Health Quality Ontario .
Ontario health technology assessment series. Date of publication 2019 Feb 19;volume 19(2):1-86.
1. Ont Health Technol Assess Ser. 2019 Feb 19;19(2):1-86. eCollection 2019.
Compression Stockings for the Prevention of Venous Leg Ulcer Recurrence: A Health
Technology Assessment.
Health Quality Ontario.
Collaborators: Sehatzadeh S, Djalalov S, Falk L, Kheterpal S, Wells D, Higgins C,
Walter M.
Background: People with chronic venous insufficiency who develop leg ulcers face
a difficult condition to treat. Venous leg ulcers may persist for long periods of
time and have a negative impact on quality of life. Treatment requires frequent
health care provider visits, creating a substantial burden across health care
settings.The objective of this health technology assessment was to evaluate the
effectiveness, safety, cost-effectiveness, budget impact, and patient experiences
of compression stockings for prevention of venous leg ulcer recurrence.
Methods: We conducted a systematic review of the literature to identify
randomized trials and observational studies examining the effectiveness of
compression stockings in reducing the risk of recurrence of venous leg ulcers
after healing and/or reported on the quality of life for patients and any adverse
events from the wearing of compression stockings. We performed a literature
search to identify studies and evaluated the quality of the evidence using the
Grading of Recommendations Assessment, Development, and Evaluation (GRADE)
approach.We conducted a cost-utility analysis with a 5-year time horizon from the
perspective of the Ontario Ministry of Health and Long-Term Care. We compared
compression stockings to usual care (no compression stockings) and simulated a
hypothetical cohort of 65-year-old patients with healed venous ulcers, using a
Markov model. Model input parameters were obtained primarily from the published
literature. In addition, we used Ontario costing sources and consultation with
clinical experts. We estimated quality-adjusted life years gained and direct
medical costs. We conducted sensitivity analyses and a budget impact analysis to
estimate the additional costs required to publicly fund compression stockings in
Ontario. All costs are presented in 2018 Canadian dollars.We spoke to people who
recently began using compression stockings and those who have used them for many
years to gain an understanding of their day-to-day experience with the management
of chronic venous insufficiency and compression stockings.
Results: One randomized controlled trial reported that the recurrence rate was
significantly lower at 12 months in people who were assigned to the compression
stocking group compared with people assigned to the control group (risk ratio
0.43, 95% CI, 0.27-0.69; P = .001) (GRADE: Moderate). Three randomized controlled
trials reported no significant difference in recurrence rates between the levels
of pressure. One randomized controlled trial also reported that the risk of
recurrence was six times higher in those who did not adhere to compression
stockings than in those who did adhere. One single-arm cohort study showed that
the recurrence rate was considerably higher in people who did not adhere or had
poor adherence (79%) compared with those who adhered to compression stockings
(4%).Compared with usual care, compression stockings were associated with higher
costs and with increased quality-adjusted life years. We estimated that, on
average, the incremental cost-effectiveness ratio of compression stockings was
$27,300 per quality-adjusted life year gained compared to no compression
stockings. There was some uncertainty in our results, but most simulations (>
70%) showed that the incremental cost-effectiveness ratio remained below $50,000
per quality-adjusted life-year. We estimated that the annual budget impact of
funding compression stockings would range between $0.95 million and $3.19 million
per year over the next five years.People interviewed commonly reported that
chronic venous insufficiency had a substantial impact on their day-to-day lives.
There were social impacts from the difficulty or inability to walk and emotional
impacts from the loss of independence and fear of ulcer recurrence. There were
barriers to the wearing of compression stockings, including replacement cost and
the difficulty of putting them on; however, most people interviewed reported that
using compression stockings improved their condition and their quality of life.
Conclusions: The available evidence shows that, compared with usual care,
compression stockings are effective in preventing venous leg ulcer recurrence and
likely to be cost-effective. In people with a healed venous leg ulcer, wearing
compression stockings helps to reduce the risk of recurrence by about half.
Publicly funding compression stockings for people with venous leg ulcers would
result in additional costs to the Ontario health care system over the next 5
years. Despite concerns about cost and the daily chore of wearing compression
stockings, most people interviewed felt that compression stockings provided
important benefits through reduction of swelling and prevention of recurrence.
PMCID: PMC6394515
PMID: 30828407 [Indexed for MEDLINE]
