The value of compression therapy in treating lower leg ulcers is clinically proven, but until government subsidised funding is approved, many patients will continue to suffer unnecessarily, as The Australian Wound Management Association’s (AWMA) Robin Osborne explains.
At this time an estimated 300,000 Australians are undergoing medical treatment for lower limb wounds such as venous leg ulcers, yet best-practice care is only being accessed by, at most, half of this patient load.
The reason is an anomaly in the public health funding system that sees patients treated in the acute setting receiving compression bandages and stockings, and certain kinds of antibiotics and pain relief medication, free of charge. The great majority, however - who are cared for by GPs and community nurses, or who comanage their condition at home – are left to carry the costs of these often highly-priced consumables.
The Australian Wound Management Association (AWMA) is the peak body for the nation’s 3,000 nurses, doctors and allied health professionals who help manage a challenging condition that is especially common amongst the elderly.
On behalf of AWMA’s executive and its representative state and territory branches, the national president,
Professor Bill McGuiness, is spearheading a campaign to encourage the federal government to subsidise the cost of these proven wound care products (which are funded in the ACT and NT jurisdictions, and covered by DVA for eligible patients).
Internationally, a range of comparable countries, including the UK and New Zealand, do fund these items,
notably compression therapy, which clinicians have long believed to improve healing time. Without best-practice management, leg ulceration can extend to many months, or even years, causing a high level of patient discomfort and considerable social isolation.
Prof McGuiness oversees the specialist wound care clinic at Melbourne’s Alfred Hospital and holds an appointment in this field at La Trobe University. From years of hand-on and supervisory experience he is convinced of the value of compression therapy, not only for patients themselves but for the public health system at large, regardless of the apparent drawback, from a funding body’s perspective, of the higher up-front costs.
He is not alone in holding this view. In a recent contribution to the online Cochrane Collaboration
CD000265.pub3/full] Dr Susan O’Meara et al reported on how most leg ulcers are associated with venous disease, and confirmed the value of compression therapy:
“Compression bandages help blood to return to the heart from the legs... Compression stockings are sometimes used as an alternative to compression bandages… [and] applying compression was better than not using compression, and that multi-component bandages worked better than single-component systems.
“Multi-component systems (bandages or stockings) appear to perform better when one part is an elastic
(stretchy) bandage. A very detailed analysis showed that a system called the ‘four-layer bandage’ or ‘4LB’ (i.e. four different bandages applied to the leg, including an elastic one) heals ulcers faster than the ‘short-stretch bandage’ or ‘SSB’ (a type of bandage with very minimal stretch).
“Venous leg ulcers… can take a long time to heal (weeks or months) and can cause distress to patients, as well as being very costly to the health service.”
They raised some interesting historical background: various forms of bandaging have been applied over the years – as far back as the 17th Century, compression was applied as rigid lace-up stockings, while elasticated bandages were first produced in the middle of the 19th Century.
So the value of compression therapy has long been recognised, even if, as the UK researchers said, the aetiology of leg ulceration remains poorly understood.
AWMA is dedicated to enabling all patients to receive compression therapy from the start of their treatment regime, along with being encouraged (by partnering clinicians) and assisted (through government subsidy) to continue such care until definite improvement is achieved.
Official figures show that the cost of wound care in Australia presently runs to more than $3.0 billion a year,
which is a huge impost on the nation’s stretched health budget. Yet a significant proportion of this budgetary outlay could be averted if the right wound care products were available to all from the start of a person’s care.
Subsidisation is clearly the most equitable way to ensure this. Consistent with the present (and future) emphasis on out-of-hospital care, perhaps the key goal of the national Health Reform Agenda, it is estimated that GPs are now involved in the treatment of some 86 per cent of patients with a venous leg ulcer, with community nurses spending up to 80 per cent of their time treating leg ulceration.
For these patients in the primary care setting, the cost issue looms large: the outlay on recommended wound care products averages $50.00 per week, and can range as high as $200.00 per week for those experiencing multiple or complex ulceration.
Patients who do pay for these items often make financial sacrifices in other parts of their life. Clinicians speak of patients buying compression bandages as saying it can mean “eating lentils for dinner.”
However, many people cannot afford this essential therapy. As up to 90 per cent of sufferers are aged
60 years or older, and many are of limited means, the economic barrier means a great many people are missing out on compression therapy, and as a result their wounds are taking a lot longer to heal than they should.
Benchmark healing time is accepted to be around three months when compression therapy and other best-practice supports are used. However, clinicians are all too familiar with patients whose lower leg ulcers persist for years at a time.
The irony is that while compression therapy products do cost more up-front, the faster healing times they help achieve mean that the overall cost per wound healed is considerably lower – around 50 per cent less, according to the latest data received by AWMA.
Common sense on this issue received a setback from 1 January 2012 when item 10996, which identified wound care as an integral part of General Practice, was removed from the Medicare schedule. This impacted significantly on the availability of resources, including nursing services, to be dedicated to wound care.
The replacement block funding grant for practice nurses does not provide a financial incentive for a nurse to work independently of a GP and will not facilitate resources being dedicated to management of wound care.
The result is more pressure for GPs to be involved in every consultation and a consequent diversion of wound management away from the community health sector, which is more accessible at various levels for many patients. Already, several wound clinics have raised concerns about their viability, saying they may face closure without the 10996 funding.
Patient stories confirm the therapeutic value of compression therapy.
For example, Richard [not his real name], now a Melbourne chef in his 40s, recalls owing his life to the care provided by the specialist wound clinic at the Alfred Hospital.
Richard was born without an inferior vena cava (IVC) – the large vein that carries blood from the lower part of the body back to the heart. The extremely rare condition was diagnosed in his teens when, after a normally active childhood, he developed recurrent blockages of the smaller vessels struggling to do the job of the IVC.
Life became a lot harder when the problems developed into recurrent leg ulcers. For the best part of 20 years, Richard faced a roundabout of doctors’ and hospital visits, painkillers and short-term relief.
“It became steadily worse and ended up being all about survival. Until I was referred to the specialist clinic at the Alfred no one ever got on top of it and it came very close to killing me,” Richard said.
“I had leg ulcers as big as my hands. I was in constant pain and at times had to crawl on hands and knees to get around.
“I lost my job and was a frequent flyer at hospital. I ended up on life support in ICU with septicaemia and pneumonia - very close to death.”
Richard said things changed dramatically when he was referred to the specialist Wound Management Clinic at the Alfred.
“Prof McGuiness and his team brought the pain under control, laid down the law about giving up smoking and adopting a healthier lifestyle and brought best practice including compression stockings to treating the ulcers.
“The results have been dramatic. For the first time in almost 20 years I am ulcer-free. For the first time in at least eight or nine years I can run and swim and on a hot day I can go out in shorts – something I haven’t been able to do since all this started.”
Richard estimated that resolving his health problems - including the long battle with leg ulcers – was priced at around $250,000. Fortunately, he received his care in the hospital setting, meaning that the significant cost of the consumables was covered by the public health system.
“Not many people can afford health bills like that and a lot of it was avoidable. We need the best treatment at the start – not when the problems have escalated to the point where the patient is at death’s door.”
Although younger than the average leg ulcer patient, Richard’s medical issues were typical, including lower limb swelling and the frequency of fluid buildup, weeping wounds, reduced mobility and difficult of important social interaction, from shopping through to family contact.
Patients regret not being able to have grandkids sitting on their knee because of the risk of being kicked, or because the wounds are weeping or are malodorous. The condition is recognised as being very isolating, and as a result often associated with depression. Again, with more financial impost on the system.
One strategy to address this concern is the AWMA-backed ‘leg club’ concept that operates in various states. Patients can receive their wound care while socialising with those in a similar clinical situation. These gatherings have proved very popular and the Association is looking at rolling out more in the time ahead.
AWMA’s bottom line is that the latest generation of wound care products developed by industry worldwide, in collaboration with leading clinicians, offers the best healing prospects for patients. While this is beyond dispute, it raises the question of how society can afford to subsidise proper access for all patients who need best-practice care.
What might be termed band-aid care is achieving little more than covering up wounds on a temporary basis, but not contributing properly to the healing process.
He stresses that this is not a criticism of clinicians, who work professionally and compassionately with the resources at their disposal. The onus for change lies with the larger health system which must accept that a strategic investment in best-practice care will produce real cost savings, not just in the longer term but almost immediately – not least for leg ulcer patients themselves.
The Association’s membership of 3,000 nurses, doctors and allied health professionals well understands the
issues, so the next step is to encourage supportive action from patients, carers and friends, whom AWMA wants to contact Federal MPs to tell their wound care stories and urge action at the political level.
This will be one focus of next year’s National Wound Awareness Week, 18-22 March 2013, an annual event aimed at raising the profile of lower leg ulcers amongst medical clinicians, patients and the broader public. More details about the week and the Australian Wound Management Association are at www.awma.com.au/awma/index.php
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