1. Introduction
A chronic wound is a skin injury that fails to proceed through the normal skin repair response [
1]. Due to their protracted healing time, chronic wounds give rise to major costs and resource consumption in health care systems. Pressure injuries (PI) and lower-extremity ulcers (LU) of venous (VLU), ischaemic (IU) or neuropathic aetiology—in the latter case, specifically diabetic foot ulcers (DFU)—overburden community nurses who provide the associated care for patients and family members in clinics and at home [
2,
3].
Chronic wounds have a great impact on quality of life [
4]. Various national health systems now include the implementation of good PI management practices among their patient-safety strategies [
5]. However, there are no standardised epidemiological indicators for chronic wound management. Incidence and prevalence data are scarce or nonexistent in community settings, in contrast to hospitals and nursing homes [
6,
7]. This lack of epidemiological information is compounded by the disparate methods used and results obtained in studies conducted at the community level [
8].
Studies on PI prevalence have reported diverse results ranging from 0.031% to 0.11% in the general population and from 6.7% to 12.6% in the population receiving home care [
9,
10,
11,
12,
13,
14]. Studies of LU have attempted to measure prevalence; however, as with other chronic wounds, the varying methods used, and results obtained, render it difficult to establish a value that can be extrapolated beyond the study population. These studies have included different populations (community, nursing home and hospital), various data collection methods and assorted aetiologies. In studies included in a 2019 meta-analysis, LU prevalence ranged between 0.04% and 0.70% [
8].
Another meta-analysis conducted in 2003 observed a prevalence of VLU between 0.12% and 0.32% and concluded that due to differences in the study populations, it was inappropriate to group the prevalence rates reported in the various studies [
15]. Subsequently, other prevalence studies have been published that share characteristics with lower-extremity ulcer studies, reporting results that range from 0.01% to 0.09% [
7,
12,
16,
17,
18,
19,
20].
Chronic wound studies have included the prevalence of DFU in the community. DFU account for approximately 13% of all chronic wounds, a lower percentage than PI or LU [
21]. In 2017, Zhang et al. [
22] analysed the global prevalence in all types of population and found that men and patients with diabetes mellitus type 2 presented a higher number of cases. They also observed substantial differences between continents (ranging from 13% in North America to 3% in Oceania) and estimated a community prevalence of 2.9% in people with diabetes.
Other studies that have analysed chronic wounds in the community setting with different methodologies show higher prevalence data, ranging between 3.7% and 11.8% [
23,
24,
25].
These widely varying results in the literature hinder extrapolation of the data to other epidemiological assessment systems and thus would hamper the assessment of community care models for people with chronic wounds. Consequently, it is necessary to determine the prevalence of chronic wounds at the local level in different health care systems. This would provide a rationale for conducting further large-scale epidemiological studies in the community.
The aim of the present study was to determine the prevalence of chronic wounds in the community in the south of the province of Barcelona, exploring the demographic and clinical profile of patients with these wounds.
4. Discussion
The aim of our study was to determine the prevalence of chronic wounds due to the lack of recent data on primary care settings in Spain, finding an observed prevalence of 0.11%. By aetiology, VLU presented the highest prevalence, of 0.04%, followed by PI, of 0.03%. Patients aged 75 or more were the most prevalent in wound treatment in primary care, accounting for 69.4% of cases. Among treated patients, this age group contained the highest frequency of PI (76.3%, n = 180), VLU (63.6%, n = 182) and LEUUA (70.5%, n = 62).
Only one study has analysed the prevalence of all chronic wounds in community settings in Spain [
16], in contrast to the more frequent, up-to-date studies published on the prevalence of chronic wounds in hospitalised patients or nursing home residents.
Our results are comparable to those reported in other community studies applying a diverse range of methods. Our total prevalence of chronic wounds was 0.11%, similar to that found in Helsinki (0.10% in 2008 and 0.08% in 2016) [
21] and in Ireland (0.10% in 2014) [
10]. Three studies conducted in the UK have also reported similar results (0.09%–0.15%) [
7,
12,
33].
The prevalence of PI in our study was 0.03% across the population and 0.23% in people aged over 64 years old. This result is similar to the findings reported in other community studies conducted across Europe [
10,
11,
12,
34].
In Spain, the most recent study on PI prevalence [
13] reported a prevalence of 0.05% in the adult population, 0.27% in people aged over 65 years and 6.11% in patients treated at home. These figures are similar to those found in our study, with the exception of the results for people treated at home, since we observed a prevalence of 2.42%. With regard to the other PI characteristics, both the most frequent stage (stage 2, 43.7%) and the most frequent locations (sacrum, heel, foot, trochanter and gluteus) coincide with the results obtained in most published studies [
11,
13,
20,
34]. The percentage of patients in our study using pressure relief surfaces was lower (45%) than that reported in other studies (51%) [
20].
In our study, the prevalence of VLU in the adult population, in people aged over 65 years and by sex was similar to the results obtained in other studies. For example, Hall and Srinivasaiah [
12,
20] estimated a prevalence of approximately 0.04% in the total population. Studies conducted closer to our study area have found similar distributions adjusted by sex and higher frequencies, ranging between 0.07% and 0.09% [
16,
17,
19]. Other studies have reported a lower prevalence, from 0.01% to 0.03% [
7,
18]. The use of compression therapy in our study was low (19.9%) compared with the results obtained in previous studies (50%) [
10,
20]. Of particular note is the use of compression therapy in 14.8% of LU not diagnosed as venous.
In relation to LU, it was necessary to pool our results for VLU, IU, PI and LEUUA in order to compare them with those of other studies. The percentage of LU with respect to total wounds identified was 77%, higher than the 60% estimated in other studies [
10,
21]. The prevalence of LU was 0.06% (
n = 411), similar to that reported by Ahmajärvi [
21], but higher than the figures given in other studies, which have ranged from 0.04% to 0.05% [
12,
18,
29,
33,
35], and lower than the 0.15% reported in the meta-analysis by Martinengo [
8]. The very high figure found in this meta-analysis may have been due to the inclusion of a one-year cumulative prevalence study [
36], which differed from our study design.
The prevalence of DFU was 0.01% in the total population and 0.16% in the population with diabetes, prompting caution with regard to reliability. This prevalence is similar to that reported in other, nonspecific studies on DFU, which have found prevalence ranging between 0.01% and 0.03% in the total population, and similar percentages of DFU with respect to the total of chronic wounds (13.5%) [
10,
12,
16,
21]. However, it is not possible to compare our results with those of more specific studies of DFU due to differences in the methods used and outcome variable studied. Some studies have reported a cumulative prevalence ranging between 0.08% and 2.9% in the population with diabetes [
22,
36,
37,
38,
39]. These data confirm that patients with DFU present a different demographic and clinical profile to that of all other cases of chronic wounds, since these ulcers are more prevalent in men, occur at an earlier age of onset and have a smaller surface area [
22]. Knowledge of the age of onset of the different chronic wounds would be useful to tailor preventive measures to age groups with a higher prevalence.
In our study, and in the majority of the literature, the frequency of ulcers is higher in women than men [
12,
23,
24,
33,
36]. Our view is that such sex differential reflects the population pyramid in our country and across Europe. As women generally have a longer life expectancy, there are disproportionately represented in the over-65-years age stratum [
40]. The higher the number of people over 65 years, the higher the number of chronic wounds. We adjusted the prevalence by sex, with a total prevalence of 0.10 in men and 0.12% in women.
When analysing the aetiology, a higher prevalence of LU was found in women (0.06%), which resonates with the published data [
16,
17,
18,
19]. Prevalence of DFU and IU was higher in men, which may be due to the relationship of this type of wound with cardiovascular risk, which is greater in men, and the fact they appear at younger ages [
22,
38,
41].
Differences in results between studies are often attributed to methodological variability [
10,
12,
13,
21,
42]. However, it is less common to cite this variability when the results are similar. Consequently, we suggest the need to develop standardised protocols for epidemiological studies of chronic wounds in the community in order to enable subsequent reliable comparisons.
One of the strengths of our study was that it was conducted within the context of a universal health care system with the participation of all Institut Català de la Salut primary care centres in the region, and it included the majority of patients receiving some type of health care. The percentage of people being treated increased with age, and this helped minimise selection bias in the age group with the highest prevalence of chronic wounds.
With regard to the implications for professional practice, our data could help inform the redesign of community health care models for patients with chronic wounds, facilitating a reduction in costs [
2,
3] and use of resources [
11], and improve quality of life indicators [
6].
Our results indicate the need to increase the use of alternating air pressure surfaces for PI and compression therapy for VLU. It would also be helpful to establish a network of nurses specialising in chronic wounds in primary care to support primary care teams and coordinate with hospital specialists in chronic wounds, in order to achieve integrated, effective and efficient health care.
Limitations
This study also presents some limitations. For example, our sample did not include patients who did not attend their assigned public health care centres, because they received treatment either in nursing homes, in private institutions or exclusively in hospitals, and this may have led to an underestimation of the real prevalence in nonresidential community settings. With regard to the diagnostic process, it should also be borne in mind that this was based on the clinical opinion of the primary care team, and in many instances, the diagnosis was not subject to specialist assessment. Another possible limitation that might have affected the data obtained for DFU was a lack of awareness among professionals of the diagnostic process for these ulcers because the Diabetic Foot Hospital Unit did not exist at the time of the study and was only created later that same year.