A venous ulcer is a break in the continuity of the skin resulting from venous hypertension [
Venous leg ulcers are usually located in the “gaiter” region of the leg as shown in the image above. They have certain characteristics: (i) ruddy coloured base, (ii) large area, (iii) shallow depth, (iv) irregular wound margins, (v) moderate to heavy exudates, (vi) pitting or nonpitting oedema, (vii) granulation tissue, (viii) warm skin temperature, and (ix) pulses present with normal capillary refill of less than 2 seconds [
Dressings for venous ulcers are chosen on the basis of ability to absorb fluid and odour, adhesiveness, antibacterial and haemostatic properties, potential to cause sensitivity reactions, ease of handling, tendency to shed fibres, and interval required between dressing changes [
A trial of this nature has not been done at University Hospital of South Manchester leg ulcer clinic. A retrospective comparison was made to assess differences in efficacy and cost-effectiveness between simple nonadhesive Ultra dressings (e.g., NA Ultra) and modern dressings.
There is no significant difference in leg ulcer healing rates when comparing simple nonadherent Ultra dressings with modern dressings such as Inadine, Iodoflex, Medihoney, Aquacel Ag, and Atrauman Ag.
Modern dressings significantly improve leg ulcer healing rates compared to simple nonadherent Ultra dressings.
Venous leg ulcer patients showing a measurable change in area over time were included.
Patients with an Ankle Brachial Pressure Index (ABPI) <0.8 or a history of deep vein thrombosis, diabetes mellitus, inability to move, or mental health problems were excluded.
Patient medical records were collected and divided into two groups: those treated with “simple nonadherent Ultra dressings” and those treated with “modern” dressings. Records that did not satisfy the inclusion criteria were eliminated leaving a total of 24 patients. Twelve were treated with simple nonadherent Ultra dressings and the rest were treated with an array of different dressings including silver based dressings such as Atrauman Ag and Aquacel Ag, iodine based dressings such as Iodoflex and Inadine, and the honey based Medihoney dressing.
According to medical records all venous ulcer patients underwent a complete history and examination. The wound was assessed for slough, granulation, epithelialisation, and level of exudate. The surrounding skin was assessed for dryness, eczema, and haemosiderin pigmentation. The calf and ankle circumference were measured and appropriate compression therapy started. Dressings were changed weekly and the ulcers reviewed. The ulcer area was calculated every week by tracing the ulcer on graph paper and counting the squares. Pictures were taken to keep a visual record of the healing process and the percentage of granulation tissue was noted.
The time taken to complete healing, defined as 100% epithelialisation of the wound, was calculated in weeks according to the record of weekly reviews. For some patients data was lacking and the time to complete healing could not be determined. In these patients the time period between two measured ulcer areas was taken and the healing rate was calculated as change in area/time taken for that change in cm2/week. The average healing rate and standard deviation were calculated for both groups. The unpaired Student’s
The cost of dressings for treatment was also measured by multiplying the total area of dressing used for the treatment period by the cost of dressing per unit area. The cost of dressings is subsidised by the NHS supply line. Access to these prices was denied. The NHS supply line prices were estimated to be 50% of the market price based on knowledge of the price of Inadine in both the market and NHS supply line. The market price was standardised as the price at
There were 6 males and 6 females in the simple nonadherent Ultra group compared to 2 males and 10 females in the other group. The average age was 68.67 years for the simple nonadherent group compared with an average age of 71.5 years in the other group. Eighteen of the 24 patients had completely healed ulcers. Seven were from the simple nonadherent Ultra dressing group and 11 were from the group containing other dressing types. The data available was not sufficient to determine if the remaining 6 patients’ ulcers completely healed.
The healing rate was usually less than 1 cm2 per week and more than 0.1 cm2 per week independent of the type of dressing used. There are anomalies in both groups where ulcer healing rate exceeds 1 cm2 per week. In the simple nonadhesive Ultra dressing group there is an anomalous decreased value for the healing rate equal to 0.02 cm2 per week. It is possible that these anomalies resulted from factors other than the type of dressing used such as the duration of the ulcer, the type of compression therapy, or patient compliance.
The mean healing rate for simple nonadherent Ultra dressings is 0.353 cm2 per week with a standard deviation of 0.3185 (Table
Results for simple nonadherent Ultra dressings. The mean healing rate was 0.353 cm2/week with a standard deviation of 0.3185 and the mean cost of dressings was 0.702 GBP with a standard deviation of 1.08. The standard error was 0.092.
Age | Gender | Initial ulcer area [cm2] | Final ulcer area [cm2] | Change in ulcer area [cm2] | Duration of change in area [weeks] | Rate of healing [cm2/week] | Dressing type | Cost of dressing per patient [GBP] |
---|---|---|---|---|---|---|---|---|
66 | F | 6 | 0 | 6 | 26 | 0.23 | Ultra | 1.21 |
79 | M | 2 | 0 | 2 | 8 | 0.25 | Ultra | 0.12 |
69 | M | 1.4 | 0 | 1.4 | 17 | 0.08 | Ultra | 0.19 |
80 | M | 28.8 | 7.9 | 20.9 | 17 | 1.23 | Ultra | 3.82 |
82 | F | 3.6 | 0.3 | 3.3 | 17 | 0.19 | Ultra | 0.48 |
81 | F | 7.6 | 3.2 | 4.4 | 23 | 0.19 | Ultra | 1.36 |
50 | F | 1.2 | 0 | 1.2 | 2 | 0.6 | Ultra | 0.02 |
70 | F | 3.2 | 0 | 3.2 | 8 | 0.4 | Ultra | 0.20 |
64 | M | 3.2 | 0 | 3.2 | 12 | 0.27 | Ultra | 0.30 |
53 | M | 6.46 | 2.3 | 4.16 | 13 | 0.32 | Ultra | 0.66 |
82 | F | 0.15 | 0 | 0.15 | 8 | 0.02 | Ultra | 0.009 |
48 | M | 2.0 | 0.2 | 1.8 | 4 | 0.46 | Ultra | 0.06 |
Results for different types of modern dressings. The mean healing rate was 0.415 cm2/week with a standard deviation of 0.383 and the mean cost of dressings was 4.78 GBP with a standard deviation of 4.816. The standard error was 0.111.
Age | Gender | Initial ulcer area [cm2] | Final ulcer area [cm2] | Change in ulcer area [cm2] | Duration of change [weeks] | Rate of healing [cm2/weeks] | Dressing type | Estimated cost of dressing per patient [GBP] |
---|---|---|---|---|---|---|---|---|
88 | M | 2.5 | 0 | 2.5 | 3 | 0.83 | Atrauman Ag | 0.15 |
79 | M | 3.9 | 0 | 3.9 | 16 | 0.24 | Inadine | 0.52 |
58 | F | 0.8 | 0 | 0.8 | 8 | 0.1 | Atrauman Ag | 0.13 |
63 | F | 1.2 | 0 | 1.2 | 9 | 0.13 | Urgotul | 1.2 |
78 | F | 5 | 0 | 5 | 22 | 0.23 | Medihoney | 6.6 |
51 | F | 8.8 | 0 | 8.8 | 18 | 0.49 | Iodoflex | 9.2 |
79 | F | 13.5 | 0 | 13.5 | 17 | 0.79 | Medihoney | 13.8 |
84 | F | 5.85 | 0 | 5.85 | 17 | 0.34 | Aquacel Ag | 9.54 |
80 | F | 11.5 | 6 | 11.5 | 4 | 1.34 | Iodoflex | 2.67 |
59 | F | 4 | 0 | 4 | 26 | 0.15 | Aquacel Ag | 9.98 |
88 | F | 2.24 | 0 | 2.24 | 13 | 0.17 | Medihoney, Actifoam | 3.33 |
51 | F | 2.21 | 0 | 2.21 | 13 | 0.17 | Inadine | 0.24 |
Cost is significantly different between simple dressings and modern dressings. However the healing rate between the two is not significantly different.
Simple nonadherent Ultra dressing ( |
Other types of dressing ( |
Degrees of freedom ( |
One-tailed |
Two-tailed |
Cohen’s | |
---|---|---|---|---|---|---|
Mean healing rate |
0.353 |
0.415 |
22 | 0.336 | 0.672 | 0.176 |
|
||||||
Mean cost dressing/ |
0.702 |
4.78 |
22 | 0.0045 | 0.009 | 1.17 |
A multiple regression analysis was also performed to validate the data (Table
Results of the multiple regression analysis are shown.
ANOVA | |||||
---|---|---|---|---|---|
df | SS | MS |
|
Significance | |
Regression | 1 | 0.006517 | 0.0065169 | 0.058734699 | 0.813405139 |
Residual | 10 | 1.10955 | 0.110955 | ||
Total |
|
|
Regression statistics | |
---|---|
Multiple |
0.076414 |
|
0.005839 |
Adjusted |
−0.09358 |
Standard error | 0.333099 |
Observations | 12 |
The cost of dressings was also estimated. Total costs of simple nonadherent Ultra dressings range from
The amount of money that can be saved depending on the number of ulcer patients treated per year.
Number of ulcer patients treated/year |
|
|
|
|
---|---|---|---|---|
Mean yearly cost of simple NA Ultra dressing/ |
7020 | 35100 | 52650 | 70200 |
|
||||
Mean yearly cost of other dressings | 47800 | 239000 | 358500 | 478000 |
|
||||
Yearly saving using NA Ultra | 40780 | 203900 | 305850 | 407800 |
Many prospective randomised controlled trials have compared modern dressings with simple nonadhesive dressings, for example, NA Ultra. A meta-analysis published in Wound Repair and Regeneration evaluated 31 studies comparing polyurethane, activated charcoal, alginates, hydrocolloids, and collagen dressings with conventional dressings and found no significant differences in wound healing [
Ulcer healing is a complex and dynamic process that includes clotting, inflammation, granulation tissue formation, epithelialisation, neovascularisation, collagen synthesis, and wound contraction [
The results indicate that leg ulcer healing rates do not significantly vary depending on the type of dressing used while significant savings in cost can be made by the increased use of simple nonadherent Ultra dressings.
In the current economic climate there is an urgent need to make the best use of available resources. This requires healthcare practitioners to identify where cuts can be made without affecting patient care. The use of modern dressings is one such area as all available evidence suggests that the cheaper simple nonadhesive dressings work just as well [
Cost of dressing shows wide variation. However, estimated yearly savings of more than
Of note, the ulcer area is generally greater in the modern dressings group resulting in greater mean cost. The significant cost difference cannot be ascribed to this alone. In this study it is assumed that the same area of dressing is used at each follow-up visit. In reality, the area of dressing used is likely to be less each week as some ulcer healing would have taken place. This is countered by the assumption that all of the dressing area was used to cover the ulcer without any waste. This likely overcompensates for the initial assumption resulting in an underestimate of the dressing costs and yearly savings. This was done for the sake of simplicity as consistent application of the same formula would not affect the comparison in costs between both groups.
Some of the factors that affect wound healing [
Systemic factors which impair wound healing | Local factors which impair wound healing |
---|---|
Inadequate oxygenation |
Infection and pus |
Since this is a retrospective study, ulcer area calculation and management were not biased by the motives of the research decreasing the likelihood of confounding due to different treatments. However, the retrospective nature of the study does open itself to bias in data selection and misclassification. To minimize this, selection of patient records was randomized by asking an individual not involved in the research to hand over the patient records once the exclusion criteria had been satisfied.
The use of different comparators for the “modern dressings” group may also make the comparison unfair. It is possible that one of the many modern dressings is significantly better than simple dressings while another is significantly worse making the cumulative effect negligible. However, given that all the modern dressings are antimicrobial in nature we can reasonably treat them as a single group and compare them collectively. The lack of patients treated with a particular type of dressing makes individual comparison difficult even though such a comparison would be ideal.
The small sample size (
Based on these results it is not altogether clear if a large scale randomised controlled trial to determine efficacy and cost-effectiveness of dressings is warranted. All studies undertaken so far have been consistent in concluding that healing rates do not depend on type of dressing. However, most of these have suffered from methodological limitations. There is also a tendency to intuitively think antimicrobial dressings or moisture enhancing dressings would improve healing rates given that infection and dryness impair healing. This is coupled with anecdotal evidence and individual claims that modern dressings work and simple dressings do not. A cost-benefit analysis is suggested for a large scale prospective study comparing specific dressings in uncomplicated venous ulcer patients.
There is no significant difference in healing rates for different types of dressings. The cost of dressing should be the primary factor influencing dressing selection unless the patient prefers a particular dressing. Patients should be informed that there is no conclusive evidence that modern dressings provide superior wound healing.
The author declares that there is no conflict of interests regarding the publication of this paper.
The author would like to thank Mr. Mustafa Khanbhai and Ms. Zaedia Bruce for their help in data collection.