Evaluation of a Skin Barrier Ring With Assisted Flow: A Prospective Cohort Study

PURPOSE

The purpose of this study was to assess the effect of a skin barrier ring with assisted flow in preventing peristomal skin complications (PSCs) in patients with an ileostomy and to evaluate the participants' perceptions of the device.

DESIGN

Single-group, prospective cohort study.

SUBJECTS AND SETTING

Both inpatients and outpatients with newly created (n = 14) or established (n = 1) ileostomies were recruited from 2 clinical sites in the United States: one was an academic teaching hospital system in the Midwestern United States and the second was a teaching hospital located in the Southeastern United States.

METHODS

Participants used the skin barrier ring with assisted flow after receiving education on its use. The pouching system was changed on a routine basis as determined by the ostomy nurse specialist. The Ostomy Skin Tool (OST) was used to assess each participant's peristomal discoloration (D), erosion (E), and tissue overgrowth (T) on admission to the study (baseline) and at final assessment (60 ± 33 days). Secondary outcomes (device handling, comfort, and discretion) were assessed through a questionnaire administered during the final data collection visit.

RESULTS

The mean baseline DET score among the 14 participants with a new ileostomy was 2 or less, indicating no PSCs. The incidence of PSCs in this study was 40% (n = 6). Thirteen of 15 participants (86.7%) agreed that the skin barrier ring with assisted flow was easy to apply. Fourteen (93.4%) agreed that the device was comfortable and easy to remove. All 15 participants (100%) agreed it was discreet under clothing.

CONCLUSIONS

Sixty percent of participants (n = 9) using the investigational device experienced a PSC. More than 90% of participants agreed that the device was comfortable and easy to remove, and all participants (100%) agreed it was discreet when worn under clothing.

Psychometric validation of the Ostomy Skin Tool 2.0

Background

Peristomal skin complications (PSCs) pose a major challenge for people living with an ostomy. To avoid severe PSCs, it is important that people with an ostomy check their peristomal skin condition on a regular basis and seek professional help when needed.

Aim

To validate a new ostomy skin tool (OST 2.0) that will make regular assessment of the peristomal skin easier.

Methods

Seventy subjects participating in a clinical trial were eligible for the analysis and data used for the validation. Item-level correlation with anchors, inter-item correlations, convergent validity of domains, test-retest reliability, anchor- and distribution-based methods for assessment of meaningful change were all part of the psychometric validation of the tool.

Results

A final tool was established including six patient reported outcome items and automatic assessment of the discolored peristomal area. Follow-up with cognitive debriefing interviews assured that the concepts were considered relevant for people with an ostomy.

Conclusion

The OST 2.0 demonstrated evidence supporting its reliability and validity as an outcome measure to capture both visible and non-visible peristomal skin complications.

Healthcare resource use and associated costs for patients with an ileostomy experiencing peristomal skin complications

Peristomal skin complications (PSCs) have a significant impact on quality of life and ostomy treatment costs. This study aimed to assess the healthcare resource use for patients with an ileostomy and PSCs symptoms. Two surveys were developed and, after validation by healthcare professionals and patients, data were collected on healthcare resource use while not experiencing any PSCs symptoms and while experiencing complications of various severities, as defined by the modified Ostomy Skin Tool. Costs applied to resource use were assigned from relevant United Kingdom sources. Additional healthcare resource use associated with PSCs, relative to no complications, was estimated to result in a total cost per instance of £258, £383, and £505 for mild, moderate, or severe PSC, respectively. The average estimated total cost per complication instance, weighted across mild, moderate, and severe PSCs, was £349. Severe-level PSCs were associated with the highest cost, because of the treatment-level required and the longer duration of symptoms. There is potential for clinical benefits and economising in stoma care if interventions are implemented that reduce the incidence and/or severity of PSCs.

An ostomy baseplate with a skin-protection technology reduces peristomal skin complications: a randomized controlled trial (the ATTRACT study)

BACKGROUND

Peristomal skin complications (PSCs) are the predominant complication for people living with a stoma, negatively affecting their health-related quality of life (HRQoL). PSCs may also have an impact on healthcare costs for society with more visits to healthcare professionals and increased consumption of products and treatment strategies, which amplifies the need for new strategies to reduce or prevent PSCs.

OBJECTIVES

To evaluate the performance of an ostomy baseplate with a skin-protection technology. The target group comprised people living with a stoma with liquid faecal effluent, who struggled with PSCs.

METHODS

A randomized, controlled, open-labelled, cross-over trial was conducted from September 2021 to February 2022 in five different countries. Each participant tested the investigational product against a comparator product (SenSura® Mio). The Ostomy Skin Tool 2.0 was used to evaluate the peristomal skin and HRQoL was measured using the Dermatology Life Quality Index (DLQI) questionnaire. Data were analysed in mixed repeated-measures models.

RESULTS

A total of 79 adult participants (mean age 54.5 years, female 45.6%) were included in the intention-to-treat (ITT) population. A significant reduction in PSCs (P = 0.015) and HRQoL (P = 0.035) was found for the investigational product when compared with the comparator product. Also, significantly more study participants preferred the investigational product when compared with the comparator product (P = 0.017).

CONCLUSIONS

The investigational product, an ostomy baseplate with a skin-protective technology, reduced PSCs and improved the HRQoL of people living with a stoma with liquid faecal effluent. Consequently, the investigational product was the preferred ostomy appliance of the participants. Thus, the product investigated in this study may be a new solution to be included in everyday clinical practice to overcome leakage-induced PSCs for people living with a stoma.

Utilities associated with stoma-related complications: peristomal skin complications and leakages

AIM

Peristomal skin complications (PSCs) and leakages are major issues for people living with a stoma. The purpose of this study is to understand how these stoma-linked complications impact health-related quality of life (HRQoL) in a UK population.

MATERIALS AND METHODS

The study used time trade-off (TTO) methodology to quantify health state utilities associated with two stoma-related complications: PSC and leakages. Respondents assessed 10 different health states with different PSC severity levels (no, mild, moderate or severe PSC) and frequencies of leakage events (2, 12 or 48 leakages onto clothes per year, and no leakage due to a digital solution). The average disutility value for each health state was also assessed. The study was conducted via a web-based survey in the UK adult general population.

RESULTS AND LIMITATIONS

The analysis included 758 respondents. Respondents considered living with a stoma with no PSC to be more favorable than the other health states. Severe pain, itching and/or burning (PIB) was associated with the largest disutility compared to no PSC. The disutility (0-1 scale) compared to no PSC was 0.287 (p < .0001), 0.106 (p < .0001) and 0.025 (p=.0005) for PIB scores of 8, 5 and 2, respectively, on a 1-10 scale. More frequent leakage events were associated with lower utility. The utility decreases compared to no PSC were 0.114 (p < .0001), 0.057 (p < .0001) and 0.022 (p < .0001) for 48, 12 and 2 leakage events per year, respectively. The health state with a digital notification solution that notifies the user before a leakage event happens was considered as good as no PSC.

CONCLUSIONS

Experiencing mild, moderate, and severe levels of PSC or leakage onto clothes is associated with a significant reduction in HRQoL compared to no PSC and/or no leakage. Stoma appliances that reduce the skin complications or keep leakage from reaching the clothes are likely to improve HRQoL.

Perception of leakage: data from the Ostomy Life Study 2019

BACKGROUND

Leakage is a common problem for people with a stoma.

AIM

To investigate how people with a stoma and stoma care nurses perceive different patterns of effluent under the baseplate.

METHODS

The Ostomy Life Study 2019 included a user survey and a nurse survey covering experiences of leakage and the perception of leakage.

FINDINGS

Most people with a stoma perceived effluent reaching outside the baseplate as leakage (88-90%), whereas effluent close to the stoma only was not perceived as leakage by the majority (81-91%). Effluent covering major parts of the baseplate was perceived as leakage by most respondents with a colostomy or ileostomy (83%), whereas fewer respondents with a urostomy perceived this as leakage (57%). Most of the nurses (70%) did not perceive effluent close to the stoma as leakage.

CONCLUSION

This study revealed that effluent confined to the area next to the stoma is generally not perceived as leakage.

Factors predictive of optimal peristomal skin status in patients with an ostomy: a secondary analysis

Peristomal skin problems are common in ostomy patients and are connected to decreased quality of life and patient independence, as well as increased treatment costs. This study analysed the factors related to peristomal skin changes in order to better define the clinical profile of patients with optimal peristomal skin status. Secondary analysis of data from a nationwide, cross-sectional, retrospective, multicentre study performed in Spain (Uses and Attitudes in Ostomy) (Bueno Cruz et al, 2021) evaluated clinical data, including demographics, preoperative stoma site marking, type of ostomy, device used, frequency of leakage and scores from the Ostomy Skin Tool (OST) and quality of life (QoL) questionnaires. Risk factors for peristomal skin changes were analysed using multivariate analysis, and a predictive nomogram to anticipate optimal peristomal skin status (defined here as discolouration (D), erosion (E), and tissue overgrowth (T) (DET) score of 0) was developed. Some 871 patients with an ostomy using different commercial devices in Spain were evaluated. Multivariate analysis to predict optimal peristomal skin status revealed leakage frequency, patient age, type of ostomy, preoperative siting and type of baseplate used were independent predictors of peristomal skin status. Optimal peristomal skin care should be a treatment goal for nurse specialists in stomal therapy, and its individual influencing variables should be taken into account by nurses specialising in ostomy care.

Multinational survey on living with an ostomy: prevalence and impact of peristomal skin complications

BACKGROUND

Peristomal skin complications (PSCs) impair life for people with an ostomy. Visual signs of PSCs include discolouration, but sensation symptoms like pain, itching, and burning are equally important and underreported.

AIM

To provide improved understanding of PSC prevalence and associated challenges in the communities of ostomy patients and ostomy care nurses.

METHODS

The Ostomy Life Study 2019 encompassed a patient survey (completed by 5187 people with an ostomy) and a nurse survey (completed by 328 ostomy care nurses).

FINDINGS

In total, 88% of patients experienced PSCs and 75% experienced PSC symptoms in the absence of discolouration. Eighty per cent of nurses considered ostomy-related issues to be the main reason for PSCs, and a correlation between PSC severity and number of nurse consultations was demonstrated.

CONCLUSION

This study revealed a remarkably high PSC incidence in the absence of discolouration and highlighted direct consequences of having compromised skin and the health-economic consequences.

Peristomal Skin Health: A WOCN Society Consensus Conference

The Wound, Ostomy, and Continence Nurses (WOCN) Society identified the need to define and promote peristomal skin health. A task force was appointed to complete a scoping literature review, to develop evidence-based statements to guide peristomal skin health best practices. Based on the findings of the scoping review, the Society convened a panel of experts to develop evidence- and consensus-based statements to guide care in promoting peristomal skin health. These consensus statements also underwent content validation using a different panel of clinicians having expertise in peristomal skin health. This article reports on the scoping review and subsequent 6 evidenced-based statements, along with the generation and validation of 19 consensus-based statements, to assist clinical decision-making related to promoting peristomal skin health in adults.

The ostomy leak impact tool: development and validation of a new patient-reported tool to measure the burden of leakage in ostomy device users

BACKGROUND

Leakage is a major concern for people who use a stoma, but people's experience and its impact is not well understood. This study aimed to establish a definition of leakage through clinical and user input. This information was used to develop and validate a new measurement tool to understand the impact of leakage for people using a stoma appliance, in the UK, US, France, and Denmark.

METHODS

Participants were recruited from a panel of users, hosted by Coloplast, that includes people who currently use Coloplast products. Six clinicians and 41 users took part in concept elicitation interviews. The qualitative findings were used to draft items. A panel of clinical experts was organized to develop and validate items (N = 6). Cognitive debrief interviews were conducted with five users in each country, which resulted in removing some items and revising the measure. A psychometric validation was conducted with 340 people in four countries whereby participants were asked to complete a series of measures online. Full psychometric analyses including validity and reliability were conducted.

RESULTS

A final tool was established consisting of three domains related to the burden of leakage: "Emotional impact," "Usual and social activities," and "Coping and control." Convergent validity was evaluated by benchmarking to existing health-related quality of life instruments (domains of SF-36 and Ostomy-Q). This showed high correlation between domains of the leakage tool and other measures, in particular for the Emotional impact domain when compared with SF-36 Emotional well-being and Ostomy-Q Confidence domain (p < 0.001). Coping and control correlated moderately well with most PROs tested for except the physical functioning domains, which showed only modest correlation (p < 0.001). Usual and social activities correlated equally well with all domains. Internal consistency was high for Emotional impact and Usual and social activities (> 0.92).

CONCLUSION

The study highlights how users define leakage and its impact in a way that is meaningful to them. This information has been used to develop an instrument to measure leakage which can potentially be used by clinicians and researchers. The instrument demonstrated evidence supporting its reliability and validity as an outcome measure to assess the impact of leakage in stoma care.

Use of Convexity in Ostomy Care: Results of an International Consensus Meeting

Ostomy skin barriers that incorporate a convexity feature have been available in the marketplace for decades, but limited resources are available to guide clinicians in selection and use of convex products. Given the widespread use of convexity, and the need to provide practical guidelines for appropriate use of pouching systems with convex features, an international consensus panel was convened to provide consensus-based guidance for this aspect of ostomy practice. Panelists were provided with a summary of relevant literature in advance of the meeting; these articles were used to generate and reach consensus on 26 statements during a 1-day meeting. Consensus was achieved when 80% of panelists agreed on a statement using an anonymous electronic response system. The 26 statements provide guidance for convex product characteristics, patient assessment, convexity use, and outcomes.

[LSD score. A new classification system for peristomal skin lesions]

BACKGROUND

Peristomal skin lesions are frequent complications of ostomy; however, there is no generally accepted nomenclature and classification system.

OBJECTIVE

An interdisciplinary German expert panel (GESS) composed of ten members, developed an innovative semiquantitative classification system for peristomal skin lesions for further stratification of ostomy therapy. This score is based on criteria which can be assessed by stomal therapists and treating physicians.

RESULTS

The new peristomal skin lesion score grades three categories: lesion (L), status of ostomy (S) and disease (D). The L category describes the integrity of the skin as normal (L0), lesion with sustained integrity of skin (L1), integrity destroyed (L2) and local infection (L3). The S category rates the complexity of ostomy therapy as normal (S0), increased (S1) and high but not sufficiently effective (S2). The additional letters for categorization O. R. P. H. E. US describe anatomical pathologies of the stoma itself: ostomy stenosis (O), retraction (R), prolapse (P), hernia (H), edema (E) and unfavorable site (US). A systemic disorder is either absent (D0), irrelevant (D1) or relevant (D2). The LSD score is the basis for a management algorithm.

CONCLUSION

The LSD score is comprehensive, standardized and holistic. Its straightforward use by health professionals can improve the consistency of the description of skin lesions and enhance the quality of ostomy therapy.

Considering the benefits of a new stoma appliance: a clinical trial

For people living with a stoma, leakage is one of the main problems compromising quality of life. The right choice of stoma appliance is therefore of utmost importance. This randomised, controlled clinical trial investigated the benefits of a new stoma appliance, SenSura Mio Convex Soft, specifically for people who experience leakage using a flat stoma appliance. The degree of leakage under the baseplate was measured using a new objective method. The study included 38 participants with an ileostomy or colostomy. Results showed that while being flexible and comfortable, the new appliance reduced leakage significantly and provided a better feeling of security when compared with the participants' own flat stoma appliance. The product was the preferred of the convex stoma appliances in the study. This study demonstrated that it may be a solution for people with a stoma challenged by leakage using flat stoma appliances.

Peristomal skin complications are common, expensive, and difficult to manage: a population based cost modeling study

BACKGROUND

Peristomal skin complications (PSCs) are the most common post-operative complications following creation of a stoma. Living with a stoma is a challenge, not only for the patient and their carers, but also for society as a whole. Due to methodological problems of PSC assessment, the associated health-economic burden of medium to longterm complications has been poorly described.

AIM

The aim of the present study was to create a model to estimate treatment costs of PSCs using the standardized assessment Ostomy Skin Tool as a reference. The resultant model was applied to a real-life global data set of stoma patients (n = 3017) to determine the prevalence and financial burden of PSCs.

METHODS

Eleven experienced stoma care nurses were interviewed to get a global understanding of a treatment algorithm that formed the basis of the cost analysis. The estimated costs were based on a seven week treatment period. PSC costs were estimated for five underlying diagnostic categories and three levels of severity. The estimated treatment costs of severe cases of PSCs were increased 2-5 fold for the different diagnostic categories of PSCs compared with mild cases. French unit costs were applied to the global data set.

RESULTS

The estimated total average cost for a seven week treatment period (including appliances and accessories) was 263€ for those with PSCs (n = 1742) compared to 215€ for those without PSCs (n = 1172). A co-variance analysis showed that leakage level had a significant impact on PSC cost from 'rarely/never' to 'always/often' p<0.00001 and from 'rarely/never' to 'sometimes' p = 0.0115.

CONCLUSION

PSCs are common and troublesome and the consequences are substantial, both for the patient and from a health economic viewpoint. PSCs should be diagnosed and treated at an early stage to prevent long term, debilitating and expensive complications.