Bollettino epidemiologico nazionaleTreatment of Chronic Skin Lesions in an Integrated Home-Based Care Program
By Dr. Claudio Volpe, Director, Integrated Home-Based Care Program, Local Health Agency, Chieti
An integrated home-based care service (Servizio di Assistenza Domiciliare Integrata; ADI) was initiated in the Local Health Agency (Azienda Sanitaria Locale; ASL) of Chieti in July 1998 with the objective of improving the quality of life of patients receiving care in their homes, promoting the integration of social and health services, encouraging early hospital discharge, avoiding unnecessary hospitalization, and reducing health care expenses. Currently, the ADI is active in all 28 communes served the by the ASL (population 176,582 residents as of December 31, 2000). Services are provided by 10 district health offices, coordinated centrally by a department of outpatient assistance. General practitioners or, in the case of inpatients, the hospital wards, can request home-based services for their patients. Prior to admission, each patient is evaluated regarding eligibility for the program, and an individualized assistance plan is developed by the evaluation unit of the district health offices in collaboration with the patient’s general practitioner.
Between July 1998 and the end of 1999, the ADI enrolled 465 patients (2.6/1000 of the resident population); in 2000, a total of 704 were enrolled (4.0/1000 of the resident population). Chronic skin lesions account for a major proportion of the patients for whom ADI assistance has been provided. In 1999, 264 (47% of the 556 patients who received ADI assistance were treated for chronic skin lesions; in 2000, 252 (30%) of the 830 patients were treated for such conditions. In 1999, 215 (81%) of the 264 with chronic lesions were new cases, while in 2000, the corresponding value was 173/252 (69%).
In 2000, the most recent year for which data are available, 192 of the 264 patients (76%) had decubitus ulcers at least one site (most commonly, the sacral area, the trocanters, and/or the heels). Of the remaining patients with chronic skin lesions, the most common condition was vascular skin lesions of the lower extremities (13%), while post-surgical lesions, cancer, and burns accounted for 9%, 2%, and 1%, respectively.
The median age of patients with chronic skin lesions was 82 years, with a range of 12 years (a girl with burns) to 100 years; 58% were female. Eighty-seven percent of the requests for home-based care were from general practitioners, with the remaining 13% coming from inpatient wards.
Of the patients treated in 2000, 36% were cured, 19% were hospitalized (for other conditions), 25% died (from other conditions), and 21% were still being followed at the end of 200, of whom 73% had been enrolled after July 1 and 58% after October 1.
Table 1 presents more detailed information on the new cases of patients with decubitus ulcer, the largest single group of patients with chronic skin lesions. These patients are believed to represent virtually all of the residents with decubitus ulcer, with the exception of a limited number of cases treated directly by their general practitioners and those in nursing homes).
Decubitus ulcers, also known as pressure ulcers, can be considered an important indicator of the quality of health services in hospitals, in home health programs, and in nursing homes. These preliminary data represent for the ADI of the Local Health Agency of Chieti baseline data that can be used to monitor temporal trends in the problem and to try to reduce its incidence and the need for treatment.
Comment
Maria Lazzarato and Maria Rolfini
District Health Service, Office of the Director of Health Services, Emilia-Romagna
Chronic skin lesions, the most common of which are decubitus ulcers, are a frequent cause of morbidity in elderly patients who are hospitalized or institutionalized, and their treatment may be costly (1). Their prevalence varies according to the age structure of the population, the case definition being used, and the quality of health care. Population-based incidence and prevalence data are not readily available because most studies have been conducted in hospital and nursing home settings.
Considering the many factors which may influence prevalence, the estimates of frequency obtained in Chieti based on the ADI data are not readily generalizable. For example, in Emilia-Romagna, in a setting with a population similar to that of Chieti (176, 065), the ADI coverage is 7 per 1000 population compared with 4 per 1000 for Chieti, and the prevalence of decubitus ulcers is 3 per 1000 compared with 1.3 per 1000.
The Chieti study, like other studies performed in Italy and internationally in both domiciliary and institutional settings, shows that the prevalence of decubitus ulcers increases with increasing age, that they are more commonly seen among women, and that the principal location is the sacro-coccygeal area.
With respect to outcome, hospitalisation and deaths are not usually a consequence of the cutaneous lesions but instead represent concomitant conditions. However, the data on cure are reassuring, even in the absence of comparison data. Nonetheless, in the absence of more compete data on prevalence before and after the implementation of the program, the impact of the ADI program on hospitalisation rates is difficult to fully assess.
Based on our experience, early hospital discharge is dependent on the presence of a team with a wide variety of professional competencies and on the ability to deliver intensive nursing care at home. Competencies needed include education, artificial nutrition; multiprofessional and multidisciplinary patient evaluation; management of infusion pumps, of respiratory problems, and of ostomy sites; support to patients with terminal illnesses and their families, etc. In the case of chronic cutaneous lesions, home nursing services can be of assistance in providing continuity of care and permitting early discharge.
The information on cutaneous lesions that emerges from this study consist of quantitative clinical indicators that focus attention on performance problems that may merit additional epidemiologic studies. Descriptive epidemiologic surveillance is not the only tool for improving services; in addition to periodically monitoring coverage and outcome, it is also important to evaluate the effectiveness and the appropriateness of services through evaluations of clinical practice (clinical governance) related to the treatment of such pathologies (2, 3). In this way, essential information can be obtained to better understand what has been done (for example, use of protocols, guidelines, etc), by whom, and with what results. Based on such evaluations, clinical practice can be further improved.
1. Agostini JV, Baker DI, Bogadus ST. Chapter 27. Prevention of pressure ulcers in older patients. In: Shojania KG, Duncan BW, McDonald KM, et al., eds. Making Health Care Safer: ACritical Analysis of Patient Safety Practices. Evidence Report/Technology Assessment No. 43. AHRQ Publication No. 01-E058, Rockville, MD: Agency for Healthcare Research and Quality. July 2001.
2. Grimshaw J.M., Shirran L., Thomas R.E., Mowatt G., Fraser C., Bero L., Grilli R., Harvey E.L., Oxman A.D., O'Brien M.A. "Changing provider behaviour: an overview of systematic reviews of interventions", Medical Care, 39 Supplement 2, II-2 - II-45
3. Bates-Jensen BM. Quality indicators for prevention and management of pressure ulcers in vulnerable elders. Ann Intern Med. 2001;135:744-751