Patient survey reports association between compression stocking use adherence and stasis dermatitis flare frequency

Abstract

To the Editor: Compression stocking use for stasis dermatitis is an effective treatment to control symptoms, especially during acute flares.1Raju S. Hollis K. Neglen P. Use of compression stockings in chronic venous disease: patient compliance and efficacy.Ann Vasc Surg. 2007; 21: 790-795Abstract Full Text Full Text PDF PubMed Scopus (220) Google Scholar The annual health care cost of stasis dermatitis is $195 to $515 million, including unnecessary hospitalizations.2Weng Q.Y. Raff A.B. Cohen J.M. et al.Costs and consequences associated with misdiagnosed lower extremity cellulitis.JAMA Dermatol. 2017; 153: 141-146Crossref PubMed Scopus (98) Google Scholar High rates of noncompliance (60%-70%) with compression stocking use have been documented, but underlying factors are not well understood.1Raju S. Hollis K. Neglen P. Use of compression stockings in chronic venous disease: patient compliance and efficacy.Ann Vasc Surg. 2007; 21: 790-795Abstract Full Text Full Text PDF PubMed Scopus (220) Google Scholar We sought to characterize the patient-reported concerns that influence adherence to prescribed use of compression stockings. A cross-sectional survey was conducted at Saint Louis University with Institutional Review Board approval. An electronic medical record search identified patients who were seen in the outpatient dermatology clinic between February 1, 2017, and May 1, 2018, and were coded with International Classification of Diseases, 10th Revision I87.2 for stasis dermatitis. We reviewed patient records to confirm a board-certified dermatologist had diagnosed stasis dermatitis and recommended compression stocking use at the most recent office visit. We contacted 111 eligible patients, and 100 consented to participate. After obtaining verbal consent by phone, a physician administered an 11-item questionnaire (available online as Supplemental Material via Mendeley at https://doi.org/10.17632/gcfvmthr24.1). A flare was defined as an uncomfortable increase in symptoms, such as edema, erythema, pruritus, or weeping. Baseline characteristics of the sample (n = 100) and responses are described in Table I. Only 26% of patients reported wearing stockings daily as recommended (ie, ≥12 hours daily). A statistically significant association (P = .02) between flare frequency and compression stocking use was observed (Fig 1). Approximately 5% of patients with daily stocking use reported very frequent flares (≥3 times weekly), whereas 64% who reported no stocking use had very frequent flares. The most common reasons cited by patients for noncompliance with the physician recommendation, listed in order of frequency, were inability to put on the stockings, discomfort, unclear how the treatment will help, and cost.Table IPatient demographics and interview responsesVariableResult∗Data are presented as number (%), as mean ± SD, or as indicated. (N = 100)Demographics and medical history Female54 (54) Age, y68.8 ± 12.0 Use of topical steroids61 (61) History of hospitalization for cellulitis22 (22)Interview responses Knowledge of physician recommended stocking use91 (91) General understanding of how stockings work74 (74) Knowledge of hours recommended by the physician<8 h/d2 (2)8-12 h/d9 (10)12-16 h/d15 (16)>16 h/d7 (8)Unknown58 (64) Knowledge of compression strength36 (39) Patient use of compression stockingsAlmost daily26 (26)2-3 times/wk11 (11)3-5 times/wk21 (21)Not at all42 (42) Hours compression stockings worn when used(n = 58)<8 h/d11 (19)8-12 h/d22 (38)12-16 h/d17 (29)>16 h/d8 (14) Number of times reason cited for noncompliance with recommended treatmentInability to put on the compression stockings31Discomfort (too tight)25Unclear how the treatment will help13Cost12Other (too hot, appearance, other medical conditions, physician's lack of emphasis)11 Patient-reported interventions to increase complianceEducation regarding tips for putting on the stockings30Prescription for a slightly lower strength of compression26Financial assistance14Additional education from the physician regarding the utility of compression stockings12∗ Data are presented as number (%), as mean ± SD, or as indicated. Open table in a new tab The cross-sectional design does not permit drawing conclusions about the temporal relationship between compression stocking use and flare prevention. Sampling from a single, Midwestern academic institution limits the generalizability, and all telephone survey research is subject to recall bias. The sample size limited our ability to conduct stratified analysis. Patients expressed frustration with the inability to apply compression stockings because of tightness, poor fit, texture, or warmth. Although not as common, some patients reported out-of-pocket cost as a barrier. Furthermore, patients reported wanting physicians to provide more education about compression stocking application and ways of relieving discomfort. Physicians can provide such education during office visits. Early morning application, professionally fitted stockings, and donning-doffing devices can be promoted. If patients cite discomfort, physicians could prescribe a lower strength or recommend an alternate material. Local medical supply companies can help reduce out-of-pocket costs and offer patient assistance in selecting optimal fit, fabric, color, and length. At the initial encounter, we recommend referral to a local medical company that can assist in optimal stocking design and coordinate insurance benefits whenever possible. At subsequent visits, we recommend physicians regularly address barriers to compression stocking use. These simple interventions can contribute to improved patient compliance with compression stocking use and reduced flare frequency.