Abstract

Chronic leg ulcers in the elderly population often result in complex, costly and long-term therapies. A comprehensive investigation of the Ottawa-Hull region found that the incidence of leg ulcers has risen and that patients with this condition were receiving non-standardized care by a wide variety of care providers. The investigation, combined with external evidence, was used to redesign the delivery of leg ulcer care, leading to the implementation of an evidence-based leg ulcer care system in the Ottawa-Hull region. This study investigated the effects of implementing the evidence-based service and found improved clinical and cost outcomes. Background: Chronic leg ulcers occur primarily in the elderly population. As the population continues to age, the cost of providing leg ulcer care is rising. Previously, leg ulcer patients in the Ottawa-Hull region received care in their homes through referrals from physicians. Care providers, including registered nurses (RNs) and registered practical nurses (RPNs), provided treatments and care based on individual physician's orders. Practice audits revealed a lack of standardization in the assessments conducted by these care providers and inconsistent patterns of care, which prompted collaboration between researchers, health care organizations and regional decision-makers to redesign the leg ulcer home care delivery system. This evidence-based initiative led to organizational changes, the introduction of a primary nursing delivery model, and clinical changes through the development and adoption of the Ottawa Carleton Community Care Leg Ulcer Protocol. To implement the new system, community nurses received standardized leg ulcer care training over a period of one year through Thames Valley University's (UK) distance education courses.

Under the new model, regional service for leg ulcers has been centralized in one agency. This has ensured that all services are provided by teams of RNs who have received university training in leg-ulcer assessment and care and whose protocols are evidence based as opposed to physician directed, as they were under the former service delivery model.

Methods: The old and new service models were evaluated. The primary outcome evaluated was time to healing, and secondary outcomes included pain, quality of life and resource allocation. Data were collected from participants over one year in each of two study periods, "pre-implementation" (n=71; October 1999 - September 2000) and "post-implementation" (n=167; November 2000 - September 2001), at admission and 3 months afterwards.

Findings: Under the new model, the frequency of treatment visits after the initial assessment decreased. For example, the proportion of patients requiring daily visits decreased from 38% to 6% and the average number of nursing visits declined from 37 to 25 between study periods. In addition, the average number of visits to each patient per week declined from 3 to 2.1, while the average cost per case decreased substantially from $1923 to $406. There was a notable increase in the use of compression therapy, and 3- month healing rates improved from approximately 18-40% to 48-61%. Health-related quality of life and pain did not change significantly between the new model and the old model.

Conclusions: The implementation of a nurse-led, evidence-based leg ulcer service resulted in faster healing rates and lower supply costs in the Ottawa-Hull region. The proportion of patients receiving the appropriate compression bandaging treatment nearly doubled and the average number of nursing visits decreased, while healing rates nearly tripled. However, this study did not examine the cost-effectiveness of the service, which home care decision-makers will find of interest. This paper raises the question of whether this model of evidence-based service delivery can be used as a strategy to improve clinical outcomes and contain supply costs in other areas of home care services, particularly those incurring a large proportion of the home care budget. In order to resolve this question, the cost of developing specialized teams and centralized agencies should be evaluated.

Reference: Harrison MB, Graham ID, Lorimer K, Friedberg E, Pierscianowski T, Brandys T. "Leg-ulcer care in the community, before and after implementation of an evidence-based service." Canadian Medical Association Journal, 2005; 172(11): 1447-1452.