Leg ulceration: An exploration of the role of socio-economic factors in the epidemiology, access to health care and outcomes.

Background
Tackling health inequalities has been a priority policy area for the NHS since the 1990’s. To date there has been scant research addressing this area in relation to leg ulcers, despite there being some evidence of inequalities in leg ulcer prevalence. The overarching aim of this thesis is to examine the relationship between the epidemiology, management and outcomes of leg ulcers in relation and socio-economic factors.

Methods
The epidemiology and management of leg ulcers was examined using the GPRD and THIN primary care databases. Regression models were undertaken to quantify the relationship between variables and leg ulcer rates. Multilevel logistic models were undertaken to examine three aspects of guideline recommended care in the cohort of patients diagnosed with incident venous leg ulcers; initial assessment using Doppler ultrasound, provision of compression bandaging and referrals. Analysis conducted using the THIN database adjusted for Townsend deprivation fifth rank of each patient, a proxy measure of socio-economic position. Analyses of patient management using the GPRD adjusted for practice level deprivation. Second, the relationship between socio-economic position with leg ulcer outcomes including healing and adverse events was investigated using two recently completed leg ulcer treatment RCTs.

Results
Socio-economic gradients were found in rates of incident venous and prevalent venous and arterial leg ulcers. The reported management of most patients fell short of standards recommended by leg ulcer guidelines although there were wide variations between practices. Only the initial assessment of patients was found to have a relationship with deprivation. Patients living in or attending practices in the most deprived areas had reduced odds of having a record of receiving Doppler assessment of their leg. No relationship was observed between deprivation and healing or adverse outcomes in the clinical trials.

Conclusions
There are health inequalities evident in leg ulcer development and some aspects of management. The wider implementation of guideline recommendations for care may have the potential to ameliorate some of these health inequalities as results demonstrated that low socio-economic position patients were no less likely to achieve positive leg ulcer outcomes when provided with high quality care.