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Speeding recovery from venous leg ulcers can help reduce potentially complex side effects

Much has changed in the new post-Covid era of healthcare provision.  How do healthcare systems address the challenges of remote management of patients that require one to one support and how can MedTech help address some of the fundamental challenges?

HIGH WYCOMBE, England, June 22, 2022 /PRNewswire/ — The unprecedented health crisis caused by the global Covid-19 pandemic arguably led to changes in the provision of healthcare services that would have taken place anyway.  However, the crisis sped up these changes exponentially.

Wound on the leg

There was no compelling reason for GP consultations to be in person.  Yet before Covid most were[1].  Out of necessity, the pandemic turbo charged more remote healthcare diagnostics, telephone and video consultations with healthcare staff, higher levels of self-diagnosis and faster innovation in the development of new standards of care for patients with Covid, including increasingly non-pharmaceutical interventions.  The challenge now is to continue to accelerate innovation further in all areas.

The evolution of healthcare services to use more technology and rely less on face-to-face contact was a clear direction of travel even before Covid.  This was driven by several factors: the growing ageing population combined with the increasing capabilities of healthcare systems to help patients manage and treat chronic illness, both put increased pressure on healthcare funding.  The development of new and innovative technological solutions to supplement and support pharmaceutical interventions enables healthcare systems to manage this demand more effectively.

This is a one-way path: patients will increasingly become responsible for managing larger elements of their own wellbeing.  This will be welcomed by many, for whom the process of physically attending a consultation – either at a GP surgery or hospital – seemed unnecessary.

Complex conditions

Despite this, healthcare systems need to find ways to accommodate those that are unwilling or unable to adapt to self-service systems of healthcare.

Particularly vulnerable are the elderly, partly because they will struggle to adapt to new processes and may not be as digitally literate or have the skills to access online or remote healthcare systems.  While internet usage among the over 75s has grown rapidly in the last decade, only half of over 75s are regular internet users[2]. Those with complex conditions that are hard to heal are also likely to struggle.  These are often the same group of patients.

Consider those with venous leg ulcers (VLU).  VLUs are chronic skin ulcers that mainly affect the gaiter area and, in many cases, are caused by continuous venous hypertension or chronic venous insufficiency.  VLUs are a common health condition that impact up to three percent of the global population.  The risk of developing a VLU increases with age, with prevalence doubling among those older than 65 years[3].

VLUs take months to heal, while some never heal at all[4]. Even if a wound has healed, the chance of recurrence remains high[5]. It is therefore essential for healthcare professionals and patients to collaborate to ensure the recommended care is fully understood and working.

Current standard of care (SoC) for VLUs recommends compression therapy, elevation and exercise[6]. For older, immobile patients unable to exercise, compression therapy and elevation is the only option.  Compression therapy requires nurses to apply bandages to the wounds, wrapping them tightly to stimulate blood flow. However, during the pandemic, wound clinics where this bandaging took place were largely closed.  Many community nurses that visited multiple patients in the home were either re-assigned to other healthcare roles or forbidden to visit vulnerable patients.

This meant that patients became more responsible for treating their own conditions.  Patients required to treat their wounds independently at home are extremely likely to find self-management of VLUs challenging. According to The National Institute for Health and Care Excellence (NICE): “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.”  It is unlikely a patient will be able to effectively achieve this alone.

As ways of administering healthcare changes from in person to remote, there is a significant risk that patients, including those with VLUs, will be left behind – further slowing their recovery.  This costs healthcare systems money, but also has a significantly negative impact on the quality of life of these patients.

Infections

One of the complications of non-healing VLUs is an increased risk of infection.  Research on the number of VLUs that become infected varies.  In an article published in the International Wound Journal, titled ‘Identifying risk factors associated with infection in patients with chronic leg ulcers'[7], the authors noted that, of more than 500 patients suffering with leg ulcers, almost ten percent were suffering with infected VLUs.

Other research papers found higher levels of infected VLUs among patients. In a cross–sectional study of 77 chronic leg ulcers from 75 participants, De Souza found 27 percent of the ulcers were infected[8]. Similarly, Rondas et al in 2015 found 22 percent (16/72 chronic wounds) were infected[9]. It is therefore likely that – at any one time – as many as a quarter of VLU patients will be suffering from an infected wound.   With some VLUs taking many months or even years to heal, the incidence of infection increases in patients with slow healing wounds.

When infection is present in a VLU, the patient may suffer with fever, increased pain, cellulitis, necrotic tissue, and purulent exudate with or without odour[10]. The most obvious consequences of infection are a reduced speed of wound healing and increased complications and mortality in patients with leg ulcers, resulting in a negative impact on the patients’ quality of life and increased financial burden on the healthcare system and society.

Healthcare professionals are then faced with additional complications. The priority is to address the infection because the wound will not heal when infected.  To address a wound infection nurses will sometimes use antiseptic dressings.  However, the most common treatment is a course of anti-biotics.

A cocktail of concern

In recent years healthcare systems have become more reluctant to provide people with anti-biotics because of concerns over anti-biotic resistance.  Anti-biotics kill germs, but some germs find a way to survive and can then multiply.  Some resistant germs can also pass on this resistance to other germs.

Anti-biotic resistance in germs has seen the emergence of so-called superbugs such as methicillin-resistant Staphylococcus aureus (MRSA) and Clostridium difficile (C. diff).  These types of infections can be serious and challenging to treat and are becoming an increasing cause of disability and death around the world. A further concern is that new strains of bacteria may emerge that cannot be treated by any existing anti-biotics.

There were more than 150 outbreaks of MRSA in UK hospitals in the first three months of 2022 alone[11], demonstrating that this issue is a significant concern for the NHS.  Elderly patients with medical complications and a history of regular treatment with anti-biotics (and therefore have built up some personal resistance to the drugs) may be at more risk of receiving a negative outcome from treatment with these drugs than others.  In other words, patients at risk of complex, chronic or hard to heal VLUs are likely to be more vulnerable to infections but less able to address these through the existing standard of care.

In an environment where the continued use of pharmaceutical interventions may lead to diminishing returns for patients and require increased investment of funds, healthcare systems are looking for new non-drug-based ways to address significant healthcare issues.

MedTech’s potential to help

Helping hard to heal patients requires new thinking. One of the most promising areas is innovation in medical technology (MedTech) that can help address chronic conditions without the need for, or with less need for drugs.

MedTech solutions can support current standards of care or offer an alternative to deliver faster healing and a better patient experience – potentially also at a lower cost.

As an example, VLU patients have recently been trialling the geko™ device alongside standard of care.   It gently stimulates the common peroneal nerve activating the calf and foot muscle pumps, resulting in increased blood flow in the deep veins of the calf12 equal to 60 percent of walking without a patient having to move13.

Initial results have been promising: the increased blood flow is healing VLUs faster than standard of care alone.  Patients experienced the closure of wounds more quickly, which reduces the cost to healthcare systems, but most importantly, reassures patients that progress can be and is being made to close the wound.  The obvious additional benefit is that faster healing wounds have less time to be exposed to the risk of infection, reducing the further complications that many patients – particularly those with chronic wounds – may face.

New world solutions for a new world of healthcare

The changes in healthcare provision brought about by Covid are likely to remain in the future.  This may mean more remote treatment for patients, but this should not be at the expense of the individual care that specific patients require to address hard to heal conditions such as VLUs.

Embracing MedTech innovation is a significant opportunity for healthcare systems globally, particularly where doing so demonstrably addresses wide reaching and chronic conditions that cost healthcare systems money and significantly reduce the quality of life of patients.  A new way of delivering healthcare should have space for new thinking in treating conditions with innovation that may not always be pharmaceutical.  MedTech has the potential to address issues that are difficult to resolve with current standard of care alone.

References:

  1. Green M, McKee M, & Katikireddi S (2022). Remote general practitioner consultations during COVID-19. The Lancet Digital Health, 4(1), e7. doi: 10.1016/s2589-7500(21)00279-x

  2. The Guardian. Britons aged 75 and over using internet nearly double in seven years. 2021. Available from: https://www.theguardian.com/technology/2021/apr/06/britons-aged-75-and-over-using-internet-nearly-double-in-seven-years

  3. NHS England. Overview: Venous Leg Ulcer. 2019. Available from: https://www.nhs.uk/conditions/leg-ulcer/

  4. Guest JF, Fuller GW, Vowden P. Venous leg ulcer management in clinical practice in the UK: costs and outcomes. Int Wound J 2018;15:29–37

  5. Finlayson K, Wu M-L, Edwards HE. Identifying risk factors and protective factors for venous leg ulcer recurrence using a theoretical approach: a longitudinal study. Int J Nurs Stud 2015;52:1042–51

  6. NHS England. Treatment: Venous Leg Ulcer. 2019. Available from: https://www.nhs.uk/conditions/leg-ulcer/treatment/

  7. Bui, UT, Edwards H, & Finlayson K (2018). Identifying risk factors associated with infection in patients with chronic leg ulcers. International wound journal, 15(2), 283–290. doi.org/10.1111/iwj.12867

  8. De Souza JM, Vieira ÉC, Cortez TM, Mondelli AL, Miot HA, Abbade LPF. Clinical and microbiologic evaluation of chronic leg ulcers: a cross–sectional study. Adv Skin Wound Care. 2014;7:222–227. [PubMed] [Google Scholar]

  9. Rondas AALM, Schols JMGA, Stobberingh EE, Halfens RJG. Prevalence of chronic wounds and structural quality indicators of chronic wound care in Dutch nursing homes. Int Wound J. 2015;12:630–635. [PMC free article] [PubMed] [Google Scholar]

  10. Wound Source. Complications of Venous Leg Ulcers. 2019. Available from: https://www.woundsource.com/blog/complications-venous-leg-ulcers

  11. GOV UK. MRSA bacteraemia: monthly data by location of onset. 2022. Available from: https://www.gov.uk/government/statistics/mrsa-bacteraemia-monthly-data-by-location-of-onset

  12. Nicolaides A, Griffin M. Measurement of blood flow in the deep veins of the lower limb using the geko™ neuromuscular electro-stimulation device. Journal of International Angiology August 2016-04

  13. Tucker A, Maass A, Bain D, Chen LH, Azzam M, Dawson H, et al. Augmentation of venous, arterial and microvascular blood supply in the leg by isometric neuromuscular stimulation via the peroneal nerve. The international journal of angiology: official publication of the International College of Angiology, Inc. 2010 Spring;19(1): e31-7

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Antibiotic resistance

Antibiotic resistance

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