Graduated Compression Stockings.

PURPOSE: The purpose of this evidence-based practice project was to reduce the incidence of pressure injuries (PIs) from the use of graduated compression stockings in patients on a gastrointestinal (GI) sarcoma surgery unit. Before this project, the standard of care for preventing deep vein thrombosis (DVT) included the use of graduated compression stockings, anticoagulation therapy, and intermittent pneumatic compression devices. We sought to examine the impact on PI and DVT risk of using only anticoagulation therapy and intermittent pneumatic compression devices. METHODS: The pilot phase of the project began in June 2017 when nurses on the GI sarcoma surgery unit initiated a practice change in which graduated compression stockings were removed during the 7 AM shift change and put back on the patient before bedtime. Data on the incidence of DVTs and PIs were already being collected in our institution's electronic health record and safety intelligence reporting system. The project team monitored the incidence of PIs and DVTs throughout the project. After the pilot project concluded in August 2017, the GI sarcoma surgery unit staff continued the practice of taking off graduated compression stockings during the day, until on June 2018 the use of graduated compression stockings was formally discontinued for all surgical patients, both during the day and night. RESULTS: Data collected during the pilot phase revealed that no PIs or DVTs occurred among the 497 study patients on the GI sarcoma surgery unit. From June to October 2017, the unit cared for a total of 856 patients and PI and DVT rates remained at zero. From the start of the pilot project in June 2017 to October 2018 (five months after the discontinuation of graduated compression stockings on all surgical units) the unit cared for 3,141 patients-an average of 174 patients per month-and had a zero rate of PIs and DVTs. CONCLUSIONS: We found that the use of graduated compression stockings confers more risks than benefits for patients. Our findings prompted the discontinuation of graduated compression stockings use in postoperative patients throughout our institution. In the 17 months after the pilot project was initiated, no PIs occurred among patients in the GI sarcoma surgery unit, which also maintained a zero rate of DVTs.

Prophylaxis of venous thromboembolism in general surgery in Spain. Analysis of a national survey. / Profilaxis del tromboembolismo venoso en cirugía general en España. Análisis de una encuesta nacional.

INTRODUCTION: Venous thromboembolism (VTE) represents a serious postoperative complication that can be prevented by adequate thromboprophylaxis. Surveys provide relevant information about clinician's attitudes and preferences regarding VTE prophylaxis. METHODS: Transversal, descriptive study based on a survey sent to general surgeons members of the Spanish Association of Surgeons (AEC), that included 31 questions regarding postoperative VTE and its prevention, as well as three clinical scenarios. RESULTS: 530 surgeons, 21.8% of the 2,429 invited by electronic mail to participate, completed the survey. Most of the answering clinicians work on in big teaching hospitals, and 28.5% are residents. VTE represents a serious problem for 28% of participants. Although 81% consider that their knowledge on the prevention of postoperative VTE is adequate, a similar percentage recognizes the need for further education. The vast majority (98.7%) use low molecular weight heparins, which are considered the most effective and safe modality, followed by mechanical methods. The Caprini risk assessment score is used by 81% of surgeons, who usually start pharmacological prophylaxis preoperatively. However, there are remarkable differences in the dosing of heparins, timing of initiation, and duration, especially in non-oncologic surgical patients. CONCLUSIONS: Most Spanish surgeons are interested in the prevention of postoperative VTE. Overall, the level of knowledge on thromboprophylaxis is adequate. However, our results indicate that there is a need for better education on relevant practical aspects of prophylaxis that could be achieved by incorporating recommendations from recent guidelines to local hospital-based protocols.

Compression for venous leg ulcers.

BACKGROUND: Around one percent of people in industrialised countries will suffer from a leg ulcer at some time. The majority of these leg ulcers are due to problems in the veins, resulting in an accumulation of blood in the legs. Leg ulcers arising from venous problems are called venous (varicose or stasis) ulcers. The main treatment has been a firm compression garment (bandage or stocking) in order to aid venous return. There is a large number of compression garments available and it is unclear whether they are effective in treating venous ulcers and which compression garment is the most effective. OBJECTIVES: To undertake a systematic review of all randomised controlled trials of the clinical effectiveness of compression bandage or stocking systems in the treatment of venous leg ulceration.Specific questions addressed by the review are:1. Does the application of compression bandages or stockings aid venous ulcer healing? 2. Which compression bandage or stocking system is the most effective? SEARCH STRATEGY: For this update we searched the Cochrane Wounds Group Specialised Register (14/10/08); The Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library Issue 4 2008); Ovid MEDLINE (1950 to October Week 1 2008); Ovid EMBASE (1980 to 2008 Week 41) and Ovid CINAHL (1982 to October Week 1 2008). No date or language restrictions were applied. SELECTION CRITERIA: Randomised controlled trials recruiting people with venous leg ulceration that evaluated any type of compression bandage system or compression hosiery were eligible for inclusion. Comparators included no compression (e.g. primary dressing alone, non-compressive bandage) or an alternative type of compression. Trials had to report an objective measure of ulcer healing in order to be included (primary outcome for the review). Secondary outcomes of the review included ulcer recurrence, costs, quality of life, pain, adverse events and withdrawals. There was no restriction on date, language or publication status of trials. DATA COLLECTION AND ANALYSIS: Details of eligible studies were extracted and summarised using a data extraction table. Data extraction was performed by one review author and verified independently by a second review author. MAIN RESULTS: Overall, 39 RCTs reporting 47 comparisons were included.Review question 1: there was reasonable evidence from seven RCTs that venous ulcers heal more rapidly with compression than without.Review question 2: findings from six trials of single-component compression suggested that this strategy was less effective than multi-component compression. Evidence from compression systems with two components (3 trials) and three components (4 trials) suggested better outcomes when an elastic component was included. Different versions of compression with four-components (based on the Charing Cross four-layer bandage system) have similar effectiveness (3 trials). Compression with four components (variants of the Charing Cross four-layer bandage) is more effective than multi-component compression that includes a short-stretch bandage (6 trials). It is difficult to determine the relative effectiveness of the four-layer bandage compared with paste bandage systems because of differences in the paste systems (5 trials). There was no difference in effectiveness between the adjustable compression boot and compression bandages (2 trials) or between single-layer compression stockings and paste bandages (2 trials). Two-layer stockings appeared more effective than the short-stretch bandage (2 trials). The relative effectiveness of tubular compression when compared with compression bandages was not clear from current evidence (2 trials).Three trials reported ulcer recurrence; because of sparseness of data and trials not being primarily designed to assess this outcome, firm conclusions could not be drawn. Although several trials included cost data, only one reported a rigorously conducted cost-effectiveness analysis with findings suggesting that the four-layer bandage was more cost-effective than multi-component compression comprising a short-stretch bandage. Seven trials assessed health-related quality of life and none observed significant differences between treatment groups. Several trials evaluated pain either as a stand-alone outcome, or as part of the assessment of adverse events. In general, the data did not indicate clear differences between treatment groups. It is possible that stockings could be associated with less pain than bandages but in view of scarcity of available data this requires further evaluation. Many of the trials reported adverse events and / or withdrawals. Overall, these outcomes appeared similar across different treatment groups. AUTHORS' CONCLUSIONS: Compression increases ulcer healing rates compared with no compression. Multi-component systems are more effective than single-component systems. Multi-component systems containing an elastic bandage appear more effective than those composed mainly of inelastic constituents.

Modelling the relative cost-effectiveness of amelogenin in non-healing venous leg ulcers.

OBJECTIVE: To assess the cost-effectiveness of using amelogenin plus compression bandaging versus compression bandaging alone in treating non-healing venous leg ulcers (VLUs) of over six months duration, from the perspective of the national health service in England. METHOD: A 12-month Markov model was constructed that depicted the management of a chronic, non-healing VLU of over six months duration. The model considers the decision by a clinician to treat a recalcitrant VLU with amelogenin plus compression bandaging or compression bandaging alone, and was used to estimate the relative cost-effectiveness of amelogenin plus compression bandaging at 20062007 prices. RESULTS: According to the model, 60% of all wounds treated with amelogenin plus compression bandaging are expected to heal within 12 months of the start of treatment compared with 41% of wounds treated with compression bandaging alone (p<0.01). Additionally, 23% of all amelogenin-treated wounds are expected to improve compared with 18% of wounds in the compression bandaging alone group. This difference in effectiveness between the two groups is expected to lead to a 7% improvement in health gain among amelogenin-treated patients when compared with those treated with compression bandaging alone (0.800 versus 0.746 QALYs; p<0.01) at 12 months after the start of treatment. Use of amelogenin is expected to lead a 10% reduction in NHS cost over 12 months from pound4,261 (95% CI: pound3,409; pound5,114) to pound3,816 (95% CI: pound3,227; pound4,405), due in part to a reduction in the requirement for nurse visits. Hence, amelogenin plus compression bandaging was found to be a dominant treatment. Moreover, use of amelogenin is expected to free-up NHS resources for alternative use within the system. CONCLUSION: Within the models limitations, amelogenin plus compression bandaging is expected to afford the NHS a cost-effective dressing compared with compression bandaging alone in the management of chronic non-healing VLUs of more than six months duration. DECLARATION OF INTEREST: This study was sponsored by Mölnlycke Heath Care. The authors have no other conflicts of interest that are directly relevant to the content of this manuscript.

The use of a new two-in-one treatment (K Two Start) in a venous leg ulcer.

Delayed or palliative wounds affect a high number of patients, resulting in increased costs and decreased nursing time elsewhere. In this case study, an 87-year-old female patient was treated with a new wound healing product, after one year of unsuccessful treatment. K Two Start was used in the new treatment regime. After one week, the patient no longer felt constantly in pain, and after 16 weeks, the wound had healed. The cost for the unsuccessful year of treatment (9077 UK pounds) is compared to the successful trial (1329 UK pounds). A total saving of 7748 UK pounds was estimated by the use of the new treatment regime.

Compression Stockings for the Prevention of Venous Leg Ulcer Recurrence: A Health Technology Assessment.

BACKGROUND: People with chronic venous insufficiency who develop leg ulcers face a difficult condition to treat. Venous leg ulcers may persist for long periods of time and have a negative impact on quality of life. Treatment requires frequent health care provider visits, creating a substantial burden across health care settings.The objective of this health technology assessment was to evaluate the effectiveness, safety, cost-effectiveness, budget impact, and patient experiences of compression stockings for prevention of venous leg ulcer recurrence. METHODS: We conducted a systematic review of the literature to identify randomized trials and observational studies examining the effectiveness of compression stockings in reducing the risk of recurrence of venous leg ulcers after healing and/or reported on the quality of life for patients and any adverse events from the wearing of compression stockings. We performed a literature search to identify studies and evaluated the quality of the evidence using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach.We conducted a cost-utility analysis with a 5-year time horizon from the perspective of the Ontario Ministry of Health and Long-Term Care. We compared compression stockings to usual care (no compression stockings) and simulated a hypothetical cohort of 65-year-old patients with healed venous ulcers, using a Markov model. Model input parameters were obtained primarily from the published literature. In addition, we used Ontario costing sources and consultation with clinical experts. We estimated quality-adjusted life years gained and direct medical costs. We conducted sensitivity analyses and a budget impact analysis to estimate the additional costs required to publicly fund compression stockings in Ontario. All costs are presented in 2018 Canadian dollars.We spoke to people who recently began using compression stockings and those who have used them for many years to gain an understanding of their day-to-day experience with the management of chronic venous insufficiency and compression stockings. RESULTS: One randomized controlled trial reported that the recurrence rate was significantly lower at 12 months in people who were assigned to the compression stocking group compared with people assigned to the control group (risk ratio 0.43, 95% CI, 0.27-0.69; P = .001) (GRADE: Moderate). Three randomized controlled trials reported no significant difference in recurrence rates between the levels of pressure. One randomized controlled trial also reported that the risk of recurrence was six times higher in those who did not adhere to compression stockings than in those who did adhere. One single-arm cohort study showed that the recurrence rate was considerably higher in people who did not adhere or had poor adherence (79%) compared with those who adhered to compression stockings (4%).Compared with usual care, compression stockings were associated with higher costs and with increased quality-adjusted life years. We estimated that, on average, the incremental cost-effectiveness ratio of compression stockings was $27,300 per quality-adjusted life year gained compared to no compression stockings. There was some uncertainty in our results, but most simulations (> 70%) showed that the incremental cost-effectiveness ratio remained below $50,000 per quality-adjusted life-year. We estimated that the annual budget impact of funding compression stockings would range between $0.95 million and $3.19 million per year over the next five years.People interviewed commonly reported that chronic venous insufficiency had a substantial impact on their day-to-day lives. There were social impacts from the difficulty or inability to walk and emotional impacts from the loss of independence and fear of ulcer recurrence. There were barriers to the wearing of compression stockings, including replacement cost and the difficulty of putting them on; however, most people interviewed reported that using compression stockings improved their condition and their quality of life. CONCLUSIONS: The available evidence shows that, compared with usual care, compression stockings are effective in preventing venous leg ulcer recurrence and likely to be cost-effective. In people with a healed venous leg ulcer, wearing compression stockings helps to reduce the risk of recurrence by about half. Publicly funding compression stockings for people with venous leg ulcers would result in additional costs to the Ontario health care system over the next 5 years. Despite concerns about cost and the daily chore of wearing compression stockings, most people interviewed felt that compression stockings provided important benefits through reduction of swelling and prevention of recurrence.

[Compression Therapy in Patients with Leg Ulcers - which Costs do Really Occur?] / Kompressionstherapie bei Patienten mit Ulcus cruris ­ welche Kosten entstehen wirklich?

INTRODUCTION: Patients with leg ulcers often have severe edema of the lower extremities, which should be treated as part of a successful wound treatment. Today in Germany the necessary compression therapies are often performed with very error-prone and time-consuming short-stretch bandages only. Multicomponent systems, adaptive compression bandages and leg ulcer stocking systems are newer, much less error-prone treatment options. In addition to the often lacking knowledge, the fears of high costs are also mentioned as reasons for the lack of prescription of these systems. It was therefore our aim to investigate the costs of different treatment options, differentiated in the outpatient and inpatient sector. METHODS: For the economic calculations, both material and personnel costs were taken into account for different scenarios. RESULTS: Both material and personnel costs were included in the calculation. We were able to demonstrate that the cost for a continuous compression therapy for inpatients accrues between 5.29 Euros to 18.50 Euros per day. For the outpatient setting costs of 2.29 Euros to 34.29 Euros per day were calculated. The different constellations of compression therapy can make sense thus not only for medically but also for economically aspects. CONCLUSION: As a consequence of this data, both the different systems and the economic factors of compression therapy in patients with leg ulcers should be known to the therapists. These treatment options should then be prescribed and performed according to individual factors, taking into account the needs and abilities of the patients.

Randomized clinical trial of honey-impregnated dressings for venous leg ulcers.

BACKGROUND: The efficacy of honey as a treatment for venous ulcers has not been evaluated, despite widespread interest. This trial aimed to evaluate the safety and effectiveness of honey as a dressing for venous ulcers. METHODS: This community-based open-label randomized trial allocated people with a venous ulcer to calcium alginate dressings impregnated with manuka honey or usual care. All participants received compression bandaging. The primary outcome was the proportion of ulcers healed after 12 weeks. Secondary outcomes were: time to healing, change in ulcer area, incidence of infection, costs per healed ulcer, adverse events and quality of life. Analysis was by intention to treat. RESULTS: Of 368 participants, 187 were randomized to honey and 181 to usual care. At 12 weeks, 104 ulcers (55.6 per cent) in the honey-treated group and 90 (49.7 per cent) in the usual care group had healed (absolute increase 5.9 (95 per cent confidence interval (c.i.) -4.3 to 15.7) per cent; P = 0.258). Treatment with honey was probably more expensive and associated with more adverse events (relative risk 1.3 (95 per cent c.i. 1.1 to 1.6); P = 0.013). There were no significant differences between the groups for other outcomes. CONCLUSION: Honey-impregnated dressings did not significantly improve venous ulcer healing at 12 weeks compared with usual care. REGISTRATION NUMBER: ISRCTN 06161544 (http://www.controlled-trials.com).

Cost benefit of intermittent pneumatic compression for venous thromboembolism prophylaxis in general surgery.

AIM: In moderate to high-risk general surgical patients, the cost effectiveness of mechanical prophylaxis for venous thromboembolism (VTE) is uncertain. Therefore, we determined the costs and savings of intermittent pneumatic compression (IPC) plus graduated compression stockings (GCS). METHODS: Postoperative VTE events in the absence of prophylaxis, efficacy of prophylaxis and costs of prophylaxis have been obtained from the English literature and Medicare 2004 reimbursement schedule. RESULTS: In 1000 moderate to high risk general surgical patients, in the absence of prophylaxis, the cost of investigating and treating 72 patients with clinical suspicion of DVT and 32 with PE is calculated to be $263,779. This corresponds to a cost of $263 per surgical patient. The cost of IPC combined with TED stockings in 1000 similar patients would be $66 760, and the cost of diagnosis and treatment of the reduced numbers (69% reduction) of clinical VTE is $ 83,574 making a total of $150 344. This means a saving of $133,435 ($263,779 - $150,344) per 1000 patients. This corresponds to a saving of $113 per surgical patient. Sensitivity analysis demonstrates that despite variation in costs or efficacy for IPC plus GCS, marked savings persist. CONCLUSIONS: Prophylaxis with IPC not only prevents VTE but also saves money.