High Cost of Stage IV Pressure Ulcers

Abstract

Objective

To calculate and analyze the cost of treatment for stage IV pressure ulcers.

Methods

A retrospective chart analysis of patients with stage IV pressure ulcers was conducted. Hospital records and treatment outcomes of these patients were followed for a maximum of 29 months and analyzed. Costs directly related to the treatment of pressure ulcers and their associated complications were calculated.

Results

Nineteen patients with stage IV pressure ulcers (11 hospital-acquired and 8 community-acquired) were identified and their charts reviewed. The average hospital treatment cost associated with stage IV pressure ulcers and related complications was $129,248 for hospital-acquired ulcers during one admission, and $124,327 for community-acquired ulcers over an average of 4 admissions.

Conclusions

The costs incurred from stage IV pressure ulcers are much greater than previously estimated. Halting the progression of early stage pressure ulcers has the potential to eradicate enormous pain and suffering, save thousands of lives, and reduce healthcare expenditures by millions of dollars.

INTRODUCTION

A pressure ulcer is a localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction¹. Pressure ulcers are chronic wounds with physiologically impaired healing ^{2, 3}. An estimated 15% of acute care patients have pressure ulcers ⁴, and pressure ulcer incidence has increased by 63% in recent years ⁵. Pressure ulcers are an epidemic among bed bound populations, with a reported prevalence as high as 26% among hospitalized patients ⁶, 43% among those in nursing homes⁶, and 39% among patients with spinal cord injuries ⁷. These estimates likely underestimate the true scope of the pressure ulcer pandemic, as many cases are underreported due to concern that a pressure ulcer may be interpreted as negligent care ⁸. Every year, billions of dollars are spent on the treatment of pressure ulcers and associated morbidities, representing a significant portion of health care resources. This figure will continue to rise over the next decade. Additionally, the financial burden to hospitals will also increase as the Center for Medicaid and Medicare Services (CMS) recently classified hospital-acquired stage III and IV pressure ulcers as a “never event” and that care for these ulcers will no longer be reimbursed ^{9, 10}. Appropriate cost effective treatment modalities are therefore of the utmost importance. Emphasis must be placed not on decreasing incidence, but on early treatment of pressure ulcers in order to minimize co-morbidities and ensuing costs.

The morbidities associated with pressure ulcers represent a considerable health care problem, particularly when healing does not occur (see Table 1) ¹¹. Approximately 50% of stage II ¹² and 95% of stage III and IV pressure ulcers do not heal within 8 weeks ¹³. Patients with pressure ulcers usually demonstrate significantly impaired physical and social function, self-care, and mobility ¹⁴. Common associated morbidities include pain, depression, local infection, anemia, osteomyelitis, and sepsis ^{11, 15–18}. In addition, patients with pressure ulcers often require either long-term hospitalization or frequent hospital admissions. The presence or development of a pressure ulcer can increase the length of a patient’s hospital stay by an average of 10.8 days ¹⁹. These extended hospitalizations are associated with higher costs and increased incidence of nosocomial infection and/or other complications ²⁰.

Table I.

Morbidities Associated with Pressure Ulcers ¹¹, ¹⁶–¹⁸, ²⁹–³¹

Pain

Depression

Local infection

Osteomyelitis

Anemia

Sepsis

Gas Gangrene

Necrotizing fasciitis (rare)

Death

The average hospital charge per pressure ulcer patient was reported to be $48,000 in 2006⁵. This represents a minimum annual outlay of 11 billion dollars to the U.S. health care system ²¹, excluding nursing home and home health care costs. Table II illustrates the cost components generally attributed to pressure ulcers. Besides being outdated, there is a great deal of variability among cost estimates. Moreover, hospital costs calculated in previous studies greatly underestimate the true cost of stage IV pressure ulcers, since costs incurred from secondary complications were not accounted for. Pressure ulcers do not have a separate category of Diagnostic Related Group (DRG); charges and reimbursements are therefore often fragmented into different diagnostic categories. Only by focusing on pressure ulcers as a separate disease entity and including all directly related complications can the financial and clinical costs of stage IV pressure ulcers be understood. The purpose of this study was to identify and report additional morbidities which are directly related to pressure ulcers, and to calculate and analyze the costs of treatment of stage IV pressure ulcers and associated complications. Although only the financial costs of hospitalizations due to pressure ulcers were presented in this study, it is important to emphasize the burden of pain, suffering, and decreased quality of life experienced by patients and their families affected by this disease.

Table II.

Costs Previously Associated with Treatment of Pressure Ulcers ²⁵, ²⁷, ³²–³⁶

Component	Costs/Fee
Nursing care	$152–$996/ulcer*
Medications	$350/year to $4,898/hospital stay/patient
Dressings	$93–$7021/ulcer*
Laboratory tests	$733–$1,455/patient
Radiology	$109–$235/patient
Alternating pressure overlays, mattresses	$0.86–$3.57/day‡
Debridement & surgical procedures	$29.33–$344.26/debridement†
Chronic-care bed in Hospital	$280–$600/day
Home Health Care supplies	$75–$150/week
Home Health Care nurse visit	$105/visit§
Office visit	$339–$520/year§
Malpractice lawsuits	$279,000/monetary settlement

^*Over a 12-week treatment period

^†2007 Medicare repayment values for Manhattan, NY Medicare payment facilities. CPT Codes 11040 (Debridement; skin, partial thickness) and 11044 (debridement; skin, subcutaneous tissue, muscle, and bone). (No published costs available).

^‡Converted from Pounds Sterling based on 2002 exchange rate (2 year product life)

^§Fees

METHODS

A retrospective chart review of patients with stage IV pressure ulcers in a university based, tertiary-care hospital was conducted. The true costs related to the pressure ulcers, which included costs of ensuing morbidities, were calculated and analyzed. The inclusion criteria for the study are:

1. Patients admitted with stage IV pressure ulcers (community-acquired), or acquired stage IV pressure ulcers during the hospital stay (hospital-acquired) were included.

   Hospital-acquired pressure ulcer (HAPU): These patients were admitted to the hospital for a separate medical condition (e.g., pneumonia requiring mechanical ventilator support, complication of major surgery), and acquired a stage IV pressure ulcer in the hospital. Their hospital stays were therefore prolonged even after the presenting medical condition had been stabilized or resolved. The wound healing team was consulted after the stage IV ulcer was observed.

   Community-acquired pressure ulcer (CAPU): These patients were admitted to the hospital for stage IV pressure ulcers or related complication. The ulcers were acquired at home or in a long-term care facility.

2. The stage IV pressure ulcer or resulting morbidity was the sole reason for a portion (HAPU), or the entire hospital stay (CAPU), as determined by consensus from the health care team.

3. All stage IV pressure ulcers were treated in accordance with standard published treatment guidelines ^{22, 23}. The wound healing team consisted of a surgeon, medical physicians, physician’s assistants, nurses, a physical therapist, and a nutritionist. The director of the Medical Intensive Care Unit and the nursing director of the Respiratory Care Unit were also part of the team. The wound care team ensured continuity of care for these patients. All ulcers were documented with the Wound Electronic Medical Record (WEMR), a Microsoft Access®-based relational database which documents the following: a digital photograph of the wound; a real-time graph of the wound healing rate (length, width, depth and area over time); wound location; presence of drainage, cellulitis and/or pain; fever; ambulation status; degree of undermining; a summary of the patient’s medical history; hematology and chemistry laboratory data; radiology and pathology reports; deep wound culture reports; and wound treatment regimens ²⁴.

The hospital records for these patients were retrospectively analyzed for a maximum of 29 months to consolidate and tabulate all related costs in the following manner:

1. All charges related to treatment of stage IV pressure ulcers and ulcer-related complications were included in the calculation. For patients with hospital-acquired pressure ulcers, charges were included starting when the pressure ulcer became the primary reason for continued hospital stay. This was determined through agreement by all members of the health care providing team. All charges were incurred during one hospital stay for HAPUs. For community-acquired pressure ulcers, charges were calculated for all hospital stays directly resulting from the pressure ulcer or resulting complication, as determined by the wound healing team upon admission.

2. Inpatient ledger statements were checked, and a total bill of charges for the defined period was compiled for each patient. Physician charges were excluded.

3. Hospital costs per patient were calculated as follows. The amount charged by each department for services related to the pressure ulcer was obtained for each patient. These charges were then converted to the actual hospital cost for the service using department specific conversion factors obtained from the hospital billing office. This conversion was performed for each specific charge in all categories.

4. Only costs directly related to the stage IV pressure ulcer during the patient’s hospital stay were calculated. These included the complications of renal failure, sepsis, respiratory failure, and other medical conditions directly resulting from the ulcer as determined by the wound healing team. This research was approved by the local Institutional Review Board.

RESULTS

Nineteen patients with stage IV pressure ulcers (11 hospital-acquired, 9 community-acquired) were identified, and their charts were retrospectively reviewed. The hospital cost averaged $127,185 over a maximum of 29 months. The cost for a hospital-acquired pressure ulcer patient averaged $129,248 during one hospital stay, whereas the cost for a community-acquired pressure ulcer patient averaged $124,327. Pressure ulcer-related morbidities previously omitted are included in the calculation. Necrotizing fasciitis, renal failure, cardiovascular events, other serious complications that were not previously recognized as being associated with pressure ulcers, as well as other commonly associated morbidities (Table I), were observed in patients with HAPUs and CAPUs. Table III shows the average costs for hospital- and community-acquired pressure ulcers, broken down by types of service performed.

Table III.

Breakdown of Average Costs Associated with Stage IV Pressure Ulcers

Cost Component	Average Cost
Accommodations
Hospital Accommodation	$94,915.85
Laboratory
Chemistry	$829.71
Microbiology	$1,082.67
Hematology	$246.23
Stat laboratory	$360.94
Radiology
General Radiology	$2,607.50
Nuclear medicine	$1,088.92
Computerized Axial Tomography Scan	$609.61
Magnetic Resonance Imaging	$223.46
Operating Room Services
Operating room	$4,441.66
Blood bank	$1,783.00
Recovery room	$592.38
Anesthesia	$363.16
Pathology
Pathology	$769.52
Clinical microscopy	$1,057.30
Ancillary Services
Respiratory therapy	$4,522.01
Central sterile supply	$125.53
Electrocardiography	$40.86
Pharmacy	$6,903.49
Consultation Services
Rehabilitation	$801.06
Core cardiology	$425.23
Endocrinology	$145.98
Emergency room	$619.00
Miscellaneous
Other	$700.50
Total	$127,185

DISCUSSION

The costs of stage IV pressure ulcers and related complications are extremely high. In this study, we emphasize that in calculating costs, the amount spent on treating associated medical complications of pressure ulcers must also be included. Our cost estimate in this study represents only a fraction of the total economic burden of pressure ulcers. There are also expenses of long-term care, such as nursing home and home health care, outpatient visits, social services, and patient transportation, all of which are not accounted for. Other indirect costs include time lost from work, forced early retirement, patient pain and suffering, impact on the patients’ families, and expenses associated with morbidity and mortality. In addition, malpractice suits associated with the development of pressure ulcers, averaging $250,000 per settlement and reportedly accounting for a total of $65 million, were not included in our calculations ²⁵. It is widely accepted that prevention of pressure ulcers decreases associated morbidity, mortality and health care costs. One study showed that the implementation of a comprehensive prevention program decreased the incidence of all pressure ulcers by 87% ²⁶. At a monthly cost of $519.73 per patient, preventing pressure ulcers would be significantly less expensive than treating stage IV pressure ulcers and associated morbidities, as exemplified in this study.

Although initially more expensive, providing the best quality care from the onset of treatment reduces healing time and is by far the most economical approach ²⁷. Despite appropriate care, pressure ulcers may not be preventable in certain patients ²⁸. An alternative approach to reducing morbidity and mortality from pressure ulcers is early detection and treatment to halt progression to stage IV ulcers. Our clinical experience in treating patients with pressure ulcers has shown that while prevention may not be feasible in all cases, halting progression is a feasible goal for all pressure ulcers, except in patients receiving palliative care. A comprehensive program of early recognition and treatment should be implemented to prevent these high costs as well as to reduce morbidity and mortality. The Wound Electronic Medical Record (WEMR) is an essential tool to synthesize the complex clinical information required to manage patients with pressure ulcers because it captures all the critical clinical information on one page, so that appropriate medical decisions can be made ²⁴. Furthermore, the WEMR allows all clinicians to view the wound, the variables that affect wound healing, and the wound area, thus facilitating change in real time.

The design of this study differs from previous studies by including the costs of treating associated complications in the analysis of pressure ulcer treatment costs. This is a possible limitation since some of the included costs may have resulted from underlying morbidity independent of pressure ulcers. To minimize this error, costs were included only when the entire health care team agreed that the incurred costs resulted from the pressure ulcer or its complication. By including the costs of all pressure ulcer-related complications, the cost analysis in this study is more representative of the actual cost of stage IV pressure ulcers. A second limitation may be that the costs of a metropolitan hospital are higher relative to other hospitals in the country. It is nevertheless likely that the costs of treating stage IV pressure ulcers are significantly underestimated in this study. Higher stage pressure ulcers rarely heal fully in a tertiary care setting, and the excluded costs associated with outpatient care would only underestimate the overall cost of treatment. Future studies are needed to determine the substantial costs associated with stage IV pressure ulcers that fall beyond the scope of this study.

Again, we believe that many of these costs can be eliminated by an early treatment protocol.

CONCLUSION

Although not meant to be a definitive cost analysis, this study illustrates the high costs associated with stage IV pressure ulcers. The magnitude of these costs has not been fully appreciated because costs are usually attributed in a fragmented manner. Costs resulting from ulcer progression and its associated medical complications may be prevented by early recognition and treatment of pressure ulcers and monitoring for complications. The exorbitant morbidity, mortality, and costs attributable to stage IV pressure ulcers demand a better understanding of the molecular basis of physiologic impairment, which will lead to new pharmacological therapies. Moreover, future studies are warranted to evaluate the efficacy of prevention and treatment modalities as they are developed.