Many adults with vascular disease and/or diabetes suffer with chronic leg or foot ulcers, leading to loss of functional ability, poor quality of life and long term ill-health
. Studies on patients with chronic leg ulcers have reported the average duration of these ulcers is around 12–13 months
[2, 3], around 60–70% of patients have recurring ulcers
, 24% of patients are hospitalised because of the ulcers and most people suffer from the condition for an average of 15 or more years
. Care for chronic wounds is reported to cost 2-3% of total health care spending in developed countries
[5, 6] and these costs are set to rise with ageing populations
. Treatment in the U.S. costs over 3 billion $US and the loss of over 2 million workdays a year
. Similarly, Harding quotes a cost of £400 million each year in the U.K.
. In Australia, wound dressings are the second most frequent procedure in General Practitioner practice
 and chronic wound care accounts for 22–50% of community nursing time in the UK and Australia
[10, 11]. In addition to direct health care costs, chronic wounds are associated with hidden burdens on the community resulting from loss of mobility, decreased functional ability, social isolation and loss of participation in the workforce and society.
Despite reports of improved healing and reduced recurrence rates following the introduction of evidence based guidelines and coordinated care
[6, 12], a significant evidence-practice gap has been reported around the world in appropriate assessment of chronic leg ulcers and timely use of best practice treatments
[13–18]. For example, around 70% of chronic leg ulcers are caused by venous disease and compression therapy is the gold standard treatment
, yet a U.S. study found only 17% of patients with venous leg ulcers received compression
, and Australian studies found 40–60% of venous leg ulcers in Australia did not receive adequate compression
A number of reasons have been identified as contributing to this evidence-practice gap, including lack of information and skills
[15, 17], difficulties with access to evidence based guidelines
, the costs and lack of reimbursement associated with specialist wound care and treatments such as compression bandaging
[14, 21], limited access to specialist multidisciplinary teams
, poor communication
 and limited evidence on effective assessment, referral and treatment pathways of care to manage this chronic condition
. Coyer et al.
 found clients were confused as to whom to access for care (whether general practitioners, community clinics, pharmacists, outpatient departments, vascular specialists, skin specialists); and health professionals themselves often find it difficult to manage care across disparate levels (community nurses, general practitioners, vascular/endocrine/wound care specialists, allied health professionals) in health care systems which lack models of service delivery that integrate chronic disease primary care and focus on health promotion, illness prevention and early intervention.
In the area of wound healing many practitioners are involved in the trajectory of care. The absence of wound care as a medical specialty and dispersion of responsibility for wound care among a variety of health care providers often results in poor continuity of care across the health service continuum and a lack of consistent, evidence-based care and long-term preventative care
[23, 24]. The diversity of budgets and financial climate of cost control means that there is extraordinary complexity in the funding and provision of wound care and preventive care in the community
[14, 25]. Up-front costs for long term wound care (wound dressings, bandages, costs of health care service providers) and follow-up preventative care have been identified as a barrier to implementing evidence based practice
The potential benefits of specific health service pathways for chronic leg ulcer management and facilitation of evidence based wound care are not clear from current research. A few studies have demonstrated improved clinical outcomes following the introduction of evidence based protocols
[26–28], however, the relative benefits (both in patient outcomes and effective use of health resources) of alternative models of care are not well evaluated. This area of translational research is important in addressing gaps between research findings and wide-spread implementation of new information to improve patient outcomes.
This project was conducted in Queensland, a state of Australia, which has complex and diverse systems of health care provision and funding, differing in each state. For the participants in this study in Queensland, reimbursement varies according to the health care providers. A base level rebate is provided by the government for visits to a General Practitioner or medical specialist (on referral), and some patients are charged this amount (i.e. no cost to the patient), while others are charged an additional fee each visit as determined by the General Practitioner or medical specialist. Upon referral from a medical practitioner, patients can access a consultation at outpatient specialist wound clinics at public hospitals at no cost.
Community nursing services are provided primarily by non-government not-for-profit organisations with government funding to support the cost for eligible patients i.e., those who are aged over 65 years (or over 50 years for Aboriginal and Torres Strait Islander patients), or disabled, or those who are at risk of premature or inappropriate admission to long term residential care. There is usually a top-up fee for the patient each visit in addition to the costs for consumables. Participants receiving allied health professional services (e.g. podiatrists, occupational therapists, physiotherapists) in the community would usually incur the full costs of consultations, although some may be eligible for some reimbursement of costs with a referral from a medical practitioner, or may have private health insurance to cover some of the costs. The costs associated with dressings and bandaging are not subsidised for community living patients attending any health or allied health service provider, and as these may be substantial, it often influences choice of treatments.
The aim of this project was to explore the effectiveness of alternative health service pathways of care for patients with chronic leg ulcers, on
implementation of evidence-based guidelines;
wound healing and recurrence rates; and
efficient use of health services and cost-effectiveness of care.