Cost effectiveness of community leg ulcer clinics

Owing to an editorial error during processing a letter by Franks and Moffat that had been published on 14 March 1998 was used again as the penultimate letter in this cluster (17 October 1998:1079-81). The correct letter is published below.

Sensitivity of tools used may explain difference in results between studies

EDITOR— Morrell et al presented evidence from a randomised trial that supported the use of community clinics in patients being treated for chronic leg ulceration.1After the success of the Riverside project2 we have helped several community trusts to implement similar services. Evidence from these audits are in agreement with the trial in some ways but different in others.

Although we in Riverside achieved a healing rate of 69% after 12 weeks of treatment,2 subsequent changes in the service have resulted in more modest benefits. Before implementation of the new service an audit of 519 patients showed a baseline healing rate at 12 weeks of just 15%, which improved after implementation to 41% in an audit of 438 patients. After adjustment for the known risk factors of ulcer size, ulcer duration, mobility, and ankle movement3 healing rates improved to 20% before implementation and to 56% after implementation.4

Our results show lower costs of treatment after implementation, principally through reduced nurse time. We are surprised at the large difference in unit costs of treatment between the clinic (£29.90) and a home visit (£10.60).1 Our results indicate that the mean cost per visit before implementation was £19.35. In our studies mean cost per visit was similar in both phases, but there was a considerable reduction in frequency of visits after implementation (19.0 v 11.7 per 12 week cycle) (World Congress of Phlebology, Sydney, September 1998).

The other most notable difference between our results and those of Morrell et al concerns patients' perceived health. Using the Nottingham health profile we have consistently shown improvements after effective treatment in both observational studies and trials. The difference between our results and those of Morrell et al may be due to the sensitivity of the tools being used or the longer duration of the trial compared with our audits. The initial benefits noted by patients in the short term may be counterbalanced by the long term deterioration in this elderly population.

The challenge to clinicians is now developing evidence based services. The results from our work suggest that effective implementation can be achieved by trusts to improve clinical and patient outcomes while reducing costs.