Study Evaluates Impact of UK NICE Guideline for Leg Ulcers on Treatment Referrals


April 19, 2017—Huw O.B. Davies, MD, et al conducted an evaluation of the impact of the United Kingdom's National Institute for Health and Care Excellence (NICE) Clinical Guideline (CG)168 that is available online ahead of print in PhlebologyCG 168, which was issued in July 2013, sought to improve the care of patients with leg ulcers. The guideline recommends that patients with a break in the skin below the knee that had not healed within 2 weeks be referred to a specialist vascular service for diagnosis and management. 

As summarized in Phlebology, investigators analyzed referrals to a specialist academic leg ulcer service. Patients referred with leg ulceration during an 18-month period before CG168 (January 2012–June 2013) were compared with patients referred after an 18-month period commencing 6 months after the publication of CG168 (January 2014–June 2015).

The investigators reported that there was a two-fold increase in referrals (181 patients [220 legs] vs 385 patients [453 legs]), but no change in mean age, sex, or median duration of ulcer at referral (16.6 vs 16.2 weeks). The mean time from referral to specialist appointment increased (4.8 vs 6 weeks;  =  .0001), as did legs with superficial venous insufficiency (SVI; 36% vs 44%; = .05).

There was a trend toward more SVI endovenous interventions (32% vs 39%; = .271), with an increase in endothermal treatment (2 vs 32 legs; = .001), but no change in sclerotherapy treatment (24 vs 51 legs). In both groups, 62% of legs had compression. There was a reduction in legs treated conservatively with simple dressings (26% vs 15%; = .0006).

The investigators concluded that since the publication of CG168, there has been a considerable increase in leg ulcer referrals. However, they found that patients are still not referred until ulceration has been present for many months. Although many ulcers are multifactorial and compression remains the mainstay of treatment, there has been an increase in SVI endovenous intervention. Further efforts are required to persuade community practitioners to refer patients earlier, educate patients, and encourage further investments in chronically underfunded leg ulcer services, advised the investigators in Phlebology.


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