The Cost of Healing Pressure Ulcers Across Multiple Health Care Settings: George C. Xakellis and Rita Frantz

The Cost of Healing Pressure Ulcers Across Multiple Health Care Settings

Abstract

The reported costs of treating pressure ulcers have varied widely from study to study Previous studies have focused on single health care settings and computed only the costs occurring while the patient was a resident in that facility. The purpose of this study was to assess the cost of managing pressure ulcers from their initial occurrence in long-term care through their natural history, including hospital treatment of complications. The 30 patients in this year-long study developed 45 ulcers. The mean length of treatment toran ulcer was 116 days (SD 127). The mean cost of treatment, including long-term care and hospital costs, was $2731 per ulcer (SD 12184): excluding hospital costs, the mean cost of treatment was $489 per ulcer (SD 629). The mean cost of treatment per patient was $4,647 (SD 15,102); exctuding hospital costs, the mean treatment cost was $1,284 per patient (SD 1,380). Eighty percent of the total cost of pressure ulcer treatment was generated by the 4% of patients who required hospitalization for their pressure ulcers. In the absence of complications, pressure ulcers can be treated successfully and cost-effectively in long-term care.

ADV WOUND CARE 1996;9(6):18-22

The development of clinical practice guidelines for preventing and treating pressure ulcers identified a lack of sound data on the Cost of treating pressure ulcers. ^1,2 The reported costs of treating pressure ulcers differ widely from study to study. Studies of pressure ulcer direct treatment costs in the hospital setting range from $3.55 to $80 per day. ^3,4 In long-term care, Frantz ⁵ found the mean Cost of treating a pressure ulcer to be $5.35 per day. This amount decreased to $3.74 per ulcer per day when a standardized skin care protocol was instituted. ⁶ Sebern's ⁷ study of treatment costs in the home care setting found that the mean cost of treating Stage II ulcers ranged from $15.09 to $24.26 per day, and the mean cost of treating Stage III ulcers ranged from $25.21 to $26.25 per day. These studies are limited because they defined treatment duration as the study time, rather than the time from ulcer occurrence to healing. The studies also are limited by their focus on a single health care setting despite the fact that for some patients, ulcer treatment spans several settings.

In recent years, some studies looked at the cost of ulcer treatment from occurrence to healing. ^8,9 However, these studies also focused on a single setting and did not consider the total cost of managing patients with pressure ulcers across the long-term-care and hospital settings. As a consequence, the cost of pressure ulcers across health care settings from incidence to healing remains unclear. The purpose of this study was to assess the cost of managing pressure ulcers from their development in long-term care through their natural history. This analysis included costs of treating the ulcer and ulcer complications for which the patient was hospitalized. Treatment costs were accrued until the ulcer healed or the patient died.

Methods

A secondary analysis was done of data collected for a previous retrospective study of the cost of treating ulcers in long-term pressure care.6 The study was approved by the University of Iowa Institutional Review Board.

Subjects were residents in an 830-bed long-term-care facility in the Midwest that serves primarily veterans and their families. For purposes of this study, the sample was defined as patients who developed ulcers from January 1 through December 31, 1992. All subjects were followed from the time an ulcer was identified until the ulcer healed, the patient died, or patient follow-up concluded on December 31, 1993.

In 1992, the 30 patients in this study (29 men, one woman; mean age 71.4 years [SD = 13.2]) developed 45 ulcers. Eighteen patients developed one ulcer, nine patients developed two ulcers, and three patients developed three ulcers. The ulcers fell into the following stages: Stage II, 37 ulcers (27 patients); Stage Ill, seven ulcers (five patients); and Stage IV, one ulcer (one patient). Pressure ulcers most frequently developed on the coccyx (n = 10), malleolus (n = 7), and trochanter (n = 7). Other ulcers sites were the heel (n 5), leg (n 5), sacrum or buttock (n 3), ischial tuberosities (n = 3), toe or foot (n = 2), knee (n = 1), hand (n = 1), and elbow (n = 1).

Ninety-four topical wound treatments were administered to the 45 ulcers studied (see \ 1). The predominant treatment was some type of dressing. Three patients were admitted to the hospital during the study - two for pressure ulcer complications and one for pneumonia.

Eighteen subjects were on a turning schedule: 17 were turned every 2 hours and one every 4 hours. Seventeen patients had a pressure-reducing device on their bed: 11 had a 6-inch foam mattress and six had an "all in one" mattress (foam and normal bedding material). Fourteen patients had a pressure-reducing device for their chair (10 jay cushions, three foam cushions, and one ROHO cushion).

Data regarding ulcer treatment in the long-term-care facility were taken from the original study's chart review. Data on the location, stage, number of ulcers, number of days, and types of treatment were obtained from pressure ulcer flow sheets and treatment records in the patient record. Days to endpoint were calculated for each ulcer. For patients with multiple ulcers, all ulcers that developed in the long-term-care facility were included in the analysis.

Table 1 - Wound Care Treatments (n = 94)
Category	Ulcers Treated*
Cleansing Agents
Normal saline	13
Mineral Oil	1
Proshield	1
Cara-Klenz	1

Antiseptic agents
Hydrogen peroxide	2
0.25% acetic acid	2

Topical agents
Antibiotics
Polysporin	2
Bactraban	5
Silvadene	3

Nonantibiotic
A & D Ointment	7
Mineral Oil	1
Citric Acid	1
Proderm	1

Dressings
Hydrocolloid	23
Saline-moistened gauze	24
Transparent Film	5
Adaptic	1

* A pressure ulcer may have received more than one treatment.

Cost of ulcer treatment

Costs of ulcer treatment were calculated from the provider perspective across the continuum of care. Long-term-care costs were based on actual costs of supplies and labor incurred by the institution, and included nursing care, supplies (cleansing solutions, enzymatic agents, antiseptics, dressings, cotton-tipped applicators, tape, gloves, and syringes), laboratory tests, X-ray procedures, and antibiotic treatments for systemic infections attributable to the pressure ulcer.' Estimates of the amount of supplies used for the treatments were identified in the laboratory using models of various size pressure ulcers.5'6 The cost of debridement was computed using the Medicare reimbursable charge for the procedure.

Estimates of the time required to complete pressure ulcer treatments were based on data from a workload study conducted by the facility's department of nursing. The study quantified the amount of time required to perform nursing care activities in order to more accurately estimate the number of nursing personnel needed for patient care. Among the activities evaluated were procedures related to pressure ulcer prevention and treatment (such as positioning and dressing changes). Time estimates were determined by direct observation of the activity as it was performed independently by 10 staff members whose usual responsibilities involved carrying out the task. Time estimates included the time required to prepare supplies, provide treatment, and clear away equipment. These estimates were further validated by a panel of nurse clinicians who reviewed the average time required to perform each activity.

The long-term-care costs were computed by multiplying the day to endpoint by the patient's daily cost of treatment. The total cost a hospitalization was added to the long-term-care costs for subjects who were hospitalized for treatment of the pressure ulcer or its complications. Hospital costs wer estimated using hospital charges as a proxy for the hospital's actual costs. Physician fees were unavail able and were not included.

The cost of hospitalization was not added to the pressure ulcer costs for patients admitted to the hospital for reasons other than the pressure ulcer (for example, pneumonia). In these cases, the days in the hospital were added to the patient's total length of pressure ulcer treatment, and the cost was computed using the individual's daily rate from long-term care.

A second analysis was conducted to calculate the cost per patient to treat all ulcers until closure. In this analysis, treatment costs were added for patients with multiple ulcers. Days of treatment were computed based on the number of unique days where at least one ulcer was being treated. Cost of treatment was the sum of costs of local treatment for all ulcers plus the cost of any hospitalizations.

Cost of pressure management

The cost of pressure-management interventions was computed separately and included the cost of support surfaces and nursing time for repositioning patients while they had an ulcer. Cost of support surfaces was defined as the facility's purchase price for mattresses and chair cushions. Total cost of the equipment used by a subject was attributed entirely to the subject, because in most cases, this equipment is used by a single person in this facility.

Nursing time for repositioning subjects - 3.5 minutes on average - was obtained from the workload measurement study cited above. ⁶ Cost per minute was calculated using salary and benefits for a nursing assistant, the staff member who usually performs patient repositioning. Average salary and benefits for nursing assistants in this facility were $11.15 per hour. Frequency of repositioning was documented from treatment sheets on subjects in this sample. Cost of repositioning for subjects in this study was calculated as the cost of repositioning (from the workload measurement study) multiplied by the number of repositionings performed on subjects during the course of their pressure ulcer treatment.

Table 2 - Outcomes of Pressure Ulcer Treatment
Category	Healed	Unhealed		Total
Category	Healed	Patient Died	Study Ended	Total
Stage II	31	5	1	37
Stage III	3	4	0	7
State IV	1	0	0	1
Total	35	9	1	45

Results

Treatment and clinical outcomes

Treatment outcomes by ulcer and stage are reported in Table 2. Of the Stage II ulcers, 31 ulcers on 22 patients healed, five patients died with an unhealed ulcer each, and one was unhealed at the end of the study. Of the Stage III ulcers, three ulcers on three patients healed, and two patients died with four unhealed ulcers. The Stage IV ulcer (one patient) healed. Three ulcers required debridement (one Stage II, one Stage Ill, one Stage IV). One patient with a Stage II ulcer developed osteomyelitis and required hospitalization. One patient with a Stage III ulcer required hospitalization and surgical repair of the ulcer because it failed to heal.

Cost of ulcer treatment

The 45 ulcers were treated for a total of 5,200 days at a total cost of $122,887. The mean length of treatment for an ulcer was 116 days (SD = 127), and the mean cost was $2,731 (SD = 12,184). Excluding the cost of hospital treatment, total ulcer treatment costs were $22,011, or $489 per ulcer (SD = 629). A summary is presented in Table 3.

Breaking results down by ulcer stage, the 37 Stage II ulcers were treated for 4,031 days with mean treatment time of 109 days per ulcer (SD = 122). Cost for treating Stage II ulcers was $41,407, or $1,119 per ulcer (SD = 4,234). When hospital treatment of the ulcers was excluded, the total cost of treatment for Stage II ulcers was $16,407, or $443 per ulcer (SD= 581). The eight Stage III and [V ulcers were treated for 1,169 days with a mean treatment time of 146 days per ulcer (SD = 150). Cost for treating these ulcers was $81,480, with a mean of $10,185 per ulcer (SD = 27,635). Exduding cost of hospitalization, the total cost of treating Stage III and lY ulcers was $5,604 with a mean cost of $700 per ulcer (SD = 831).

Cost of pressure management

Pressure-management measures used for the 30 patients cost $16,515, with a mean cost of $550 per person (SD = 838), as shown in Table 4. Two types of pressure management were used: support surfaces and patient repositioning. Support surfaces cost $4,511, with a mean cost of $150 per patient (SI) = 179). Patient repositioning cost $12,004 with a mean cost of $400 per patient (SD 81.8).

Table 3 - Cost Estimates of Pressure Ulcer Treatment by Ulcer (n=45)
Ulcer Stage	Length of treatment		Ulcer treatment (including hospital cost)*		Ulcer treatment (excluding hospital cost)
Ulcer Stage	Days	Mean (SD)	Cost	Mean (SD)	Cost	Mean (SD)
Stage II (n=37	4.031	109 (122)	$41,407	$1,119 (4,234)	$16,407	$443 (581)
Stage III and IV (n=8)	1,169	146 (150)	$81,480	$10,185 (27,635)	$5,604	$700 (831)
All Ulcers (n=45)	5,200	116 (127)	$122,887	$2,371 (12,184)	$22,011	$489 (629)
* Of the 30 patients in the study, two were hospitalized for complications of pressure ulcers.

Cost of treatment per patient

The 30 patients with pressure ulcers were treated for a total of 4,280 days. The mean length of treatment was 143 days (SD = 139). Total cost of treatment (total ulcer treatment and pressure management costs) was $139,402, or $4,647 per patient (SD = 15,102). Long-term-care treatment costs (ulcer treatment and pressure management costs) were $38,526, or $1,284 per patient (SD 1,380).

Discussion

The cost of treating a pressure ulcer varies widely and is very sensitive to the development of complications requiring hospital treatment. Ulcers treated in the long-term--care setting were relatively inexpensive, with a mean cost of $489 per ulcer (SD = 629). The addition of hospital expenditures increases this mean cost sixfold to $2,731 (SD = 12,184). From the patient perspective, treatment cost increased fourfold when hospital costs were included. This dramatic increase occurred because of the large cost of treating the 4% of patients who needed hospitalization. Eighty percent of the total cost of pressure ulcer treatment was generated by these 4% of patients. The economic advantage of treating pressure ulcers in long-term care probably was enhanced by this facility's reliance on relalively inexpensive treatment methods, such as using adjunctive devices on patients with lower extremity ulcers who were able to reposition themselves.

Our finding that treatment costs are highly concentrated in the occasional hospitalized patient raises two additional issues. First, can complications be prevented and their associated costs saved? The challenge is to identify patients at high risk for hospitalization and address their problems proactively. Facilities with a high hospitalization rate of patients with pressure ulcers will have dramatically higher overall costs for pressure ulcer treatment. Controlling costs requires preventing hospitalizations for complications. Unfortunately, current practice lacks well-developed tools to predict which patients will develop complications. Identifying such risk factors would allow practitioners to intervene aggressively before complications occur.

The second issue is to whom the savings accrue if the long-term-care facility succeeds in healing ulcers and preventing complications. Currently, the cost of treating pressure ulcers in long-term care is borne by the facility. However, any savings resulting from reduced hospitalizations accrue to third-party payers. The size of these potential savings justifies alternative financial arrangements that would provide incentives to long-term-care facilities to promote uncomplicated ulcer healing.

This study has a number of limitations. First, in spite of our at-tempt to follow all ulcers to healing, one ulcer persisted for over a year and was still unhealed at the study conclusion. Thus, the total cost of treatment for this ulcer w artificially defined by the duration of the study. Second, the cost for supplies was limited to direct procurement costs and did not include indirect costs. Consequen treatment costs underestimate a long-term-care facility's total expenditures. Third, the study was conducted in a single setting; therefore, the cost estimations a complication rate may not be ge eralizable to other settings. A final limitation is the use of hospital charges as a proxy for hospital costs. This approach was selected because the bulk of hospital cos are an allocation of overhead charges applied to each admissi Unfortunately, the amount of allocation varies with hospital occupancy rates. As a consequence, it is nearly impossible to compute actual costs incurred by the hospital for a given admission. Since we studied treatment cost from the provider's perspective, we needed some way to calculate the hospital's cost rather than the third-party payer's cost. Therefore, we used charges as a proxy for costs. It is understood that charges will present a somewhat inflated view of the actual treatment costs because of the cost-shifting that occurs in the hospital setting.

Conclusion

This study suggests that the majority of pressure ulcer treatment costs are generated by the small number of patients who need hospitalization for treatment of complications. In the absence of complications, pressure ulcers can be treated successfully and cost-effectively in long-term care. Further research focusing on the total cost of pressure ulcer treatment across multiple settings is needed to establish a valid model of cost over the natural history of the pressure ulcer.

References

Panel on the Prediction and Prevention of Pressure Ulcers in Adults. Pressure ulcers in adults: Prediction and prevention. Clinical Practice Guideline, No. 3. AHCPR Publication No. 92-0047. Rockville, Md.: Agency for Health Care Policy and Research. May 1992.
Bergstrom N, Bennett MA, Carlson CE, et al. Treatment of pressure ulcers. Clinical Practice Guideline, No. 15. Publication No. 95-0652. Rockville, Md: Agency for Health Care Policy and Research. December 1994.
Alterescu V. rhe financial costs of inpatient pressure ulcers to an acute care facility. Decubitus 1989;2(3): 14-23.
Colwell JC, Foreman MD, Trotter JP. A comparison of the efficacy and costeffectiveness of two methods of managing pressure ulcers. Decubitus 1993; 6(4):28-36.
Frantz RA, Gardner 5. Harvey P. Specht J. The cost of treating pressure ulcers in a long-term--care facility. Decubitus 1991;4(3):37-45.
Frantz RA, Bergquist S, Specht J. The cost of treating pressure ulcers following implementation of a research-based skin care protocol in a long-term-care facility. Adv Wound Care 1995;8(l):36-45.
Sebern MD. Pressure ulcer management in home health care: Efficacy and cost effectiveness of moisture vapor permeable dressing. Arch Phys Med Rehabil 1986;67(10):726-9.
Xakellis GC, Chrischilles EA. Hydrocolloid versus saline-gauze dressings in treating pressure ulcers: A cost-effectiveness analysis. Arch Phys Med Rehabil 1992;73:463-9.
Alm A, Hornmack PA, Fall L, Linder L, Bergstrand B, et al. Care of pressure sores: A controlled study of the use of a hydrocolloid dressing compared with wet saline gauze compresses. Acta Derm Venereol (Stockh) 149 suppl: 1-10.

George C. Xakellis, MD, is Director, Medical Development and Delivery, John Deere Health Care. Moline, III.
Rita Frantz, RN, PhD, FAAN, is Professor, University of Iowa College of Nursing, Iowa City.

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