Human Wound and Its Burden: Updated 2020 Compendium of Estimates

Significance: Chronic wounds impact the quality of life (QoL) of nearly 2.5% of the total population in the United States and the management of wounds has a significant economic impact on health care. Given the aging population, the continued threat of diabetes and obesity worldwide, and the persistent problem of infection, it is expected that chronic wounds will continue to be a substantial clinical, social, and economic challenge. In 2020, the coronavirus disease (COVID) pandemic dramatically disrupted health care worldwide, including wound care. A chronic nonhealing wound (CNHW) is typically correlated with comorbidities such as diabetes, vascular deficits, hypertension, and chronic kidney disease. These risk factors make persons with CNHW at high risk for severe, sometimes lethal outcomes if infected with severe acute respiratory syndrome coronavirus 2 (pathogen causing COVID-19). The COVID-19 pandemic has impacted several aspects of the wound care continuum, including compliance with wound care visits, prompting alternative approaches (use of telemedicine and creation of videos to help with wound dressing changes among others), and encouraging a do-it-yourself wound dressing protocol and use of homemade remedies/substitutions. Recent Advances: There is a developing interest in understanding how the social determinants of health impact the QoL and outcomes of wound care patients. Furthermore, addressing wound care in the light of the COVID-19 pandemic has highlighted the importance of telemedicine options in the continuum of care. Future Directions: The economic, clinical, and social impact of wounds continues to rise and requires appropriate investment and a structured approach to wound care, education, and related research.

Health Care Spending in Patients With Stage 3 and Stage 4 Pressure Injuries and Patients With Diabetic Foot Ulcers Treated Early With Clostridial Collagenase Ointment: A Retrospective Data Review

INTRODUCTION

Clostridial collagenase ointment (CCO) is the only enzymatic agent indicated for debriding chronic dermal ulcers that is approved by the United States Food and Drug Administration.

OBJECTIVE

The objective of this study is to estimate health care spending among patients with Stage 3 and Stage 4 pressure injuries (PIs) and patients with diabetic foot ulcers (DFUs) who experienced early (ie, within 30 days of index diagnosis) versus late (31 to 90 days of index diagnosis) initiation of CCO.

METHODS

Patients with PIs and DFUs between January 2007 and March 2017 were identified. One-to-one matched cohorts were used to compare all-cause health care spending and disease-related health care spending between the early initiation and late initiation groups.

RESULTS

Compared to the early CCO initiation group, all-cause health care spending for the late CCO initiation group was higher in both patients with PIs and in patients with DFUs within the 12-month follow-up period. Compared to the early CCO initiation group, disease-related health care spending for the late CCO initiation group was higher in both patients with PIs and in patients with DFUs within the 12-month follow-up period. All computations were statistically significant.

CONCLUSIONS

Early initiation of CCO provides both all-cause and disease-related health care savings to payers and persons managing patients with PIs or DFUs. Payers, providers, and facilities should consider mechanisms to encourage the early use of CCO to lower costs.

Five-layer border dressings as part of a quality improvement bundle to prevent pressure injuries in US skilled nursing facilities and Australian nursing homes: A cost-effectiveness analysis

The BORDER III trial found that five-layer silicone border dressings effectively prevented pressure injuries in long-term care, but the value of this approach is unknown. Our objective was to analyse the cost-effectiveness of preventing facility-acquired pressure injuries with a quality improvement bundle, including prophylactic five-layer dressings in US and Australian long-term care. Markov models analysed the cost utility for pressure injuries acquired during long-term care from US and Australian perspectives. Models calibrated outcomes for standard care compared with a dressing-inclusive bundle over 18 monthly cycles or until death based on BORDER III outcomes. Patients who developed a pressure injury simulated advancement through stages 1 to 4. Univariate and multivariate probabilistic sensitivity analyses tested modelling uncertainty. Costs in 2017 USD and quality-adjusted life years (QALYs) were used to calculate an incremental cost-effectiveness ratio (ICER). Dressing use yielded greater QALYs at slightly higher costs from perspectives. The US ICER was $36 652/QALY, while the Australian ICER was $15 898/QALY, both of which fell below a willingness-to-pay threshold of $100 000/QALY. Probabilistic sensitivity analysis favoured dressings as cost-effective for most simulations. A quality improvement bundle, including prophylactic five-layer dressings, is a cost-effective approach for pressure injury prevention in all US and Australia long-term care residents.

The national cost of hospital-acquired pressure injuries in the United States

Our objective was to estimate the US national cost burden of hospital-acquired pressure injury (HAPI) using economic simulation methods. We created a Markov simulation to estimate costs for staged pressure injuries acquired during hospitalisation from the hospital perspective. The model analysed outcomes of hospitalised adults with acute illness in 1-day cycles until all patients were terminated at the point of discharge or death. Simulations that developed a staged pressure injury after 4 days could advance from Stages 1 to 4 and accrue additional costs for Stages 3 and 4. We measured costs in 2016 US dollars representing the total cost of acute care attributable to HAPI incidence at the patient level and for the entire United States based on the previously reported epidemiology of pressure injury. US HAPI costs could exceed $26.8 billion. About 59% of these costs are disproportionately attributable to a small rate of Stages 3 and 4 full-thickness wounds, which occupy clinician time and hospital resources. HAPIs remain a concern with regard to hospital quality in addition to being a major source of economic burden on the US health care system. Hospitals should invest more in quality improvement of early detection and care for pressure injury to avoid higher costs.

Financial and Clinical Risk Evaluation of Pressure Injuries in US Hospitals: A Business Case for Initiating Quality Improvement

INTRODUCTION

Pressure injuries (PIs) are a serious, avoidable condition that affect many patients during hospital stays. Yet, to date, there is no comprehensive assessment of the financial and clinical risks of PIs.

OBJECTIVE

This study evaluates the cost of treatment, impact of reimbursement policies, and clinical consequences of PIs for US hospitals.

METHODS

A financial and clinical calculator was created to estimate the impact of PI prevention using a traditional literature review to drive assumptions.

RESULTS

Two drivers of hospital revenue loss resulting from PIs were identified: nonpayment for PI treatment by health insurance providers and personal injury litigation. Increased hospital length of stay (LOS) and patient mortality associated with PIs further contributed to negative consequences. For an average 160-bed hospital, the authors estimated an annual total financial risk of $5.97 million, 911 days added to LOS, and 16.4 deaths related to avoidable PIs.

CONCLUSIONS

Results of this analysis will be useful for health care organizations implementing quality improvement initiatives and new technologies, such as digital wound care management systems, to reduce the prevalence of PIs, thereby protecting patients and mitigating financial and clinical risks.

Treatment and cost of pressure injury stage III or IV in four patients with spinal cord injury: the Basel Decubitus Concept

Study design

Retrospective chart analyses as part of a quality improvement project.

Objectives

To demonstrate treatment of pressure injury (PI) in patients with spinal cord injuries (SCI) and analyse costs using the "modified Basel Decubitus Concept".

Setting

Inpatient setting of a specialised acute care and rehabilitation clinic for SCI.

Methods

Complex treatment courses of four patients with chronic SCI and PI stage III or IV were described and costs were recorded. The total healthcare services' costs per patient and different profession's involvement were analysed in relation to patient characteristics, treatment phases and milestones demonstrated.

Results

The treatment of PI stage III and IV in patients with SCI included input from plastic surgery, rehabilitation medicine, nursing and other involved professions. Recommended interventions were chosen according to the "modified Basel Decubitus Concept". The cost course of PI treatment in patients with SCI depicted the multimodal treatment concept, including three clinically and financially relevant milestones (debridement, flap surgery and mobilisation to wheelchair) as well as the highest costs in the functionally highly dependent patient. Acute care and rehabilitation overlapped with different intensities during the whole treatment process.

Conclusion

Multimodal treatment concepts connecting acute and rehabilitation care were applied in these complex health conditions. Cost-explication models including treatment phases and milestones helped to understand resources more easily and integrate aspects of process-based management and quality of care. Scientific evidence is needed to create a recommended quality standard in line with adequate financing of this health condition.

Prevalence of Pressure Injuries Nationwide from 2009 to 2015: Results from the National Inpatient Sample Database in Korea

This study aimed to investigate the prevalence pattern of pressure injuries (PIs), or ‘sores’, in South Korea and investigate the factors affecting its development. We estimated the annual prevalence of PIs using the National Inpatient Sample (NIS) data extracted from the Health Insurance Review and Assessment Service (HIRA) database from 2009 to 2015. Multivariable logistic regression was performed to examine the association between hospitalization and socio-demographic characteristics, such as sex, age, type of health insurance, Charlson Comorbidity Index (CCI), and plegia comorbidity. We found that inpatients with PIs make up to 0.86% of the total population in South Korea in 2015, which had shown a steady increase from the previous years. And male, old age, low socioeconomic status (SES), and the patients’ severity such as high CCI and the plegia comorbidity were strongly associated with hospitalization due to PI. Based on our results, it would be anticipated that the medical cost for treatment and management of PIs will increase in the future, and it will be accelerated due to the rapidly aging society. In addition, patients in low SES and patients with severe comorbidities would be relatively more burdensome, threatening their household economy and further reducing the quality of life. Therefore, PIs should not be overlooked as the responsibility of just the nursing care professionals but should be recognized as one of the serious societal problems. The establishment of an intense medical care system is needed not only to reduce the prevalence of PIs but also to increase the awareness in people with PI patients.

Incidence of pressure ulcers in intensive care units and direct costs of treatment: Evidence from Iran

BACKGROUND AND OBJECTIVE

Pressure ulcer (PU) is one of the important and frequent complications of hospitalization, associated with high treatment costs. The present study was conducted to determine the incidence of PU and its direct treatment costs for patients in intensive care unit (ICU) in Iran.

MATERIAL AND METHODS

In this retrospective study, medical records of 643 discharged patients from ICU of two selected hospitals were examined. The demographic and clinical data of all patients and data of resources and services usage for patients with PU were extracted through their records. Data analysis was done using logistic regression tests in SPSS 22 software. The cost of PU treatment was calculated for each grade of ulcer.

RESULTS

The findings showed that 8.9% of patients developed PU during their stay in ICU. Muscular paralysis (OR = 5.1), length of stay in ICU (OR = 4.0), diabetes (OR = 3.5) age (OR = 2.9), smoking (OR = 2.1) and trauma (OR = 1.4) were the most important risk factors of PU. The average cost of PU treatment varied from USD 12 for grade I PU to USD 66 834 for grade IV PUs. The total treatment costs for all studied patients with PU was estimated at USD 519 991.

CONCLUSION

The cost of PU treatment is significant. Since the preventive measures are more cost-effective than therapeutic measures, therefore, effective preventive interventions are recommended.

Cohort study evaluating pressure ulcer management in clinical practice in the UK following initial presentation in the community: costs and outcomes

OBJECTIVES

The aim of this study was to estimate the patterns of care and annual levels of healthcare resource use attributable to managing pressure ulcers (PUs) in clinical practice in the community by the UK's National Health Service (NHS), and the associated costs of patient management.

METHODS

This was a retrospective cohort analysis of the records of 209 patients identified within a randomly selected population of 6000 patients with any type of wound obtained from The Health Improvement Network (THIN) Database, who developed a PU in the community and excluded hospital-acquired PUs. Patients' characteristics, wound-related health outcomes and healthcare resource use were quantified over 12 months from initial presentation, and the corresponding total NHS cost of patient management was estimated at 2015/2016 prices.

RESULTS

50% of all the PUs healed within 12 months from initial presentation, but this varied between 100% for category 1 ulcers and 21% for category 4 ulcers. The mean time to healing ranged from 1.0 month for a category 1 ulcer to 8 months for a category 3/4 ulcer and 10 months for an unstageable ulcer. Patients were predominantly managed in the community by nurses with minimal clinical involvement of specialist clinicians. Up to 53% of all the ulcers may have been clinically infected at the time of presentation, and 35% of patients subsequently developed a putative wound infection a mean 4.7 months after initial presentation. The mean NHS cost of wound care over 12 months ranged from £1400 for a category 1 ulcer to >£8500 for the other categories of ulcer. Additionally, the cost of managing an unhealed ulcer was 2.4 times more than that of managing a healed ulcer (mean of £5140 vs £12 300 per ulcer).

CONCLUSION

This study provides important insights into a number of aspects of PU management in clinical practice in the community that have been difficult to ascertain from other studies, and provides the best estimate available of NHS resource use and costs with which to inform policy and budgetary decisions.

Predicting excess cost for older inpatients with clinical complexity: A retrospective cohort study examining cognition, comorbidities and complications

BACKGROUND

Hospital-acquired complications increase length of stay and contribute to poorer patient outcomes. Older adults are known to be at risk for four key hospital-acquired complications (pressure injuries, pneumonia, urinary tract infections and delirium). These complications have been identified as sensitive to nursing characteristics such as staffing levels and level of education. The cost of these complications compared to the cost of admission severity, dementia, other comorbidities or age has not been established.

METHOD

To investigate costs associated with nurse-sensitive hospital-acquired complications in an older patient population 157,178 overnight public hospital episodes for all patients over age 50 from one Australian state, 2006/07 were examined. A retrospective cohort study design with linear regression analysis provided modelling of length-of-stay costs. Explanatory variables included patient age, sex, comorbidities, admission severity, dementia status, surgical status and four complications. Extra costs were based on above-average length-of-stay for each patient's Diagnosis Related Group from hospital discharge data.

RESULTS

For adults over 50 who have length of stay longer than average for their diagnostic condition, comorbid dementia predicts an extra cost of A$874, (US$1,247); any one of four key complications predicts A$812 (US$1,159); each increase in admission severity score predicts A$295 ($US421); each additional comorbidity predicts A$259 (US$370), and for each year of age above 50 predicts A$20 (US$29) (all estimates significant at p<0.0001).

DISCUSSION

Hospital-acquired complications and dementia cost more than other kinds of inpatient complexity, but admission severity is a better predictor of excess cost. Because complications are potentially preventable and dementia care in hospitals can be improved, risk-reduction strategies for common complications, particularly for patients with dementia could be cost effective.

CONCLUSIONS

Complications and dementia were found to cost more than other kinds of inpatient complexity.

Estimated reduction in expenditure on hospital-acquired pressure injuries after an intervention for early identification and treatment

AIM

An intervention designed to reduce numbers of hospital-acquired pressure injuries was delivered in Counties Manukau Health hospitals. An audit of a sample of patients was carried out to estimate the cost savings that would have been acquired across the district health board (DHB) due to a reduction in pressure injuries.

METHOD

The pressure injury intervention was delivered from 2011 to 2015. A monthly prospective audit of patients with stages 1, 2, 3 and 4 pressure injuries was carried out. This involved a random sample of five patients per ward in all hospitals in Counties Manukau DHB.

RESULTS

It was found that the annual estimated cost of treating pressure injuries in hospital patients was NZ$12,290,484 less in 2015 than in 2011.

CONCLUSION

Implementation of strategies for managing hospital-acquired pressure injuries can lead to potentially large financial savings for hospitals, as well as reducing the burden of managing this difficult condition for patients and staff.

Economic Evaluations of Strategies to Prevent Hospital-Acquired Pressure Injuries

GENERAL PURPOSE

To provide information from a review of literature about economic evaluations of preventive strategies for pressure injuries (PIs).

TARGET AUDIENCE

This continuing education activity is intended for physicians, physician assistants, nurse practitioners, and nurses with an interest in skin and wound care.

LEARNING OBJECTIVES/OUTCOMES

After participating in this educational activity, the participant should be better able to:1. Identify the purpose and methods used for this study.2. Compare costs and effectiveness related to preventative strategies for PIs.

ABSTRACT

BACKGROUND: Pressure injuries (PIs) are a common and resource-intensive challenge for acute care hospitals worldwide. While a number of preventive strategies have the potential to reduce the cost of hospital-acquired PIs, it is unclear what approach is the most effective.

OBJECTIVE

The authors performed a narrative review of the literature on economic evaluations of preventive strategies to survey current findings and identify important factors in economic assessments.

DATA SOURCES

Ovid, MEDLINE, NHS Economic Evaluation Databases, and the Cochrane Database of Systematic ReviewsSELECTION CRITERIA: Potentially relevant original research articles and systematic reviews were considered.

DATA EXTRACTION

Selection criteria included articles that were written in English, provided data on cost or economic evaluations of preventive strategies of PIs in acute care, and published between January 2004 and September 2015. Data were abstracted from the articles using a standardized approach to evaluate how the items on the Consolidated Health Economic Evaluation Reporting Standards checklist were addressed.

DATA SYNTHESIS

The searches identified 192 references. Thirty-three original articles were chosen for full-text reviews. Nineteen of these articles provided clear descriptions of interventions, study methods, and outcomes considered.

CONCLUSIONS

Limitations in the available literature prevent firm conclusions from being reached about the relative economic merits of the various approaches to the prevention of PIs. The authors' review revealed a need for additional high-quality studies that adhere to commonly used standards of both currently utilized and emerging ways to prevent hospital-acquired PIs.

Pressure RElieving Support SUrfaces: a Randomised Evaluation 2 (PRESSURE 2): study protocol for a randomised controlled trial

BACKGROUND

Pressure ulcers represent a major burden to patients, carers and the healthcare system, affecting approximately 1 in 17 hospital and 1 in 20 community patients. They impact greatly on an individual's functional status and health-related quality of life. The mainstay of pressure ulcer prevention practice is the provision of pressure redistribution support surfaces and patient repositioning. The aim of the PRESSURE 2 study is to compare the two main mattress types utilised within the NHS: high-specification foam and alternating pressure mattresses, in the prevention of pressure ulcers.

METHODS/DESIGN

PRESSURE 2 is a multicentre, open-label, randomised, double triangular, group sequential, parallel group trial. A maximum of 2954 'high-risk' patients with evidence of acute illness will be randomised on a 1:1 basis to receive either a high-specification foam mattress or alternating-pressure mattress in conjunction with an electric profiling bed frame. The primary objective of the trial is to compare mattresses in terms of the time to developing a new Category 2 or above pressure ulcer by 30 days post end of treatment phase. Secondary endpoints include time to developing new Category 1 and 3 or above pressure ulcers, time to healing of pre-existing Category 2 pressure ulcers, health-related quality of life, cost-effectiveness, incidence of mattress change and safety. Validation objectives are to determine the responsiveness of the Pressure Ulcer Quality of Life-Prevention instrument and the feasibility of having a blinded endpoint assessment using photography. The trial will have a maximum of three planned analyses with unequally spaced reviews at event-driven coherent cut-points. The futility boundaries are constructed as non-binding to allow a decision for stopping early to be overruled by the Data Monitoring and Ethics Committee.

DISCUSSION

The double triangular, group sequential design of the PRESSURE 2 trial will provide an efficient design through the possibility of early stopping for demonstrating either superiority, inferiority of mattresses or futility of the trial. The trial optimises the potential for producing robust clinical evidence on the effectiveness of two commonly used mattresses in clinical practice earlier than in a conventional design.

TRIAL REGISTRATION

ISRCTN01151335 . Registered on 14 May 2013. Protocol version: 5.0, dated 25 September 2015 Trial sponsor: Clare Skinner, Faculty Head of Research Support, University of Leeds, Leeds, LS2 9JT; 0113 343 4897; C.E.Skinner@leeds.ac.uk.

Parafricta Bootees and Undergarments to Reduce Skin Breakdown in People with or at Risk of Pressure Ulcers: A NICE Medical Technologies Guidance

As part of the development of the National Institute for Health and Care Excellence (NICE) Medical Technologies Guidance on Parafricta Bootees and Undergarments to reduce skin breakdown in people with, or at risk of, pressure ulcers, the manufacturer (APA Parafricta Ltd) submitted clinical and economic evidence, which was critically appraised by an External Assessment Centre (EAC) and subsequently used by the Medical Technologies Advisory Committee (MTAC) to develop recommendations for further research. The University of Birmingham and Brunel University, acting as a consortium, were commissioned to act as the EAC, independently appraising the submission. This article is an overview of the original evidence submitted, the EAC's findings and the final NICE guidance. Very little comparative evidence was submitted to demonstrate the effectiveness of Parafricta Bootees or Undergarments. The sponsor submitted a simple cost analysis to estimate the costs of using Parafricta in addition to current practice-in comparison with current practice alone-in hospital and community settings separately. The analysis took a National Health Service (NHS) perspective. The basis of the analysis was a previously published comparative study, which showed no statistical difference in average lengths of stay between patients who wore Parafricta Undergarments and Bootees, and those who did not. The economic model incorporated the costs of Parafricta but assumed shorter lengths of stay with Parafricta. The sponsor concluded that Parafricta was cost saving relative to the comparators. The EAC made amendments to the sponsor's analysis to correct for errors and to reflect alternative assumptions. Parafricta remained cost saving in most analyses, and the savings per prevalent case ranged from £757 in the hospital model to £3455 in the community model. All analyses were severely limited by the available data on effectiveness-in particular, a lack of good-quality comparative studies.

Pressure Ulcers in the United States' Inpatient Population From 2008 to 2012: Results of a Retrospective Nationwide Study

Pressure ulcers are common, increase patient morbidity and mortality, and costly for patients, their families, and the health care system. A retrospective study was conducted to evaluate the impact of pressure ulcers on short-term outcomes in United States inpatient populations and to identify patient characteristics associated with having 1 or more pressure ulcers. The US Nationwide Inpatient Sample (NIS) database was analyzed using the International Classification of Disease, 9th Revision, Clinical Modification (ICD-9 CM) diagnosis codes as the screening tool for all inpatient pressure ulcers recorded from 2008 to 2012. Patient demographics and comorbid conditions, as identified by ICD-9 code, were extracted, along with primary outcomes of length of stay (LOS), total hospital charge (TC), inhospital mortality, and discharge disposition. Continuous variables with normal distribution were expressed in terms of mean and standard deviation. Group comparisons were performed using t-test or ANOVA test. Continuous nonnormal distributed variables such as LOS and TC were expressed in terms of median, and nonparametric tests were used to compare the differences between groups. Categorical data were presented in terms of percentages of the number of cases within each group. Chi-squared tests were used to compare categorical data in different groups. For multivariate analysis, linear regressions (for continuous variable) and logistic regression (for categorical variables) were used to analyze the possible risk factors for the investigated outcomes of LOS, TC, inhospital mortality, and patient disposition. Coefficients were calculated with multivariate regression with all included patients versus patients with pressure ulcers alone. The 5-year average number of admitted patients with at least 1 pressure ulcer was determined to be 670 767 (average overall rate: 1.8%). Statistically significant differences between patients with and without pressure ulcers were observed for median LOS (7 days [mean 11.1 ± 15] compared to 3 days [mean 4.6 ± 6.8]) and median TC ($36 500 [mean $72 000 ± $122 900] compared to $17 200 [mean $32 200 ± $57 500]). The mortality rate in patients with a pressure ulcer was significantly higher than in patients without a pressure ulcer (9.1% versus 1.8%, OR = 5.08, CI: 5.03-5.1, P <0.001). Pressure ulcers were significantly more common in patients who were older or had malnutrition. The results of this study confirm the importance of prevention initiatives to help reduce the negative impact of pressure ulcers on patient outcomes and costs of care.

Quality Improvement Initiatives Need Rigorous Evaluation: The Case of Pressure Ulcers

The Partnership for Patients (PfP) and the Agency for Healthcare Research and Quality (AHRQ) have reported a 23.5% decline in hospital-acquired pressure ulcers (HAPU) over 4 years resulting in a cumulative cost savings of more than $10 billion and 49 000 averted deaths, claiming that this significant decline may have been spurred in part by Medicare payment incentives associated with severe (stage 3 or 4) HAPUs. Hospitals with a high rate of severe HAPUs have a payment penalty imposed, creating a financial disincentive to report severe HAPUs, possibly contributing to the magnitude of the reported decline. Despite the financial disincentive to report, the number of severe HAPUs found in claims data over the corresponding 4-year period did not decline but instead remained unchanged. The results from claims data, combined with some flaws in estimating HAPUs, call into question the validity of the decline in HAPUs reported by PfP and AHRQ.

Pressure Mapping Comparison of Four OR Surfaces

Mortality and health care costs associated with hospital-acquired pressure ulcers (HAPUs) increase yearly. After four hours of surgery, the risk of developing a pressure ulcer increases by 33% for every 30 minutes of surgery. Prolonged immobility, lower blood pressures, and increased surface interface pressure may hinder the blood supply delivered to the skin, eventually leading to pressure ulcers. We measured and compared four different OR surfaces to identify the most effective pressure redistribution surface for prolonged OR procedures. The best surface attributes that provide efficient pressure redistribution should have the following properties: the lowest average interface pressure, the lowest peak interface pressure, and the highest skin contact area. Although all surfaces had similar average interface pressures, the air-inflated static seat cushion had the best pressure redistribution properties in the sacral region compared with the other surfaces tested.

Recording pressure ulcer risk assessment and incidence

This article reports on the introduction of an innovative computer-based system developed to record and report pressure ulcer risk and incidence at an acute NHS trust. The system was introduced to ensure that all patients have an early pressure ulcer risk assessment, which prompts staff to initiate appropriate management if a pressure ulcer is detected, thereby preventing further patient harm. Initial findings suggest that this electronic process has helped to improve the timeliness and accuracy of data on pressure ulcer risk and incidence. In addition, it has resulted in a reduced number of reported hospital-acquired pressure ulcers.

A quality improvement programme to reduce pressure ulcers

This article outlines an innovative way of preventing pressure ulcers in the acute hospital setting. A programme using Rapid Spread Methodology was undertaken to reduce hospital-acquired pressure ulcers over a short period of time. Results demonstrated a reduction to zero in the prevalence of hospital-acquired pressure ulcers and an 80% reduction in their incidence, in a six-month period.

Under Pressure: Financial Effect of the Hospital-Acquired Conditions Initiative-A Statewide Analysis of Pressure Ulcer Development and Payment

OBJECTIVES

To assess the financial effect of the 2008 Hospital-Acquired Conditions Initiative (HACI) pressure ulcer payment changes on Medicare, other payers, and hospitals.

DESIGN

Retrospective before-and-after study of all-payer statewide administrative data for more than 2.4 million annual adult discharges in 2007 and 2009 using the Healthcare Cost and Utilization Project State Inpatient Datasets for California. How often and by how much the 2008 payment changes for pressure ulcers affected hospital payment was assessed.

SETTING

Nonfederal acute care California hospitals (N = 311).

PARTICIPANTS

Adults discharged from acute-care hospitals.

MEASUREMENTS

Pressure ulcer rates and hospital payment changes.

RESULTS

Hospital-acquired pressure ulcer rates were low in 2007 (0.28%) and 2009 (0.27%); present-on-admission pressure ulcer rates increased from 2.3% in 2007 to 3.0% in 2009. According to clinical stage of pressure ulcer (available in 2009), hospital-acquired Stage III and IV ulcers occurred in 603 discharges (0.02%); 60,244 discharges (2.42%) contained other pressure ulcer diagnoses. Payment removal for Stage III and IV hospital-acquired ulcers reduced payment in 75 (0.003%) discharges, for a statewide payment decrease of $310,444 (0.001%) for all payers and $199,238 (0.001%) for Medicare. For all other pressure ulcers, the Hospital-Acquired Conditions Initiative reduced hospital payment in 20,246 (0.81%) cases (including 18,953 cases with present-on-admission ulcers), reducing statewide payment by $62,538,586 (0.21%) for all payers and $47,237,984 (0.32%) for Medicare.

CONCLUSION

The total financial effect of the 2008 payment changes for pressure ulcers was negligible. Most payment decreases occurred by removal of comorbidity payments for present-on-admission pressure ulcers other than Stages III and IV. The removal of payment for hospital-acquired Stage III and IV ulcers by implementation of the HACI policy was 1/200th that of the removal of payment for other types of pressure ulcers that occurred in implementation of the Hospital-Acquired Conditions Initiative.

Results of a retrospective comparative study: material cost for managing a series of large wounds in subjects with serious morbidity with a hydrokinetic fiber dressing or negative pressure wound therapy

This retrospective observational study analyzed lesions with regard to healing trends and cost of materials.

MATERIALS AND METHODS

The observed lesions were mostly postsurgical or stage IV pressure ulcers in patients with serious morbidity. The wounds were treated with a hydrokinetic fiber dressing (sorbion Sachet S, sorbion Gmbh & Co, a BSN medical company, Senden, Germany) (n = 26) or negative pressure wound therapy (NPWT) (n = 16).

RESULTS

Primary healing trends (ie, reduction of wound size, change from necrosis to granulation tissue, and change from granulation tissue to epithelium) and secondary healing trends (ie, periwound conditions) were similar for wounds treated with the hydrokinetic dressing when compared to wounds treated with NPWT. Cost of materials was substantially lower for wounds treated with the hydrokinetic fiber dressing compared to the NPWT, with cost reductions of $1,640 (348%) to $2,242 (1794%) per wound, depending on the criteria used for the analysis.

CONCLUSION

In this set of wounds, the hydrokinetic fiber dressing was shown to lead to similar healing results while providing substantial reductions of the cost of materials. For the types of wounds presented in this observational study, the hydrokinetic fiber dressing seems to be an effective substitution for negative pressure wound therapy.

Risk-Adjusted Staffing to Improve Patient Value

The presence of hospital-acquired conditions, infections, or other adverse events are a reflection of inadequate patient safety and can have short and long-term impacts of quality of life for patients as well as financial implications for the hospital. Using unit-level information to develop a tool, the Patient Risk Assessment Profile, nurses on an inpatient surgical unit proactively assessed patient risk to guide staffing decisions and nurse-patient assignment with the goal to improve patient value, reduce adverse events, and avoid unnecessary hospital costs. Findings showed decreased adverse event rates for patient falls, catheter-acquired urinary tract infection, central line-acquired blood stream infection, and pressure ulcer prevalence after the intervention was implemented. In addition, end-of-shift over-time and patient cost per case decreased as well yielding an operational impact in hospital financial performance.

[Cost-effectiveness research in elderly residents in long-term care: prevention is better than cure, but not always cheaper]

Cost-effectiveness research in elderly residents in long-term care facilities is based on general principals of cost-effectiveness research; these have been developed primarily from the perspective of relatively healthy adults in curative medicine. These principals are, however, inadequate when evaluating interventions for the fragile elderly in long-term care, both in terms of the value attached to the health of patients and to the specific decision-making context of the institution. Here we discuss the pitfalls of cost-effectiveness research in long-term care facilities, illustrated by two prevention interventions for prevalent conditions in nursing homes: pressure ulcers and urinary tract infections. These turned out to be effective, but not cost-effective.

Turning for Ulcer Reduction (TURN) Study: An Economic Analysis

BACKGROUND

The Turning for Ulcer Reduction (TURN) study was a multisite, randomized controlled trial that aimed to determine the optimal frequency of turning nursing facility residents with mobility limitations who are at moderate and high risk for pressure ulcer (PrU) development. Here we present data from the economic analysis.

OBJECTIVES

This economic analysis aims to estimate the economic consequences for Ontario of switching from a repositioning schedule of 2-hour intervals to a schedule of 3-hour or 4-hour intervals.

DATA SOURCES

Costs considered in the analysis included those associated with nursing staff time spent repositioning residents and with incontinent care supplies, which included briefs, barrier cream, and washcloths.

RESULTS

The total economic benefit of switching to 3-hour or 4-hour repositioning is estimated to be $11.05 or $16.74 per day, respectively, for every resident at moderate or high risk of developing PrUs. For a typical facility with 123 residents, 41 (33%) of whom are at moderate or high risk of developing PrUs, the total economic benefit is estimated to be $453 daily for 3-hour or $686 daily for 4-hour repositioning. For Ontario as a whole, assuming that there are 77,933 residents at 634 LTC facilities, 25,927 (33%) of whom are at moderate or high risk of developing PrUs, the total economic benefits of switching to 3-hour or 4-hour repositioning are estimated to be $286,420 or $433,913 daily, respectively, equivalent to $104.5 million or $158.4 million per year.

LIMITATIONS

We did not consider the savings the Ontario Ministry of Health and Long-Term Care might incur should less frequent repositioning reduce the incidence of work-related injury among nursing staff, so our findings are potentially conservative.

CONCLUSIONS

A switch to 3-hour or 4-hour repositioning appears likely to yield substantial economic benefits to Ontario without placing residents at greater risk of developing PrUs.

Health economic benefits of cyanoacrylate skin protectants in the management of superficial skin lesions

Superficial skin damages, including stage II pressure ulcer, skin tears and moisture-associated skin damages (MASDs) are common and constitute a significant disease burden to the health care system. A cost analysis was conducted by comparing a cyanoacrylate barrier film with routine care in the treatment of superficial skin damages in a chronic care facility. The analysis included 12 patients: four patients with stage II pressure ulcers, six with MASD and two with skin tears. Cost analysis was conducted comparing the cost of care 7 days before and 7 days after the acrylate barrier was used. The total cost took into consideration the time, products and supplies required to manage the skin problem.

Implementing trials of complex interventions in community settings: the USC-Rancho Los Amigos pressure ulcer prevention study (PUPS)

BACKGROUND

Randomized trials of complex, non-pharmacologic interventions implemented in home and community settings, such as the University of Southern California (USC)-Rancho Los Amigos National Rehabilitation Center (RLANRC) Pressure Ulcer Prevention Study (PUPS), present unique challenges with respect to (1) participant recruitment and retention, (2) intervention delivery and fidelity, (3) randomization and assessment, and (4) potential inadvertent treatment effects.

PURPOSE

We describe the methods employed to address the challenges confronted in implementing PUPS. In this randomized controlled trial, we are assessing the efficacy of a complex, preventive intervention in reducing the incidence of, and costs associated with, the development of medically serious pressure ulcers in people with spinal cord injury.

METHODS

Individuals with spinal cord injury recruited from RLANRC were assigned to either a 12-month preventive intervention group or a standard care control group. The primary outcome is the incidence of serious pressure ulcers with secondary endpoints including ulcer-related surgeries, medical treatment costs, and quality of life. These outcomes are assessed at 12 and 24 months after randomization. Additionally, we are studying the mediating mechanisms that account for intervention outcomes.

RESULTS

PUPS has been successfully implemented, including recruitment of the target sample size of 170 participants, assurance of the integrity of intervention protocol delivery with an average 90% treatment adherence rate, and enactment of the assessment plan. However, implementation has been replete with challenges. To meet recruitment goals, we instituted a five-pronged approach customized for an underserved, ethnically diverse population. In intervention delivery, we increased staff time to overcome economic and cultural barriers to retention and adherence. To ensure treatment fidelity and replicability, we monitored intervention protocol delivery in accordance with a rigorous plan. Finally, we have overcome unanticipated assessment and design concerns related to (1) determining pressure ulcer incidence/severity, (2) randomization imbalance, and (3) inadvertent potential control group contamination.

LIMITATIONS

We have addressed the most daunting challenges encountered in the recruitment, assessment, and intervention phases of PUPS. Some challenges and solutions may not apply to trials conducted in other settings.

CONCLUSIONS

Overcoming challenges has required a multifaceted approach incorporating individualization, flexibility, and persistence, as well as the ability to implement needed mid-course corrections.

Introduction to economic assessment

This is the first in a series of four continuing professional development articles that explain some of the principles of economic assessment and describe the most commonly cited approaches. The series aims to enable readers to critically examine economic assessments in the context of nurse-led service innovation. It introduces a tried-and-tested methodology, with associated tools and templates, used to conduct economic assessments in nursing. In this article, the principles of economic assessment are introduced and two case studies of nurse-led innovation are used to illustrate how they are applied in practice.

Hospital report cards for hospital-acquired pressure ulcers: how good are the grades?

BACKGROUND

Value-based purchasing programs use administrative data to compare hospitals by rates of hospital-acquired pressure ulcers (HAPUs) for public reporting and financial penalties. However, validation of these data is lacking.

OBJECTIVE

To assess the validity of the administrative data used to generate HAPU rates by comparing the rates generated from these data with those generated from surveillance data.

DESIGN

Retrospective analysis of 2 million all-payer administrative records from 448 California hospitals and quarterly hospitalwide surveillance data from 213 hospitals from the Collaborative Alliance for Nursing Outcomes (as publicly reported on the CalHospitalCompare Web site).

SETTING

196 acute care hospitals with at least 6 months of available administrative and surveillance data.

PATIENTS

Nonobstetric adults discharged in 2009.

MEASUREMENTS

Hospital-specific HAPU rates were computed as the percentage of discharged adults (from administrative data) or examined adults (from surveillance data) with at least 1 stage II or greater HAPU (HAPU2+). Categorization of hospital performance based on administrative data was compared with the grade assigned when surveillance data were used.

RESULTS

When administrative data were used, the mean hospital-specific HAPU2+ rate was 0.15% (95% CI, 0.13% to 0.17%); when surveillance data were used, the rate was 2.0% (CI, 1.8% to 2.2%). Among the 49 hospitals with HAPU2+ rates in the highest (worst) quartile from administrative data, use of the surveillance data set resulted in performance grades of "superior" for 3 of these hospitals, "above average" for 14, "average" for 15, and "below average" for 17.

LIMITATION

Data are from 1 state and 1 year.

CONCLUSION

Hospital performance scores generated from HAPU2+ rates varied considerably according to whether administrative or surveillance data were used, suggesting that administrative data may not be appropriate for comparing hospitals.

PRIMARY FUNDING SOURCE

Agency for Healthcare Research and Quality.

The cost-benefit of using soft silicone multilayered foam dressings to prevent sacral and heel pressure ulcers in trauma and critically ill patients: a within-trial analysis of the Border Trial

Little is known about the cost-benefit of soft silicone foam dressings in pressure ulcer (PU) prevention among critically ill patients in the emergency department (ED) and intensive care unit (ICU). A randomised controlled trial to assess the efficacy of soft silicone foam dressings in preventing sacral and heel PUs was undertaken among 440 critically ill patients in an acute care hospital. Participants were randomly allocated either to an intervention group with prophylactic dressings applied to the sacrum and heels in the ED and changed every 3 days in the ICU or to a control group with standard PU prevention care provided during their ED and ICU stay. The results showed a significant reduction of PU incidence rates in the intervention group (P = 0·001). The intervention cost was estimated to be AU$36·61 per person based on an intention-to-treat analysis, but this was offset by lower downstream costs associated with PU treatment (AU$1103·52). Therefore, the average net cost of the intervention was lower than that of the control (AU$70·82 versus AU$144·56). We conclude that the use of soft silicone multilayered foam dressings to prevent sacral and heel PUs among critically ill patients results in cost savings in the acute care hospital.

Are labour-intensive efforts to prevent pressure ulcers cost-effective?

BACKGROUND

Pressure ulcers are a major problem in Danish healthcare with a prevalence of 13-43% among hospitalized patients. The associated costs to the Danish Health Care Sector are estimated to be €174.5 million annually. In 2010, The Danish Society for Patient Safety introduced the Pressure Ulcer Bundle (PUB) in order to reduce hospital-acquired pressure ulcers by a minimum of 50% in five hospitals. The PUB consists of evidence-based preventive initiatives implemented by ward staff using the Model for Improvement.

OBJECTIVE

To investigate the cost-effectiveness of labour-intensive efforts to reduce pressure ulcers in the Danish Health Care Sector, comparing the PUB with standard care.

METHODS

A decision analytic model was constructed to assess the costs and consequences of hospital-acquired pressure ulcers during an average hospital admission in Denmark. The model inputs were based on a systematic review of clinical efficacy data combined with local cost and effectiveness data from the Thy-Mors Hospital, Denmark. A probabilistic sensitivity analysis (PSA) was conducted to assess the uncertainty.

RESULTS

Prevention of hospital-acquired pressure ulcers by implementing labour-intensive effects according to the PUB was cost-saving and resulted in an improved effect compared to standard care. The incremental cost of the PUB was -€38.62. The incremental effects were a reduction of 9.3% prevented pressure ulcers and 0.47% prevented deaths. The PSAs confirmed the incremental cost-effectiveness ratio (ICER)'s dominance for both prevented pressure ulcers and saved lives with the PUB.

CONCLUSION

This study shows that labour-intensive efforts to reduce pressure ulcers on hospital wards can be cost-effective and lead to savings in total costs of hospital and social care.

KEY LIMITATIONS

The data included in the study regarding costs and effects of the PUB in Denmark were based on preliminary findings from a pilot study at Thy-Mors Hospital and literature.

Clinical and economic benefit of enzymatic debridement of pressure ulcers compared to autolytic debridement with a hydrogel dressing

OBJECTIVE

The purpose of this study was to determine the cost-effectiveness of enzymatic debridement using collagenase relative to autolytic debridement with a hydrogel dressing for the treatment of pressure ulcers.

METHODS

A 3-stage Markov model was used to determine the expected costs and outcomes of wound care for collagenase and hydrogel dressings. Outcome data used in the analysis were taken from a randomized clinical trial that directly compared collagenase and hydrogel dressings. The primary outcome in the clinical trial was the proportion of patients achieving a closed epithelialized wound. Transition probabilities for the Markov states were estimated from the clinical trial. A 1-year time horizon was used to determine the expected number of closed wound days and the expected costs for the two alternative debridement therapies. Resource utilization was based on the wound care treatment regimen used in the clinical trial. Resource costs were derived from standard cost references and medical supply wholesalers. The economic perspective taken was that of the long-term care facility. No cost discounting was performed due to the short time horizon of the analysis. A deterministic sensitivity analysis was conducted to analyze economic uncertainty.

RESULTS

The number of expected wound days for the collagenase and hydrogel cohorts are estimated at 48 and 147, respectively. The expected direct cost per patient for pressure ulcer care was $2003 for collagenase and $5480 for hydrogel debridement. The number of closed wound days was 1.5-times higher for collagenase (317 vs 218 days) than with the hydrogel. The estimated cost/closed wound day was 4-times higher for the hydrogel ($25) vs collagenase ($6).

CONCLUSIONS

In this Markov model based on a randomized trial of pressure ulcer care in a long-term care setting collagenase debridement was economically dominant over autolytic debridement, yielding better outcomes at a lower total cost. Since it was a single institution study with a small sample size, the results should be interpreted with caution. Specifically, the findings may not necessarily be generalized to other hydrogel dressings, healthcare settings, age groups, or to wounds of other etiologies.

Pressure ulcers management: an economic evaluation

INTRODUCTION

Pressure ulcer management represents a growing problem for medical and social health care systems all over the world, particularly in European Union countries where the incidence of pressure ulcers in older persons (> 60 years of age) is predicted to rise.

OBJECTIVES

The aim of this study was to provide evidence for the lower impact on economic resources of using advanced dressings for the treatment of pressure ulcers with respect to conventional simple dressings.

METHODS

Two different models of analysis, derived from Activity Based Costing and Health Technology Assessment, were used to measure, over a 30-day period, the direct costs incurred by pressure ulcer treatment for community-residing patients receiving integrated home care.

RESULTS

Although the mean cost per home care visit was higher in the advanced dressings patient group than in the simple dressings patient one (E 22.31 versus E 16.03), analysis of the data revealed that the cost of using advanced dressings was lower due to fewer home care visits (22 versus 11).

CONCLUSION

The results underline the fact that decision-makers need to improve their understanding of the advantages of taking a long-term view with regards to the purchase and use of materials. This could produce considerable savings of resources in addition to improving treatment efficacy for the benefit of patients and the health care system.

The costs and outcomes of treating a deep pressure ulcer in a patient with quadriplegia 

 The cost of pressure ulcers, especially Stage III and Stage IV ulcers, is substantial. A 27-year-old man with a 6-year history of quadriplegia developed an ischial pressure ulcer. Twelve months of treatment with wet-to-dry dressings were followed by admission to several facilities and 15 months of care with biological dressings and negative pressure wound therapy (NPWT). When admitted to the authors' wound care center, the wound measured 4.5 cm x 3.2 cm with exposed bone. A review of his insurance records showed that paid claims totaled $242,350, including $52,992 for NPWT rental costs. The patient was considered a good candidate for minimally invasive surgical intervention with external tissue expanders. Following a 14-day course of antibiotics to treat his infection, the wound was debrided and the tissue expanders applied. After 16 days, the wound was closed. The patient returned to work 6 weeks after the procedure. At the 23-month follow-up, the wound remained closed. Insurance payments for the care that resulted in wound closure totaled $43,814. This case study illustrates the potential of the external tissue expansion technique to close deep pressure ulcers within a relatively short amount of time at comparatively lower cost. Studies including control treatments are needed to confirm these conclusions.

Pressure ulcer risk assessment

The Department of Health wants to reduce harm caused by pressure ulcers dramatically. Identifying which patients are at risk is an important part of prevention. This article discusses the most common risk factors, the advantages and disadvantages of risk assessment tools, and challenges in prevention.

A cost-effective pressure damage prevention strategy

This article describes the development of a pressure ulcer prevention strategy, with the aim of establishing if the implementation of best practice would impact on the incidence of pressure ulcers in a healthcare setting. The strategy was piloted in a large 78-bedded nursing home. A full audit of the patients' notes and existing care pathways was conducted in order to inform the structure of the prevention plan. It was found that there were no protocols for the use of Cavilon barrier products and that it was not part of a standard care pathway. A prevention strategy was designed based on these findings and an education package delivered to all staff. Training in the appropriate use of Aderma (TM) Dermal Pads was also provided so that they could be put in place as an early preventative measure in patients at risk of pressure damage or those showing the symptoms. The results of the study showed that by establishing a best practice care pathway, the incidence of pressure ulcers could be reduced.

Medicaid program; payment adjustment for provider-preventable conditions including health care-acquired conditions. Final rule

This final rule will implement section 2702 of the Patient Protection and Affordable Care Act which directs the Secretary of Health and Human Services to issue Medicaid regulations effective as of July 1, 2011 prohibiting Federal payments to States under section 1903 of the Social Security Act for any amounts expended for providing medical assistance for health care-acquired conditions specified in the regulation. It will also authorize States to identify other provider-preventable conditions for which Medicaid payment will be prohibited.

High cost of stage IV pressure ulcers

BACKGROUND

The aim of this study was to calculate and analyze the cost of treatment for stage IV pressure ulcers.

METHODS

A retrospective chart analysis of patients with stage IV pressure ulcers was conducted. Hospital records and treatment outcomes of these patients were followed up for a maximum of 29 months and analyzed. Costs directly related to the treatment of pressure ulcers and their associated complications were calculated.

RESULTS

Nineteen patients with stage IV pressure ulcers (11 hospital-acquired and 8 community-acquired) were identified and their charts were reviewed. The average hospital treatment cost associated with stage IV pressure ulcers and related complications was $129,248 for hospital-acquired ulcers during 1 admission, and $124,327 for community-acquired ulcers over an average of 4 admissions.

CONCLUSIONS

The costs incurred from stage IV pressure ulcers are much greater than previously estimated. Halting the progression of early stage pressure ulcers has the potential to eradicate enormous pain and suffering, save thousands of lives, and reduce health care expenditures by millions of dollars.

A transparency and accountability framework for high-value inpatient nursing care

Transparency and accountability are terms that typically refer to activities aimed at measuring and holding providers responsible for their performance through such vehicles as public disclosure of comparative results. Today, transparency and accountability policies are widely accepted strategies to drive quality improvement and stimulate consumer choice. Yet nursing, the single largest health care profession, has not yet been engaged in these policy directions nor considered in their design or implementation. The framework reported here offers nurses and their professional organizations a model for which to advocate for policy change. Hospital and health system executives who have the freedom to establish institutional policies might implement this framework to achieve higher value. This framework provides both the context and components of a system that, if implemented, would measure, report, and reward hospital nursing's contributions to high value.

To what extent can pressure relieving surfaces help reduce the costs of pressure ulcers?

Pressure ulcers in acute care often involve extended hospital stays and additional health service resources. As well as the economic burden, pressure ulcers have a significant impact on patient morbidity. Pressure relieving surfaces have been recommended as a form of pressure ulcer prevention for patients at risk of developing ulcers, although such surfaces can be considerably more expensive than the standard ones used in hospitals. This summary looks at the clinical and economic evidence on pressure relieving surfaces, and discusses the likely impact on hospital budgets as a result of investing in a range of pressure relieving surfaces. The findings suggest that using pressure relieving surfaces for those at risk of developing a pressure ulcer can result in health service efficiencies and quality of life gains for patients.