ECONOMIC EVALUATION OF PREVENTIVE STRATEGIES FOR PRESSURE ULCERS: A SYSTEMATIC REVIEW

Purpose: Pressure ulcers (PU) are highly prevalent and costly to treat. Data regarding their relative cost-effectiveness has not been consolidated. We conducted a systematic review to identify the cost-effectiveness of studies examining prevention strategies.

Methods: Medline and Embase (1980-2008) were searched for published economic evaluations of PU prevention and treatment strategies.  Included articles must report costs and consequences of strategies used to prevent PUs.  Extracted data included study characteristics and outcomes produced (costs, QALYs, PUs-prevented, ICER, staff time saved, and PU-free-days), where available. Study quality was assessed using a checklist proposed by Neumann et al. Cost-effectiveness data was abstracted and summarized according to four classes of interventions. Costs were adjusted to 2008 Canadian dollars.

Results: A total of 16 studies (1,659 citations) were included. Studies reported cost-effectiveness of support surfaces, incontinence care protocols, staff time, and combination of risk assessment, prevention, and treatment.  Quality of publications was considered “poor” (range: 4.5-7 out of 19). Five studies evaluating support surfaces showed that high specificity foam mattresses significantly reduced PU incidence compared with standard mattresses. Cost-saving ranged from $78-251 per 0-0.4 QALY gained, $157 per 1 PU prevented, $50 per 24% PU incidence reduction, and $78 per 11 PU-free days. Four studies evaluating incontinence care protocols suggested that compared with standard care (i.e., skin care with soap and water); no-rinse cleanser had a cost saving of $13-22 per-patient-per-day (pppd), taking staff time into account. Additional cost savings could be observed with the addition of moisture barrier products. Six studies evaluating staff time indicated that increasing registered nurse time pppd was associated with reduced PU incidence, with optimal 30-40 minutes direct nurse contact to patient care (odds-ratio=0.16). Increasing staff time by 1.52 hours pppd would decrease PU incidence by 25% and cost $121 pppd. One before-after-design study evaluating an intensive PU prevention protocol in long-term care reported an average cost-saving per day of ulcer-free life gained of $1.13. PU-prevention protocol included: staff training, repositioning, and use of pressure reducing mattresses. Treatment also varied.  

Conclusion: All evaluated interventions were reported to be cost-saving and with beneficial health outcomes produced. Analyzed studies vary in design, settings, underlying assumptions, PU interventions and reporting outcomes. Study quality was low. Higher quality estimates of the economic attractiveness of prevention strategies are required.