Davies Huw Ob, Popplewell Matthew, Bate Gareth, Ryan Ronan P, Marshall Tom P, Bradbury Andrew W
1 Department of Vascular Surgery, University of Birmingham, Birmingham, UK.
2 Medical Innovation Development Research Unit (MIDRU), Heartlands Hospital, Birmingham, UK.
Phlebology. 2019 Jun;34(5):311-316. doi: 10.1177/0268355518805658. Epub 2018 Oct 18.
NICE Clinical Guidelines (CG) 168, published in July 2013, recommend specialist vascular referral for all leg ulcers, defined as a break in the skin below the knee that has not healed within two weeks.
To examine the impact of CG168 on the primary care management of leg ulcers using The Health Improvement Network database.
An eligible population of approximately two million adult patients was analysed over two 18-month periods before and after publication of CG168. Those with a new diagnosis of leg ulcers in each time period were analysed in terms of demographics, specialist referral and superficial venous ablation.
We identified 7532 and 7462 new diagnoses of leg ulcers in the pre- and post-CG168 cohorts, respectively. Patients with a new diagnosis of leg ulcers were elderly (median age: 77 years both cohorts) and less likely to be male (47% both cohorts). There were 2259 (30.0%) and 2329 (31.2%) vascular service referrals in the pre- and post-CG168 cohorts, respectively (hazard ratio, 1.05, 95% CI: 0.99, 1.11, p = 0.096). The median interval between general practitioner diagnosis and referral was 1.5 days in both cohorts. Patients from both cohorts who were referred for a new diagnosis of leg ulcers were equally likely to receive superficial venous ablation.
Disappointingly, we have been unable to demonstrate that publication of NICE CG168 has been associated with a meaningful change in leg ulcer management in primary care in line with guideline recommendations.
2013年7月发布的英国国家卫生与临床优化研究所（NICE）临床指南（CG）168建议，对于所有腿部溃疡患者均应转至血管专科就诊，腿部溃疡定义为膝盖以下皮肤破损且两周内未愈合。
利用健康改善网络数据库研究CG168对腿部溃疡初级护理管理的影响。
在CG168发布前后的两个18个月期间，对约200万成年患者的合格人群进行了分析。对每个时间段新诊断为腿部溃疡的患者，从人口统计学、专科转诊和浅静脉消融方面进行了分析。
我们在CG168发布前和发布后的队列中分别确定了7532例和7462例新诊断的腿部溃疡患者。新诊断为腿部溃疡的患者年龄较大（两个队列的中位年龄均为77岁），男性比例较低（两个队列均为47%）。CG168发布前和发布后的队列中分别有2259例（30.0%）和2329例（31.2%）转至血管专科就诊（风险比，1.05；95%置信区间：0.99，1.11；p = 0.096）。两个队列中，全科医生诊断与转诊之间的中位间隔均为1.5天。两个队列中因新诊断腿部溃疡而转诊的患者接受浅静脉消融的可能性相同。
令人失望的是，我们未能证明NICE CG168的发布与初级护理中腿部溃疡管理的有意义变化相关，未符合指南建议。
