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

Authors

Sarah J Whitehead, MSc, BSc, is research fellow, York Trials Unit, University of York; Paul Trueman,MA, BA, is professor of health economics and director, Health Economics Research Group, Brunel University, London.

Background

The management of pressure ulcers is an extremely costly activity that often does not receive the attention it deserves. An estimated 400,000 new pressure ulcers occur each year in England, with management costs reported to be £1.8-£2.6bn per year, equivalent to around 2% of all healthcare expenditure (Posnett and Franks, 2008). In addition to the financial burden, pressure ulcers also have an impact on patient morbidity, carers, families and society as a whole.

Views differ about the extent to which pressure ulcers can be prevented (Brandeis et al, 2001). However, many can be avoided by preventive measures; using appropriate surfaces to reduce pressure, friction and shearing forces is a key part of prevention. The Royal College of Nursing defined pressure relieving devices as “beds, mattresses, overlays,…cushions and other devices aimed at pressure redistribution” (National Institute for Clinical Excellence, 2003) [note to subs – corr title as was then]. Although definitions for the different surface types available tend to vary, we have summarised the various surfaces using three broad categories, in line with other studies:

• Standard foam;
• Continuous low pressure;
• Alternating pressure.

The costs of these surfaces can vary considerably.

NICE (2005) guidance recommended that people with pressure ulcers should have access to appropriate pressure relieving surfaces and strategies 24 hours a day. All those assessed as having a grade 1 or 2 ulcer should be allocated to a high specification foam mattress or cushion with pressure relieving properties, as a minimum provision. For those with grade 3 or 4 ulcers, minimum provision recommended is an alternating pressure mattress or sophisticated continuous low pressure system. These recommendations have implications for the choice of surfaces used in hospitals.

Aim

We aimed to review the key clinical and economic evidence on the use of pressure relieving surfaces. In addition, the effects of changing the range of surfaces currently used in hospitals, measured in terms of the incidence of pressure ulcers and their financial implications, were explored using an illustrative case study. This article presents a short summary of the findings (for a more detailed discussion see Trueman and Whitehead, 2010).

Literature review

A targeted search of the published literature was conducted to identify clinical and economic evidence on pressure relieving surfaces. This was a purposive search to identify the best quality clinical studies and review articles on pressure relieving surfaces rather than a systematic literature search. The papers identified were reviewed for relevance, with the key points from relevant studies highlighted below.

Clinical evidence on pressure relieving surfaces

Several studies have reported the effectiveness of pressure relieving surfaces in terms of the development of pressure ulcers but, in general, they generate findings that are difficult to interpret. Common limitations include small sample sizes, different definitions of surface types and categorisation of surfaces changing over time. It is often difficult to determine the extent to which study protocols were followed, and whether other aspects such as manual turning influenced the findings. This creates complexity in attempting to compare study results.

The Prevention of Pressure Ulcer Study (PPUS-1) and the PRESSURE (Pressure RElieving Support SUrfaces: a Randomised Evaluation) trial are among the most robust studies conducted to date.

The PPUS-1 trial found that 22% of patients on standard foam mattresses developed pressure ulcers, compared with 15% of those on viscoelastic polymer foam mattresses (Russell et al, 2003). The PRESSURE trial investigated the use of alternating pressure overlays and mattresses; both surfaces resulted in similar outcomes, with approximately 10% of patients developing pressure ulcers (Nixon et al, 2006).

A Cochrane review examined the effectiveness of pressure relieving surfaces compared with standard surfaces, in terms of pressure ulcer incidence (McInnes et al, 2008). The review found it difficult to draw firm conclusions from the existing evidence and recommended that rigorous research comparing different support surfaces is needed. The main conclusion was that “standard hospital mattresses have been consistently outperformed by a range of foam-based, low pressure mattresses, and also by ‘higher-tech’ pressure-relieving surfaces” for pressure ulcer prevention (McInnes et al, 2008). In general, the evidence suggests that pressure relieving surfaces can provide clinical benefits although it remains equivocal on their comparative performance versus standard foam mattresses and the relative benefits of advanced surfaces.

Economic evidence on pressure relieving surfaces

Economic evaluations of different surface types have been carried out, which examine both the associated costs and effectiveness of surfaces. An economic evaluation was conducted alongside the PRESSURE trial and found that alternating pressure mattresses are more likely to be cost effective than alternating pressure overlays (Iglesias et al, 2006). Another high quality evaluation (Fleurence, 2005) also compared the two types of alternating pressure surfaces; the study indicated that mattresses were more cost effective than overlays for pre-existing superficial or severe pressure ulcers, but found the opposite was true for patients at risk of developing a pressure ulcer but with no pre-existing ulcer.

There is a lack of economic evidence for the comparison of different types of high specification surfaces, that is, to determine whether the extra costs of high-tech surfaces are justified by extra benefits, in terms of avoiding pressure ulcers, for example.

Illustrative case study

In addition to the literature review, an illustrative case study exploring the impact of the use of pressure relieving surfaces on hospital budgets was developed. This considers inpatients at risk of developing a pressure ulcer in an average sized hospital in the UK, and examines the financial implications of moving some of these patients from standard foam surfaces to more advanced pressure relieving surfaces. While this is intended to be a hypothetical analysis, the data used in it is derived from published sources.

The case study looks at a typical medium sized hospital with 500 beds, which operates at an 80% occupancy rate. The average length of stay is five days, representing the average for all elective stays in the UK (Hospital Episode Statistics, 2009). Based on this, the hospital has an estimated 29,220 admissions per year.

Prevalence and incidence of pressure ulcers

Prevalence and incidence data was derived from a large observational pressure ulcer study (Whittington and Briones, 2004) and is summarised in Table 1. At any one time, 19% of inpatients are assumed to have an existing pressure ulcer while 8% are at risk of developing one. Of those with an existing ulcer, 62% are assumed to have a grade 1 ulcer, 30% grade 2, 4% grade 3 and 3% grade 4 (percentages have been rounded to whole numbers). Any pressure ulcers that develop in the at risk group are assumed to be identified at grade 1.

Applying these rates to our hypothetical hospital, we predict that an estimated 7,890 patients are treated for pressure ulcers each year, including 2,338 at risk patients.

Cost of managing pressure ulcers

The cost of management is based on a published study (Bennett et al, 2004), which provides a comprehensive cost for managing different grades of pressure ulcers in the UK (Table 2). Patients identified as being at risk are assumed to cost the same to manage as those with a grade 1 ulcer.

Costs and effectiveness of pressure relieving surfaces

The type of surface influences the likelihood of pressure ulcers developing. The probabilities of pressure ulcer development related to the different surfaces are taken from clinical studies (Table 3). The costs of the different surface types are average costs based on list prices, assuming surfaces are used for three years, also shown in Table 3.

Implications of allocating at risk patients to appropriate surfaces

Our analysis assumes that all patients identified as being at risk of developing a pressure ulcer are currently allocated to standard foam mattresses. Suppose that some are placed on a high specification surface, instead of standard foam. The case study findings show that when just 15% of at risk patients are allocated to pressure relieving surfaces, the likelihood of developing pressure ulcers is reduced; 48 pressure ulcers are avoided, as shown in Table 4. The high specification surfaces cost an additional £3,314. However, there are cost savings of £64,199 that would otherwise have been spent on pressure ulcer management. The overall impact on the health service is a saving of £60,885, which indicates that investing in pressure ulcer prevention is an efficient use of healthcare resources. Further details of the methods used for this calculation can be found in Trueman and Whitehead (2010).

Discussion

Pressure ulcers are highly prevalent and have a significant impact on patients and health service resources. The use of pressure relieving surfaces is recommended to help prevent pressure ulcers (NICE, 2005). In light of current financial constraints, it is acknowledged that high specification surfaces are more expensive than those used as standard in hospitals. However, our analysis suggests that investing in pressure relieving surfaces can reduce the number of pressure ulcers, and the associated costs of treatment, which can be substantial.

The analysis presented here is based on a hypothetical cohort and brings together evidence from a number of different studies to generate an illustrative case study of the financial costs associated with managing pressure ulcers. However, audits have been conducted that show cost savings resulting from implementing an effective portfolio of surfaces for pressure ulcer management (Pagnamenta, 2007), which support these findings.

We are aware that not all patients need a high specification surface; instead healthcare resources would be best directed towards those at increased risk. The critical issue for appropriately managing resources is how best to identify those people at risk of developing a pressure ulcer during their hospital stay and ensure that they are allocated to an appropriate pressure relieving surface. Wound management professionals need to take an active role in providing screening tools that allow hospitals to allocate patients appropriately.

A further consideration is the degree to which our findings are relevant to practice. Clearly, the “savings” generated in the example are based on avoiding pressure ulcers. As such, it could be argued that these savings are not realised in practice, that is, there is no cash saving associated with an avoided adverse event during a hospital stay. While this is true to an extent, better inpatient management that avoids pressure ulcers will lead to greater efficiencies and ultimately reduced length of stay. As financing models for hospitals encourage and reward throughput, this can ultimately lead to increased revenues for a hospital.

Healthcare planners might also argue that the findings are irrelevant, as pressure relieving surfaces incur large scale acquisition costs which cannot be offset against savings from shorter lengths of stay or revenues from increased throughput. There is some sympathy for this argument. Investing in a portfolio or range of pressure relieving surfaces requires significant investment, although the impact of this can be reduced by using rental agreements which are available for many of the higher-tech surfaces.

Furthermore, we should not lose sight of the primary aim of healthcare. Avoiding an adverse event during a hospital stay, such as a pressure ulcer, not only produces financial efficiencies but also prevents loss of quality of life and pain and suffering which patients may otherwise experience. While no attempt has been made to capture these in this analysis, this is a main aim for healthcare professionals.

Conclusion

Evidence suggests that the number of pressure ulcers can be reduced by using pressure relieving surfaces for at risk patients in hospital settings. Despite the increased costs of acquiring such surfaces, our case study has illustrated that these costs can be offset by avoiding treatment costs.

In order to reduce the strain on hospital budgets caused by pressure ulcers, the implementation of a planned approach to pressure ulcer prevention and management, incorporating a range of pressure relieving surfaces, can lead to improvements in health service efficiency and patients’ quality of life.

• This summary is based on the study by Trueman and Whitehead (2010). The review and development of the budget impact model were supported by a research grant from KCI Europe.

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