Investigation of the effect of deprivation on the burden and management of venous leg ulcers: a cohort study using the THIN database.

John E. Mendelson,Emily S. Petherick,Nicky A. Cullum,Kate E. Pickett

doi:10.1371/journal.pone.0058948

John E. Mendelson, Emily S. Petherick + Show 2 more

Open Access

https://doi.org/10.1371/journal.pone.0058948

Copy DOI

Abstract

BackgroundThere has been limited examination of the contribution of socio-economic factors to the development of leg ulcers, despite the social patterning of many underlying risk factors. No previous studies were found that examined social patterns in the quality of treatment received by patients with leg ulcers.MethodsUsing The Health Improvement Network (THIN) database we identified a cohort of over 14000 patients with a diagnosis of venous leg ulceration, prospectively recorded between the years 2001 and 2006, with linked area-level socio-economic information (Townsend deprivation quintile). We assessed socio-economic differences in the incidence and prevalence of leg ulcers using negative binomial regression. Socio-economic differences in two key areas of guideline recommended leg ulcer management, arterial Doppler assessment and compression bandaging, were assessed using multilevel regression.ResultsThe risk of incident venous leg ulceration increased for patients living in areas of higher deprivation, even after adjustment for known risk factors age and gender. Overall reported rates of Doppler assessment and provision of compression therapy were low, with less than sixteen per cent of patients having a database record of receiving these recommended diagnostic and treatment options. Patients diagnosed with incident venous leg ulcers living in the most deprived areas were less likely to receive the recommended Doppler-aided assessment for peripheral vascular disease than patients living in the least deprived areas (odds ratio 0.43, 95% confidence interval 0.24–0.78). Documented provision of compression therapy did not vary with deprivation.ConclusionsA socio-economic gradient in venous leg ulcer disease was observed. The overall rates of people with venous leg ulcers who were documented as receiving guideline recommended care (2001–2006) were low. Reported use of Doppler ultrasound assessment was negatively associated with socio-economic status. These findings suggest that the inequalities experienced by leg ulcer patients may be exacerbated by reduced access to guideline-based management.

Highlights

Prevalence studies, undertaken nationally and internationally, have produced consistent estimates that one per cent of the population has chronic leg ulceration; with approximately 20% of these people having an open ulcer at any point in time [1]
Studies suggest that the majority of leg ulcers are associated with venous disease, but other risk factors include immobility, obesity, trauma, arterial disease, vasculitis, diabetes and neoplasia [2,3,4] Regardless of the pathology, all leg ulcers represent a failure of the underlying vessels to effectively transport blood to and from the tissues of the lower limbs
Some of the risk factors associated with venous disease severity, for example obesity, [9] have a social gradient, as the prevalence of obesity is highest among women with low socio-economic status [10]

Summary

Introduction

Prevalence studies, undertaken nationally and internationally, have produced consistent estimates that one per cent of the population has chronic leg ulceration; with approximately 20% of these people having an open ulcer at any point in time [1]. Some of the risk factors associated with venous disease severity, for example obesity, [9] have a social gradient, as the prevalence of obesity is highest among women with low socio-economic status [10]. It is known that the risks of both venous insufficiency and peripheral arterial disease increase with cigarette smoking [11,12] which has a social gradient in both individual and area based measures of socio-economic status. The social determinants of health encountered by the individual and the area in which they live and receive treatment may influence many aspects of the development, persistence and recurrence of leg ulcers. No previous studies were found that examined social patterns in the quality of treatment received by patients with leg ulcers

Objectives

Methods

Results

Conclusion