When choosing compression products to treat venous leg ulcers, price variation for compression hosiery over compression bandaging is justified, provided that the hosiery is clinically appropriate and meets the needs and preferences of the person with a venous leg ulcer.
Price variation for compression wraps over other compression products is not justified unless a compression wrap is the only suitable option.
NHS service providers should give access to a range of compression products, including compression wraps, so that a product that is clinically appropriate and meets people's needs and preferences is available for everyone with a venous leg ulcer.
A healthcare professional and the person with the venous leg ulcer should decide together which compression product to use (see the NICE webpage on shared decision making). Decisions should take into account how the choice of compression product might affect the person's quality of life, including:
ability to complete activities of daily living
adherence to the treatment regimen
physical health, including whether they can apply products themselves
mental health and wellbeing
relationships with others, including whether they have informal carer support at home.
More information is needed to address the remaining uncertainty around compression wraps. Evidence should be of sufficient sample size to detect a statistically significant difference, report details of concomitant treatments and ideally be done in a community setting in the NHS. Studies should include appropriate criteria for patient selection and positioning of the technology in the care pathway.
Key patient and clinical performance outcomes for compression wraps that should be captured include:
time to complete wound healing
duration of treatment
health-related quality of life
ease of application
adherence to treatment
reasons for treatment discontinuation.
What this means in practice
Considerations for procurement and commissioning
According to the National Wound Care Strategy Programme, in 2019 there were around 739,000 leg ulcers in England with estimated associated healthcare costs of £3.1 billion per year. Venous leg ulcers account for 60% to 80% of all leg ulcers.
The price varies between, and within, different types of compression products.
Many factors can influence which type of compression product is best to treat a venous leg ulcer. Commissioners and procurement specialists should work with NHS healthcare professionals to ensure access to a range of compression products.
Evidence suggests the clinical effectiveness of compression hosiery and bandaging is broadly similar. Economic modelling suggests that compression hosiery, which enables self-management, is cost effective compared with compression bandaging, which relies on more frequent visits from a nurse to change the compression product. Compression wraps also have the potential to enable self-management, but there is some evidence that they are not cost effective compared with other compression products.
Considerations for wound management formulary groups
These recommendations are not intended to restrict choice. When developing a formulary, a range of compression bandages and other types of compression products, including both compression hosiery and compression wraps, will be needed to provide options for different clinical and patient preference scenarios.
Decision making should prioritise cost-effective options, taking into account the factors listed in recommendation 1.4.
Considerations for healthcare professionals
These recommendations do not replace clinical reasoning. If more than 1 type of compression product is clinically appropriate, the choice of product should be based on the preferences of the person with the leg ulcer and cost effectiveness. This should take into account the factors listed in recommendation 1.4.
Additional items, such as hosiery applicators, bandage overshoes and waterproof bandage protectors, should be offered alongside the compression product through formularies or GP prescribing, if appropriate.
Healthcare professionals should work with NHS commissioners and procurement specialists to ensure access to a range of compression products.
Information for people with venous leg ulcers
You should be involved when deciding which compression product to use. You should be given information on the compression product that is being prescribed and, when possible, offered options that meet your needs. You should also be made aware of how you can access products that support using the compression product, such as waterproof protectors for compression bandages.
You should be given support if you experience any issues or wish to change to another type of compression product.
NICE has produced tools and resources to support the implementation of this guidance.
There are many compression products available to treat venous leg ulcers. This assessment aims to determine whether the differences in clinical, economic and non-clinical outcomes attributed to the different types of compression products could justify price variation.
Evidence from clinical trials shows that the clinical effectiveness of 2‑layer compression bandaging, 4‑layer compression bandaging and 2‑layer compression hosiery is broadly similar. But evidence from a large UK study (VenUS 6) shows that compression wraps are less effective than these products.
The external assessment group's (EAG's) economic modelling suggests that compression hosiery is more cost effective than compression bandaging and compression wraps over periods of up to 1 year. A large UK study (VenUS IV) also shows that compression hosiery is cost effective compared with 4‑layer compression bandaging. But the VenUS 6 study suggests that compression wraps are not cost effective in the long term.
So, price variation for compression hosiery over compression bandaging is justified, but the available evidence does not support price variation for compression wraps over other compression products.