Abstract
Pressure injuries have a negative effect on well‐being and the cost of treatment places a significant burden on the health care system. Research has, however, tended to extrapolate or estimate the cost of pressure injuries resulting in uncertainty regarding the true cost of this condition. The aim of this prospective observational study was to quantify the cost of pressure injury treatment in the Australian residential aged care setting. An electronic health care record audit and observation of usual pressure injury treatment was undertaken with a sample of 20 participants who had 23 pressure injuries. The actual treatment cost, an evidence‐based practice model cost, and a projected treatment cost were calculated. The overall cost of pressure injury treatment was AU$98,489.22. The average daily cost by pressure injury stage was AU$26.42 for a Stage 1 pressure injury, AU$37.17 for a Stage 2 pressure injury, AU$30.01 for a Stage 3 pressure injury, and AU$10.22 for an Unstageable pressure injury. The projected cost of treatment was AU$104,510.41. At 42 days this cost extended to AU$116,552.79. This study has quantified the cost of pressure injury treatment in a residential aged care setting. The study may inform future efforts to accurately calculate the cost of PIs and the effectiveness of strategies to reduce the economic burden of this condition.
Keywords: direct cost, observational study, older people, pressure injury, residential aged care
1. INTRODUCTION
Pressure injuries (PIs) are defined as localised damage to the skin and/or underlying tissue, which usually occurs over a bony prominence.1 PIs arises from pressure, friction, and shear,2 which leads to deformation within tissues and cells3 and ischaemia, lymphatic flow blockage, and reperfusion damage.4, 5 The resulting PI may be significant in terms of severity of tissue damage, effect on quality of life, and cost of treatment and care.
The detrimental effects of pressure, shear, and friction, together with ageing skin, reduced mobility, altered sensory perception, incontinence, and poor nutrition,4, 6, 7 predisposes many older people to a high risk of PI development. Those who live in residential aged care (also referred to as long‐term care facilities and nursing homes) often rely on health care providers to move their bodies and manage pressure risk; therefore, this group is at particularly high risk of developing pressure injuries.
Consequently, PIs in residential aged care in Australia are a common occurrence. Recent estimates suggest an incidence rate of 6.4% to 11.7%.8, 9 The associated cost is substantial, an estimated AU$13.61 million (±SD AU$5.02 million) in 2012.8
PIs are an international concern,15 and although it is widely accepted that PIs are costly, report of the actual cost of treating pressure injuries is scant. Research conducted by Dealey et al 2004 and updated in 2012.10, 13 suggests that the cost of PI treatment is higher when the severity of the PI is greater. Specifically, their research estimated that the cost of healing is AU$1298 for a Stage 1 PI that heals in 28 days, AU$5602 for a Stage 2 PI that heals in 94 days, AU$9665 for a Stage 3 PI that heals in 127 days, and AU$15082 for a Stage 4 PI that heals in 155 days.10
The incidence and cost of PIs are compelling reasons to invest in PI research; however, with regard to cost, research to date has tended to estimate or extrapolate,8, 10, 11, 12, 13 resulting in considerable uncertainty about the actual cost of PIs. This issue has been identified in a recent systematic review which highlighted the need for research that more accurately calculates the direct cost of PI treatment.14
Given the high incidence of PIs in the residential aged care setting, and the challenges associated with accurately articulating the cost of PIs, a study was conducted to quantify the direct costs of PI treatment in the residential aged care setting. The findings of the study may be used to more accurately articulate the cost of PI treatment and to support appropriate investment in prevention and treatment strategies.
2. METHODS
2.1. Aim
The aim of the study was to develop a costing tool to quantify the direct cost of PI treatment in the residential aged care setting. Direct cost was defined in the study as costs incurred by the health care system and/or the patient as a direct result of the condition as opposed to indirect costs such as loss of income because of being unable to work.15
2.2. Design
A quantitative, observational longitudinal panel study was undertaken. The study was approved by the Human Research Ethics Committee of the governing university and the participating aged care provider.
2.3. Setting and sample
The study was conducted in eight residential aged care facilities with a total population of 1043 residents in Melbourne, Australia. A non‐probability, purposive sample (n = 24) was selected on account of the likely prevalence of PIs in the population,16 the time available for recruitment, and the requisite PI characteristics (Stages 1‐4, Unstageable and Deep Tissue Injury).
2.4. Eligibility criteria
Participants of the study
Were permanent residents of a participating aged care facility.
Had one or more PIs (Stage 1, Stage 2, Stage 3, Stage 4, Unstageable [US]), or Deep Tissue Injury (DTI) as defined by the National Pressure Ulcer Advisory Panel1 and the Australian Wound Management Association.4
Were not classified as palliative or in the terminal stage of an illness.
2.5. Treatment
The treatment of the PI and any associated pressure area care (PAC) activities were provided as usual by the clinical staff employed by the facilities, which included Registered Nurses, Endorsed Enrolled Nurses, and Personal Care Attendants. The participant's treatment and care therefore was not altered as a result of participation in the study.
2.6. Data collection
The researcher (LW) liaised directly with the aged care facility staff to (1) access the electronic health record to complete chart audit for each participant and (2) to directly observe treatment of the participants PI. Study data were collected between July and October 2015.
2.7. Study measures
An existing data collection tool was unable to be sourced for this study; therefore, a tool was designed. The content of the tool was based on a review of the literature, clinical guidelines, government reports, expert opinion, and consultation with a health economist. The resulting tool included both chart and observation audit items.
The chart audit items included age, gender, comorbidities, medicines use, and continence to describe the sample. PI stage, duration, dressing type, use and frequency, use of PAC equipment, and consultations with external care providers was included to enable costing of the PI treatment. The observation audit items included assessment of the PI stage, the PI treatment activities that were conducted, the number and level of staff utilised for PI treatment, and the time taken to complete PI treatment activities. The latter was measured with an iPhone in stopwatch mode, an approach that offers accuracy when measuring time spent on treatment activities.13
The data collection tool was piloted with 10 residents prior to its use in the study. Minor adjustments to the data collection tool were subsequently made, including the deletion of redundant items. The data collected during the pilot were not included in the analysis.
2.8. Study costings
The cost of PI dressings (which included the use or omission of dressing packs, irrigation solutions, primary dressings, secondary dressings, fixation products, and peri‐wound creams) and the cost of nutritional supplements were calculated using retail costs from national community distributors. Medications were costed according to the Australian Government Department of Health Pharmaceutical Benefits Scheme, and rental costs were applied to the PAC equipment that was used. The staff costs (the time that the Registered Nurses, Endorsed Enrolled Nurses, and Personal Care Attendants spent providing PI care) were calculated according to the local government award rates per staff member.
The study sought to calculate three costs:
The actual practice treatment cost (overall, daily, and by PI stage)
An evidence‐based practice model cost (overall, daily, and by PI stage)
An overall projected cost.
To calculate the actual practice treatment cost, the mean cost of dressing products was calculated from the observation of each PI treatment episode, multiplied by the number of treatments attended to date, and divided by the duration of the PI. Similarly, staff time for treatment was calculated from the mean cost of time spent providing PI treatment multiplied by the number of treatments and then divided by the PI duration to establish a daily cost of staff time. Supplements and medications, PAC equipment, and external consultant clinician costs were also included to establish a total cost per PI. Items such as nutritional supplements, medications, and PAC equipment were costed only once if the participant had more than one PI. One example of an actual treatment cost calculation has been provided in Figure 1.
Figure 1.
An example of the cost calculation for pressure injury treatment
An evidence‐based practice model includes consideration of the best research evidence, clinical expertise, patient preferences, and resource availability.17 To model best practice, PI treatment included the use of products that were available to staff at the facility, specifically dressing packs, irrigation solutions, barrier wipes, a hydrofibre dressing/silver hydrofibre dressing, and silicone dressings. The silver‐impregnated hydrofibre was selected for the cost modelling for the Stage 2, Stage 3, and PIs because of the increased risk of infection for PIs of worsening severity the average cost of the silver‐impregnated hydrofibre or standard hydrofibre dressing was selected for cost‐modelling of Stage 2 and 3 PIs due to the increased risk of infection of worsening PIs. The unstageable PI was cost modelled using a dry dressing regimen due to the unknown severity of an US until it reveals itself.4 Participants in the study were generally unable to indicate treatment preferences; however, when preferences were reported by the treating clinician, these were accounted for in treatment selection.
The evidence‐based practice model also included pressure redistributing equipment, specifically an alternating air mattress for all PIs for the bed and an air cushion for the chair for sacral, buttock and IT PIs, which were included for all participants given that clinical practice guidelines suggests managing existing PIs on a high specification reactive or active alternating pressure support surface.4 The resulting cost of treatment for each PI was multiplied by the estimated number of dressing changes per week, taking into account the PI severity (weekly dressing changes for Stages 1 and 2 PIs, twice‐weekly dressing changes for Stage 3 PIs, and thrice‐daily dressing changes for US PIs given the need for monitoring as the PI evolved to stageable). This cost was multiplied by the duration of time to healing, according to time frames published by Dealey et al.,10 specifically 28 days for a Stage 1 PI, 94 days for a Stage 2 PI, 127 days for a Stage 3 PI, and 155 days for a Stage 4 PI applied to the Unstageable PI. One example of an evidence‐based practice model cost calculation for PI treatment has been provided in Figure 2.
Figure 2.
An example of the evidence‐based practice cost calculation for pressure injury treatment. Note: Dealeys estimates on PI healing duration for a Stage 3 PI were used for this calculation. 36 dressing changes were estimated to provide moist wound healing using modern wound dressings
To calculate an overall projected cost, the actual practice treatment cost (daily) was used. This cost was multiplied by arbitrary time frames (14, 28, and 42 days) to determine the cost of treatment following completion of the study for the PIs that did not heal within the data collection period (19/23).
2.9. Analysis
Data were entered in IBM Statistical Package for the Social Sciences (SPSS) for Macintosh version 22.0 IBM Corp: Armonk, NY, USA, and Microsoft Excel 2008 for Mac version 12.3.6. 2007 Microsoft corporation: Redmond, WA, USA. A check of 10% of the data was undertaken prior to analysis.
3. RESULTS
3.1. Sample characteristics
The sample (n = 20) was predominantly female (n = 16, 80%) on average, 83 years of age (minimum 60 years, maximum 97 years), nearly half (n = 9, 45%) scored high or severe PI risk on the Braden Scale, and the majority (n = 18, 90%) were incontinent of urine and faeces. One chart audit was conducted for each participant, and a total of 43 wound treatment observations were completed (minimum one observation, maximum four observations), while facility staff attended to usual PI care.
3.2. Anatomical location, stage and duration of the pressure injuries
The PIs were distributed over boney prominences, and the sacrum (six PIs) and the heel (six PIs) were most commonly affected (Table 1). The total number of PI days for the sample to date was 3547 days. The four Stage 1 PIs had a 10‐day duration on average (ave), the seven Stage 2 PIs had a 91‐day duration (ave), the 11 Stage 3 PIs had a 257‐days duration (ave), and the one US PI had a 39‐day duration.
Table 1.
Pressure injury stage and anatomical location (n = 23)
| Stage 1 (n = 4) |
Sacrum = 2 Heel = 1 Thoracic spine = 1 |
| Stage 2 (n = 7) |
Sacrum = 1 Heel = 2 Malleolus = 2 Toe = 1 Buttock = 1 |
| Stage 3 (n = 11) |
Sacrum = 3 Heel = 2 Malleolus = 2 Toe = 3 Ischial tuberosity = 1 |
| Unstageable (n = 1) | Heel = 1 |
3.3. PI treatment
The PIs treated in the study received frequent wound care. On average, dressings were changed every 1.6 days. The frequencies of dressing changes by PI stage were 1.9 days for the Stage 1 PI, 2.4 days for the Stage 2 PI, 1.5 days for the Stage 3 PI, and 5.6 days for the US PI.
A range of primary dressing products was used in the treatment of PIs in this study. Betadine was the product most commonly applied as a primary dressing and was used on 24% of wounds at the final treatment observation. Other dressings included Sorbact (14%), Mesalt (12%), Iodosorb paste (9%), Interpose (9%), Mepilex border (9%), Askina border (5%), Askina Foam (5%), Flaminal forte (5%), Mesorb (2%), Aquacel Ag (2%), Hypergel (2%), and Tegaderm foam (2%). Overall, the data suggest that 47% of wounds were not treated with the goal of maintaining a moist wound‐healing environment (this was generally consistent across all PI stages) and that the use of antimicrobial dressings was not the norm given this was observed in only 30% of cases.
3.4. The actual practice treatment cost (overall, daily, and by PI stage)
The actual practice treatment cost for the sample overall (from the PI start date to the final data collection) was AU$98489.22. This cost was associated with 3547 PI days (to date). The overall daily cost of PI treatment was AU$27.77. The daily cost of PI treatment for Stage 1 PIs was, on average, AU$26.42 (minimum AU$9.43, maximum AU$48.51). The daily cost of PI treatment for Stage 2 PIs was, on average, AU$37.17 (minimum AU$15.61, maximum AU$76.70). The daily cost of PI treatment for Stage 3 PIs was, on average, AU$30.01 (minimum AU$3.07, maximum AU$61.38). The daily cost of PI treatment for the unstageable PI was AU$10.22 (see Table 2, “actual practice” column).
Table 2.
Actual practice and evidence‐based practice model comparison
| Actual practice (3547 days) | Evidence‐based practice model (2322 days) | |
|---|---|---|
|
Overall (total) n = 20, PI = 23 |
AU$98489.22 | AU$99693.15 |
|
Overall (daily) n = 20, PI = 23 |
$27.77 | $42.93 |
| Daily cost by PI stage (PIs = 23) | ||
| Stage 1 | AU$26.42 | AU$34.91 |
| Stage 2 | AU$37.17 | AU$40.92 |
| Stage 3 | $30.01 | AU$47.35 |
| Unstageable | $10.22 | AU$45.05 |
The following costs are reflected in the overall cost of PI treatment and are listed from highest to lowest cost order: PAC equipment (AU$32300.75), staff time attending wound treatment (AU$29369.02), wound dressings (AU$21764.86), nutritional supplements (AU$14361.60), consultations from external clinician (AU$600.00), and additional medications (AU$93.00). Of note, the cost of staff time for positioning the resident was not included in this cost because it was not a requirement at the participating facility that this care, as attended, be documented. Had the conduct of (positioning as it was scheduled in the care plan) been included in the overall cost of treatment, the cost would increase by AU$50517.43 to AU$149006.65.
Only four PIs healed during the study, therefore the cost of healing was only able to be determined for these PIs. The Stage 1 heel PI cost AU$391.43 (AU$30.11/days) to heal, the Stage 2 heel PI cost AU$7304.98 (AU$23.56/days), the Stage 3 sacrum PI cost AU$1450.08 (AU$30.21/days), and the US heel PI cost AU$398.48 (AU$10.22/days).
3.5. The evidence‐based practice model cost (overall, daily, and by PI stage)
Applying the evidence‐based practice model resulted in 2322 days to healing for the sample overall. The resulting evidence‐based practice cost of treatment for the 20 participants and the 23 PIs was AU$99693.15. The daily cost of the 23 pressure was, on average, AU$44.77 per PI. The cost of PI by stage was AU$34.91 for Stage 1 PIs, AU$40.92 for Stage 2 PIs, AU$47.35 for Stage 3 PIs, and AU$45.05 for the US PIs (see Table 2, “evidence‐based practice model” column).
3.6. The overall projected cost
Utilising the overall cost of PI treatment for the sample (AU$98489.22 to date), the projected cost of treatment for the 19 PIs that had not healed was calculated. At 14 days following the end of data collection, the cost was AU$104510.41 (an additional AU$6021.19 and extra AU$316.90 per PI). The cost at 28 days was AU$110531.60 (an additional AU$12042.38 and extra AU$633.81 per PI), and at 42 days, it was AU$116552.79 (an additional AU$18063.57 extra AU$950.71 per PI) (see Figure 3).
Figure 3.
The projected cost of pressure injury treatment
4. DISCUSSION
The study found that the cost of treating PIs in this sample of 20 aged care residents who had 23 PIs was significant, AU$98489.22 overall and a cost of AU$27.77/day. Of note, the cost of repositioning was unable to be determined, however, if this had been attended as recommended in the care plan, the cost would increase to AU$149006.65 according to our model. The study showed a trend for higher cost of treatment by PI stage, consistent with international research that suggests increasing PI severity is associated with higher cost.11 Of note in our study, was that the Stage 3 PIs were less costly than the Stage 2 PIs, which may be explained by the longer duration of the wounds and, potentially, the use of less costly products as these wounds became more chronic. The lower cost of the DTI in the study may be the result of the small sample.
The majority of the PIs in this study (n = 19, 82.6%) did not heal, which was not unexpected given the short data collection period. The projected cost model demonstrated the ongoing significant cost of these PIs, with a projected cost of treatment 14 days following the end of data collection of AU$104510.41 (an additional AU$6021.19 in total and extra AU$316.90 per PI), this extending to AU$116552.79 (an additional AU$18063.57 and extra AU$950.71 per PI) at 42 days following completion of the study.
The contributors to the overall cost of PI treatment provide an indication of the major costs associated with the PIs in this study. PAC equipment (AU$32300.75) represented nearly one third of the cost, and staff time attending wound treatment (AU$29369.02) and wound dressings cost (AU$21764.86) were also major cost contributors. The frequent dressing changes conducted with this sample (every 1.6 days on average) and the high use of dressings that do not promote moist wound healing (in 47% of cases) suggests this cost item may have scope for reduction if an evidence‐based approach to dressing selection and frequency of use was adopted for the entire wound episode. Of note, the Stage 3 PIs in the present study had greater than double the duration expected for this severity of PI according to previous research10; therefore, the management of these PIs in particular may be a major contributor to ongoing cost in this sample.
The evidence‐based practice model cost for the 23 PIs in the study showed that the cost of PI treatment until healing with this approach (AU$99693.15) would be similar to the actual care costs of the sample to date, of which 19 PIs had not yet healed (AU$98489.22). This result arose principally because the modelled duration of treatment was much shorter with the evidence‐based practice approach (2322 PI days) than the actual duration of the wounds to date in this study (3547 PI days). This similar cost finding therefore is not favourable as the actual cost of the PIs continues to increase, whereas the evidence‐based practice PI costs are complete (to healing).
4.1. Strengths and limitations of the study
The strengths of the study include the prospective design, direct observation of PI treatment, and data collection from two sources (audit and observation). The limitations of the study include the small sample, the sample arising from one care setting, a short monitoring period resulting in few wounds healing during the study, and the lack of Stage 4 injuries and DTIs in the sample.
4.2. Conclusion
This study developed a costing tool to quantify the direct cost of PI treatment in the residential aged care setting. The daily cost of PIs in the study was AU$26.42 for a Stage 1 PI, AU$37.17 for a Stage 2 PI, AU$30.01 for a Stage 3 PI, and AU$10.22 for an US PI. The study found that PIs are associated with considerable treatment cost and a cost that may be reduced with the application of evidence‐based treatment. The methodology and results of the study may inform future efforts to accurately calculate the cost of PIs and the effectiveness of strategies to reduce the economic burden of this condition.
ACKNOWLEDGEMENTS
The authors acknowledge the support of the Australian Commonwealth Government Wound Management Innovation Cooperative Research Centre. The authors thank the staff and residents of REGIS aged care, Victoria, Australia. This study was funded by a research grant from the Australian Commonwealth Government Wound Management Innovation Cooperative Research Centre (Linked to CRC Project 3‐32).
Wilson L, Kapp S, Santamaria N. The direct cost of pressure injuries in an Australian residential aged care setting. Int Wound J. 2019;16:64–70. 10.1111/iwj.12992
Funding information Australian Commonwealth Government Wound Management Innovation Cooperative Research Centre
REFERENCES
- 1. National Pressure Ulcer Advisory Panel . NPUAP Pressure Injury Stages. Paper presented at the NPUAP 2016 Staging Consensus Conference, Rosemont, Chicago; 2016.
- 2. National Pressure Ulcer Advisory Panel , European Pressure Ulcer Advisory Panel , & Pan Pacific Pressure Injury Alliance . (2014). Prevention and Treatment of Pressure Ulcers: Quick Reference Guide. Perth: Australia Cambridge Media. [Google Scholar]
- 3. Santamaria N, Gerdtz M, Kapp S, Wilson L, Gefen A. A randomised controlled trial of the clinical effectiveness of multi‐layer silicone foam dressings in the prevention of pressure injuries in high‐risk aged care residents: the Border III Trial. Int Wound J. 2018;15:1‐9. 10.1111/iwj.12891. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 4. Australian Wound Management Association . Pan Pacific Clinical Practice Guideline for the Prevention and Management of Pressure Injury. Abridged Version, AWMA. Osborne Park, WA: Cambridge Publishing; 2012. [Google Scholar]
- 5. Gefen A, van Nierop B, Bader D, Oomens C. Strain‐time cell‐death threshold for skeletal muscle in a tissue‐engineered model system for deep tissue injury. J Biomech. 2008;41(9):2003‐2012. [DOI] [PubMed] [Google Scholar]
- 6. Iglesias C, Nixon J, Cranny G, et al. Pressure relieving support surfaces (PRESSURE) trial: cost effectiveness analysis. Br Med J. 2006;333(1416):1416. 10.1136/bmj.38850.711435.7C. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 7. Strachan V. PUPPS 3 ‐ Pressure ulcer point prevalence survey statewide report. Melbourne, Victoria, Australia: Department of Human Services; 2006. [Google Scholar]
- 8. Graves N, Zheng H. Modelling the direct health care costs of chronic wounds in Australia. Wound Pract Res. 2014;22(1):20‐33. [Google Scholar]
- 9. Nguyen K‐H, Chaboyer W, Whitty J. Pressure injury in Australian public hospitals: a cost‐of‐illness study. Aust Health Rev. 2015;39:329‐336. 10.1071/AH14088. [DOI] [PubMed] [Google Scholar]
- 10. Dealey C, Posnett J, Walker A. The cost of pressure ulcers in the United Kingdom. J Wound Care. 2012;21(6):261‐266. [DOI] [PubMed] [Google Scholar]
- 11. Agreda J, Bou J, Posnett J, Soriano J, Miguel L, Santos M. The burden of pressure ulcers in Spain. Wounds. 2007;19(7):201‐206. [PubMed] [Google Scholar]
- 12. Bennett G, Dealey C, Posnett J. The cost of pressure ulcers in the UK. Age Ageing. 2004;33:230‐235. 10.1093/ageing/afh086. [DOI] [PubMed] [Google Scholar]
- 13. Demarre L, Verhaege S, Annemans L, Van hecke A, Grypdonck M, Beeckman D. 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;52(7):1166‐1179. 10.1016/j.ijnurstu.2015.03.005. [DOI] [PubMed] [Google Scholar]
- 14. Demarre L, Van Lancker A, Van Hecke A, et al. The cost of prevention and treatment of pressure ulcers: a systematic review. Int J Nurs Stud. 2015;52(11):1754‐1774. 10.1016/j.ijnurstu.2015.06.006. [DOI] [PubMed] [Google Scholar]
- 15. Wounds International . (2013). International Consensus: Making the Case for Cost‐Effective Wound Management: Wounds International 2013.
- 16. Santamaria N, Gerdtz M, Dealey C, et al. Study Protocol: A Cluster Randomised Trial of the Effectiveness of Mepilex Border Sacrum and Mepilex Heel Dressings in the Prevention of Sacral and Heel Pressure Ulcers in Aged Care Facilities. Parkville: Melbourne University; 2015. [Google Scholar]
- 17. Schneider Z. The significance of nursing and midwifery research. Nursing and Midwifery Research Methods and Appraisal for Evidence‐Based Practice. 4th ed. Australia: Elsevier; 2013. [Google Scholar]