Cost-Effectiveness of Lorlatinib for the Treatment of Adult Patients with Anaplastic Lymphoma Kinase Positive Advanced Non-Small Cell Lung Cancer in Spain

Purpose

The objective of the present study was to evaluate the efficiency of lorlatinib compared to alectinib and brigatinib for the treatment of adult patients with anaplastic lymphoma kinase (ALK)-positive advanced non-small cell lung cancer (NSCLC) previously not treated, in Spain.

Methods

A partitioned survival model comprised progression free, non-intracranial progression, intracranial progression, and death health states was constructed to estimate the total costs, life-years gained (LYG) and quality-adjusted life years (QALYs) accumulated in a lifetime horizon. Overall survival (OS) and progression-free survival (PFS) for lorlatinib were obtained from the CROWN study. For alectinib and brigatinib, a network meta-analysis of randomized controlled trials was conducted to estimate OS and PFS hazard ratios versus crizotinib. Utilities were estimated based on EQ-5D-5L data derived from the CROWN (lorlatinib), ALEX (alectinib) and ALTA-1L (brigatinib) studies. According to the Spanish National Health Service perspective the total costs (expressed in euros using a 2021 cost year) included drug acquisition and the administration's subsequent treatment, ALK+ advanced NSCLC management and adverse-event management, and palliative care. Unitary costs were obtained from local cost databases and literature. Costs, LYGs and QALYs were discounted at 3% annually. Deterministic and probabilistic sensitivity analyses were used to test the model's robustness.

Results

Lorlatinib provided higher health outcomes (+0.70 LYG/patient, +1.42 QALYs/patient) and lower costs (-€9239/patient) than alectinib. Lorlatinib yielded higher LYG (+1.74) and QALYs (+2.30) versus brigatinib but higher costs/patient (+€36,627), resulting in an incremental-cost-effectiveness-ratio of €15,912/QALY gained.

Conclusion

The results of this study suggest that lorlatinib may be a dominant treatment option versus alectinib. Considering a willingness-to-pay threshold of €25,000/QALY, lorlatinib may be an efficient option compared to brigatinib.

Cost‑Effectiveness of Lorlatinib in First-Line Treatment of Adult Patients with Anaplastic Lymphoma Kinase (ALK)‑Positive Non‑Small‑Cell Lung Cancer in Sweden

BACKGROUND

We aimed to investigate the cost effectiveness of lorlatinib, a third-generation anaplastic lymphoma kinase (ALK) tyrosine kinase inhibitor (TKI), used first-line in Sweden to treat patients with ALK-positive (ALK+) non-small cell lung cancer (NSCLC). In January 2022, the European Medicines Agency (EMA) extended its approval of lorlatinib to include adult patients with ALK+ NSCLC not previously treated with an ALK inhibitor. Extended first-line approval was based on results from CROWN, a phase III randomized trial that enlisted 296 patients randomized 1:1 to receive lorlatinib or crizotinib. Our analysis compared lorlatinib against the first-generation ALK-TKI crizotinib, and second-generation ALK TKIs alectinib and brigatinib.

METHODS

A partitioned survival model with four health states [pre-progression, non-intracranial (non-central nervous system [CNS]) progression, CNS progression, and death] was constructed. The progressed disease state (which is typically modelled in cost-effectiveness analyses of oncology treatments) was explicitly separated into non-CNS and CNS progression as brain metastases, which are common in NSCLC, and can have a large impact on patient prognosis and health-related quality of life. Treatment effectiveness estimates in the lorlatinib and crizotinib arms of the model were derived from CROWN data, while indirect relative effectiveness estimates for alectinib and brigatinib were informed using network meta-analysis (NMA). Utility data were derived from the CROWN study in the base case, and cost-effectiveness results were compared when applying UK and Swedish value sets. Costs were obtained from Swedish national data. Deterministic and probabilistic sensitivity analyses were conducted to test model robustness.

RESULTS

Fully incremental analysis identified crizotinib as the least costly and least effective treatment. Brigatinib was extendedly dominated by alectinib and, subsequently, alectinib was extendedly dominated by lorlatinib. Lorlatinib was associated with an incremental cost-effectiveness ratio (ICER) of Swedish Krona (SEK) 613,032 per quality-adjusted life-year (QALY) gained compared with crizotinib. Probabilistic results were generally consistent with deterministic results, and one-way sensitivity identified NMA HRs, alectinib and brigatinib treatment duration, and the CNS-progressed utility multiplier as key model drivers.

CONCLUSIONS

The ICER of SEK613,032 for lorlatinib versus crizotinib falls below the typical willingness-to-pay threshold per QALY gained for high-severity diseases in Sweden (approximately SEK1,000,000). Furthermore, as brigatinib and alectinib were extendedly dominated in the incremental analysis, the results of our study indicate that lorlatinib may be considered a cost-effective treatment option for first-line patients with ALK+ NSCLC in Sweden when compared with crizotinib, alectinib, and brigatinib. Longer-term follow-up data for endpoints informing treatment effectiveness for all first-line treatments would help to reduce uncertainty in the findings.

Cost-effectiveness of imipenem/cilastatin/relebactam for hospital-acquired and ventilator-associated bacterial pneumonia

Aim: This study evaluates the cost-effectiveness of imipenem/cilastatin/relebactam (IMI/REL) for treating hospital-acquired bacterial pneumonia and ventilator-associated bacterial pneumonia (HABP/VABP) in an 'early adjustment prescribing scenario'. Methods: An economic model was constructed to compare two strategies: continuation of empiric piperacillin/tazobactam (PIP/TAZ) versus early adjustment to IMI/REL. A decision tree was used to depict the hospitalization period, and a Markov model used to capture long-term outcomes. Results: IMI/REL generated more quality-adjusted life years than PIP/TAZ, at an increased cost per patient. The incremental cost-effectiveness ratio of $17,529 per QALY is below the typical US willingness-to-pay threshold. Conclusion: IMI/REL may represent a cost-effective treatment for payers and a valuable option for clinicians, when considered alongside patient risk factors, local epidemiology, and susceptibility data.

Cost-Effectiveness of Imipenem/Cilastatin/Relebactam Compared with Colistin in Treatment of Gram-Negative Infections Caused by Carbapenem-Non-Susceptible Organisms

INTRODUCTION

Imipenem/cilastatin/relebactam (IMI/REL), a combination β-lactam antibiotic (imipenem) with a novel β-lactamase inhibitor (relebactam), is an efficacious and well-tolerated option for the treatment of hospitalized patients with gram-negative (GN) bacterial infections caused by carbapenem-non-susceptible (CNS) pathogens. This study examines cost-effectiveness of IMI/REL vs. colistin plus imipenem (CMS + IMI) for the treatment of infection(s) caused by confirmed CNS pathogens.

METHODS

We developed an economic model comprised of a decision-tree depicting initial hospitalization, and a Markov model projecting long-term health and economic impacts following discharge. The decision tree, informed by clinical data from RESTORE-IMI 1 trial, modeled clinical outcomes (mortality, cure rate, and adverse events including nephrotoxicity) in the two comparison scenarios of IMI/REL versus CMS + IMI for patients with CNS GN infection. Subsequently, a Markov model translated these hospitalization stage outcomes (i.e., death or uncured infection) to long-term consequences such as quality-adjusted life years (QALYs). Sensitivity analyses were conducted to test the model robustness.

RESULTS

IMI/REL compared to CMS + IMI demonstrated a higher cure rate (79.0% vs. 52.0%), lower mortality (15.2% vs. 39.0%), and reduced nephrotoxicity (14.6% vs. 56.4%). On average a patient treated with IMI/REL vs. CMS + IMI gained additional 3.7 QALYs over a lifetime. Higher drug acquisition costs for IMI/REL were offset by shorter hospital length of stay and lower AE-related costs, which result in net savings of $11,015 per patient. Sensitivity analyses suggested that IMI/REL has a high likelihood (greater than 95%) of being cost-effective at a US willingness-to-pay threshold of $100,000-150,000 per QALY.

CONCLUSIONS

For patients with confirmed CNS GN infection, IMI/REL could yield favorable clinical outcomes and may be cost-saving-as the higher IMI/REL drug acquisition cost is offset by reduced nephrotoxicity-related cost-for the US payer compared to CMS + IMI.

631. Economic Analysis of Imipenem/Cilastatin/Relebactam Compared to Piperacillin/Tazobactam for Treating Hospital-Acquired and Ventilator-Associated Bacterial Pneumonia

Background

Hospital-acquired and ventilator-associated bacterial pneumonia (HABP/VABP) is associated with high rates of morbidity and mortality; this is often worse among patients who experience a delay in receiving appropriate therapy. Initial treatment choice and early adjustment occurs prior to pathogen susceptibility results and may be based on suspicion of a resistant infection and/or clinical deterioration. This study assesses the cost effectiveness of Imipenem/cilastatin/relebactam (IMI/REL) in an early adjustment prescribing scenario compared to PIP/TAZ for patients with high risk of resistant infection from a US perspective.

Methods

Although early adjustment data was not directly available, pathogen susceptibility data derived from 2017-19 Study for Monitoring Antimicrobial Resistance Trends (SMART) surveillance program was applied to estimate patients who may have clinical worsening, likely due to a resistant infection. The efficacy and safety data for IMI/REL and PIP/TAZ were informed by the modified intent-to-treat population of a phase III trial (RESTORE-IMI 2). Our analysis comprised a decision tree (reflecting hospitalization period) followed by a yearly Markov model (capturing lifetime impact). The decision tree captured short-term outcomes (clinical cure, all-cause mortality, and hospital resource use). The Markov model translated short term outcomes into quality-adjusted life years (QALYs). Results were expressed as an incremental cost-effectiveness ratio (ICER). Sensitivity analyses were conducted to test the robustness of model results.

Results

Compared with PIP/TAZ, IMI/REL in the early adjustment setting was associated with increased costs (&10,087 per patient) but a higher cure (+7%) and lower mortality (-3%) rate. The resulting ICER (&12,173/QALY) falls well below typical US willingness to pay thresholds. Model drivers were the SMART-based susceptibility profiles and RESTORE-IMI 2 response and mortality rates.

Conclusion

Our results suggest that IMI/REL, used as an early adjustment option, could be considered cost effective for patients with worsening HABP/VABP in a US setting, when compared against PIP/TAZ.

Disclosures

Jaesh Naik, MSc, BresMed Health Solutions (Employee) Lewis Ralph, MSc, Bresmed (Employee) Ryan J. Dillon, MSc, Merck & Co. Inc., (Employee, Shareholder) Joe Yang, Ph.D., Merck & Co (Employee)

Bridging the age gap in breast cancer: impact of omission of breast cancer surgery in older women with oestrogen receptor-positive early breast cancer on quality-of-life outcomes

BACKGROUND

Primary endocrine therapy may be an alternative treatment for less fit women with oestrogen receptor (ER)-positive breast cancer. This study compared quality-of-life (QoL) outcomes in older women treated with surgery or primary endocrine therapy.

METHODS

This was a multicentre, prospective, observational cohort study of surgery or primary endocrine therapy in women aged over 70 years with operable breast cancer. QoL was assessed using European Organisation for Research and Treatment of cancer QoL questionnaires QLQ-C30, -BR23, and -ELD14, and the EuroQol Five Dimensions 5L score at baseline, 6 weeks, and 6, 12, 18, and 24 months. Propensity score matching was used to adjust for baseline variation in health, fitness, and tumour stage.

RESULTS

The study recruited 3416 women (median age 77 (range 69-102) years) from 56 breast units. Of these, 2979 (87.2 per cent) had ER-positive breast cancer; 2354 women had surgery and 500 received primary endocrine therapy (125 were excluded from analysis due to inadequate data or non-standard therapy). Median follow-up was 52 months. The primary endocrine therapy group was older and less fit. Baseline QoL differed between the groups; the mean(s.d.) QLQ-C30 global health status score was 66.2(21.1) in patients who received primary endocrine therapy versus 77.1(17.8) among those who had surgery plus endocrine therapy. In the unmatched analysis, changes in QoL between 6 weeks and baseline were noted in several domains, but by 24 months most scores had returned to baseline levels. In the matched analysis, major surgery (mastectomy or axillary clearance) had a more pronounced adverse impact than primary endocrine therapy in several domains.

CONCLUSION

Adverse effects on QoL are seen in the first few months after surgery, but by 24 months these have largely resolved. Women considering surgery should be informed of these effects.

Cost Effectiveness of Ceftolozane/Tazobactam Compared with Meropenem for the Treatment of Patients with Ventilated Hospital-Acquired Bacterial Pneumonia and Ventilator-Associated Bacterial Pneumonia

Introduction

The clinical efficacy and safety of ceftolozane/tazobactam for the treatment of ventilated hospital-acquired bacterial pneumonia (vHABP) and ventilator-associated bacterial pneumonia (VABP) has been demonstrated in the phase III randomised controlled trial ASPECT-NP. However, there are no published data on the cost-effectiveness of ceftolozane/tazobactam for vHABP/VABP. These nosocomial infections are associated with high rates of morbidity and mortality, and are increasingly complicated by growing rates of resistance and the inappropriate use of antimicrobials. This study is to assess the cost-effectiveness of ceftolozane/tazobactam compared with meropenem for the treatment of vHABP/VABP in a US hospital setting.

Methods

A short-term decision tree followed by a long-term Markov model was developed to estimate lifetime costs and quality-adjusted life-years associated with ceftolozane/tazobactam and meropenem in the treatment of patients with vHABP/VABP. Pathogen susceptibility and clinical efficacy were informed by the Program to Assess Ceftolozane/Tazobactam Susceptibility (PACTS) database and ASPECT-NP, respectively. A US healthcare sector perspective was adopted, capturing direct costs borne by third-party payers or integrated health systems, and direct health effects for patients.

Results

In the confirmed treatment setting (post-susceptibility results), the incremental cost-effectiveness ratio for ceftolozane/tazobactam compared to meropenem was US$12,126 per quality-adjusted life-year (QALY); this reduced when used in the early treatment setting (before susceptibility results) at $4775/QALY.

Conclusion

Ceftolozane/tazobactam represents a highly cost-effective treatment option for patients with vHABP/VABP versus meropenem when used in either the confirmed or early treatment setting; with increased cost-effectiveness shown in the early setting.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40121-021-00436-4.

Bridging the age gap in breast cancer: cluster randomized trial of two decision support interventions for older women with operable breast cancer on quality of life, survival, decision quality, and treatment choices

BACKGROUND

Rates of surgery and adjuvant therapy for breast cancer vary widely between breast units. This may contribute to differences in survival. This cluster RCT evaluated the impact of decision support interventions (DESIs) for older women with breast cancer, to ascertain whether DESIs influenced quality of life, survival, decision quality, and treatment choice.

METHODS

A multicentre cluster RCT compared the use of two DESIs against usual care in treatment decision-making in older women (aged at least ≥70 years) with breast cancer. Each DESI comprised an online algorithm, booklet, and brief decision aid to inform choices between surgery plus adjuvant endocrine therapy versus primary endocrine therapy, and adjuvant chemotherapy versus no chemotherapy. The primary outcome was quality of life. Secondary outcomes included decision quality measures, survival, and treatment choice.

RESULTS

A total of 46 breast units were randomized (21 intervention, 25 usual care), recruiting 1339 women (670 intervention, 669 usual care). There was no significant difference in global quality of life at 6 months after the baseline assessment on intention-to-treat analysis (difference -0.20, 95 per cent confidence interval (C.I.) -2.69 to 2.29; P = 0.900). In women offered a choice of primary endocrine therapy versus surgery plus endocrine therapy, knowledge about treatments was greater in the intervention arm (94 versus 74 per cent; P = 0.003). Treatment choice was altered, with a primary endocrine therapy rate among women with oestrogen receptor-positive disease of 21.0 per cent in the intervention versus 15.4 per cent in usual-care sites (difference 5.5 (95 per cent C.I. 1.1 to 10.0) per cent; P = 0.029). The chemotherapy rate was 10.3 per cent at intervention versus 14.8 per cent at usual-care sites (difference -4.5 (C.I. -8.0 to 0) per cent; P = 0.013). Survival was similar in both arms.

CONCLUSION

The use of DESIs in older women increases knowledge of breast cancer treatment options, facilitates shared decision-making, and alters treatment selection. Trial registration numbers: EudraCT 2015-004220-61 (https://eudract.ema.europa.eu/), ISRCTN46099296 (http://www.controlled-trials.com).

2200. Cost-effectiveness of Ceftolozane/Tazobactam for Treating Ventilated Nosocomial Bacterial Pneumonia

Background

Ventilated, hospital-acquired and ventilator-associated bacterial pneumonia (vHABP/VABP) are associated with high rates of antibiotic resistance and high morbidity and mortality in hospitalized patients. Ceftolozane/tazobactam (C/T) has shown non-inferiority to meropenem for treating HABP/VABP in a Phase III trial, ASPECT-NP. This study evaluates cost-effectiveness of C/T against meropenem in treating HABP/VABP.

Methods

We developed a model consisting of a short-term decision tree (reflecting the in-hospital period) followed by a long-term Markov structure (capturing lifetime costs and outcomes). Patient characteristics and clinical efficacy were informed by subjects in ASPECT-NP who received any dose of study drugs. Susceptibility was based on the Program to Assess C/T Susceptibility surveillance database. Second-line and salvage treatment were added to resemble real-world treatment patterns and used to calculate overall clinical cure and mortality rates based on results from a network meta-analysis. We analyzed two clinical scenarios: (1)”confirmed treatment’ in which C/T or meropenem is used after pathogen susceptibility is known; (2) ‘initial treatment’ of high-risk patients before susceptibility is known. Model outcomes include, percentage clinically cured, short-term mortality, direct medical costs, quality-adjusted life years (QALYs), and incremental cost-effectiveness ratios. Sensitivity analyses (SAs) were conducted to test the robustness of results.

Results

In the confirmed treatment setting, C/T had a higher cure rate (5.0 percentage points, the same below), lower short-term mortality (−5.1%), cost more ($2,728), and yielded higher lifetime QALYs (0.61) than meropenem ($4,472/QALY gained). In the initial treatment setting, C/T sustained a better clinical performance (9.5% more cure, −6.8% mortality, 1.16 more QALYs), yet cost less than meropenem (−$5,662) due to better susceptibility. The response and mortality rates from ASPECT-NP had the greatest impact on results. SAs showed that the result of C/T being cost-effective over meropenem was generally robust.

Conclusion

The results indicate that, compared with meropenem, C/T could be a cost-effective option for patients with vHABP/VABP in the US setting.

Disclosures

All authors: No reported disclosures.

The Effect of Six Different Statins on the Proliferation, Migration, and Invasion of Human Smooth Muscle Cells

Intimal hyperplasia (IH) can occur after any vascular injury and results from smooth muscle cells (SMC) proliferation, migration, and invasion into the subintimal space. The purpose of this study was to investigate the effect of six different statins on the proliferation, migration, and invasion of human venous SMC. The statins were all used at their Cmax concentrations. SMCs were used to construct growth curves in the presence of 10% fetal calf serum or 10% fetal calf serum supplemented with the six statins. Migration and invasion experiments were performed using modified Boyden chambers. The invasion experiments were performed using Matrigel coated plates. We found that all of the statins significantly inhibited SMC proliferation compared to the platelet-derived growth factor control (ranging from fluvastatin 33% of control to pravastatin 72% of control, P = 0.03). SMC migration through uncoated polycarbonate membranes in presence of the six statins was significantly reduced (ranging from lovastatin 43% to pravastatin 57% of control, P = 0.006). All six statins also significantly reduced SMC invasion (ranging from fluvastatin 65% to simvastatin 87% of control, P = 0.002). We conclude that the inhibitory effect of statins on SMC proliferation, migration, and invasion is a class, rather than drug specific effect.

A Comparison of Six Statins on the Development of Intimal Hyperplasia in a Human Vein Culture Model

OBJECTIVE

Intimal hyperplasia (IH) threatens the patency of up to 35% of saphenous vein (SV) bypass grafts. In addition to reducing cholesterol levels, statins may modulate smooth muscle cell proliferation and migration. Statins inhibit matrix metalloproteinase (MMP) activity. We therefore investigated the effect of six statins on neointimal formation and MMP activity in human SV organ culture.

STUDY DESIGN

Human SV specimens were cultured for 14 days in the presence of six different statins and subsequently processed for measurement of neointimal thickness and MMP activity. The drug concentrations chosen corresponded to the manufacturers' Cmax.

RESULTS

The six statins all significantly reduced IH development (P = 0.004) in association with reduced expression of proMMP-2 and 9 (P = 0.03) and reduced activity of activated MMP-2 and 9 (P = 0.03).

CONCLUSION

This study suggests that the potential benefit of statins in reducing IH is a class effect and not confined to specific statins. The reduction of IH produced by statins may in part be due to their inhibition of MMPs.

The diagnosis and management of 689 chronic leg ulcers in a single-visit assessment clinic

OBJECTIVES

accurate diagnosis is essential if patients with chronic leg ulceration are to receive optimal treatment. This prospective study describes the findings of a standardised assessment protocol and the initial management of a consecutive series of patients with chronic leg ulceration presenting to a single-visit leg ulcer assessment clinic.

METHODS

between January 1993 and January 1999, a total of 555 patients (220 men and 335 women of median age 73, range 28-95 years) with 689 chronic leg ulcers were assessed. Full clinical assessment, ankle:brachial pressure index and lower limb venous duplex scan were performed according to a standardised protocol and diagnostic and management data were recorded prospectively on a computerised database.

RESULTS

venous disease alone was responsible for 496 of 689 (72%) ulcers. Isolated superficial venous reflux (SVR) was identified in 52% of limbs and two-thirds of these had superficial venous surgery. Combined SVR and segmental deep venous reflux (DVR) was present in 13%, and full-length DVR was present in 33% of limbs. Nineteen (4%) limbs had deep venous stenosis or obstruction. Overall, superficial venous surgery was performed in 43% and compression bandages or hosiery alone were applied in 52% of limbs. Mixed arterio-venous ulceration was present in 100 (14.5%) limbs of which 56 had arterial revascularisation, 38 had superficial venous surgery and 23 had compression alone. Fifteen limbs with pure arterial ulceration had angioplasty (n=13) or simple dressings alone (n=2). Ulceration due to lymphoedema (n=17), mixed lymphoedema and venous reflux (n=11) and other causes (n=50) were managed by compression, dressings or skin grafting.

CONCLUSIONS

a standardised protocol of clinical and duplex assessment can lead to a diagnosis in 97% of chronic leg ulcers. Duplex is essential to confirm or exclude potentially correctable venous disease and allow tailored surgical intervention for those patients who many benefit.

Lower limb ulceration: a detailed study of aetiology in 555 patients

Background

The purpose of the study was to investigate the aetiology of lower limb ulceration.

Methods

The aetiology of lower limb ulceration was reviewed in 555 patients with 689 ulcerated limbs referred to a single-visit leg ulcer clinic.

Results

The mean age of the patients was 70 (range 27–95) years and 335 (60 per cent) were women. The aetiology of the ulceration in 689 limbs was venous in 496 (72 per cent), arterial in 14 (2 per cent), mixed venous and arterial in 101 (15 per cent), with other causes in 78 (11 per cent). Of the 496 venous ulcers, 261 (53 per cent) had isolated superficial reflux, 233 (47 per cent) had deep venous reflux, of which 165 (71 per cent) had full-length and 68 (29 per cent) segmental reflux, and two patients had isolated perforator reflux. Deep venous obstruction was present in 16 limbs (3 per cent) with venous ulcers and 14 of these demonstrated continuous flow in the long saphenous vein (LSV). Of the 261 ulcerated legs with isolated superficial reflux, 197 (75 per cent) had LSV reflux only, 22 (8 per cent) had short saphenous vein (SSV) reflux only and 41 (16 per cent) had combined LSV and SSV reflux. Of those with LSV reflux, 65 per cent had a medial malleolar ulcer and 20 per cent had a lateral malleolar lesion. Of those with SSV reflux, 62 per cent had a lateral malleolar ulcer and 38 per cent had a medial malleolar ulcer.

Conclusion

Half of the ulcerated legs have superficial venous reflux; these combined with the superficial and segmental deep venous reflux group comprise the 65 per cent of patients who may benefit from superficial venous surgery. Continuous flow in the LSV should alert the clinician to deep venous obstruction, in which circumstance compression therapy should be used with extreme caution. Duplex is central to the investigation of the ulcerated leg.

The clinical management and outcome of venous ulcers in legs with deep-venous obstruction

OBJECTIVE

as a result of a serious complication from compression bandaging in a patient with venous ulceration and deep-vein obstruction, a policy of incremental compression in such limbs has been developed. The purpose of this retrospective study is to review the outcome of this policy.

DESIGN

limbs with deep-venous obstruction (stenosis or occlusion) were treated initially with 3-layer compression bandaging and reviewed 24 h later. If 3-layer bandaging was tolerated, it was re-applied for a further 48 h. If there were no problems, then 4-layer bandaging was applied and the patient reviewed at 24 and 72 h. If 4-layer bandaging could not be tolerated, the limb was returned to 3-layer bandaging.

RESULTS

of 325 limbs seen in a venous-ulcer clinic, 22 (7%) had deep-vein obstruction. Fifteen (68%) limbs were able to tolerate 4-layer bandaging, five (23%) could tolerate 3-layer bandaging and two limbs (9%) could only tolerate class 2 compression hosiery. The overall 1-year healing rate was 55%. There were no serious complications from bandaging.

CONCLUSIONS

a protocol of incremental compression bandaging is safe in ulcerated legs with deep-vein obstruction and produces healing in up to 55% of cases.