Secondary Endpoints
Length of inpatient stay did not change significantly during the study
period (p=.57), regardless of sex (p=.5141), or age (p=.85).
Bed-day usage was significantly reduced from median 62.5(27-92.5), to
36.5(21-44) bed-days per month (p=.035).
In 2011, 291 unplanned admissions due to VLU cost the state
inpatient stay of \euro7,608, or \euro533.38 per bed-day. The
results of applying these costs to the 2014-2018 Saolta data are shown
in table 3 and figure 1. Figure 1 shows the median monthly cost borne by
the health service for the inpatient care of patients admitted primarily
for management of VLUs in the two-year period immediately before and the
two-year period since commencement of the VLU clinic.
The cost of management of varicose veins on a surgical daycase basis
amounts to \euro2,211 per case. The current data show a median cost
per inpatient stay throughout the study period of \euro3,733.66, which
did not change significantly, as length of stay was not significantly
reduced. There was however a significant reduction in costs per month
from median \euro33 336.25(\euro14,401.26-\euro49,337.65) to
reduced admission rate.
Discussion
To our knowledge this study represents the first time that a dedicated
see-and-treat service for VLUs has been assessed in terms of its
potential to reduce the burden on inpatient services, and therefore
costs.
We have shown that ulcer admission rates have fallen after beginning a
rapid access clinic providing aggressive treatment of VLUs with surgical
intervention. It remains unclear whether rapid access to the actual
interventions is wholly responsible for the reduced admissions and
observed healing rates do not support this, though it is likely one
important factor. We believe that the reduction of inpatient admissions
is a result of a combination of factors. These include reduced time from
referral to specialist assessment and treatment, greater availability of
an alternative referral pathway for primary care physicians, and the
safety net effect of frequent follow up and easy access in the event of
a setback. The observed saving in bed-days alone suggests there is value
providing such a service for management of VLUs, even before financial
costs are considered. Cost per admission remained static during the
study period, as length of stay per case did not significantly change.
The number of admissions however was reduced, leading to significant
cost savings as well as freeing up beds. The cost of surgical daycase
interventions for varicose veins to the HSE amounts to \euro2,211 per
case. While the addition of 108 of these cases into the system since the
commencement of the clinic would offset savings made in admission costs,
since current guidelines already advocate surgery in these patients for
prevention of recurrence, the majority undergo a daycase treatment of
their varicose veins
An analysis of the breakdown of costs in VLU management, albeit
performed in the US where the funding model is markedly different to the
Irish or most European systems, found that just 22% of the costs
relating to venous leg ulcer management were incurred in the inpatient
setting. The rest of the costs incurred were split between outpatient
management (42%) and community care (35%) costs18.
In these areas the one-stop clinic can also have secondary benefits, and
from its inception one of the main goals of the clinic was to streamline
the process by which patients with VLUs are managed. A one-stop clinic
reduces the number of hospital visits and removes the need for separate
waiting lists for assessment and intervention. Reducing the number of
visits required (from one for assessment, one for the procedure at a
later date, and perhaps another for ultrasound assessment in between)
into a single visit reduces the total number of outpatient visits.
Prompt treatment, while not removing the need for community follow up,
should also reduce the number of healthcare interactions required by
these patients in the community. Improving the ulcer healing time can
eliminate at least one public health nurse visit for every extra
ulcer-free week, and in some cases 2-3 visits. Accepting the evidence of
the EVRA trial, treatment of reflux was offered to all patients in whom
it was felt to be appropriate. We do not dispute these data, but perhaps
in a real world rather than a trial setting our improvements in healing
are not as promising. In addition, as the same-day service removes the
waiting period in a typical system between assessment and treatment,
public health nurse visits to patients on a surgical waiting list are
also saved.
Early and easy access for these patients, also streamlines wound care in
the community. More and more of these interactions amount to a simple
dressing change, as a full assessment has been carried out already. If
an ulcer is thought to be making poor progress, the public health nurses
know the patient will be seen within a month and in the event of a
problem, they have a definite referral pathway, to have patients about
whom there is a concern seen at the next weekly clinic. This removes the
dilemma, over whether to send a non-acute patient to the emergency
department if the patient cannot wait on a normal outpatient waiting
list while an ulcer continues to deteriorate. This is reflected in the
evidence presented. While admission rates with inflamed or infected
ulcers remained relatively unchanged, there was a marked reduction in
admissions of ulcers without inflammation. These patients tend to be
those admitted for inpatient management of difficult ulcers, or ulcers
resistant to treatment. While many of those with infection will require
admission for antibiotics regardless of treatment strategy, the
provision of a different referral pathway for the non-infected but
difficult to manage cases allows them to remain in the community,
contributing to the reduction in admission rates observed.
There were no other significant changes made in service provision in the
geographical area in question which account for the significant
reduction in inpatient admissions over the course of the study period.
We therefore suggest that in light of clinical guidance recommending the
surgical management of venous reflux to encourage ulcer
healing16, 17 that this be undertaken in a one-stop
clinic to maximise efficiency.