The need for an Intersociety Consensus Guideline for venous ulcer

The management of venous leg ulcers (VLU) consumes considerable resources in healthcare systems and accounts for up to 1% of healthcare budgets in some industrialized countries. Best practice clinical guidelines incorporate evidence-based diagnostic and therapeutic recommendations in a cost-effective manner and have been associated with improved quality and less costly outcomes for many diseases. The objective of this study was to determine whether there are common elements in guidelines for VLU and their evidentiary strength.

A systematic analysis of guidelines for VLU that were identified through http://clinicaltrials.gov, a government-sponsored Web site, and other Web sites. The proportion of guidelines proposing a recommendation as well as the strength of the guidelines were analyzed.

Fourteen guidelines were identified, of which 13 were evidence-based, with the majority using the grading of recommendations, assessment, development, and evaluation method. Five were sponsored by a government agency and nine by a medical or nursing society, while nine had been developed or updated within the last 5 years. Ankle/brachial index and venous duplex were recommended in 100% and 64%, respectively, of the guidelines. All recommended wound dressings and high compression, with both at the strongly recommended level of 75% and 77%, respectively. Debridement was suggested in 86%, but only one-third at the strong level. For adjunctive measures, 80% advocated pentoxifylline and approximately 50% physical therapy for improving ankle joint mobility. The majority emphasized the preventive value of compression stockings and surgical reduction of superficial venous hypertension, with a strong recommendation in 58% in the former and 73% in the latter.

While there are numerous evidence-based guidelines for VLU, there is consensus on strong recommendations for dressings and compression only among the various guidelines. A number of the guideline elements need further study and refinement. To improve patient care and reduce wasted resources, it is imperative for specialty societies to collaborate and develop this consensus document.