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The cost of pressure ulcer prevention and treatment in hospitals and nursing homes in Flanders: A cost-of-illness study Liesbet Demarre´ a,*, Sofie Verhaeghe a, Lieven Annemans b,c, Ann Van Hecke a,d, Maria Grypdonck a, Dimitri Beeckman a,e,f a University Centre for Nursing and Midwifery, Department of Public Health, Faculty of Medicine and Health Sciences, Ghent University, Ghent, Belgium b Health Economics, Department of Public Health, Faculty of Medicine and Health Sciences, Ghent University, ICHER (Interuniversity Center for Health Economics Research), Ghent, Belgium c Brussels University, Belgium d Ghent University Hospital, Ghent, Belgium e Florence Nightingale School of Nursing & Midwifery, King’s College London, London, UK f Department of Bachelor in Nursing, Artevelde University College, Ghent, Belgium

A R T I C L E I N F O

A B S T R A C T

Article history: Received 10 July 2014 Received in revised form 6 March 2015 Accepted 6 March 2015

Introduction: The economic impact of pressure ulcer prevention and treatment is high. The results of cost-of-illness studies can assist the planning, allocation, and priority setting of healthcare expenditures to improve the implementation of preventive measures. Data on the cost of current practice of pressure ulcer prevention or treatment in Flanders, a region of Belgium, is lacking. Aim: To examine the cost of pressure ulcer prevention and treatment in an adult population in hospitals and nursing homes from the healthcare payer perspective. Design: A cost-of-illness study was performed using a bottom-up approach. Settings: Hospitals and nursing homes in Flanders, a region of Belgium. Methods: Data were collected in a series of prospective multicentre cross-sectional studies between 2008 and 2013. Data collection included data on risk assessment, pressure ulcer prevalence, preventive measures, unit cost of materials for prevention and treatment, nursing time measurements for activities related to pressure ulcer prevention and treatment, and nursing wages. The cost of pressure ulcer prevention and treatment in hospitals and nursing homes was calculated as annual cost for Flanders, per patient, and per patient per day. Results: The mean (SD) cost for pressure ulcer prevention was s7.88 (8.21) per hospitalised patient at risk per day and s2.15 (3.10) per nursing home resident at risk per day. The mean (SD) cost of pressure ulcer prevention for patients and residents identified as not at risk for pressure ulcer development was s1.44 (4.26) per day in hospitals and s0.50 (1.61) per day in nursing homes. The main cost driver was the cost of labour, responsible for 79–85% of the cost of prevention. The mean (SD) cost of local treatment per patient per day varied between s2.34 (1.14) and s77.36 (35.95) in hospitals, and between s2.42 (1.15) and s16.18 (4.93) in nursing homes. Conclusions: Related to methodological differences between studies, the cost of pressure ulcer prevention and treatment in hospitals and nursing homes in Flanders was found to be low compared to other international studies. Recommendations specific to pressure ulcer prevention are needed as part of methodological guidelines to conduct cost-of-illness studies. ß 2015 Elsevier Ltd. All rights reserved.

Keywords: Pressure ulcers Prevention Treatment Cost-of-illness Health economics Nursing homes Hospitals

* Corresponding author at: University Centre for Nursing and Midwifery, Ghent University, Block A, De Pintelaan 185, 9000 Gent, Belgium. Tel.: +32 9 332 33 14. E-mail address: [email protected] (L. Demarre´). http://dx.doi.org/10.1016/j.ijnurstu.2015.03.005 0020-7489/ß 2015 Elsevier Ltd. All rights reserved.

Please cite this article in press as: Demarre´, L., et al., The cost of pressure ulcer prevention and treatment in hospitals and nursing homes in Flanders: A cost-of-illness study. Int. J. Nurs. Stud. (2015), http://dx.doi.org/10.1016/j.ijnurstu.2015.03.005

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What is already known about the topic?  The cost of pressure ulcer prevention and treatment has an important impact on national health care expenditures.  The cost of pressure ulcer prevention and treatment varies between studies, and is related to differences in study methodologies.  Cost-of-illness studies can help the identification of the cost drivers for pressure ulcer prevention and treatment, and guide the decision making about allocating healthcare resources. What this paper adds  The cost for pressure ulcer prevention per patient/ resident per day was higher in hospitals compared to nursing homes.  Cost of labour was the main cost driver of pressure ulcer prevention, responsible for 79–85% of the total cost.  Reliable risk assessment policy and continuous monitoring and adoption of preventive measures may decrease healthcare expenditures by lowering the costs of prevention for patients not at risk and cost of treatment. 1. Introduction Pressure ulcers are defined as localised injuries of the skin and/or underlying tissue over a bony prominence due to pressure and shear (NPUAP & EPUAP, 2009). Pressure ulcers are internationally considered as an important quality indicator, and most pressure ulcers are avoidable (National Pressure Ulcer Advisory Panel, 2011; Van Den Bos et al., 2011). In addition to the impact on the physical, psychological, and social well-being of patients, pressure ulcers have financial implications for all involved parties (Gorecki et al., 2009; Hopkins et al., 2006; Langemo et al., 2000; National Institute for Clinical Excellence, 2005; Spetz et al., 2013). The costs of pressure ulcers are receiving increased attention because of limited public and healthcare budgets. Furthermore, insight is needed as to costs related to the treatment of mainly avoidable events, such as pressure ulcers. Health economics is the discipline that deals with the application of economic principles to health and the healthcare sector (Annemans, 2008). Different approaches in health economics can be used, such as health economic evaluations, and cost of illness/injury studies. The former approach can be defined as a comparative analysis of both the costs and health effects of two or more alternative health interventions. The latter method can be defined as a calculation of the economic burden of an injury or illness by quantifying the (direct) medical costs (Hodgson and Meiners, 1982). Although the relevance of cost-of-illness studies has been questioned because the variation in methodology leads to inconsistent cost estimates, and a lack of information on effectiveness of the included treatments, these studies can aid our understanding of the importance of health problems and provide information on the impact of prevention and treatment of an illness on the total healthcare budget (Akobundu et al., 2006; Larg and Moss,

2011). Furthermore, these insights can help policymakers and health service management to identify the cost drivers for pressure ulcer prevention and treatment and guide decision making about allocating healthcare resources, such as materials and nursing staff. The perspective of an economic study reflects who is paying the costs. Different health economic perspectives can be identified, such as the societal, governmental, organisational or institutional, insurer, or patient perspective. The choice of perspective is related to the research goal and the disease under study, but the available cost data may influence the chosen perspective (Larg & Moss, 2011). The broader the perspective, the less chance there is that cost shift between sectors will affect the outcome, thereby minimising the potential biases of more narrow views (Byford & Raftery, 1998; Cleemput et al., 2008; Larg and Moss, 2011). The results of cost-of-illness studies are subject to uncertainty, such as the lifetime of materials, prevalence figures, or labour costs. This uncertainty can be handled by sensitivity analyses that examine the influence of possible variances in prevalence, labour cost, or material cost. A recent systematic review pointed out that the cost of pressure ulcer prevention per patient per day varied between s15.70 and s87.57 across all types of health care settings. The mean costs of pressure ulcer treatment ranged between s1.71 and s470.49 per patient per day across all types of health care settings (Demarre´ et al., 2015). The costs of pressure ulcer prevention and treatment are driven by labour, prolonged hospitalisation, complications due to pressure ulcers, and material cost. The cost of nursing labour was found high compared to the cost of materials (Dealey et al., 2012; Frantz et al., 2001; Xakellis et al., 2001). Nursing time related to activities for treatment of prevention of pressure ulcers varies as a result of the methodology used to measure these times. This variation in study methodology influences the mean cost of pressure ulcer prevention and treatment. Several studies used subjective time measurements, such as expert opinion or a Delphi method, to calculate the duration of nursing activities related to pressure ulcer prevention and treatment (Agreda et al., 2007; Alterescu, 1989; Assadian et al., 2011; Bayoumi et al., 2008; Bennett et al., 2004; Dealey et al., 2012; Foglia et al., 2012; Hale, 1990; Schuurman et al., 2009; Severens et al., 2002). Nursing time measured through direct observation was found to result in lower times compared to using a Delphi method (Boudt, 2013; Burke et al., 2000). The method of direct observation requires a researcher to observe a person for a period of time and uses a chronometer to measure length of time of the activities. This method most accurately measures the time spent on an activity related to pressure ulcer prevention and treatment (Burke et al., 2000). Unfortunately, a set of accurate chronometer measurements of nursing time is currently lacking, although it could be used in future cost-of-illness studies, thereby increasing the quality of data collected. Most of the previously conducted studies on cost of pressure ulcer prevention have calculated the cost of preventive measures based on models or algorithms of prevention which were created from best practice guidelines, or based on findings from the literature

Please cite this article in press as: Demarre´, L., et al., The cost of pressure ulcer prevention and treatment in hospitals and nursing homes in Flanders: A cost-of-illness study. Int. J. Nurs. Stud. (2015), http://dx.doi.org/10.1016/j.ijnurstu.2015.03.005

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(preventive measures under highly standardised conditions) (Dealey et al., 2012; Bayoumi et al., 2008; Bennett et al., 2004). In these model-based cost calculations, the cost of prevention in patients not at risk is not included in the total cost and the cost of patients at risk will probably be higher compared to cost calculations based on daily care (this is the care provided to patients without interference of research/researchers). This higher cost could be the result of inadequate, incomplete, or missing preventive measures in patients at risk, which was observed in several studies in Europe and the United States (Baumgarten et al., 2010; Beeckman et al., 2013; Gunningberg, 2005; van Gaal et al., 2011; Vanderwee et al., 2011). On the other hand, in a national study, in which all Belgian hospitals were invited to participate, more than 70% of the patients perceived not at risk received some preventive measures (Vanderwee et al., 2011). For Flanders, a region in Belgium, data on the cost of current practice of pressure ulcer prevention or treatment are not available. These cost calculations based on daily care can provide insight into the actual expenditures and economic impact of pressure ulcer prevention and treatment in current practice, and may improve the allocation of preventive measures. 1.1. Aim The purpose of this study was to investigate the cost of pressure ulcer prevention and treatment in an adult population in hospitals and nursing homes from a mixed economic perspective (patient, institutional, and insurer). The economic perspective of a study reflects on who is paying the costs (Davidoff and Powe, 1996).

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2.2. Data sources Data were collected in a series of prospective multicentre cross-sectional studies. The first study was a prospective multicentre crosssectional pressure ulcer point prevalence study including pressure ulcer prevalence and preventive measures used in hospitals. Data were collected in April 2008. Methods and results were reported in detail elsewhere (Vanderwee et al., 2011). The second study was a prospective multicentre crosssectional pressure ulcer point prevalence study including pressure ulcer prevalence and preventive measures used in nursing homes. Data were collected in March 2012. The third study was a prospective multicentre crosssectional in hospitals collecting data on the cost of materials, simultaneously with time measurements for a set of activities involved in pressure ulcer prevention and treatment in hospitals, using direct time measurements by the researcher. Data were collected between November 2012 and April 2013. Data collection on cost of nursing labour in hospitals was adopted from a manual for costbased pricing of hospital interventions of the Belgian Health Care Knowledge Centre (Swartenbroekx et al., 2012). The fourth study was a prospective multicentre crosssectional study in nursing homes collecting data on the cost of materials, simultaneously with labour cost and time measurements for a set of activities involved in pressure ulcer prevention and treatment, which were measured using direct observation by the researcher. Data were collected between May 2012 and September 2012. An overview of the data collected in hospitals and nursing homes is provided in Tables 1a and 1b.

2. Methods 2.1. Design A cost-of-illness study was performed using a bottomup approach (person-based approach calculating the resources used for individuals receiving pressure ulcer prevention or treatment). Cost-of-illness studies can comprise direct and indirect costs, as well as medical and non-medical costs (Larg and Moss, 2011). Direct medical costs are defined as diseaserelated costs, such as prevention, detection, treatment, and rehabilitation, which are paid by the patient, healthcare institution, insurers, and/or government (Annemans, 2008; Larg and Moss, 2011; Rice, 1967). Direct medical costs in the field of pressure ulcers can consist of labour cost and cost for materials (Dealey et al., 2012; Haalboom, 1991; Schuurman et al., 2009). Direct non-medical costs are disease-related costs, which are not part of the healthcare service, such as travel costs to the health care provider. Indirect medical costs are future costs of general healthcare, such as the healthcare costs arising from living longer (Annemans, 2008). Indirect non-medical costs include costs related to reduced work productivity due to morbidity or premature death because of illness (Annemans, 2008). In this study, only direct medical costs were included.

2.2.1. Hospitals Pressure ulcer prevalence and preventive measures: All hospitals in Flanders (N = 77), except for psychiatric institutions, were invited to measure pressure ulcer prevalence and the applied preventive interventions. Forty-eight hospitals participated, representing 454 wards and 11 792 patients. The European Pressure Ulcer Advisory Panel (EPUAP) minimum dataset was used to collect the data. The EPUAP minimum dataset included data on patient characteristics, risk assessment (Braden scale or presence of pressure ulcer), pressure ulcer prevalence, and preventive measures applied. In Belgium, patients and residents with a Braden score of less than 17 are considered as being in need of preventive measures (Defloor et al., 2004; Vanderwee et al., 2011). Skin observation included the location and severity of a pressure ulcer and the presence of incontinence-associated dermatitis (IAD). Pressure ulcer severity was categorised using the National Pressure Ulcer Advisory Panel and European Pressure Ulcer Advisory Panel (NPUAP & EPUAP) classification (NPUAP & EPUAP, 2009). The data on pressure ulcer preventive measures included prevention in bed and while seated. Data on equipment and repositioning frequency were recorded. It was recorded whether the equipment was present in the patient’s or resident’s bed or armchair at the time of the observation.

Please cite this article in press as: Demarre´, L., et al., The cost of pressure ulcer prevention and treatment in hospitals and nursing homes in Flanders: A cost-of-illness study. Int. J. Nurs. Stud. (2015), http://dx.doi.org/10.1016/j.ijnurstu.2015.03.005

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Table 1a Overview of the data collected in hospitals in Flanders: type of data, data sources, year of data collection, setting and sample. Type of data

Data source/reference

Year of data collection

Setting and sample

Data on pressure ulcer prevalence and preventive measures were previously presented by Vanderwee et al. (2011) Data of frequency of risk assessment and skin assessment was adopted from Gunningberg et al. (2012)

Data collected during a one-day measurement in the week of April 15th 2008

Hospitals Wards Patients

n = 48 n = 48 n = 11 792

Hire/purchase prices preventive devices from resources manager Lifespan of the devices: based on information of medical technology companies Type and amount of materials used for pressure ulcer treatment: direct observation by researcher Prices of materials: pharmacy and the logistics department (adjusted for discounts), if missing official prices from databases of The National Institute for Health and Disability Insurance (NIHDI) were used (downloaded from http://www.riziv.be/drug/nl/)

Data collected during one-day measurements between November 2012 and April 2013

Hospitals Wound treatments

n = 10 n = 78

Nursing times for activities related to prevention and treatment

Data collected through direct observation by the researcher (LD, DB, HD), using a chronometer.

Data collected during one-day measurements between November 2012 and April 2013

Hospitals Patients Time measurements

n = 15 n = 753 n = 1717

Labour cost

Cost of nursing wages based manual for cost-based pricing of hospital interventions of the Belgian Health Care Knowledge Centre (Swartenbroekx et al., 2012)

Prevalence data  Demographic data  Risk assessment (Braden Scale or presence of a pressure ulcer)  Pressure ulcer prevalence Category I–IV Preventive measures in bed and chaira

Cost of materials  Pressure ulcer prevention Mattresses Cushions  Local treatment Dressings Wound cleaning solutions, Disinfectants Sets Consult of general Practitioner Consult surgeon Surgery Medication Nutritional supplement, Contact precaution materials

Data retrieved from manual for cost-based pricing of hospital interventions of the Belgian Health Care Knowledge Centre (Swartenbroekx et al., 2012)

a Preventive measures in bed and chair: including primary prevention and secondary prevention (measures to prevent further deterioration, occurrence or recurrence of pressure ulcers).

The repositioning frequency was based on the reported frequency in the residents’ chart. Both evidence-based effective and non-effective measures were registered. The EPUAP methodology was used to collect the data. This methodology involves training for study coordinators and data collectors prior to the study, and data collection by two observers. The first observer was a nurse from the ward under study, the second observer a nurse from a different ward (Vanderwee et al., 2007). Data were collected in March 2008. Further study details are presented elsewhere (Vanderwee et al., 2011). Data on frequency of risk assessment and skin assessment performed in daily care were lacking. Therefore, recent data from another European country were adopted (Gunningberg et al., 2012). Unit cost (per day) of materials for prevention and treatment: A random sample of 10 hospitals, drawn from all hospitals in Flanders (N = 77), was used to collect data on the unit cost of materials. This random selection was

intended to maximise the chance of selecting a representative sample of hospitals, thereby including potential cost differences among institutions. Medical resource use for pressure ulcer treatment was examined through direct observation by the researcher (LD). To calculate the treatment cost, 78 treatments were observed. The treatment of wounds was observed in order to assess type and amount of materials used. Resources used for treatment of pressure ulcers included cleaning solvents, disinfectants, topical agents, dressings, antibiotics, medication, nutritional support, and contact isolation measures in case of wound infection with multi-resistant bacteria. Costs of medical resources used for treatment were provided by the pharmacies and logistics departments of participating hospitals. These costs were adjusted to account for discounts provided to the participating hospitals. If data on the cost of these resources could not be retrieved from these departments, official prices were collected from databases of The National Institute for Health and

Please cite this article in press as: Demarre´, L., et al., The cost of pressure ulcer prevention and treatment in hospitals and nursing homes in Flanders: A cost-of-illness study. Int. J. Nurs. Stud. (2015), http://dx.doi.org/10.1016/j.ijnurstu.2015.03.005

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Table 1b Overview of the data collected in nursing homes in Flanders: type of data, data sources, year of data collection, setting and sample. Type of data

Data source/reference

Year of data collection

Setting and sample

Data collected by teams of two observers (including one nurse from the ward being surveyed, and one nurse from a different ward) using the EPUAP minimum dataset Data of frequency of skin assessment adopted from Gunningberg et al. (2012). No further risk assessment was assumed

Data collected during a one-day measurement in the week of 19th of March 2012

Nursing homes Wards Residents

n = 84 n = 294 n = 8008

Hire/purchase prices preventive devices from resources manager Lifespan of the devices: based on information of medical technology companies Type and amount of materials used for pressure ulcer treatment: direct observation by researcher. Prices of materials: pharmacy and the logistics department (adjusted for discounts), if missing official prices from databases of The National Institute for Health and Disability Insurance (NIHDI) were used (downloaded from http://www.riziv.be/drug/nl/)

Data collected during one-day measurements between May 2012 and September 2012

Nursing homes Wound treatments

n = 20 n = 59

Nursing time for activities related to prevention and treatment

Data collected through direct observation by the researchers (LD), using a chronometer

Data collected during one-day measurements between May 2012 and September 2012

Nursing homes Residents Time measurements

n = 20 n = 198 n = 1052

Labour cost

Cost of the wages provided by the organisations and based on NIHDI (National Institute for Health and Disability Insurance)

Data collected during one-day measurements between May 2012 and September 2012

Nursing homes

n = 20

Prevalence data  Demographic data  Risk assessment (Braden Scale or presence of a pressure ulcer)  Pressure ulcer prevalence Category I–IV  Preventive measures in bed and chaira

Cost of materials  Pressure ulcer prevention mattresses cushions  Local treatment dressings wound cleaning solutions, disinfectants sets consult of general practitioner consult surgeon surgery medication nutritional supplement, contact precaution materials

a Preventive measures in bed and chair: including primary prevention and secondary prevention (measures to prevent further deterioration, occurrence or recurrence of pressure ulcers).

Disability Insurance (NIHDI) (http://www.riziv.be/drug/ nl/). Nursing time measurements: The same sample of 10 hospitals was used to collect data on time needed for activities related to pressure ulcer prevention and treatment using direct time measurement. Nurses were observed by a researcher (LD, DB, HD), who used a chronometer to measure the length of time in a set of activities. The activities were related to pressure ulcer prevention and treatment, and included activities related to risk assessment, patient repositioning, the application of materials, local wound treatments (cleansing, use of topical agents, dressing changes), and documentation. A sample size of 15 registrations per activity was pursued (Van Goubergen, 2005). In order to achieve sufficient measurements, an additional convenience sample of five hospitals was included. A total of 753 patients were observed, and 1717 time measurements collected. Wages: Nursing labour cost per second was calculated by multiplying the nursing time of each activity by nursing wages. The nursing wages were based on the manual for

cost-based pricing of hospital interventions of the Belgian Health Care Knowledge Centre (Swartenbroekx et al., 2012). 2.2.2. Nursing homes Pressure ulcer prevalence and preventive measures: All nursing homes in Flanders (N = 760) were invited to take part in a survey to measure pressure ulcer prevalence and the applied preventive measures. Ninety nursing homes were willing to participate; five withdrew their consent and one provided incomplete data. The remaining 84 nursing homes represented 294 wards and 8008 residents. Similar to hospitals, data on patient characteristics, risk assessment (Braden scale or presence of pressure ulcer), pressure ulcer prevalence, and preventive measures applied were collected using the European Pressure Ulcer Advisory Panel (EPUAP) minimum dataset. Furthermore, the EPUAP methodology was used to collect the data (Vanderwee et al., 2007, 2011). Data were collected in March 2012. Data on frequency of risk assessment and skin assessment performed in daily care were lacking.

Please cite this article in press as: Demarre´, L., et al., The cost of pressure ulcer prevention and treatment in hospitals and nursing homes in Flanders: A cost-of-illness study. Int. J. Nurs. Stud. (2015), http://dx.doi.org/10.1016/j.ijnurstu.2015.03.005

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Therefore, recent data from another European country were adopted (Gunningberg et al., 2012). Unit cost (per day) of materials for prevention and treatment: A random sample of 20 nursing homes, drawn from the 84 nursing homes of the prevalence study, was invited to take part in the cost study. Medical resource use for pressure ulcer treatment was examined through direct observation by the researcher (LD). To calculate the treatment cost, 59 treatments were observed. The observation of treatment of wounds was similar to hospitals. Costs of medical resources used for treatment were provided by the pharmacy and the logistics department of participating nursing homes. These costs were adjusted to account for discounts provided to the participating nursing homes. If data on cost of these resources could not be retrieved from these departments, official prices were collected from databases of The National Institute for Health and Disability Insurance (NIHDI) (http://www.riziv. be/drug/nl/). Nursing time measurements: The same sample of 20 nursing homes was used to collected data on the time needed to perform the activities related to pressure ulcer prevention and treatment using direct time measurement. A total of 198 residents were observed by the researcher (LD) using a chronometer; 1052 time measurements were collected. Data on time measurements on activities similar to those in hospitals were collected. Wages: The same sample of 20 nursing homes was used to collect data on nursing labour cost. The cost of the wages provided by the organisations and based on NIHDI (National Institute for Health and Disability Insurance). 2.3. Costs calculations 2.3.1. Prevention The main outcome was the mean cost of pressure ulcer prevention per patient or resident, at risk and not at risk, per day. For every patient or resident included in the pressure ulcer prevalence study, the cost of prevention was calculated using the material cost per day (including unit cost of all materials provided to that patient) and labour cost per day (including the nursing labour cost per activity multiplied by the frequency of the activity per day). The preventive measures provided per patient or resident (type, amount and frequency) were collected during the pressure ulcer prevalence studies. Cost of prevention per patient or resident per day was calculated by adding the unit cost per day per patient of devices used for pressure ulcer prevention and the labour cost to provide prevention per patient per day. The mean (SD) cost for patients or residents at risk and not at risk was calculated. Extrapolations of the cost per patient or resident per day were used to calculate the cost per patient per hospitalisation, and the annual cost of pressure ulcer prevention and treatment for Flanders. The cost of pressure ulcer prevention per hospitalisation was calculated by multiplying the cost per patient per day and the average length of stay in hospitals (Trybou, 2011). The cost for prevention for residents (at risk and not at risk) during

their time living in a nursing home was not calculated, because no data were available on the average length of stay in Flemish nursing homes. Stay length was assumed to be more than 1 year; thus, annual cost of prevention in nursing homes was used. To calculate the annual cost of prevention in Flanders, the proportion of patients or residents at risk and not at risk was multiplied by the cost per patient or resident, at risk and not at risk, and the number of care days per year. To facilitate comparison among studies reporting national costs, cost per inhabitant was calculated using the World Health Organisation database to obtain data on the number of inhabitants per country per year (Global Health Observatory, 2015). The formulas used to calculate the cost of pressure ulcer prevention are provided in Table 2. 2.3.2. Treatment The main outcome was the mean cost of pressure ulcer treatment per patient or resident per day per pressure ulcer severity category. Similar to the cost calculation for prevention, for every patient or resident included in the pressure ulcer prevalence study, the cost of treatment was calculated. The mean cost of treatment was calculated per pressure ulcer severity category and included the material cost per day (including unit cost of all materials provided to treat a pressure ulcer) and labour cost per day (including the nursing labour cost per activity multiplied by the frequency of the activity per day). The mean (SD) cost for patients and residents was calculated per pressure ulcer severity category. Extrapolations of the cost per patient or resident per day were used to calculate the cost per patient per hospitalisation, the cost until healing in nursing homes, and the annual cost of pressure ulcer treatment in hospitals and nursing homes in Flanders. In hospitals no extra length of stay due to a pressure ulcer category I was assumed. Based on the results of the multivariate study of Graves et al. (2005) an extra length of stay of 4.31 days due to pressure ulcers category II–IV was assumed. For nursing home residents cost until healing was calculated. Time until healing was complete per pressure ulcer severity category was adopted from the study of Dealey et al. (2012). The cost of pressure ulcer treatment per resident until healing was calculated using the cost per resident per day multiplied by the average healing time per pressure ulcer severity category (Dealey et al., 2012). To calculate the annual cost of treatment in Flanders, the proportion of patients with a pressure ulcer per pressure ulcer severity category was multiplied by the cost per patient or resident and the number of days of hospitalisation or residencies per year. The cost of secondary prevention was not included in the treatment cost, but was included in the annual cost of prevention. The formulas used to calculate the cost of pressure ulcer treatment are provided in Table 2. All costs were provided in Euro (s) and adjusted to the inflation rate in 2013 based on the health index (Federal Public Service (FPS) Economy, 2014).

Please cite this article in press as: Demarre´, L., et al., The cost of pressure ulcer prevention and treatment in hospitals and nursing homes in Flanders: A cost-of-illness study. Int. J. Nurs. Stud. (2015), http://dx.doi.org/10.1016/j.ijnurstu.2015.03.005

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Table 2 Formulas to calculate the cost of pressure ulcer prevention and treatment.

Prevention Cost of prevention per patient or resident at risk/not at risk per day Cost of prevention per patient at risk/not at risk Annual cost of prevention

Local treatmente Cost of treatment per patient or resident per dayj Cost of treatment per patient or residentj

Annual cost of treatment

Hospitals

Nursing homes

Unit cost devices/day/patient + labour cost prevention/patient/daya

Unit cost devices/resident/day + labour cost prevention/resident/daya

Cost/patient/day  7.57 (the average length of stay in hospitals)b Patient at risk = (% of patients at risk  cost/ patient at risk/day  8.52 million (number of care days per yearc)) Patient not at risk = (% of patients not at risk  cost/patient not at risk/day  8.52 million (number of care days per yearc))

Not applicable (no data on average length of stay in nursing homes available) Resident at risk = (% of resident at risk  cost/ resident at risk/day  69 902 (number of residenciesd)  365) Resident not at risk = (% of resident not at risk  cost/resident not at risk/day  69 902 (number of residenciesd)  365)

Unit cost materials/patient/day + labour cost/ patient/day PUf category I = Cost/patient/day  7.57 (average length of stay) PU category II–IV = Cost/patient/day per PU category  (7.57 (average length of stayb) + (4.31 (extra length of stay due to pressure ulcerg  s366.85 (hospitalisation cost/day h)

Unit cost materials/resident/day + labour cost/ resident/day PU category I = Cost/resident/day  28 days (healing time PU category I)i; PU category II = Cost/resident/day  94 days (healing time PU category II)i; PU category III = Cost/resident/ day  127 days (healing time PU category III)i; PU category IV = Cost/resident/day  155 days (healing time PU category IV)i ((% of residents with a PU category I  cost/ resident/day PU category I  69 902 (number of residenciesd)  365) + (% of residents with a PU category II  cost/resident/day PU category II  69 902 (number of residenciesd)  365) + (%of residents with a PU category III  cost/resident/ day PU category III  69 902 (number of residenciesd)  365) + (% of residents with a PU category IV  cost/resident/day PU category IV  69 902 (number of residenciesd)  365)

((% of patients with a PU category I  cost/patient PU category I  8.52 million (number of care days per yearc)) + (% of patients with a pressure category II  cost/patient PU category II  8.52 million) + (% of patients with a pressure category III  cost/patient PU category III  8.52 million) + (% of patients with a pressure category IV  cost/patient PU category IV  8.52 million (number of care days per yearc))

a

Type, amount and frequency of preventive measures per patient or resident were used from the prevalence data. Average length of stay in hospitals of 7.57 days adopted from Trybou (2011). Number of care days adopted from Flemish Institution for Health Care downloaded from http://www.zorg-en-gezondheid.be/Cijfers/ Zorgaanbod-en-verlening/Ziekenhuizen/Bezettingsgraad-en-verblijfsduur-Vlaamse-ziekenhuizen/. d Number of residencies adopted from Flemish Institution for Health Care downloaded from http://www.zorg-en-gezondheid.be/ programmatiewoonzorgcentra/. e Cost of secondary prevention (measures to prevent further deterioration, occurrence or recurrence of pressure ulcers) was provided separately from cost of local treatment to avoid double counting of preventive measures. f PU: pressure ulcer. g Extra length of stay controlled for comorbidities of 4.31 days adopted from Graves et al. 2005 controlling for comorbidities. h Hospitalisation cost per day in a hospital in Flanders was retrieved from the from databases of the National Institute for Health and Disability Insurance (NIHDI) (http://www.riziv.be/). i Average healing time per pressure ulcer severity category adopted from Dealey et al. (2012). j Calculated per PU severity category I–IV. b c

2.4. Sensitivity Analyses

3. Results

The results of any cost-of-illness study are subject to uncertainty, which was handled by a sensitivity analysis (Drummond et al., 2005; The Cochrane Collaboration, 2008). Sensitivity analyses were performed to examine the influence of variance due to device-related uncertainties (lifespan of materials, for example visco-elastic foam as a standard mattress in an organisation).

3.1. Demographic data and pressure ulcer prevalence

Ethical considerations Approval of the Ethics Review Committee of Ghent University Hospital, and the Ethics Review Committees of all participating hospitals and nursing homes was obtained for all studies included (B/67020083249, B/ 670201213428, B/670201214217, B/670201215256).

In hospitals, 38% (n = 4482) of the patients were younger than 70 years, 55% (n = 6517) were female, and 29% (n = 3453) were at risk. Non-blanchable erythema was present in 6.3% (n = 738) of the patients. Pressure ulcer prevalence for EPUAP categories II, III and IV was 3.6% (n = 426), 2.5% (n = 294), and 1.6% (n = 192), respectively (Appendix 1). In nursing homes, 52% (n = 4169) of the residents were aged between 80 and 89 years, and 29% (n = 2284) were older than 89 years. Seventy five percent of residents (n = 6052) were female, and 37% (n = 2993) of the residents were at risk. Non-blanchable erythema was present in 10.5% (n = 840) of the nursing home residents. Pressure

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ulcer prevalence for EPUAP categories II, III and IV was 2.9% (n = 230), 1.9% (n = 152), and 1.1% (n = 87), respectively (Appendix 1). 3.2. Cost of pressure ulcer prevention 3.2.1. Hospitals The mean (SD) cost of pressure ulcer prevention for patients at risk was s7.88 (8.21), consisting of 79% cost for labour and 21% cost for devices (Table 5). An overview of the nursing time related to activities for prevention and treatment is provided in Table 3. The mean cost per activity for repositioning a bedridden patient was s1.98, and s2.55 for an ambulatory patient. An overview of the cost of devices for prevention is provided in Table 4. The mean cost per day was s4.89 for an alternating device, s0.09 for a visco-elastic foam mattress and s0.05 for a visco-elastic foam cushion. Some of the patients not at risk received preventive care, resulting in a mean (SD) cost of s1.44 (4.26) per patient per day (Table 5). The mean cost for a patient at risk was s59.65 per hospitalisation, and s10.90 for a patient not at risk. The annual cost of pressure ulcer prevention in hospitals was s28.34 million, consisting of s19.67 million for patients at risk and s8.67 million for patients not at risk. 3.2.2. Nursing homes The mean (SD) cost of pressure prevention for a resident at risk was s2.15 (3.10), consisting of 85% cost for labour and 15% cost for devices (Table 5). The mean cost per activity for repositioning of a bedridden resident was s0.86, and s2.11 for an ambulatory resident (Table 3). The mean cost per day was s0.71 for an alternating device, s0.10 for a visco-elastic foam mattress, and s0.04 for a visco-elastic foam cushion (Table 4). Some of the residents not at risk received preventive care, resulting in a mean (SD) cost of s0.50 (1.61) per nursing home resident per day (Table 5). The annual cost of pressure ulcer prevention in nursing homes was s17.53 million, consisting of s9.54 million for residents at risk and s7.99 million for residents not at risk.

3.3. Cost of pressure ulcer treatment Tables 6a–6c provide an overview of the cost for the local treatment of pressure ulcers and the cost for secondary prevention in hospitals and nursing homes. The results are described for each pressure ulcer category. 3.3.1. Hospitals The mean (SD) cost of treatment per patient per day varied between s2.34 (1.14) to treat a category I pressure ulcer up to s77.36 (35.95) to treat a category IV pressure ulcer. The mean (SD) cost per day for secondary prevention varied between s6.83 (8.16) per patient with a pressure ulcer categories I and s10.74 (8.46) per patient with a pressure ulcer categories IV (Table 6a). The mean cost for the local treatment of a pressure ulcer category I totalled s17.71 per hospitalisation. The average cost to treat a pressure ulcer category II, category III, and category IV respectively, totalled s1709.54, s1784.86, and s2500.16 per hospitalisation (not including the cost of secondary prevention). The annual cost for pressure ulcer treatment was s165.75 million (Table 6b). 3.3.2. Nursing Homes The mean (SD) cost of treatment per resident per day varied between s2.42 (1.15) to treat a category I pressure ulcer up to s16.18 (4.93) to treat a category IV pressure ulcer in nursing homes. The mean (SD) cost for secondary prevention varied between s2.14 (3.19) up to s3.49 (3.97) per resident per day (Table 6a). The average cost to heal a pressure ulcer EPAUP category I, II, III, and IV totalled s67.76, s368.48, s1276.35, and s2507.90 (not including the cost of secondary prevention), assuming a healing time of respectively 28, 94, 127, and 155 days (Dealey et al., 2012). The annual cost for pressure ulcers in nursing homes was s4.86 million, based on 69 902 residencies per year (Table 6c). Overall, this accounts for a cost of pressure ulcer prevention and treatment of s33.92 per inhabitant of Flanders (Global Health Observatory, 2015).

Table 3 Nursing time and costs related to nursing activities for prevention. Activity

Risk assessment Repositioning in bed (bedridden) Repositioning in bed (not-bedridden) Repositioning in chair Registration of repositioning Heel offloading a b

Hospitals

Nursing homes

Mean time (s)/activity

Mean cost (s)

% (n) patients receiving the activity

Mean time (s)/activity

Mean cost (s)

% (n) residents receiving the activity

63.71 200.28

0.61 1.98

N.A.a 4.2 (504)

106.48 88.67

1.03 0.86

N.A.a 1.2 (101))

236.10

2.55

13.7 (1628)

192.93

2.11

9.1 (735)

99.56 9.90

0.98 0.09

8.8 (1039) N.A.b

55.88 1.98

0.54 0.02

9.6 (779) N.A.b

29.23

0.58

22.9 (2695)

5.23

0.05

13.1 (1053)

Frequency of risk assessment was not included in the data collection. Data of frequency of assessing risk was used from Gunningberg et al. (2012). Frequency of registration of repositioning was not included in the data collection, a frequency of once per shift was assumed.

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Hospital

Nursing home

Mean cost/day (s) for minimum/mean/maximum lifespan

Mean cost/day (s) for minimum/mean/maximum lifespan

Mean Lifespan

(years)

Min. Cost/day Mean (Min., Max.)

5

0.13, 0.09–0.17

7

5

5.11 0.85–16.94 0.51 0.40–0.67 0.08 0.03–0.17 0.50 0.17–1.28 0.45 0.12–0.78 0.10 0.03–0.27 0.24 0.08–0.40

7

Min. Lifespan

Visco-elastic foam mattress Alternating mattressa Static air mattress Visco-elastic foam cushion Static air

1

Gel cushion

1

Heel cushion

3

Ring cushion

1

a b

1 3

(years)

2 5 2 3 5 years 2

Mean Cost/day Mean (Min., Max.)

Max. Lifespan

0.09 0.06–0.12 4.89 0.16–16.94 0.25 0.20–0.33 0.05 0.02–0.10 0.25 0.09–0.64 0.15 0.04–0.26 0.06 0.02–0.16 0.15 0.04–0.26

9

(years)

9 3 7 3 5 7 years 3

Max. Cost/day Mean (Min., Max.)

Min. Lifespan (years)

Min. Cost/day Mean (Min., Max.)

Mean Lifespan (years)

Mean Cost/day Mean (Min., Max.)

Max. Lifespan (years)

Max. Cost/day Mean (Min., Max.)

0.07 0.05–0.09 4.76 0.47–16.94 0.17 0.13–0.22 0.04 0.01–0.07 0.16 .06–0.43 0.09 0.02–0.16 0.04 0.02–0.12 0.05 0.02–0.16

5

0.14 0.08–0.24 0.87 0.34–3.86 0.45 0.41–0.50 0.07 0.04–0.15 0.19 0.14–0.24 0.45b 0.12–0.78 0.09 0.05–0.13 0.02

7

0.10 0.06–0.17 0.71 0.24–3.86 0.22 0.20–0.25 0.04 0.03–0.09 0.09 0.07–0.12 0.15b 0.04–0.26 0.05 0.03–0.08 0.03

9

0.08 0.05–0.13 0.62 0.19–3.86 0.15 0.13–0.17 0.03 0.02–0.06 0.06 0.05–0.08 0.09b 0.02–0.16 0.04 0.02–0.05 0.02

5 1 3 1 1 3 1

7 2 5 2 3 5 years 2

In hospitals 50% of the alternating devices was rented and 50% was purchased, in nursing homes 11% of the alternating devices was rented and 89% was purchased. Missing in nursing homes; data used form dataset 3 on the cost of devices in hospitals.

9 3 7 3 5 7 years 3

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Table 4 Cost of mattresses and cushions per day based on a variable lifespan.

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Table 5 The cost of pressure ulcer prevention per patient per day in hospitals and nursing homes in Flanders. Cost per patient/day

Total s/day (SD)

Material s/day (SD)

Labour s/day (SD)

Hospitals Patient at risk Patient not at risk

7.88 (8.21) 1.44 (4.26)

1.68 (2.25) 0.25 (0.85)

6.21 (7.51) 1.19 (4.04)

Nursing homes Residents at risk Resident not at risk

2.15 (3.10) 0.50 (1.61)

0.32 (0.30) 0.10 (0.13)

1.83 (3.01) 0.40 (1.58)

care payer perspective. The mean cost for pressure ulcer prevention was s7.88 per hospitalised patient at risk per day and s2.15 per nursing home resident at risk per day. The mean cost of pressure ulcer prevention for patients and residents not considered at risk for pressure ulcer development was s1.44 per day in hospitals and s0.50 per day in nursing homes. The main cost driver was the cost of labour, responsible for 79–85% of the cost of prevention. The mean cost of treatment per patient per day varied between s2.34 (category I) and s77.36 (category IV) in hospitals, and between s2.42 (category I) and s16.18 (category IV pressure ulcer) in nursing homes.

3.4. Sensitivity analyses

4.1. Cost of pressure ulcer prevention

Analysis of uncertainty concerning the lifespan of preventive devices (minimum versus maximum lifespan): In hospitals, minimum lifespan of preventive devices resulted in 3% higher mean (SD) cost of pressure ulcer prevention per day for a patient at risk compared to the maximum lifespan (s7.80; (8.18)– s8.02; (8.27)), and 6% per day for a patient not at risk (s1.41 (4.25)–s1.50 (4.29)). In nursing homes, minimum lifespan of preventive devices resulted in 32% higher mean (SD) cost of pressure ulcer prevention per day for a resident at risk compared to maximum lifespan (s2.10; (3.08)–2.78 (3.21)), and 21% per day for a resident not at risk (s0.48 (1.60)–0.58 (1.66)). Analysis of uncertainty concerning the use of visco-elastic foam mattresses as standard mattress: If a visco-elastic foam mattress was not included in the cost of prevention, the mean (SD) cost of pressure ulcer prevention reduced with 18% per hospitalised patient at risk per day (s6.49 (7.59)), and 15% per hospitalised patient not at risk (s1.23 (4.07)). In nursing homes, if a visco-elastic foam mattress was not included in the cost of prevention the mean (SD) cost of pressure ulcer prevention reduced by 2% per resident at risk per day (s2.10 (3.10)), and by 14% per resident not at risk (s0.43 (1.61)).

The mean cost of pressure ulcer prevention in hospitals and nursing homes was low compared to other studies. A systematic review reported a cost for pressure ulcer prevention per patient at risk per day varying between s15.70 and s87.57 in hospitals, and between s2.87 and s19.69 in nursing homes and long-term care facilities (Demarre´ et al., 2015). Several reasons may account for this finding. The present study used the cost of prevention actually provided, whereas calculations the study of Dealey et al. (2012), Bayoumi et al. (2008), and Bennett et al. (2004), and others were based on prevention modelling according to the current guidelines for pressure ulcer prevention (NPUAP & EPUAP, 2009). As a result, the average cost of prevention per patient per day measured in the present study was lower than when prevention compliant to the international guidelines was provided (NPUAP & EPUAP, 2009). Another reason for the low cost may be related to the collection of time measurements by direct observation. This method may have resulted in lower costs of prevention because it more accurately reflects the share of labour cost in the total cost. This study points out that the cost of prevention for patients who are considered not at risk is high. This is partly linked with our decision to include the cost of a visco-elastic foam mattress as a cost attributable to pressure ulcer prevention. However, we observed that in some hospitals and nursing homes in Belgium, a viscoelastic foam mattress is used as a standard mattress for each patient for comfort purposes. Considering the results

4. Discussion The aim of this study was to investigate the cost of pressure ulcer prevention and treatment in an adult population in hospitals and nursing homes from the health

Table 6a The cost of pressure ulcer treatment per day in hospitals and nursing homes in Flanders. Cost per patient/resident

Hospitals Category Category Category Category

I II III IV

Nursing homes Category I Category II Category III Category IV

Treatment

Secondary prevention

Mean cost (s)/day (SD)

Mean material (s)/day (SD)

Mean labour cost (s)/day (SD)

Mean cost (s)/day (SD)

Mean material cost (s)/day (SD)

Mean labour cost (s)/day (SD)

2.34 10.81 17.15 77.36

(1.14) (4.25) (7.33) (35.95)

0.47 2.90 7.91 68.42

(0.23) (1.14) (3.38) (31.79)

0.88 7.91 9.24 8.94

(1.49) (3.11) (3.95) (4.16)

6.83 8.86 9.84 10.74

(8.16) (8.90) (8.78) (8.46)

1.46 2.14 2.68 2.88

(2.15) (2.36) (2.41) (2.39)

5.39 6.46 7.16 7.86

(7.54) (8.12) (7.92) (7.92)

2.42 3.92 10.05 16.18

(1.15) (1.33) (2.81) (4.93)

(0.07) (0.65) (1.04) (2.77)

2.26 2.00 6.32 7.08

(1.07) (0.67) (1.77) (2.16)

2.14 2.56 3.35 3.49

(3.19) (3.14) (3.42) (3.97)

0.32 0.42 0.55 0.52

(0.30) (0.33) (0.30) (0.31)

1.82 2.14 2.79 2.97

(3.09) (3.05) (3.32) (3.91)

0.16 1.93 3.73 9.09

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Table 6b The cost of pressure ulcer treatment per hospitalisation in Flanders. Length of stay

Hospital

Category Category Category Category

I II III IV

7.57 11.88 11.88 11.88

daysa daysb daysb daysb

Cost extra length of stay

Mean total cost/episode of care

Pressure ulcer prevalence

Episodes of care/year

Annual cost of treatmentc,d

N.A. s1581.12c,d s1581.12c,d s1581.12c,d

s17.71 s1709.54 s1784.86 s2500.16

6.3% 3.6% 2.5% 1.6%

1 125 370a 1 125 370a 1 125 370a 1 125 370a

s1 255 609 s69 259 141 s50 215 697 s45 017 680

Total cost treatment a b c d

s165 748 128

Flemish Institution for Health Care. Graves et al. (2005). Secondary prevention not included. Cost per extra length of stay: s366.85/day in a hospital in Flanders (Federal Public Service (FPS) Economy, 2014).

of the sensitivity analyses, this was not the main reason for the costs or prevention in patients not at risk. The study pointed out that the cost of prevention provided for patients perceived not at risk was high (s8.67 million in hospitals and s7.99 million in nursing homes). Device related costs, for example created by late or forgotten removal or relocation of mattresses or cushions for patients that were once at risk but now recovered, can be reduced. The majority of the costs for patients who were not at risk were labour related. Legitimate reasons for this labour cost in patients who were not at risk could be due to the cost of risk assessment in all patients, and to differences in risk assessment methods that may have led to the identification of other patients at risk. If activities related to prevention were provided to patients who are not at risk for pressure ulcers, this may be an opportunity to reduce labour costs by redirecting efforts to other patient activities. Although this may not directly lead to health care savings for institutions and government, due to the nursing shortage, a correct allocation of nursing time is needed. Because healthcare resources for pressure ulcer prevention (labour and materials) are limited, available resources must be used as efficiently as possible. In the present study, the majority of patients did not receive the appropriate preventive measures compliant with the NPUAP & EPUAP guideline. This was less than needed for patients at risk and more than needed for patients not at risk. A structured risk assessment policy, consisting of accurate and consistent screening as well as continuous monitoring and adaptation of preventive

measures, may reduce health care expenditures related to pressure ulcer prevention provided for patients not at risk. 4.2. Cost of pressure ulcer treatment Compared to other studies, the total cost of pressure ulcer treatment was low. A systematic review reported on the costs of pressure ulcer treatment per patient per day varying between s1.71 and s470.49 across different settings (Demarre´ et al., 2015). As for pressure ulcer prevention, data on the type and amount of materials used to treat a pressure ulcer were collected by direct observation, and not based on expert opinion. Also labour time was measured by direct observation, which was found to be an accurate method for measuring the duration of nursing activities (Burke et al., 2000), but may provide conservative aggregated nursing times because the time related to activities, such as ordering wound dressings, education and training, shift hand-over and patient transport, was not included in the total nursing time. Finally, the observed treatments of pressure ulcers were mainly conservative treatments. Surgical treatments or complications were included, but rarely observed. Medical resource use was based on prevalence data and observed during 1 or 2 days per hospital. Severe pressure ulcers (pressure ulcer prevalence category IV: 1.1–1.6% in present study) or pressure ulcers with severe complications are less common than superficial or non-complicated pressure ulcers (pressure ulcer prevalence category III or less: 1.9– 10.5% in present study); therefore there may have been an

Table 6c The cost of pressure ulcer treatment until healing and annual cost of pressure ulcer treatment in nursing homes in Flanders. Nursing homes

Healing times

Category Category Category Category

28 94 127 155

I II III IV

Total cost of treatment a b c

daysa daysa daysa daysa

Total cost/episode of care Meanc

Pressure ulcer prevalence

Number of residencies

Annual cost of treatmentc

s67.76 s368.48 s1276.35 s2507.90

10.5% 2.9% 1.9% 1.1%

69 902b 69 902b 69 902b 69 902b

s487 338 s746 967 s1 695 168 s1 928 379 s4 857 854

Dealey et al. (2012). Flemish Institution for Health Care. Secondary prevention not included.

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underobservation of these events. Due to the high cost of complications in severe pressure ulcers (Dealey et al., 2012) the costs presented in this study are considered to be conservative. The cost of pressure ulcer treatment per day was remarkably lower in nursing homes compared to hospitals. The type and materials used to treat a pressure ulcer in nursing homes differed from those used in hospitals. Financial implications for the nursing home resident were known to the nurse providing wound treatment, and often explicitly weighted when treating pressure ulcers in nursing homes, whereas the costs of materials are unfamiliar to the nurse providing wound treatment in hospitals. Furthermore the availability of materials was more restricted in nursing homes compared to hospitals, leading to lower materials costs in nursing homes. More information about the cost of materials, such as dressings, sets, and cleaning solutions, must be provided to nurses involved in pressure ulcer treatment to enable them to carry out a thorough examination of costs and benefits of treatment options. Another important reason for higher cost of pressure ulcer treatment in hospitals is that specialised pressure ulcer treatment, such as surgery or re-evaluation of nonhealing wounds, is mainly provided in hospitals. Although seldom observed in this study, surgical treatment led to higher costs in hospitals, whereas follow-up treatment and monitoring were associated with lower costs. The latter kind of treatment was usually provided in the nursing homes. 5. Limitations In addition to the previously discussed underestimation of the cost of severe pressure ulcers and their complications, this study has encompassed several other limitations. No empirical data were available on the percentage of mattress overlays versus mattress replacements. Therefore the mathematical mean of all alternating devices was used. Furthermore, no data were available on extra length of stay related to pressure ulcer risk or treatment. It is not clear whether pressure ulcer risk leads to extra length of stay. The current calculations of cost of pressure ulcer treatment assumed no attributable length of stay for patients with a Braden score of 16 or less and patients with a pressure ulcer category I, which may be an underestimation of the true cost. The percentage of patients for whom risk assessment is conducted is not known for the Belgian hospital or nursing home population. Gunningberg et al. (2012) reported that 6.0 and 10.7% of the patients in a general hospital, and 60.1 and 60.5% of the patients in a teaching hospital, received a risk assessment and skin assessment, respectively (Gunningberg et al., 2012). These percentages were used to calculate the cost for pressure ulcer prevention in hospitals. For nursing homes, the assumption that skin assessment was performed in 6% of the residents was adopted. It is not clear to what extent these figures accurately reflect the risk and skin assessment in daily care in Flanders. Further research based on the cost of

prevention in care as usual should include measurement of the proportion of patients receiving risk assessment. This study included only direct medical costs. No indirect and non-medical costs were included because the economic impact of indirect costs of pressure ulcer prevention and treatment on total societal expenditures was expected to be marginal. It was expected that the cost of productivity loss as a result of pressure ulcer development in a mainly elderly population would have been limited. 6. Conclusion The mean (SD) cost for pressure ulcer prevention was s7.88 (8.21) per hospitalised patient at risk per day and s2.15 (3.10) per nursing home resident at risk per day. The mean (SD) cost of treatment per hospitalised patient per day varied between s2.34 (1.14) and s77.36 (35.95), and between s2.42 (1.15) and s16.18 (4.93) in nursing homes residents. The cost of pressure ulcer prevention and treatment in hospitals and nursing homes in Flanders was found to be low compared to other international studies, mainly due to methodological differences between studies. There is need for pressure ulcer specific recommendations as part of methodological guidelines to conduct cost-off-illness studies. Acknowledgements The authors wish to acknowledge the hospitals, nursing homes, and nurses who participated in the study for their help during the data collection. The authors are grateful for the help of XX and XX for their assistance during the data collection. Conflict of interest: None declared. Funding: None declared. Ethical approval: Yes, all parts of the study were approved by the Ethics Review Committee of Ghent University Hospital, and the Ethics Review Committees of all participating hospitals and nursing homes (B/ 67020083249, B/670201213428, B/670201214217, B/ 670201215256).

Appendix 1 Demographic data and pressure ulcer prevalence in hospitals and nursing homes in Flanders. Characteristics

Age 89 year Missing Gender Female Male Weight 94 kg Missing Risk Braden (mean (SD)) Braden < 17 Braden

The cost of pressure ulcer prevention and treatment in hospitals and nursing homes in Flanders: A cost-of-illness study.

The economic impact of pressure ulcer prevention and treatment is high. The results of cost-of-illness studies can assist the planning, allocation, an...
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