Send to

Choose Destination
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

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



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.


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


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.


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).


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


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.


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.


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.


cost-effectiveness; health services research; nurses

Supplemental Content

Full text links

Icon for HighWire Icon for PubMed Central
Loading ...
Support Center