The costs arising from pressure ulcers attributable to malnutrition

doi:10.1016/j.clnu.2009.08.006

Clinical Nutrition

Volume 29, Issue 2, April 2010, Pages 180-186

https://doi.org/10.1016/j.clnu.2009.08.006 Get rights and content

Summary

Background & aims

To estimate the economic consequences of pressure ulcer attributable to malnutrition.

Methods

Statistical models were developed to predict the number of cases of pressure ulcer, associated bed days lost and the dollar value of these losses in public hospitals in 2002/2003 in Queensland, Australia. The following input parameters were specified and appropriate probability distributions fitted.

•
Number of at risk discharges per annum.
•
Incidence rate for pressure ulcer.
•
Attributable fraction of malnutrition in the development of pressure ulcer.
•
Independent effect of pressure ulcer on length of hospital stay.
•
Opportunity cost of hospital bed day.

One thousand random re-samples were made and the results expressed as (output) probabilistic distributions.

Results

The model predicts a mean 16,060 (SD 5671) bed days lost and corresponding mean economic cost of AU$12,968,668 (SD AU$4,924,148) (EUROS 6,925,268; SD 2,629,495) of pressure ulcer attributable to malnutrition in 2002/2003 in public hospitals in Queensland, Australia.

Conclusion

The cost of pressure ulcer attributable to malnutrition in bed days and dollar terms are substantial. The model only considers costs of increased length of stay associated with pressure ulcer and not other factors associated with care.

Introduction

Pressure ulcers are a major burden on healthcare systems. In the USA, the Joint Commission for Accreditation of Healthcare Organizations (JCAHO) estimates that there are between 1.3 and 3 million adults with pressure ulcer in the USA and that the costs of treatment of pressure ulcer are in the order of US$500 to US$40,000 per ulcer depending on the severity of the stage of the ulcer.¹ The annual cost of treating pressure ulcer in the UK was estimated to be approximately £750 million (1998 prices) with the total cost of treatment for a patient with a full thickness ulcer estimated at £30,000.²

An important part of the cost is the prolonged length of stay in hospital; saved bed days have a positive economic value if there are waiting lists for hospital services.² In an Australian study, the opportunity cost of prolonged length of hospital stay due to pressure ulcers was predicted. It was estimated that in 2001–2002 there was a median of 95,695 cases of pressure ulcer, with a median of 398,432 bed days lost, and associated opportunity costs of a median AU$285 million in Australian public hospitals.³

Malnutrition has been shown to be associated with an increased risk of developing pressure ulcers in a number of studies.4, 5, 6, 7, 8, 9 Indeed, a study undertaken by these authors has determined the effect of malnutrition on the presence of pressure ulcer in Queensland public hospitals. The odds risk of having a pressure ulcer when malnourished, when controlling for demographic variables including age, medical specialty and type of facility, was 2.6 (95% CI 1.8–3.5, p < 0.001).¹⁰ No studies have been published that have examined the economic consequences of malnutrition in the development of pressure ulcer. Some studies have examined the impact of poor nutritional status on clinical outcome and extended length of hospital stays on the subsequent economic costs and found in all cases that malnutrition is associated with increased economic costs.11, 12, 13, 14, 15, 16

The purpose of this study was to estimate the economic consequences of pressure ulcer attributable to malnutrition.

Section snippets

Methods

An economic model was developed to predict the cost of pressure ulcer attributable to malnutrition in Queensland (Australia) public hospitals in 2002/2003. The model consisted of the following input parameters.

A.
The number of relevant discharges from public hospitals in Queensland in 2002/2003.
B.
The incidence rate for pressure ulcer.
C.
The attributable fraction of malnutrition in the development of pressure ulcers.
D.
The independent effect of pressure ulcer on excess length of hospital stay.
E.
The cost of a

Results

Summary statistics for model outputs are shown in Table 3 and histograms of the outputs are shown in Fig. 2, Fig. 3, Fig. 4. This model predicts a mean of 3666 (SD 555) cases of pressure ulcer attributable to malnutrition in Queensland public acute hospitals in 2002/2003 (Fig. 2). There were approximately 2.4 million patient bed days in Queensland public hospitals in 2002/2003.²⁴ The mean number of bed days lost to pressure ulcer that were attributable to malnutrition was predicted to be

Discussion

The modeling undertaken for this study predicts that the costs of malnutrition on the Queensland public health system, measured in bed days are substantial at approximately $AU13 million (EUROS 7 million). This mean dollar value does not represent actual cash savings, but rather the opportunity cost of patient bed days not available for use by other patients. Bed days were chosen in this study to determine economic costs, due to a current lack of beds available for patients requiring hospital

Conclusion

This study estimated approximately one-third of pressure ulcers attributable to malnutrition in Queensland public hospitals in 2002/2003. This represents a substantial number (approximate mean of 16,000) of patient bed days lost to pressure ulcer attributable to malnutrition, corresponding to a mean economic cost of approximately AU$13 million (EUROS 7 million) for 2002/2003 in Queensland public hospitals. The cost effectiveness of nutrition intervention in the prevention of pressure ulcer

Acknowledgements

Funding source: funding support for this work was provided by the Royal Brisbane and Women's Hospital Research Foundation. This funding allowed M. Banks time off from her usual full time duties to undertake this work.

Authorship contributions: Merrilyn D. Banks (MB), Nicholas Graves (NG), Judith D. Bauer (JB), Susan Ash (SA).

Conception and design of the study: MB and NG.

Analysis and interpretation of data: MB and NG.

Drafting of manuscript: MB.

Revision of manuscript: MB, NG, SA, and JB.

Provision

References (37)

A. Ek et al.
The development and healing of pressure sores related to the nutritional state
Clin Nutr
(1991)
M. Elia
Nutrition and health economics
Nutrition
(2006)
C.S. Chima et al.
Relationship of nutritional status to length of stay, hospital costs, and discharge status of patients hospitalized in the medicine service
J Am Diet Assoc
(1997)
C. Braunschweig et al.
Impact of declines in nutritional status on outcomes in adult patients hospitalized for more than 7 days
J Am Diet Assoc
(2000)
D.R. Thomas
Prevention and treatment of pressure ulcers
J Am Med Dir Assoc
(2006)
R. Stratton et al.
Enteral nutritional support in prevention and treatment of pressure ulcers: a systematic review and meta-analysis
Ageing Res Rev
(2005)
S.P. Allison
Malnutrition, disease, and outcome
Nutrition
(2000)
M.I.T.D. Correia et al.
Prevalence of hospital malnutrition in Latin America: the multicenter ELAN Study
Nutrition
(2003)
J. Kondrup et al.
Incidence of nutritional risk and causes of inadequate nutritional care in hospitals
Clin Nutr
(2002)
JCAHO
National patient safety goals
(2007)

R. Stratton et al.

Disease-related malnutrition: an evidence-based approach to treatment

(2003)

N. Graves et al.

Modeling the economic losses from pressure ulcers among hospitalized patients in Australia

Wound Repair Regen

(2005)

R.M. Allman et al.

Pressure ulcer risk factors among hospitalized patients with activity limitation

J Am Med Assoc

(1995)

A.R. Fisher et al.

Factors associated with pressure ulcers in adults in acute care hospitals

Adv Skin Wound Care

(2004)

S.D. Horn et al.

The national pressure ulcer long-term care study: pressure ulcer development in long-term care residents

J Am Geriatr Soc

(2004)

J. Maklebust et al.

Risk factors associated with having a pressure ulcer: a secondary data analysis

Adv Wound Care

(1994)

D.R. Thomas

Hospital acquired pressure ulcers and risk of death

J Am Geriatr Soc

(1996)

Banks MD. Economic analysis of malnutrition and pressure ulcers in Queensland public hospitals and residential aged...

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Study designs included cohort (prospective and retrospective), case-control, and RCTs if the association between nutrition status and pressure injuries was reported. Databases searched included: PubMed, CINAHL, Embase, Scopus, Web of Science, and Cochrane Library on April 20th, 2022. The data were analyzed using OR and random effect model in Revman5.3 and STATA 15 Software. Report this systematic review and meta-analysis according to the PRISMA 2020 statement.
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This systematic review and meta-analysis showed that nutritional status is significantly associated with pressure injuries. Malnutrition can increase the incidence of pressure injuries, and specific nutritional interventions can reduce the incidence of pressure injuries compared to standard nutrition.
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Pressure injuries (PI) are a significant clinical problem across all healthcare facilities, associated with poor patient outcomes, increased length of stay and healthcare costs. Whilst it is known that underweight (Body Mass Index (BMI) < 18.5 kg/m²) and malnourished individuals have an increased risk of developing PI, few studies have investigated the effects of obesity (BMI ≥ 30 kg/m²) and morbid obesity (BMI ≥ 40 kg/m²) on PI prevalence. This study aimed to determine whether PI prevalence was associated with levels of obesity; the complex association between morbid obesity, malnutrition and PI prevalence in hospital inpatients was also explored.
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Overall PI prevalence was 6.9% and was significantly higher in the underweight and morbidly obese groups (underweight 12.7%, healthy weight 7.8%, overweight 5.7%, obese 4.8%, morbidly obese 12%; p = 0.001). In addition to BMI, malnutrition and age were significantly associated with PI prevalence. After adjusting for confounders, morbidly obese inpatients had over three times the odds of developing a PI compared to healthy weight inpatients (OR = 3.478, 95% CI 1.657–7.303; p = 0.001). Morbidly obese inpatients who were also malnourished had eleven-fold greater odds of developing a PI compared to the morbidly obese well-nourished in logistic regression analysis (OR = 11.143, 95% CI 2.279–54.481, p = 0.003).
Morbid obesity is a significant and independent risk factor for PI development. However, the clustering of nutritional risk factors (morbid obesity and malnutrition) substantially increases this risk. Therefore, routine and formal assessment of both BMI and malnutrition status are important to enable the identification of patients at high risk of PI.
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The Oligo Element Sore Trial has shown that supplementation with a disease-specific nutritional formula enriched with arginine, zinc, and antioxidants improves pressure ulcer (PU) healing in malnourished patients compared to an isocaloric–isonitrogenous support. However, the use of such a nutritional formula needs to be supported also by a cost-effectiveness evaluation.
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Although the experimental formula was more expensive (mean difference: 39.4 Euros; P < 0.001), its use resulted in money saving with respect to both non-nutritional PU care activities (difference, −113.7 Euros; P = 0.001) and costs of local PU care (difference, −74.3 Euros; P = 0.013). Therefore, given its efficacy it proved to be a cost-effective intervention. The robustness of these results was confirmed by the sensitivity analyses.
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No intervention studies were identified which examined the role of parental nutrition for the prevention or treatment of malnutrition in the RAC setting. It can be argued that all older adults admitted to RAC facilities are at risk of malnutrition in the long term, and there may be a cost-benefit to the RAC facilities to provide a liberalised, prophylactic, high energy-high protein diet as the standard menu, as this may prevent the significant costs associated with malnutrition and/or frailty [107,128,129]. Although little research has been done into the cost-effectiveness of nutritional interventions in RAC, a Dutch study showed that the cost of managing a resident at risk of malnutrition was an additional €8200 (USD$8800), and an additional €10,500 (USD$11,300) for a malnourished resident per year [130].
In developed countries the prevalence of protein-energy malnutrition increases with age and multi-morbidities increase nutritional risk in aged care residents in particular. This paper presents a narrative review of the current literature on the identification, prevalence, associated risk factors, consequences, and management of malnutrition in the residential aged care (RAC) setting. We performed searches of English-language publications on Medline, PubMed, Ovid and the Cochrane Library from January 1, 1990 to November 25, 2015. We found that, on average, half of all residents in aged care are malnourished as a result of factors affecting appetite, dietary intake and nutrient absorption. Malnutrition is associated with a multitude of adverse outcomes, including increased risk of infections, falls, pressure ulcers and hospital admissions, all of which can lead to increased health care costs and poorer quality of life. A number of food and nutrition strategies have demonstrated positive nutritional and clinical outcomes in the RAC setting. These strategies extend beyond simply enhancing the nutritional value of foods and hence necessitate the involvement of a range of committed stakeholders. Implementing a nutritional protocol in RAC facilities that comprises routine nutrition screening, assessment, appropriate nutrition intervention, including attention to food service systems, and monitoring by a multidisciplinary team can help prevent decline in residents’ nutritional status. Food and nutritional issues should be identified early and managed on admission and regularly in the RAC setting.
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La dénutrition favorise le développement de pathologies nosocomiales comme les escarres (ESC) et les infections nosocomiales (IN), mais les paramètres nutritionnels les plus fortement prédictifs de ces pathologies sont encore à préciser.
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^☆: Conference presentation: the abstract of this work was presented as a poster at the 2007 ESPEN Congress in Prague and was awarded an outstanding abstract.

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Original ArticleThe costs arising from pressure ulcers attributable to malnutrition☆

Summary

Background & aims

Methods

Results

Conclusion

Introduction

Section snippets

Methods

Results

Discussion

Conclusion

Acknowledgements

Clin Nutr

Nutrition

J Am Diet Assoc

J Am Diet Assoc

J Am Med Dir Assoc

Ageing Res Rev

Nutrition

Nutrition

Clin Nutr

National patient safety goals

Disease-related malnutrition: an evidence-based approach to treatment

Modeling the economic losses from pressure ulcers among hospitalized patients in Australia

Wound Repair Regen

Pressure ulcer risk factors among hospitalized patients with activity limitation

J Am Med Assoc

Factors associated with pressure ulcers in adults in acute care hospitals

Adv Skin Wound Care

The national pressure ulcer long-term care study: pressure ulcer development in long-term care residents

J Am Geriatr Soc

Risk factors associated with having a pressure ulcer: a secondary data analysis

Adv Wound Care

Hospital acquired pressure ulcers and risk of death

J Am Geriatr Soc

Original Article
The costs arising from pressure ulcers attributable to malnutrition☆