Underprovision of Medical Compression Therapy: Retrospective Analysis Based on Statutory Health Insurance Data on Venous Leg Ulcers, Chronic Venous Disease and Comorbidities

ABSTRACT

Chronic venous diseases (CVD), including venous leg ulcers (VLU), represent a significant health burden. Despite the central role of compression therapy in current treatment guidelines, recent evidence suggests substantial gaps in provision. A retrospective cohort study was conducted using anonymized claims data from 3.35 million insured individuals. Persons with VLU or CVD in 2017 were observed over 5 years. Compression therapy, comorbidities, antibiotic prescriptions, and physician contacts were analysed. The prevalence was 0.50% for VLU (n = 16 615) and 7.27% for CVD (n = 243 681). Across 5 years, 75.85% (VLU) and 53.10% (CVD) received compression therapy. However, 24.15% of persons with VLU were not treated with compression therapy. Persons receiving compression were predominantly female and older (VLU: 74.13 years, 59.56% women; CVD: 68.55 years, 70.86% women), exhibited a higher mean Charlson Comorbidity Index (CCI [95% CI]: VLU 4.09 [4.03–4.15], CVD 2.67 [2.65–2.68] vs. VLU 3.14 [3.05–3.23], CVD 2.12 [2.11–2.14] without compression). In the first year post‐diagnosis, 51.43% VLU persons with compression received antibacterials (vs. 36.28%). The data confirm prior estimates of disease prevalence and highlight a substantial gap in the documented use of guideline‐compliant compression therapy, especially in VLU. High multimorbidity and care intensity underscore the need for better integration of compression therapy in routine practice.

Key Points

• Compression therapy remains underutilised in persons with venous leg ulcers and chronic venous disease despite guideline recommendations.

• Nearly one in four persons with VLU had no documented compression therapy during follow‐up.

• Persons with VLU receiving compression therapy had a higher comorbidity burden and higher healthcare utilisation than those without documented compression therapy.

• The findings highlight the need for improved implementation of guideline‐recommended compression therapy in routine care.

1. Introduction

Chronic venous diseases (CVD) are one of the most common vascular disorders in industrialised countries and comprise a broad spectrum ranging from varicose veins and edema to chronic venous insufficiency (CVI) and venous leg ulcers (VLU). VLU represent the most severe form of CVI [1] and are associated with pain [2], impaired quality of life, prolonged treatment, and substantial healthcare utilisation [3].

Compression therapy, including medical compression stockings, compression bandages, and intermittent pneumatic compression, is a key component of guideline‐recommended treatment for both CVD and VLU [4]. Its clinical efficacy in symptom relief, ulcer healing, and recurrence prevention is well documented in numerous trials and meta‐analyses [5, 6]. Nevertheless, previous analyses of German statutory health insurance claims data have shown that compression therapy is not consistently prescribed in routine care [7, 8]. These findings indicate a persistent gap between guideline recommendations and real‐world healthcare provision. Existing claims data analyses have focused on incidence and prevalence estimates and prescription rates of compression therapy. However, less is known about longitudinal health care utilisation and comorbidity burden over extended follow‐up periods. Evaluating the role of comorbidities in wound management is essential for evidence‐based care planning and efficient allocation of healthcare resources [9]. Statutory health insurance (SHI) routine data enable analyses of disease prevalence, morbidity burden, and healthcare service utilisation [10].

Therefore, the present retrospective claims data analyses aimed to describe real‐world prescribing of compression therapy among persons with VLU and CVD in the German statutory health insurance system, while characterising comorbidity burden and healthcare utilisation over a 5‐year follow‐up period.

1.1. Aim

The primary objective of this study was to describe real‐world prescription rates of compression therapy among persons with VLU and CVD using German statutory health insurance data over a 5‐year follow‐up period.

1.2. Secondary Objectives Were

1. To update prevalence estimates of CVD and VLU based on SHI routine data.

2. To characterise demographics and comorbidity burden.

3. To describe antibiotic prescriptions and physician contacts as indicators of healthcare utilisation.

We hypothesised that a substantial proportion of persons with VLU and CVD would have no documented prescription of compression therapy during the observation period, despite current guideline recommendations.

2. Materials and Methods

2.1. Study Design and Data Base

This study was designed as a retrospective cohort study based on anonymised claims data from a German statutory health insurance database. The database included approximately 3.35 million insured persons, corresponding to 4.55% of all persons covered by statutory health insurance in Germany. Available data included age, sex, ICD‐10 diagnosis codes, prescription classified by Anatomical Therapeutic Chemical (ATC) codes, medical aids identified by product group codes of the German Medical Aids Directory, Pharmaceutical Central Numbers, and physician specialty codes.

The study population comprised persons with documented diagnoses of VLU and/or CVD in 2017 who were continuously observable between 1 January 2017 and 31 December 2022 or until death.

2.2. Cohort Definition

Case identification was based on ICD‐10 codes for VLU and CVD. VLU was defined using the codes I83.0, I83.2, I87.01, I87.21, and L97. CVD was defined using the codes I83.* and I87.* The claims‐based case definition is pragmatic but not fully aetiology‐specific. In particular, L97 identifies a non‐pressure chronic ulcer of the lower limb and does not, by itself, establish venous aetiology.

To increase diagnostic validity, the M2Q criterion was applied. Persons were included if diagnoses were documented in at least two quarters in 2017 or if at least one inpatient primary diagnosis was recorded.

The first quarter in 2017 fulfilling the inclusion criteria was defined as the index quarter. Persons were followed for up to 20 quarters, corresponding to 5 years, or until death (Figure 1).

FIGURE 1.

Study design with index, cohort definition and follow‐up period. CVD, chronic venous diseases; Q, quarter; VLU, venous leg ulcer; w/o, without.

2.3. Compression Therapy Definition

Compression therapy was identified from claims data using medical aid product group codes from Product Group 17 of the German Medical Aids Directory (PG17.06* and/or PG17.99*, including medical compression stockings) and predefined lists of corresponding German Pharmaceutical Central Numbers (PCN) for compression‐related products.

Persons with at least one documented prescription or reimbursement record for compression therapy during follow‐up were assigned to the compression group. Persons with a diagnosis of VLU or CVD but without any documented compression therapy record during follow‐up were assigned to the non‐compression group (Figure 1).

Claims data only allow identification of prescribed or reimbursed compression therapy but do not provide information on actual use, adherence, or correct application. These reimbursement identifiers capture the compression products documented within the SHI claims system according to the predefined product‐group/PCN algorithm. Compression products obtained without an SHI prescription or reimbursement record, including privately purchased or over‐the‐counter products, are not captured.

Since this project is a retrospective evaluation of fully anonymised statutory‐health‐insurance claims data, no formal vote from an institutional review board was required. This procedure is fully aligned with the German guideline Good Practice in Secondary Data Analysis (GPS), which states that research based exclusively on anonymised secondary data is exempt from ethics‐committee review provided that data privacy is guaranteed [11]. This study was conducted and reported in accordance with the STROBE guidelines. Artificial intelligence (ChatGPT) was used solely for language editing. The authors take full responsibility for the content and interpretation of the manuscript.

2.4. Observed Outcomes

The following patient specific outcomes were analysed, gender, age at index quarter and Charlson comorbidity index (CCI) was observed. The CCI was used as a validated proxy measure for disease burden. Although originally developed to predict 1‐year mortality, the CCI is widely applied in health services and outcomes research to reflect overall comorbidity burden and clinical complexity, particularly in populations with chronic conditions. The CCI comprises 19 predefined comorbidities, each weighted from 1 to 6 according to its estimated impact on 1‐year mortality. ¹ Higher cumulative CCI scores indicate increasing comorbidity burden and are associated with progressively higher 1‐year mortality risk, ranging from 8% in patients with a score of 0 to 59% in persons with scores ≥ 3 [12]. In this analysis, the CCI was calculated using the respective ICD‐10 diagnosis codes recorded during the first year of follow‐up. The prescription of compression therapy (PG17.06* and/or PG17.99* and/or respective PZN) was included into the analysis, including compression therapy prescribing physician type. Physician contacts were identified based on physician specialty codes recorded in the claims data. Antibiotic exposure among patients with VLU was ascertained from prescription data using ATC classification codes, counting patients with at least one prescription for the following groups: tetracyclines (J01A*), amphenicols (J01B*), beta‐lactam antibacterials including penicillins (J01C*) and other beta‐lactams (J01D*), sulfonamides and trimethoprim (J01E*), macrolides, lincosamides and streptogramins (J01F*), aminoglycosides (J01G*), quinolones (J01M*), combinations of antibacterials (J01R*), and other antibacterials (J01X*). All mentioned outcomes were analysed for each cohort and stratified by gender (Figure 1).

2.5. Statistical Analysis

All analyses were primarily descriptive. Continuous variables are presented as means with 95% confidence intervals (CI), and categorical variables as absolute and relative frequencies. Prevalence estimates for VLU and CVD were calculated using the total number of insured persons in the database as denominator. Group differences were interpreted descriptively based on the extent of overlap of 95% CI; no formal hypothesis testing, multivariable adjustment or causal modelling was performed. Therefore, differences between groups were interpreted descriptively and not as evidence of causal effects.

3. Results

Among the 3.35 million insured, 16 615 (0.50%) had a VLU diagnosis and 243 681 (7.27%) a CVD diagnosis. Over 5 years, the compression therapy treatment rate was 75.85% (VLU) and 53.10% (CVD). Still, 24.15% of VLU persons and 46.90% of CVD patients never received compression therapy during the entire study period (Figure 2).

FIGURE 2.

Patient flow.

Persons treated with compression were predominantly elderly and female (VLU: avg. 74.13 years, 59.56% women; CVD: 68.55 years, 70.86% women). Table 1 summarises demographic characteristics of persons with and without documented use of compression therapy, highlighting age and sex distribution within the studied cohorts.

TABLE 1.

Characteristics and burden of comorbidities in persons with VLU or CVD.

Persons	VLU with compression	VLU without compression	CVD with compression	CVD without compression
Total N	12 602	4013	129 386	114 295
Mean age, years [95% CI]	74.13 [73.90–74.36]	70.10 [69.69–70.51]	68.55 [68.47–68.63]	66.28 [66.20–66.36]
Female (%)	59.56	60.85	70.86	69.37
Mean Charlson Comorbidity Index, CCI [95% CI]	4.09 [4.03–4.15]	3.14 [3.05–3.23]	2.67 [2.65–2.68]	2.12 [2.11–2.14]
Mean CCI [95% CI] female; male	3.78 [3.71–3.85]	2.81 [2.70–2.93]	2.45 [2.43–2.47]	1.90 [1.89–1.92]
	4.54 [4.45–4.64]	3.65 [3.49–3.81]	3.20 [3.17–3.23]	2.62 [2.59–2.64]
Most frequent comorbidities % (female; male %)	Hypertension 76.40 (77.51; 74.76)	Hypertension 68.85 (67.24; 71.36)	Hypertension 65.02 (63.90; 67.72)	Hypertension 60.76 (58.83; 65.14)
	Type 2 DM 37.84 (34.24; 43.15)	Type 2 DM 29.85 (26.74; 34.69)	Obesity 24.42 (24.25; 24.83)	Obesity 19.98 (19.93; 20.07)
	Obesity 30.04 (28.54; 32.26)	Obesity 23.42 (23.91; 22.66)	Type 2 DM 23.55 (21.48; 28.57)	Type 2 DM 19.92 (17.98; 24.31)
	Depression 20.81 (24.78; 14.95)	Depression 22.80 (27.15; 16.04)	Depression 21.19 (24.19; 13.89)	Depression 20.23 (23.04; 13.86)

Note: Values were rounded to two decimal places; the third decimal digit determined rounding.

Abbreviations: Compression = compression therapy; CVD = Chronic venous disease; DM = diabetes mellitus; VLU = Venous leg ulcer.

3.1. Burden of Comorbidities in Persons With VLU or CVD

In total, 12 602 persons with VLU and 129 386 persons with chronic venous disease (CVD) received compression therapy. In contrast, 4013 VLU persons and 114 295 CVD persons did not receive compression therapy. Table 1 shows that the mean Charlson Comorbidity Index (CCI) was higher in persons treated with compression therapy (4.09 in VLU and 2.67 in CVD) compared to those without compression therapy (3.14 in VLU and 2.12 in CVD). The CCI was higher among men. The most common comorbidities in the index quarter were hypertension and Type 2 diabetes mellitus, obesity, and depression.

Antibiotic prescriptions were frequent in persons receiving compression therapy: in the follow‐up year of the diagnosis, 51.43% of VLU‐persons with compression received at least one prescription of antibiotics (vs. 36.28% among VLU‐persons without compression with 38.21% among female, 33.29% among male persons). Among female VLU‐persons with compression, the proportion was 51.32% (vs. 51.59% in male VLU‐persons). By year five, 35.29% of VLU‐persons were still prescribed antibiotics (vs. 23.65 among VLU‐persons without compression).

The average number of physician contacts in the first follow‐up year among persons with VLU was higher in those treated with compression therapy compared to those without (37.93 [37.41–38.44] vs. 28.02 [27.20–28.83] contacts, respectively). This trend was consistent across all medical specialties (Figure 3). Among female VLU persons with compression, the average was significantly lower than among men (36.94 [36.33–37.56] vs. 39.37 [38.48–40.27]). The number of physician contacts among female and male VLU persons without compression was reversed (28.14 [27.15–29.13] vs. 27.82 [26.40–29.24]).

FIGURE 3.

Physician contacts of persons with VLU in the first follow‐up year per specialty.

In VLU persons, general and family medicine accounted for the majority of contacts (21.50 [21.19–21.80] with compression vs. 14.68 [14.21–15.15] without compression), followed by internal medicine (5.45 [4.67–6.24] vs. 3.63 [2.66–4.60]) and dermatology (5.06 [4.83–5.28] vs. 3.32 [3.12–3.53]). Contacts with specialists in angiology (3.12 [2.68–3.56] vs. 2.21 [1.07–3.36]) and surgery (5.24 [4.97–5.51] vs. 3.45 [2.97–3.93]) were also more frequent in persons receiving compression therapy. Slightly higher contact rates were also noted for gynaecologists (3.21 [3.07–3.35] vs. 2.94 [2.77–3.11]), and orthopedists (4.36 [4.19–4.53] vs. 4.16 [3.91–4.42], Figure 3). No meaningful differences in the number of physician contacts by speciality were observed between women and men (data not shown).

4. Discussion

This study confirms earlier prevalence estimates and highlights persistent underprovision of compression therapy. While the proportion of persons receiving compression therapy increased over time, nearly one in four with VLU had no documented compression therapy during follow‐up, despite clear guideline recommendations supporting its use. These findings are particularly relevant in light of recent epidemiological data: based on SHI routine data, the prevalence of chronic leg ulcers (Ulcus cruris) in Germany has been estimated to range from 0.25% to 0.74% [13] to as high as 0.57%–0.90% in more recent analyses [14]. For venous leg ulcers (Ulcus cruris), specific estimates suggest a prevalence between 0.41% and 0.46%. Prevalence estimates may vary depending on the sampling strategy and the applied case definition. Routine data presented in the introduction, indicating that only 40% received compression [8], and 80% do not receive consistent compression therapy [7], thereby highlighting a persistent gap between real‐world practice and guideline‐based care.

Persons receiving compression therapy were generally older, more multimorbid, and exhibited higher healthcare utilisation. These findings likely reflect greater disease severity and more intensive healthcare needs among persons receiving compression therapy rather than the effects of compression therapy itself. Given the descriptive nature of the analysis and the lack of clinical severity measures, causal interpretations should be avoided. Notably, men who received compression therapy exhibited a higher comorbidity burden. This observation may indicate differences in health care utilisation patterns between women and men; however, underlying reasons cannot be determined based on claims data alone. The higher CCI in the compression group may partly be explained by its higher mean age, because comorbidity burden generally accumulates with age. The descriptive design does not permit separation of age, disease severity, multimorbidity and care intensity as explanatory factors.

The present findings demonstrate that persons with VLU who received compression therapy had a markedly higher average number of physician contacts compared to those without compression therapy. In addition to increased engagement with general practitioners, these persons also reported more frequent consultations with specialists, particularly dermatologists (5.06 vs. 3.32 contacts) and angiologists (3.12 vs. 2.21 contacts). The higher number of specialist contacts among persons receiving compression therapy may be consistent with more guideline‐adherent management, as dermatologic and angiologic co‐management is recommended in current clinical practice guidelines for chronic wound care [4]. At the same time, the intensified involvement of specialists may indicate a higher clinical burden among persons receiving compression therapy. Previous studies have indicated that individuals with complex or non‐healing ulcers should be referred to multidisciplinary wound care teams [15]. However, no conclusions regarding adherence and disease severity can be drawn from prescription and claims data alone. The same caution applies to the higher frequency of antibiotic prescriptions in the compression group: this finding should primarily be regarded as a marker of greater clinical burden and healthcare engagement rather than as an effect of compression therapy. More frequent physician contacts may also increase the probability that infections are detected and antibiotics prescribed.

Previous studies suggested substantial variability in the correct application of compression therapy in routine care [16], thus, the underutilization revealed by SHI routine care data likely underestimates the true extent of underprovision in real‐world clinical practice. Importantly, the present analysis captured prescription and reimbursement data only and could not assess correctness of application.

Overall, these results underscore the importance of interdisciplinary, coordinated care models for persons with VLU and highlight the need to integrate compression therapy into broader, structured treatment approaches rather than applying it in isolation.

The substantial comorbidity burden observed in our VLU patient cohort, as quantified by the Charlson Comorbidity Index, corroborates findings from other epidemiological studies. For instance, Smith et al. demonstrated that over half of community‐based wound care persons had at least one CCI comorbidity, with higher scores associated with delayed wound healing outcomes [9]. These findings underscore that VLUs are not merely cosmetic issues but are indicative of a chronic, multimorbid disease process. Consequently, the management of VLUs necessitates a comprehensive, multidisciplinary approach that addresses both the wound and the underlying comorbidities to improve patient outcomes.

A growing body of research underscores that structural and educational deficits in the healthcare system significantly contribute to the underutilization of compression therapy in persons with VLUs. The present findings must be interpreted against this backdrop. General practitioners (GPs), who play a pivotal role in early diagnosis and initiation of compression therapy, often lack the systemic support and training necessary for consistent guideline adherence. Previous interventional and routine data studies have suggested that structured care approaches, physician education, and improved implementation strategies may increase the use of evidence‐based compression therapy in routine care [17, 18]. In addition, a large routine data analysis highlights the considerable clinical and economic relevance of improving compression therapy implementation in routine care [7].

Structural and educational barriers to guideline implementation have also been described in previous survey‐based research among healthcare professionals involved in compression therapy. Reported challenges include deficits in the implementation of evidence‐based compression strategies [19]. These provide important context for the treatment gaps observed in the present analysis and underline the need for improved implementation strategies in routine care.

In interpreting these findings, it is important to consider both the methodological strengths and the inherent limitations of the study design.

This study is based on a large‐scale dataset from statutory health insurance claims, which provides high external validity and generalizability within the German healthcare system. By analysing real‐world SHI routine data, it is possible to detect utilisation patterns and care gaps that may not be evident in controlled research settings. Stakeholders widely expect real‐world evidence to assume increasing importance in shaping regulatory decision‐making in the years ahead [20].

Several limitations need to be considered when interpreting these findings. Claims data are collected primarily for reimbursement purposes and lack important clinical information such as wound size, ulcer duration, CEAP classification, symptom severity and treatment goals. In addition, the identification of compression therapy was based on reimbursement data and therefore does not allow conclusions regarding treatment adherence or correctness of application. Misclassification due to coding inaccuracies cannot be excluded. As previously suggested [14], prevalence estimates based solely on diagnoses may overestimate the true disease burden, assuming that active chronic wounds are associated with treatment; this appears particularly relevant for venous leg ulcers and diabetic foot ulcers. Furthermore, because no multivariable adjustment was performed, the observed differences between groups are likely influenced by confounding, particularly by disease severity and healthcare utilisation patterns. The claims data do not contain ankle‐brachial pressure index (ABPI) measurements or comparable detailed arterial assessments; therefore, patients in whom compression may appropriately have been withheld because of clinically relevant arterial disease cannot be identified. Likewise, clinical outcomes such as ulcer healing, recurrence, and wound progression were unavailable. Interpretation of the proportion without documented compression therapy should also account for limitations inherent to claims data, including incomplete differentiation of ulcer aetiology and potential undercapture of compression therapy due to coding and reimbursement practices. Thus, the observed proportion indicates potential gaps in guideline‐concordant care but should not be equated with non‐adherence at the individual patient level. Finally, the data do not capture alternative or complementary interventions, such as venous procedures or ulcer surgery with skin transplantation, nor compression obtained outside reimbursed SHI care, which may have influenced treatment decisions or resulted in underestimation of actual compression use.

5. Conclusions

Persons with venous leg ulcers and chronic venous diseases show substantial health care utilisation and a high burden of comorbidities. Compression therapy is effective and guideline‐recommended but still underutilised. Improved care coordination, physician education, and broader implementation of guideline‐recommended compression therapy may help reduce existing gaps in routine care.

Funding

This study was funded by eurocom e.V., the European Manufacturers Federation for Compression Therapy and Orthopaedic Devices.

Conflicts of Interest

The authors declare potential affiliations with industry partners in the field of compression therapy through eurocom e.V. All analyses were conducted with the aim of scientific objectivity. Markus Stücker reports relationships with Bauerfeind AG, biliotec, Coloplast, eurocom e.V., Julius Zorn GmbH, medi GmbH & Co KG, Rheacell, and URGO GmbH. Eberhard Rabe reports relationships with eurocom e.V. and Sigvaris Int. Kristina Hagenström declares no conflicts of interest. Tobias Hirsch reports relationships with medi GmbH & Co KG, Essity, Sigvaris, Bauerfeind AG, and eurocom e.V. Luis Möckel is a former employee of eurocom e.V. and currently working for pharmaceutical industry (but not in context of VLU, CVD or compression therapy). Kristin Sauer is involved in research and scientific activities conducted on behalf of eurocom e.V. (European Manufacturers Federation for Compression Therapy and Orthopaedic Devices).

Data Availability Statement

Research data are not shared.