Evidence-based Chronic Ulcer Care and Lower Limb Outcomes among Pacific Northwest Veterans

Abstract

<underline>Introduction</underline>: Chronic lower limb ulcers (LLU) impact morbidity, mortality, and quality of life. Although evidence-based (EB) care guidelines exist for most ulcer types, the literature on the impact of ulcer care component on time to healing is sparse. The purpose of this study is to investigate the frequency EB care components are performed and their impact on ulcer outcomes among rural and urban Veterans in the Pacific Northwest. As part of EB ulcer care we also assess relationship between early specialty care and ulcer healing. <underline>Methods</underline>: This is a retrospective medical records review of Veterans with venous, arterial, and diabetic foot ulcers (DFU/Neuropathic) identified by ICD-9 codes. Components of EB ulcer care for each ulcer type were identified from EB guidelines. Venous ulcers: infection assessment, sharp debridement, moist wound healing, and edema assessment and treatment. Arterial ulcers: infection and ischemia assessment, and vascular surgery consultation within 30 days. DFU/neuropathic ulcers: infection and ischemia assessment, moist wound healing, sharp debridement, and offloading. A separate Cox model was created for each of the three ulcer types with days to healing as outcome, and included health history variables and EB ulcer care components. A Cox model for access to specialty care within 30 days of presentation for ulcer care included health-history variables without adjusting for ulcer care components. <underline>Results</underline>: Only minority of Veterans across the three ulcer etiologies received components of EB ulcer care in at least 80% of visits. Among those with venous ulcers, there was a significantly higher chance of healing if edema and infection assessment were performed on at least 80% of visits (HR=3.20, p= 0.009 and HR=3.54, p= 0.006, respectively). Edema treatment was not associated with ulcer outcome. None of the ulcer care components considered for arterial ulcer significantly impacted time to healing. Among DFU/Neuropathic ulcers the chance of healing was 2.5 time higher if debridement was done at 80% of visits (p=0.03), and 2 times higher if ischemia was assessed at first visit (p=0.045). Access to specialty care within 30 days of ulcer onset was not associated with healing. <underline>Discussion</underline>: We found that Veterans in the Pacific Northwest did not uniformly receive EB ulcer care. When component of ulcer care were performed at satisfactory levels, only a few significantly impacted ulcer time to healing. Small sample size and wide variation in ulcer care may have contributed to some of the null findings observed among ulcer care components and outcome. Rural and urban clinicians need to address those components of ulcer care associated with improved outcomes.