Standard, Appropriate, and Advanced Care and Medical-Legal Considerations: Part Two -- Venous Ulcerations

William J. Ennis, DO, MBA, FACOS, Patricio Meneses, PhD


Wounds. 2003;15(4) 

In This Article

Healing Prognosis

The high prevalence of venous ulcers, variable healing rates, and costly new therapeutic options make it very important to attempt to identify patients who would benefit from these treatment options early in the course of therapy. Healing rates at 12 weeks range from 56 to 69 percent in one study based on the adequacy of the underlying arterial flow.[85] Reported healing rates vary greatly in the literature, but very few wound healing papers have utilized the CEAP classification scheme, making comparisons impossible. One study noted improved healing outcomes in patients who were younger, who lacked deep vein involvement, who had wounds of shorter duration, and who had smaller initial surface areas.[86] The initial rate of healing has been suggested to predict venous ulcer healing.[87,88,89] Authors are trying to identify predictive parameters to identify difficult-to-heal venous ulcer patients. Researchers disagree on terminology and study design.[90] Interest has turned towards identifying biochemical markers that might offer predictions of subsequent healing.[91] A recent paper describes the percentage change in area over four weeks as predictive for healing at 24 weeks.[92] If validated by other researchers, this would be a simple, useful tool for stratifying patients and moving those patients identified as nonhealers into an "appropriate" care module instead of "standard" care. These same authors published similar works analyzing an evidence-based approach for the prediction of clinical outcomes.[93] Clinicians frequently have a difficult time in agreeing on what is meant by a completely healed wound, further complicating understanding of the literature.[94] In another study analyzing demographic and historical data, researchers found that fibrin covering greater than 50 percent of the wound bed and a history of prior venous surgery are significantly associated with decreased healing rates.[95] Recent attempts at using the minimum data set (MDS) have helped uncover the prevalence of venous disease in long-term care residents.[96] Will standard-of-care recommendations apply for this frail, elderly, immobilized patient population? Or will more advanced techniques be required?

As we discuss the treatment options in the next section, it is important to keep the information noted above in focus. Standard of care may be grossly inappropriate for a patient found by either measurement criteria or a biochemical marker to be recalcitrant. Clearly, the clinical and cost-effective method for treatment in such a case would be either appropriate or advanced care.