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Cost-effectiveness of an intensive pressure ulcer prevention protocol in long-term care |
Xakellis G C, Frantz R A, Lewis A, Harvey P |
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Record Status This is a critical abstract of an economic evaluation that meets the criteria for inclusion on NHS EED. Each abstract contains a brief summary of the methods, the results and conclusions followed by a detailed critical assessment on the reliability of the study and the conclusions drawn. Health technology Implementation of an intensive pressure ulcer prevention protocol, in a long-term-care facility, using low-technology interventions such as foam overlays, heel protectors, and repositioning schedules in the prevention of pressure ulcers. The intensity of the interventions increased incrementally as the subject's risk level increased. The Braden Scale for Predicting Pressure Sore Risk was used to determine the risk level of subjects in the study. The intervention policies and procedures were created from recommendations contained in the Agency for Health Care Policy and Research (AHCRP) Clinical Practice Guidelines on Pressure Ulcers.
Type of intervention Secondary prevention and treatment.
Economic study type Cost-effectiveness analysis.
Study population Patients who were in a long-term care facility and who were ulcer-free at the initiation of the study period.
Setting Community (long-term care facility) and hospital. The economic analysis was carried out in the USA.
Dates to which data relate Effectiveness and resource use data were derived from patients who were residents in the study institution in 1994 and 1995. The price years were 1994 and 1995.
Source of effectiveness data The evidence for the final outcomes was based on a single study.
Link between effectiveness and cost data Costing was performed on the same patient sample as that used in the effectiveness analysis. Costing appears to have been conducted prospectively on the post-protocol sample and retrospectively for the pre-protocol sample.
Study sample Power calculations were not used to determine the sample size. A total of 69 patients with a mean (SD) age of 86 (8) years comprised the pre-protocol sample versus 63 patients with a mean (SD) age of 87 (6.6) years in the post-protocol sample.
Study design This was a non-randomised study with historical controls, carried out in a single centre. The duration of the follow-up in both groups was 6 months or until death or discharge. Those who developed an ulcer were followed until the end of the year to allow sufficient time for ulcer healing. The study appears to have had no loss to follow-up. The research nurse computed risk scores for the historical control group using data from medical records in order to evaluate each patient's functional level on the subscales. In the post-protocol sample, the research nurse calculated a Braden Scale score using direct clinical assessment of each subject. Based on the facility's project coordinator, an inter-rater reliability of 0.97 was established.
Analysis of effectiveness The principle used in the analysis of effectiveness (intention to treat or treatment completers only) was not explicitly specified. The primary health outcome was the time to pressure ulcer development. Other health outcomes were the number of ulcers that developed, the outcome of ulcer treatment, and the development of ulcer complications. The length of time to pressure ulcer development between the two samples was compared using survival analysis and the log-rank test. No significant difference was found in the number of subjects who were at risk in each sample, (p=0.32).
Effectiveness results In the pre-protocol sample, 16 patients developed 26 ulcers, 3 died ulcer-free, 2 went to the hospital ulcer-free, and 48 were still in the facility and were ulcer-free at the study's conclusion. In the post-protocol sample 3 patients developed 5 ulcers, 5 died ulcer-free, 3 went to the hospital ulcer-free, and 52 remained in the facility and were ulcer-free at the end of the study. The 6-month pressure ulcer incidence was 23% in the pre-protocol sample and 5% in the post-protocol sample. Mean (SD) time to ulcer development was 146 (61) days for the pre-protocol subjects and 158 (53) days for the post-protocol subjects, (p=0.003). The number of hospitalisations for pressure ulcer was zero in each study group (lack of ulcer-related complications).
Clinical conclusions Implementation of an intensive pressure ulcer prevention protocol using low-technology interventions such as foam overlays, heel protectors, and repositioning schedules in this long-term care facility significantly reduced the incidence of pressure ulcers and lengthened the time to ulcer development. These findings suggest that using research-based practice guidelines, such as those published by the AHCPR, can reduce the incidence of pressure ulcers.
Measure of benefits used in the economic analysis The measure of benefit was ulcer-free days.
Direct costs Costs were not discounted due to the short time frame of the cost analysis. Some quantities were reported separately from the costs and some cost items were reported separately. Cost analysis covered the costs of prevention (risk assessment, turning, support surfaces) and treatment (the topical and systemic treatments needed for treating any pressure ulcers that occurred). The perspective adopted in the cost analysis was that of the health care provider (long-term care facility). Cost analysis was based on actual costs, (not charges) for supplies and labour incurred by the study institution. The total costs included costs from the long-term-care setting and those from the hospital setting if transfers occurred. The nursing time for repositioning subjects and to complete the dressing changes associated with pressure ulcer treatment was obtained from a previously conducted workload measurement study published in 1991. Unit costs were based on the facility's purchase price and average staff salary and benefits. The price years were 1994 and 1995.
Statistical analysis of costs Student's t test was used to compare the groups in terms of cost components and total costs.
Indirect Costs Indirect costs were not included.
Sensitivity analysis A set of one-way sensitivity analyses was conducted on the costs of prevention in pre-protocol samples, cost of prevention in the post-protocol sample, cost of ulcer treatment pre-protocol and post-protocol, and the effectiveness of the pressure ulcer prevention protocol.
Estimated benefits used in the economic analysis The mean (SD) number of ulcer-free days was 146.4 (61) in the pre-protocol sample and 157.5 (53) days in the post-protocol sample. The pre-protocol sample had a significantly shorter time to ulcer development than the post-protocol sample, (p=0.0033).
Cost results The mean (SD) cost for prevention and treatment of pressure ulcers was $113 ($345) per subject for the pre-protocol sample and $100 ($157) per subject for the post-protocol sample, (p=0.79).
Synthesis of costs and benefits A synthesis of costs and benefits was not required since the intervention (the use of an intensive prevention protocol) was the weakly dominant strategy (better clinical outcomes with statistically comparable costs). However, the incremental cost per day of ulcer-free life gained was calculated as the cost-effectiveness ratio, resulting in a value of -$1.13 for the intervention compared to the comparator. The sensitivity analyses established that the prevention protocol remained cost-effective with all modifications, with the exception of a 50% reduction in the cost of treatment.
Authors' conclusions Implementation of a protocol that emphasised pressure ulcer prevention significantly reduced the incidence of pressure ulcers and cost per day of ulcer-free life.
CRD COMMENTARY - Selection of comparators The strategy of not using an intensive prevention protocol, as the conventional method in the study institution before the implementation of the protocol, was regarded as the comparator. You, as a database user, should consider whether this is a widely used approach in your own setting.
Validity of estimate of measure of effectiveness The internal validity of the effectiveness results can not be guaranteed due to the possibility of selection bias and effects of confounding variables (because of the non-randomised nature of the study design and the use of historical controls). The authors acknowledged this. The study groups were comparable in terms of the number of subjects who were at risk in each sample, (p=0.32); no statistical comparisons were reported for other baseline characteristics. The study sample appears to have been representative of the study population: an ulcer-free population in a long-term-care facility.
Validity of estimate of measure of benefit The estimation of benefits was obtained directly from the effectiveness analysis. This choice of estimate was justified.
Validity of estimate of costs Good features of the cost analysis were that some quantities were reported separately from the costs, adequate details of the methods of cost estimation were given, the price years and the perspective adopted in the cost analysis were reported and the use of true costs instead of charges. However, the effects of alternative procedures on indirect costs were not addressed and statistical analyses were performed on cost data, but not on resource consumption. The cost results may be generalisable to other countries in similar settings given the sensitivity analyses performed.
Other issues The authors' conclusions appear to be justified given the comprehensiveness of the analyses performed. The issue of generalisability to other settings was addressed by sensitivity analysis and by acknowledging that this study may not be applicable to other institutions in which some systematic prevention already occurs. It was also acknowledged that the lack of hospitalisation for pressure ulcer-related complications among subjects in the study limits the generalisability of the study findings. Appropriate comparisons do not appear to have been made with other studies. The degree to which the study sample was representative of the study population was addressed by acknowledging that the cost-effectiveness analysis results are likely to vary as the proportion of "at risk" subjects in the institution varies. The authors also pointed out that lack of Stage III or Stage IV pressure ulcers in the study sample may have lowered the costs compared to those experienced in other facilities.
Implications of the study Incremental increases in the intensity of preventive measures can contain costs and enhance clinical outcomes. Prevention can be less expensive than treatment if implemented consistently, using low- technology interventions, targeting more expensive interventions to those patients at higher risk, and treating ulcers that occur with inexpensive moist wound healing modalities.
Source of funding Funded in part by an allocation from the Indirect Cost-Based Research Incentive Fund administered by the Office of the Vice President of Research, The University of Iowa, Iowa City.
Bibliographic details Xakellis G C, Frantz R A, Lewis A, Harvey P. Cost-effectiveness of an intensive pressure ulcer prevention protocol in long-term care. Advances in Wound Care 1998; 11(1): 22-29 Indexing Status Subject indexing assigned by NLM MeSH Aged; Aged, 80 and over; Clinical Nursing Research; Cost-Benefit Analysis; Female; Humans; Incidence; Long-Term Care /economics /methods; Male; Nursing Assessment; Pressure Ulcer /economics /etiology /prevention & Risk Factors; Sensitivity and Specificity; Skilled Nursing Facilities; Survival Analysis; control AccessionNumber 21998007590 Date bibliographic record published 30/04/2001 Date abstract record published 30/04/2001 |
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