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BMJ Qual Saf. 2019 Feb;28(2):132-141. doi: 10.1136/bmjqs-2017-007505. Epub 2018 Aug 10.

Value of hospital resources for effective pressure injury prevention: a cost-effectiveness analysis.

Author information

1
Health Policy & Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA.
2
Armstrong Institute for Patient Safety and Quality, Johns Hopkins Medicine, Baltimore, Maryland, USA.
3
Anesthesiology & Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.
4
College of Nursing, University of Colorado, Aurora, Colorado, USA.
5
Medicine, University of Colorado Denver School of Medicine, Aurora, Colorado, USA.
6
Emergency Medicine, Baylor College of Medicine, Houston, TX, USA.
7
Community and Family Medicine, Dartmouth College Geisel School of Medicine, Hanover, New Hampshire, USA.
8
Department of Medicine, Center for Health and the Social Sciences, University of Chicago, Chicago, Illinois, USA.

Abstract

OBJECTIVE:

Hospital-acquired pressure injuries are localised skin injuries that cause significant mortality and are costly. Nursing best practices prevent pressure injuries, including time-consuming, complex tasks that lack payment incentives. The Braden Scale is an evidence-based stratification tool nurses use daily to assess pressure-injury risk. Our objective was to analyse the cost-utility of performing repeated risk-assessment for pressure-injury prevention in all patients or high-risk groups.

DESIGN:

Cost-utility analysis using Markov modelling from US societal and healthcare sector perspectives within a 1-year time horizon.

SETTING:

Patient-level longitudinal data on 34 787 encounters from an academic hospital electronic health record (EHR) between 2011 and 2014, including daily Braden scores. Supervised machine learning simulated age-adjusted transition probabilities between risk levels and pressure injuries.

PARTICIPANTS:

Hospitalised adults with Braden scores classified into five risk levels: very high risk (6-9), high risk (10-11), moderate risk (12-14), at-risk (15-18), minimal risk (19-23).

INTERVENTIONS:

Standard care, repeated risk assessment in all risk levels or only repeated risk assessment in high-risk strata based on machine-learning simulations.

MAIN OUTCOME MEASURES:

Costs (2016 $US) of pressure-injury treatment and prevention, and quality-adjusted life years (QALYs) related to pressure injuries were weighted by transition probabilities to calculate the incremental cost-effectiveness ratio (ICER) at $100 000/QALY willingness-to-pay. Univariate and probabilistic sensitivity analyses tested model uncertainty.

RESULTS:

Simulating prevention for all patients yielded greater QALYs at higher cost from societal and healthcare sector perspectives, equating to ICERs of $2000/QALY and $2142/QALY, respectively. Risk-stratified follow-up in patients with Braden scores <15 dominated standard care. Prevention for all patients was cost-effective in >99% of probabilistic simulations.

CONCLUSION:

Our analysis using EHR data maintains that pressure-injury prevention for all inpatients is cost-effective. Hospitals should invest in nursing compliance with international prevention guidelines.

KEYWORDS:

cost-effectiveness; health services research; nurses

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