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Methods: A decision analytic model was constructed using the validated Resident Assessment Instrument – Minimum Dataset (MDS) in Ontario including18,325 LTC residents from 91 long-term care facilities, and content advice from an expert panel. Evidence of efficacy was provided by systematic reviews for interventions used in the assessed prevention options. The pressure ulcer prevention options supported by at least moderate quality evidence were: current care; replacing the standard hospital mattress with an alternate foam mattress (i.e., AF, relative risk (RR) for pressure ulcer incidence (4 RCTs): 0.31); replacing the standard hospital mattress with an alternate foam mattress and introducing a repositioning program for high risk LTC residents (i.e., AF & 4-hour turning, RR (1 RCT) = 0.21); improving the provision of nutritional supplements for high-risk LTC residents with nutrition deficit (i.e., nutrition supplement, RR (4 RCTs) = 0.85); improving the use of a skin care protocol in high-risk LTC residents with uro-fecal incontinence (i.e, skin care protocol, RR (1 controlled study) = 0.36); increasing daily registered nurses time to 30-40 minutes on high risk LTC residents (i.e., increased RN time, RR (1 cohort study) = 0.25). Utility for LTC residents was derived from a validated approach by mapping MDS items to the HUI-II. Costs were derived from the MDS, and provincial data describing physician billings and hospitalizations (discounted 2008 Canadian dollars).
Results: In the base case analysis, the discounted lifetime cost of a resident receiving current care was estimated to be $152,808 over a life expectancy of 3.07 years/1.18 quality adjusted life years. All prevention options were cost saving with both life days (LD) and quality-adjusted life days (QALD) gained when compared to the current care: Increasing daily registered nurse time (-$3,445; 9.7 LD/9.9 QALD), AF & 4-hour turning (-$2,505; 7.3 LD/6.6 QALD), AF (-$2,072, 5.0 LD/4.7 QALD), skin care protocol (-$1,188; 3.0 LD/4.8 QALD), and nutrition supplement (-$413, 0.9 LD/3.1 QALD). Findings were robust to univariate deterministic sensitivity analysis.
Conclusion: All prevention options were highly economically attractive. Replacing conventional mattresses with alterate foam mattresses is a policy attractive option: efficient, low budget impact (one-time purchase at $450 per bed), and high quality evidence.