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.