title: Health service pathways for patients with chronic leg ulcers: identifying effective pathways for facilitation of evidence based wound care.
abstract: BACKGROUND
  Chronic leg ulcers cause long term ill-health for older adults and the condition places a significant burden on health service resources. Although evidence on effective management of the condition is available, a significant evidence-practice gap is known to exist, with many suggested reasons e.g. multiple care providers, costs of care and treatments. This study aimed to identify effective health service pathways of care which facilitated evidence-based management of chronic leg ulcers.
  
  
  METHODS
  A sample of 70 patients presenting with a lower limb leg or foot ulcer at specialist wound clinics in Queensland, Australia were recruited for an observational study and survey. Retrospective data were collected on demographics, health, medical history, treatments, costs and health service pathways in the previous 12 months. Prospective data were collected on health service pathways, pain, functional ability, quality of life, treatments, wound healing and recurrence outcomes for 24 weeks from admission.
  
  
  RESULTS
  Retrospective data indicated that evidence based guidelines were poorly implemented prior to admission to the study, e.g. only 31% of participants with a lower limb ulcer had an ABPI or duplex assessment in the previous 12 months. On average, participants accessed care 2-3 times/week for 17 weeks from multiple health service providers in the twelve months before admission to the study clinics. Following admission to specialist wound clinics, participants accessed care on average once per week for 12 weeks from a smaller range of providers. The median ulcer duration on admission to the study was 22 weeks (range 2-728 weeks). Following admission to wound clinics, implementation of key indicators of evidence based care increased (p < 0.001) and Kaplan-Meier survival analysis found the median time to healing was 12 weeks (95% CI 9.3-14.7). Implementation of evidence based care was significantly related to improved healing outcomes (p < 0.001).
  
  
  CONCLUSIONS
  This study highlights the complexities involved in accessing expertise and evidence based wound care for adults with chronic leg or foot ulcers. Results demonstrate that access to wound management expertise can promote streamlined health services and evidence based wound care, leading to efficient use of health resources and improved health.
authors.affiliation: School of Nursing, Institute of Health and Biomedical Innovation, Queensland University of Nursing, Kelvin Grove, Australia.
authors.forename: Helen
authors.initials: H
authors.lastname: Edwards
authors.forename: Kathleen
authors.initials: K
authors.lastname: Finlayson
authors.forename: Mary
authors.initials: M
authors.lastname: Courtney
authors.forename: Nick
authors.initials: N
authors.lastname: Graves
authors.forename: Michelle
authors.initials: M
authors.lastname: Gibb
authors.forename: Christina
authors.initials: C
authors.lastname: Parker
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D002908:Chronic Disease; D002985:Clinical Protocols / Q000592:standards*; D019091:Critical Pathways / Q000458:organization & administration*; D019317:Evidence-Based Medicine; D005260:Female; D006801:Humans; D007871:Leg Ulcer / Q000628:therapy*; D008297:Male; D008875:Middle Aged; D036301:Qualitative Research; D012189:Retrospective Studies; D011795:Surveys and Questionnaires; D014945:Wound Healing