Health status utilities and the impact of pressure ulcers in long-term care residents in Ontario

Prevalence and incidence of pressure injuries among older people living in nursing homes: A systematic review and meta-analysis

BACKGROUND

Pressure injuries are a fundamental safety concern in older people living in nursing homes. Recent studies report a disparate body of evidence on pressure injury prevalence and incidence in this population.

OBJECTIVES

To systematically quantify the prevalence and incidence of pressure injuries among older people living in nursing homes, and to identify the most frequently occurring PI stage(s) and anatomical location(s).

DESIGN

Systematic review and meta-analysis.

SETTING(S)

Nursing homes, aged care, or long-term care facilities.

PARTICIPANTS

Older people, 60 years and older.

METHODS

Cross-sectional and cohort studies reporting on either prevalence or incidence of pressure injuries were included. Studies published in English from 2000 onwards were systematically searched in Medline, PubMed, Embase, Cochrane Library, CINAHL and ProQuest. Screening, data extraction and quality appraisal were undertaken independently by two or more authors and adjudicated by another. Outcomes included pressure injury point prevalence, cumulative incidence, and nursing home acquired pressure injury rate. In meta-analyses, Cochrane's Q test and the I2 statistic were used to explore heterogeneity. Random effects models were used in the presence of substantial heterogeneity. Sources of heterogeneity were investigated by subgroup analyses and meta-regression.

RESULTS

3384 abstracts were screened, and 47 full-text studies included. In 30 studies with 355,784 older people, the pooled pressure injury prevalence for any stage was 11.6 % (95 % CI 9.6-13.7 %). Fifteen studies with 5,421,798 older people reported the prevalence of pressure injury excluding stage I and the pooled estimate was 7.2 % (95 % CI 6.2-8.3 %). The pooled incidence for pressure injury of any stage in four studies with 10,645 older people was 14.3 % (95 % CI 5.5-26.2 %). Nursing home acquired pressure injury rate was reported in six studies with 79,998 older people and the pooled estimate was 8.5 % (95 % CI 4.4-13.5 %). Stage I and stage II pressure injuries were the most common stages reported. The heel (34.1 %), sacrum (27.2 %) and foot (18.4 %) were the three most reported locations of pressure injuries. Meta-regression results indicated a reduction in pressure injury prevalence over the years of data collection.

CONCLUSION

The burden of pressure injuries among older people in nursing homes is similar to hospitalised patients and requires a targeted approach to prevention as is undertaken in hospitals. Future studies using robust methodologies focusing on epidemiology of pressure injury development in older people are needed to conduct as the first step of preventing pressure injuries.

REGISTRATION NUMBER

PROSPERO CRD42022328367.

TWEETABLE ABSTRACT

Pressure injury rates in nursing homes are comparable to hospital rates indicating the need for targeted programmes similar to those in hospitals.

The effect of a pressure ulcer prevention care bundle on nursing workload costs

AIM

This study investigated the effect of care under the guidance of a pressure ulcer prevention care bundle on pressure ulcer incidence rates and on nursing workload costs.

DESIGN, SETTING, AND PARTICIPANTS

This prospective pre-post interventional study was conducted in an anesthesia and reanimation intensive care unit. The sample consisted of 16 nurses and 84 patients.

METHODS

The study was conducted in two periods: (1) nursing workload of pre-care bundle period and (2) nursing workload of post-care bundle period. In the collection of data, 6 forms (the demographic data forms, the Braden scale, nurse information form, the care bundle follow-up form and nursing workload follow-up form) were administered. The main outcomes of the study; Pressure ulcer incidence rate was evaluated with Form V, and nursing workload costs were evaluated with Form VI. These forms were evaluated daily by the nurses. In the first period (15.09.2018-30.11.2018), pressure ulcer incidence rates and nursing workload costs were evaluated before training. Then, the researcher trained nurses on how to prevent pressure ulcers and use the care bundle. The care bundles components were risk assessment, skincare, activity, in-service training, nutrition, wetness/incontinence and support surface management, and keeping records. In the second period (01.12.2018-15.02.2019), pressure ulcer incidence rates and nursing workload costs were evaluated after the training. The outcomes of the two periods regarding the incidence of pressure ulcers and nursing workload costs were compared.

RESULTS

The pressure ulcer incidence rates before and after the care bundle were 22.1 and 13.0 per 100 patient-day, respectively. There was a decrease in pressure ulcer incidence rates after the care bundle, but it wasn't significant (p = 0.138). The total workload cost of pressure ulcer prevention was significantly lower after the care bundle than before (p = 0.001).

CONCLUSION

The pressure ulcer incidence rates were lower after the care bundle than before, albeit insignificantly. The total pressure ulcer prevention workload costs were significantly lower after the care bundle than before. The reduction in pressure ulcer incidence and workload cost indicates that the use of care bundle is effective. Healthcare professionals in intensive care units should use a pressure ulcer prevention care bundle more often.

Prevalence of pressure ulcers in long-term care: a global review

Objective:

To identify and update the prevalence and incidence of pressure ulcers (PUs) in several countries, in people with long-term conditions resident in care homes or nursing homes.

Methods:

We followed the PRISMA guideline for systematic reviews. However, due to funding constraints we do not claim this review to be systematic but it is a narrative review informed by PRISMA. Medline, Embase and CINHAL were searched for observational studies reporting incidence or prevalence data. Data reported relevant head-to-toe examination of PUs in residence in care or nursing homes. Internal and external validity of the included studies were assessed using the checklist devised by Hoy et al. 1

Results:

Inclusion criteria was met by 17 studies and included in the study. Some studies gave a full breakdown by category, some only gave overall figures, and others excluded category I PUs. However, within those constraints certain patterns are clear. Prevalence rates varied from 3.4–32.4%. Large differences in prevalence in different countries were not explained by methodological differences. While some countries, such as Germany, the Netherlands and the US had robust data, other countries, such as the UK, had none.

Conclusion:

PUs are a common problem in long-term care. However, there are substantial differences between countries and many countries have no published data.

Development and Validation of a Prognostic Tool for Identifying Residents at Increased Risk of Death in Long-Term Care Facilities

BACKGROUND

To promote better care at the end stage of life in long-term care facilities, a culturally appropriate tool for identifying residents at the end of life is crucial.

OBJECTIVE

This study aimed to develop and validate a prognostic tool, the increased risk of death (IRD) scale, based on the minimum data set (MDS).

DESIGN

A retrospective study using data between 2005 and 2013 from six nursing homes in Hong Kong.

SETTING/SUBJECTS

A total of 2380 individuals were randomly divided into two equal-sized subsamples: Sample 1 was used for the development of the IRD scale and Sample 2 for validation.

MEASUREMENTS

The measures were MDS 2.0 items and mortality data from the discharge tracking forms. The nine items in the IRD scale (decline in cognitive status, decline in activities of daily living, cancer, renal failure, congestive heart failure, emphysema/chronic obstructive pulmonary disease, edema, shortness of breath, and loss of weight), were selected based on bivariate Cox proportional hazards regression.

RESULTS

The IRD scale was a strong predictor of mortality in both Sample 1 (HR_sample1 = 1.50, 95% confidence interval [CI]: 1.37-1.65) and Sample 2 (HR_sample2 = 1.31, 1.19-1.43), after adjusting for covariates. Hazard ratios (HRs) for residents who had an IRD score of 3 or above for Sample 1 and Sample 2 were 3.32 (2.12-5.21) and 2.00 (1.30-3.09), respectively.

CONCLUSIONS

The IRD scale is a promising tool for identifying nursing home residents at increased risk of death. We recommend the tool to be incorporated into the care protocol of long-term care facilities in Hong Kong.

Turning High-Risk Individuals: An Economic Evaluation of Repositioning Frequency in Long-Term Care

Recent evidence suggests that less frequent repositioning of long-term care residents at moderate to high risk of developing pressure ulcers (PrUs) is noninferior to current repositioning standards in preventing PrUs, but the long-term health and economic consequences of less frequent repositioning have not been adequately estimated. Our objective was to estimate the cost-effectiveness of different repositioning strategies (2-, 3-, 4-hour intervals). We conducted a cost-utility analysis using a lifetime horizon based on data from a randomized clinical trial and the literature. We updated a published PrU decision model with resource usage, unit costs, and epidemiological estimates from the literature and from a small observational study. The Ontario Ministry of Health and Long-Term Care perspective was taken. We estimated lifetime costs to be CAN$5,425 (95% credible interval (CrI)=$922-12,166) less per resident with 3-hour repositioning than with 2-hour repositioning and CAN$3,296 (95% CrI=$483-9,738) less than with 4-hour repositioning. The gain in expected quality-adjusted life years from a 3- to a 2-hour repositioning strategy was 0.008, (95% CrI=0.005-0.016) and from a 3- to a 4-hour repositioning strategy was 0.009 (95% CrI=0.007-0.018). Repositioning at 3-hour intervals was the dominant strategy with respect to the incremental cost-effectiveness ratio against the 2- and 4-hour strategies. Sensitivity analysis showed a 99% probability that 3-hour repositioning was a dominant strategy. We concluded that repositioning at 3-hour intervals for residents at moderate or high risk of PrUs and who were cared for on high-density foam mattresses appeared to be the most cost-effective strategy.

Assessing the impact of a home-based stroke rehabilitation programme: a cost-effectiveness study

Background: Stroke is often a severe and debilitating event that requires ongoing rehabilitation. The Community Stroke Rehabilitation Teams (CSRTs) offer home-based stroke rehabilitation to individuals for whom further therapy is unavailable or inaccessible. The objective of this study was to evaluate the cost-effectiveness of the CSRT programme compared with a "Usual Care" cohort. Methods: We collected data on CSRT clients from January 2012 to February 2013. Comparator data were derived from a study of stroke survivors with limited access to specialised stroke rehabilitation. Literature-derived values were used to inform a long-term projection. Using Markov modelling, we projected the model for 35 years in six-month cycles. One-way, two-way, and probabilistic sensitivity analyses were performed. Results were discounted at 3% per year. Results: Results demonstrated that the CSRT programme has a net monetary benefit (NMB) of $43,655 over Usual Care, and is both less costly and more effective (incremental cost = -$17,255; incremental effect = 1.65 Quality Adjusted Life Years [QALYs]). Results of the probabilistic sensitivity analysis revealed that incremental cost-effectiveness of the CSRT programme is superior in 100% of iterations when compared to Usual Care. Conclusions: The study shows that CSRT model of care is cost-effective, and should be considered when evaluating potential stroke rehabilitation delivery methods. Implications for Rehabilitation Ongoing rehabilitation following stroke is imperative for optimal recovery. Home-based specialised stroke rehabilitation may be an option for individuals for whom ongoing rehabilitation is unavailable or inaccessible. The results of this study demonstrated that home-based rehabilitation is a cost-effective means of providing ongoing rehabilitation to individuals who have experienced a stroke.

Measuring health related quality of life (HRQoL) in community and facility-based care settings with the interRAI assessment instruments: development of a crosswalk to HUI3

Background

Health-related quality of life (HRQoL) measures are of interest because they can be used to describe health of populations and represent a broader health outcome for population health analyses than mortality rates or life expectancy. The most widely used measure of HRQoL for deriving estimates of health-adjusted life expectancy is the Health Utilities Index Mark 3 (HUI3). The HUI3 is available in most national surveys administered by Statistics Canada, and has been used as part of a microsimulation model to examine the impact of neurological conditions over the life course. Persons receiving home care and nursing home services are often not well-represented in these surveys; however, interRAI assessment instruments are now used as part of normal clinical practice in these settings for nine Canadian provinces/territories. Building on previous research that developed a HUI2 crosswalk for the interRAI assessments, the present study examined a new interRAI HRQoL index crosswalked to the HUI3.

Methods

interRAI and survey data were used to examine the distributional properties of global and domain-specific interRAI HRQoL and HUI3 index scores, respectively. Three populations were considered: well-elderly persons not receiving home care, home care clients and nursing home residents.

Results

The mean HUI3 and interRAI HRQoL index global scores declined from independent healthy older persons to home care clients, followed by nursing home residents. For the home care and nursing home populations, the interRAI HRQoL global estimates tended to be lower than HUI3 global scores obtained from survey respondents. While there were some statistically significant age, sex and diagnostic group differences in global scores and within attributes, the most notable differences were between populations from different care settings.

Discussion

The present study provides strong evidence for the validity of the interRAI HRQoL based on comparisons of distributional properties with those obtained with survey data based on the HUI3. The results demonstrate the importance of admission criteria for home care and nursing home settings, where function plays a more important role than demographic or diagnostic criteria. The interRAI HRQoL has a distinct advantage because it is gathered as part of normal clinical practice in care settings where interRAI instruments are mandatory and are used to assess all eligible persons in those sectors. In particular, those with severe cognitive and functional impairments (who tend to be under-represented in survey data) will be evaluated using the interRAI tools. Future research should build on this work by providing direct, person-level comparisons of interRAI HRQoL index and HUI3 scores, as well as longitudinal analyses to examine responsiveness to change.

The impact of an educational intervention on home support workers' ability to detect early pressure ulcer damage

OBJECTIVE

To investigate the impact of an educational intervention on home support workers' ability to detect early pressure ulcer damage.

METHOD

A repeated measure design was employed to quantify the effectiveness of an educational intervention, consisting of one pre-test and two post-tests.

RESULTS

Education was provided to home support workers and this was followed by an assessment of their ability to correctly classify 20 photographs detailing varying stages of skin damage severity. At the baseline (pre-education), 58% of the photographs were classified correctly. At post-test 1, 55% of the photographs were classified correctly. In post-test 2 this increased to 58%, achieving the original baseline scores. There was a moderate negative relationship between pre-training and post-test 2 scores (r=-0.44; n=27; p=0.02).

CONCLUSIONS

The educational intervention has been shown not to have a statistically significantly positive effect on home support workers' ability to detect early pressure ulcer damage. The moderate negative relationship between pre-training and post-test 2 scores concur with the aforementioned qualitative findings, and similarly indicate behaviour associated with individuals experiencing difficulty comprehending new health terms.

Pressure Ulcers Among Newly Admitted Nursing Home Residents: Measuring the Impact of Transferring From Hospital

OBJECTIVES

Pressure ulcers (PUs) are reported more often among newly admitted nursing home (NH) residents who transfer from hospital versus community. We examine for whom this increased risk is greatest, further defining hospitalized patients most in need of better PU preventive care.

RESEARCH DESIGN

Retrospective observational cohort study.

SUBJECTS

All NH residents (N=5617) newly admitted between April 1, 2008 and March 31, 2012 in Winnipeg, MB, Canada.

MEASURES

RAI-MDS 2.0 data were linked to administrative health care use files capturing each person's NH admission date, their presence of a PU at this time, whether they transferred into NH from hospital or community, and their PU susceptibility (eg, amount of help needed to maneuver in bed or to transfer from one surface to another, frequency of incontinence, presence of diabetes, amount of food consistently left uneaten). Log-binomial regression with interaction terms was used to analyze data.

RESULTS

67.6% of our cohort transferred into a NH directly from hospital; 9.2% of these residents were reported to have a stage 1+ PU on NH admission versus 2.6% of those who transferred from community. From regression models, transferring from hospital versus community was associated with increased PU risk equally across various subgroups of less and more susceptible residents.

CONCLUSIONS

Transferring from hospital versus community places both more and less susceptible newly admitted NH residents at increased PU risk. Using evidence-based preventive care practices is thus needed for all subgroups of hospital patients before NH use, to help reduce PU risk.

The characteristics of stroke units in Ontario: a pan-provincial survey

Background

Previous studies have demonstrated that organized, multidisciplinary care is the cornerstone of current strategies to reduce the death and disability caused by stroke. Identification of stroke units and an understanding of their composition and operation would provide insight for the further actions required to improve stroke care. The objective of this study was to identify and survey stroke units in Canada’s largest province, Ontario (population of 13 million) in order to describe availability, structure, staffing, processes of care, and type of population stroke units serve.

Methods

The Ontario Stroke Network (2011) list of stroke units and snowball sampling was used to identify all stroke units. During 2013 – 2014 an interviewer conducted telephone surveys with the stroke unit managers using closed and semi-open ended questions. Descriptive statistics were used to summarize survey responses.

Results

The survey identified 32 stroke units, and a respondent from every stroke unit (100% response rate) was interviewed. Twenty one were acute stroke units, 10 were integrated stroke units and one was classified as a rehabilitation stroke unit. Stroke units were available in all 14 Local Health Integration Networks except Central West. The estimated average number of stroke patients served per stroke unit was 604 with six-fold variation (242 to 1480) across the province. The typical population served in stroke units were patients with either ischemic or hemorrhagic stroke. Data consistently reported on the processes of stroke care, including the availability of multidisciplinary staff, specific diagnostic imaging, use of validated assessment tools, and the delivery of patient education. Details about the core components of stoke care were provided by 16 stroke units (50%).

Conclusions

This study demonstrates the heterogeneous structure of stroke units in Ontario and signaled potential disparity in access to stroke units. Many core components are in place, but half of the stroke units in Ontario do not meet all criteria. Areas for potential improvement include stroke care training for the multidisciplinary team, provision of individualized rehabilitation plans, and early discharge assessment.

Electronic supplementary material

The online version of this article (doi:10.1186/s12913-017-2099-1) contains supplementary material, which is available to authorized users.

Vaccinating Italian infants with a new multicomponent vaccine (Bexsero®) against meningococcal B disease: A cost-effectiveness analysis

The European Medicines Agency has approved a multicomponent serogroup B meningococcal vaccine (Bexsero®) for use in individuals of 2 months of age and older. A cost-effectiveness analysis (CEA) from the societal and Italian National Health Service perspectives was performed in order to evaluate the impact of vaccinating Italian infants less than 1 y of age with Bexsero®, as opposed to non-vaccination. The analysis was carried out by means of Excel Version 2011 and the TreeAge Pro® software Version 2012. Two basal scenarios that differed in terms of disease incidence (official and estimated data to correct for underreporting) were considered. In the basal scenarios, we considered a primary vaccination cycle with 4 doses (at 2, 4, 6 and 12 months of age) and 1 booster dose at the age of 11 y, the societal perspective and no cost for death. Sensitivity analyses were carried out in which crucial variables were changed over probable ranges. In Italy, on the basis of official data on disease incidence, vaccination with Bexsero® could prevent 82.97 cases and 5.61 deaths in each birth cohort, while these figures proved to be three times higher on considering the estimated incidence. The results of the CEA showed that the Incremental Cost Effectiveness Ratio (ICER) per QALY was €109,762 in the basal scenario if official data on disease incidence are considered and €26,599 if estimated data are considered. The tornado diagram indicated that the most influential factor on ICER was the incidence of disease. The probability of sequelae, the cost of the vaccine and vaccine effectiveness also had an impact. Our results suggest that vaccinating infants in Italy with Bexsero® has the ability to significantly reduce meningococcal disease and, if the probable underestimation of disease incidence is considered, routine vaccination is advisable.

The relative impact of chronic conditions and multimorbidity on health-related quality of life in Ontario long-stay home care clients

PURPOSE

To examine the relative impact of 16 common chronic conditions and increasing morbidity on health-related quality of life (HRQL) in a population-based sample of home care clients in Ontario, Canada.

METHODS

Participants were adult clients assessed with the Resident Assessment Instrument for Home Care (RAI-HC) between January and June 2009 and diagnosed with one (or more) of 16 common chronic conditions. HRQL was evaluated using the Minimum Data Set-Health Status Index (MDS-HSI), a preference-based measure derived from items captured in the RAI-HC. Multivariable linear regression models assessed the relative impact of each condition, and increasing number of diagnoses, on MDS-HSI scores.

RESULTS

Mean (SD) MDS-HSI score in the study population (n = 106,159) was 0.524 (0.213). Multivariable analysis revealed a statistically significant (p < 0.05) and clinically important (difference ≥ 0.03) decrease in MDS-HSI scores associated with stroke (-0.056), osteoarthritis (-0.036), rheumatoid arthritis (-0.033) and congestive heart failure (CHF, -0.030). Differences by age and sex were observed; most notably, the negative impact associated with dementia was greater among men (-0.043) than among women (-0.019). Further, HRQL decreased incrementally with additional diagnoses. In all models, chronic conditions and number of diagnoses accounted for a relatively small proportion of the variance observed in MDS-HSI.

CONCLUSION

Clinically important negative effects on HRQL were observed for clients with a previous diagnosis of stroke, osteo- and rheumatoid arthritis, or CHF, as well as with increasing levels of multimorbidity. Findings provide baseline preference-based HRQL scores for home care clients with different diagnoses and may be useful for identifying, targeting and evaluating care strategies toward populations with significant HRQL impairments.

Pressure UlceR Programme Of reSEarch (PURPOSE): using mixed methods (systematic reviews, prospective cohort, case study, consensus and psychometrics) to identify patient and organisational risk, develop a risk assessment tool and patient-reported outcome Quality of Life and Health Utility measures

Background

The Pressure UlceR Programme Of reSEarch (PURPOSE) consisted of two themes. Theme 1 focused on improving our understanding of individuals’ and organisational risk factors and on improving the quality of risk assessments (work packages 1–3) and theme 2 focused on developing patient-reported outcome measures (work packages 4 and 5).

Methods

The programme comprised 21 individual pieces of work. Pain: (1) multicentre pain prevalence study in acute hospitals, (2) multicentre pain prevalence study in community localities incorporating (3) a comparison of case-finding methods, and (4) multicentre, prospective cohort study. Severe pressure ulcers: (5) retrospective case study, (6) patient involvement workshop with the Pressure Ulcer Research Service User Network for the UK (PURSUN UK) and (7) development of root cause analysis methodology. Risk assessment: (8) systematic review, (9) consensus study, (10) conceptual framework development and theoretical causal pathway, (11) design and pretesting of draft Risk Assessment Framework and (12) field test to assess reliability, validity, data completeness and clinical usability. Quality of life: (13) conceptual framework development (systematic review, patient interviews), (14 and 15) provisional instrument development, with items generated from patient interviews [from (1) above] two systematic reviews and experts, (16) pretesting of the provisional Pressure Ulcer Quality of Life (PU-QOL) instrument using mixed methods, (17) field test 1 including (18) optimal mode of administration substudy and item reduction with testing of scale formation, acceptability, scaling assumptions, reliability and validity, and (19) field test 2 – final psychometric evaluation to test scale targeting, item response categories, item fit, response bias, acceptability, scaling assumptions, reliability and validity. Cost–utility: (20) time trade-off task valuations of health states derived from selected PU-QOL items, and (21) validation of the items selected and psychometric properties of the new Pressure Ulcer Quality of Life Utility Index (PUQOL-UI).

Key findings

Pain: prevalence studies – hospital and community patients experience both pressure area-related and pressure ulcer pain; pain cohort study – indicates that pain is independently predictive of category 2 (and above) pressure ulcer development. Severe pressure ulcers: these were more likely to develop in contexts in which clinicians failed to listen to patients/carers or recognise/respond to high risk or the presence of an existing pressure ulcer and services were not effectively co-ordinated; service users found the interactive workshop format valuable; including novel components (interviews with patients and carers) in root cause analysis improves the quality of the insights captured. Risk assessment: we developed a Pressure Ulcer Risk Assessment Framework, the PURPOSE-T, incorporating the Minimum Data Set, a screening stage, a full assessment stage, use of colour to support decision-making, and decision pathways that make a clear distinction between patients with an existing pressure ulcer(s) (or scarring from previous ulcers) who require secondary prevention and treatment and those at risk who require primary prevention (http://medhealth.leeds.ac.uk/accesspurposet). Quality of life: the final PU-QOL instrument consists of 10 scales to measure pain, exudate, odour, sleep, vitality, mobility/movement, daily activities, emotional well-being, self-consciousness and appearance, and participation (http://medhealth.leeds.ac.uk/puqol-ques). Cost–utility: seven items were selected from the PU-QOL instrument for inclusion in the PUQOL-UI (http://medhealth.leeds.ac.uk/puqol-ui); secondary study analysis indicated that item selection for the PUQOL-UI was appropriate and that the index was acceptable to patients and had adequate levels of validity.

Conclusions

The PURPOSE programme has provided important insights for pressure ulcer prevention and treatment and involvement of service users in research and development, with implications for patient and public involvement, clinical practice, quality/safety/health service management and research including replication of the pain risk factor study, work exploring ‘best practice’ settings, the impact of including skin status as an indicator for escalation of preventative interventions, further psychometric evaluation of PU-QOL and PUQOL-UI the measurement of ‘disease attribution.’

Funding

The National Institute for Health Research Programme Grants for Applied Research programme.

Risk Assessment Tool for Pressure Ulcer Development in Indian Surgical Wards

The aims of this paper were to compare the predictive validity of three pressure ulcer (PU) risk scales-the Norton scale, the Braden scale, and the Waterlow scale-and to choose the most appropriate calculator for predicting PU risk in surgical wards of India. This is an observational prospective cohort study in a tertiary educational hospital in New Delhi among 100 surgical ward patients from April to July 2011. The main outcomes measured included sensitivity, specificity, positive predictive value (PVP) and negative predictive value (PVN), and the area under the curve of the receiver operating characteristic (ROC) curve of the three PU risk assessment scales. Based on the cutoff points found most appropriate in this study, the sensitivity, specificity, PVP, and PVN were as follows: the Norton scale (cutoff, 16) had the values of 95.6, 93.5, 44.8, and 98.6, respectively; the Braden scale (cutoff, 17) had values of 100, 89.6, 42.5, and 100, respectively; and the Waterlow scale (cutoff, 11) had 91.3, 84.4, 38.8, and 97, respectively. According to the ROC curve, the Norton scale is the most appropriate tool. Factors such as physical condition, activity, mobility, body mass index (BMI), nutrition, friction, and shear are extremely significant in determining risk of PU development (p < 0.0001). The Norton scale is most effective in predicting PU risk in Indian surgical wards. BMI, mobility, activity, nutrition, friction, and shear are the most significant factors in Indian surgical ward settings with necessity for future comparison with established scales.

Health and economic outcomes of introducing the new MenB vaccine (Bexsero) into the Italian routine infant immunisation programme

Introduction

In January 2013 a novel type of multicomponent protein-based vaccine against group B meningococcal disease was licensed by the European Medicines Agency. With the widespread use of the meningococcal serogroup C conjugate vaccines, serogroup B remains now the major cause of bacterial meningitis and septicaemia in young children in Europe. The aim of this study is to investigate the health and the economic outcomes of MenB vaccine introduction into the Italian routine mass vaccination programme.

Methods

The present work is structured in two main parts. Firstly, we assess the epidemiological burden of group B meningococcal disease using official hospitalisation and notification data from two of the most populated Italian regions (Lombardia and Piemonte) during a 6-year study period (2007-2012). Secondly, we evaluate the cost-effectiveness of the immunisation programme in Italy from the public health payer perspective under base case parameters assumptions and performing a comprehensive sensitivity analysis to assess the robustness and the uncertainty of our model results.

Results

MenB serotype is responsible for 59% of the 341 cases of Invasive Meningococcal Disease in Lombardia and Piemonte. Incidence rate for MenB infection is estimated to be 0.21/100,000/y resulting at the highest level in children ≤4 years of age. Although the new MenB vaccine can potentially prevent about one third of the disease cases in the Italian population, model results show this strategy is unlikely to be cost-effective (ICER value over €350,000/QALY) with a vaccine that prevents disease only. These results are robust under most of the sensitivity scenarios except when allowing for lower discount rates.

Discussion

The introduction of the novel vaccine into the routine immunisation schedule needs to be carefully evaluated. The new MenB vaccine has the potential to reduce the disease burden at the population level. However, from the Italian Health Service perspective, the immunisation programme is unlikely to be cost-effective at the current incidence levels and vaccine price.

Resident health-related quality of life in Swiss nursing homes

BACKGROUND

Health-related quality of life (HRQOL) levels and their determinants in those living in nursing homes are unclear. The aim of this study was to investigate different HRQOL domains as a function of the degree of cognitive impairment and to explore associations between them and possible determinants of HRQOL.

METHOD

Five HRQOL domains using the Minimum Data Set - Health Status Index (MDS-HSI) were investigated in a large sample of nursing home residents depending on cognitive performance levels derived from the Cognitive Performance Scale. Large effect size associations between clinical variables and the different HRQOL domains were looked for.

RESULTS

HRQOL domains are impaired to variable degrees but with similar profiles depending on the cognitive performance level. Basic activities of daily living are a major factor associated with some but not all HRQOL domains and vary little with the degree of cognitive impairment.

LIMITATIONS

This study is limited by the general difficulties related to measuring HRQOL in patients with cognitive impairment and the reduced number of variables considered among those potentially influencing HRQOL.

CONCLUSION

HRQOL dimensions are not all linearly associated with increasing cognitive impairment in NH patients. Longitudinal studies are required to determine how the different HRQOL domains evolve over time in NH residents.

Patient-reported outcome measures for chronic wounds with particular reference to pressure ulcer research: a systematic review

OBJECTIVES

Pressure ulcers are a major health problem, affect patient psychological, physical and social functioning, and cause significant treatment burden. For comprehensive assessment of the benefits of an intervention, patient-reported evidence of the impact of an intervention on important patient outcomes should be made. We systematically reviewed the quality of life literature on chronic wounds to determine the suitability of generic and chronic wound-specific outcome measures for use in evaluating patient outcomes in pressure ulcer research.

DESIGN

A systematic review of the literature.

DATA SOURCES

Searches of eight electronic databases from inception until May 2012 were undertaken.

REVIEW METHODS

Quality of life domains, item content and content relevance were determined for identified outcome measures. The content validity of identified measures was assessed against an empirically derived pressure ulcer-specific conceptual framework.

RESULTS

Three generic and 14 chronic wound measures were identified but no pressure ulcer-specific measures. None of the existing measures cover all quality of life domains important in pressure ulcers. One condition-specific measure, the Venous Leg Ulcer Measure, matched most closely conceptually, but failed to represent three important domains and contained items not specific to pressure ulcers.

CONCLUSIONS

Currently, outcomes important in pressure ulcers are inadequately covered by generic and chronic wound-specific instruments despite similar conceptual models. Highlighted is the need for clear conceptualisation of content as well as determining appropriateness when selecting outcome measures in the future.

Theoretical Risk and Prevention Model for Secondary Health Conditions and Mortality After SCI: 15 Years of Research

BACKGROUND

To successfully prevent secondary health conditions (SHCs) and promote longevity after spinal cord injury (SCI), we must first understand the risk factors precipitating their occurrence and develop strategies to address these risk factors. Conceptual models may aid in identifying the nature of SHCs and guide research, clinical practice, and the development of prevention strategies.

OBJECTIVE

Our purpose is to review and refine an existing theoretical risk and prevention model (TRPM) as a means of classifying risk and protective factors for SHCs and mortality after SCI and for identifying points of intervention.

METHODS

We describe conceptual work within the field of SCI research and SHCs, including a description of the TRPM, a review of research using the TRPM, and conceptual enhancements to the TRPM based on previous research.

CONCLUSIONS

The enhanced TRPM directs research to the timing and chronicity of the SHCs and their relationship with overall health and physiologic decline. Future research should identify differences in the nature of SHCs, the extent to which they relate to risk and protective factors, and the degree to which they may be prevented with appropriate research-based strategies.

Evaluation of the cost-effectiveness of electrical stimulation therapy for pressure ulcers in spinal cord injury

OBJECTIVE

To evaluate the incremental cost-effectiveness of electrical stimulation (ES) plus standard wound care (SWC) as compared with SWC only in a spinal cord injury (SCI) population with grade III/IV pressure ulcers (PUs) from the public payer perspective.

DESIGN

A decision analytic model was constructed for a 1-year time horizon to determine the incremental cost-effectiveness of ES plus SWC to SWC in a cohort of participants with SCI and grade III/IV PUs. Model inputs for clinical probabilities were based on published literature. Model inputs, namely clinical probabilities and direct health system and medical resources were based on a randomized controlled trial of ES plus SWC versus SWC. Costs (Can $) included outpatient (clinic, home care, health professional) and inpatient management (surgery, complications). One way and probabilistic sensitivity (1000 Monte Carlo iterations) analyses were conducted.

SETTING

The perspective of this analysis is from a Canadian public health system payer.

PARTICIPANTS

Model target population was an SCI cohort with grade III/IV PUs.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURE

Incremental cost per PU healed.

RESULTS

ES plus SWC were associated with better outcomes and lower costs. There was a 16.4% increase in the PUs healed and a cost savings of $224 at 1 year. ES plus SWC were thus considered a dominant economic comparator. Probabilistic sensitivity analysis resulted in economic dominance for ES plus SWC in 62%, with another 35% having incremental cost-effectiveness ratios of $50,000 or less per PU healed. The largest driver of the economic model was the percentage of PU healed with ES plus SWC.

CONCLUSIONS

The addition of ES to SWC improved healing in grade III/IV PU and reduced costs in an SCI population.

Estado nutricional e capacidade funcional na úlcera por pressão em pacientes hospitalizados

OBJETIVO: Correlacionar a incidência de úlcera por pressão com o estado nutricional e a capacidade funcional de pacientes internados. MÉTODOS: Estudo de corte transversal realizado em dois hospitais, totalizando 130 pacientes (idade mediana = 52 (14-85) anos, 77 (59,2%) homens e 53 (40,8%) mulheres), sendo 72 (55,4%) internados para tratamento clínico, 40 (30,8%) para tratamento cirúrgico e 18 (13,8%) em terapia intensiva. Os pacientes foram avaliados pela avaliação subjetiva global e classificados, de acordo com sua capacidade funcional, em acamados e não acamados. Registrou-se a presença e número de úlceras, e sua gravidade. A classificação das úlceras foi estabelecida como grave, para lesões de 3º e 4º graus, e leve, para os graus 1 e 2. RESULTADOS: A incidência de úlcera por pressão na população estudada foi de 19,2% (n=25). Não houve associação significativa com o sexo, a idade e tipo de tratamento do paciente. Os pacientes acamados apresentaram 7,5 vezes mais chance de apresentar úlceras (19/50; 38,0%) do que os que deambulavam (6/80; 7,5%; OR=7,5; IC95%: 2,7-20,7; p<0,001). A incidência de úlcera nos pacientes gravemente desnutridos (20/49; 40,8%) foi 10 vezes maior que nos pacientes considerados não gravemente desnutridos (5/81; 6,1%; OR=10,4 IC95%: 3,6-30,5; p<0,0001) Pela análise multivariada, tanto a capacidade funcional (acamado, OR=9,2; IC95%: 2,8-30,1; p<0,001) quanto o estado nutricional (desnutrido grave, OR=3,8; IC95%: 1,0-13,9; p=0,04) associaram-se com a úlcera por pressão. CONCLUSÃO: A incidência de úlcera por pressão está diretamente correlacionada com a desnutrição e com a restrição ao leito dos pacientes internados.

An economic appraisal of the Australian Medical Sheepskin for the prevention of sacral pressure ulcers from a nursing home perspective

Background

Many devices are in use to prevent pressure ulcers, but from most little is known about their effects and costs. One such preventive device is the Australian Medical Sheepskin that has been proven effective in three randomized trials. In this study the costs and savings from the use of the Australian Medical Sheepskin were investigated from the perspective of a nursing home.

Methods

An economic model was developed in which monetary costs and monetary savings in respect of the sheepskin were balanced against each other. The model was applied to a fictional (Dutch) nursing home with 100 beds for rehabilitation patients and a time horizon of one year. Input variables for the model consisted of investment costs for using the sheepskin (purchase and laundry), and savings through the prevented cases of pressure ulcers. The input values for the investment costs and for the effectiveness were empirically based on a trial with newly admitted rehabilitation patients from eight nursing homes. The input values for the costs of pressure ulcer treatment were estimated by means of four different approaches.

Results

Investment costs for using the Australian Medical Sheepskin were larger than the monetary savings obtained by preventing pressure ulcers. Use of the Australian Medical Sheepskin involves an additional cost of approximately €2 per patient per day. Preventing one case of a sacral pressure ulcer by means of the Australian Medical Sheepskin involves an investment of €2,974 when the sheepskin is given to all patients. When the sheepskin is selectively used for more critical patients only, the investment to prevent one case of sacral pressure ulcers decreases to €2,479 (pressure ulcer risk patients) or €1,847 (ADL-severely impaired patients). The factors with the strongest influence on the balance are the frequency of changing the sheepskin and the costs of washing related to this. The economic model was hampered by considerable uncertainty in the estimations of the costs of pressure ulcer treatment.

Conclusions

From a nursing home perspective, the investment costs for use of the Australian Medical Sheepskin in newly admitted rehabilitation patients are larger than the monetary savings obtained by preventing pressure ulcers.

Do pressure ulcer risk assessment scales improve clinical practice?

Standardized assessment instruments are deemed important for estimating pressure ulcer risk. Today, more than 40 so-called pressure ulcer risk assessment scales are available but still there is an ongoing debate about their usefulness. From a measurement point of view pressure ulcer (PU) risk assessment scales have serious limitations. Empirical evidence supporting the validity of PU risk assessment scale scores is weak and obtained scores contain varying amounts of measurement error. The concept of pressure ulcer risk is strongly related to the general health status and severity of illness. A clinical impact due do the application of these scales could also not be demonstrated. It is questionable whether completion of standardized pressure ulcer risk scales in clinical practice is really needed.