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Do Healthcare Systems Promote the Prevention of Pressure Ulcers?
8 Introduction Pressure ulcers, commonly known as bedsores or decubitus ulcers, are areas of localised injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure or pressure in combination with shear
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Do Healthcare Systems
Promote the Prevention
of Pressure Ulcers? 2 Do Healthcare Systems Promote the Prevention of Pressure Ulcers? 3Acronyms
4List of Figures & Tables
sForeword
6Executive Summary
7Introduction
8Study Aims and Methodology
9Pressure Ulcers: A Chronic Clinical Challenge
10The Ageing Patient Community 10
Pressure Ulcers: A Burden for the Clinical Community 10Why Pressure Ulcers Occur
11 Discussion of Root Causes within the Healthcare Sector 11Promixate Events: Patient Factors 13
Clinical Care Factors 13
Provider Factors
14External Factors
14 Hospital Financing of Pressure Ulcer Interventions is Not What it Seems to Be 15Faulty Assumptions 16
Approach and Outcomes by Country 17
France
18Germany
18United Kingdom 19
United States
20 The Importance of Quality Measures and Incentives to Reduce Pressure Ulcer Prevalence 21Belgium
22France
22Germany
23United Kingdom
24Overcoming Barriers to Prevention
26A Caution 26
Making Current Pressure Ulcer Management More Effective 26Importance of Awareness 26
Early Detection as a First Step to Prevention 26
Standardised and Objective Detection 28
Conclusion: Towards safer health systems
29Acknowledgements and Disclosures
30Contents
4Acronyms
AHRQAgency for Healthcare Research and Quality (US)
ANAES Agence nationale d'accréditation et d'évaluation en santé (National Evaluation and Accreditation Agency (France))AQUA-Institute
(Applied Quality Improvement and Research Institute (Germany)) BM IBody Mass Index
BQS-Institute
CCGClinical Commissioning Groups (UK)
CMSCentre for Medicare and Medicaid"s (US)
COMPAQ
Coordination pour la Mesure de la Performance l"Amélioration de la Qualité (Coordination for Measuring Performance and Assuring Quality in Hospitals (France)) CQUINCommissioning for Quality and Innovation
DRGDiagnosis-Related Group
EPUAPEuropean Pressure Ulcer Advisory Panel
G-BA Gemeinsamer Bundesausschuss (German Federal Joint Committee (Germany)) GHM Groupe homogène de malades (DRG-equivalent) (France) HAS Haute Autorité de Santéfi(French National Health Authority (France)) HAPUHospital-Acquired Pressure Ulcers
HESHospital Episode Statistics
HRGHealthcare Resource Group (UK)
HSCICHealth and Social Care Information Centre (UK)
ICDInternational Classication of Diseases
LTCLong-Term Care
MDKMedizinischer Dienst der Krankenversicherung
(Medical Service of the Health Funds (Germany)) NHSNational Health Service (UK)
NICE National Institute for Health and Care Excellence (UK) NPUAPNational Pressure Ulcer Advisory Panel
PMSI Programme de médicalisation des systèmes d'informationfi (French DRG-Based Information System (France)) SGB V Sozialgesetzbuch Fünftes Buch (German Social Code, Book Five (Germany)) SEMSub-epidermal Moisture
WUWHSWorld Union of Wound Healing Societies
Do Healthcare Systems Promote the Prevention of Pressure Ulcers? 5List of Figures & Tables
Figure 1
Hierarchy of Causality for Pressure Ulcers in Complex Systems ..........................................................13
Figure 2
Pressure Ulcer Reimbursement approaches in Belgium, France, Germany and the UK for TypicalLength of Stay (LOS) for Pressure Ulcer Specic DRGs (LOS in Days) ..................................................16
Figure 3
Model for the Deduction of Additional Reimbursement due to Pressure Ulcers as Comorbidity ........18Figure 4
Share of Patients in France, Germany and the UK with an Increase in DRG Severity and Payment .....20Figure 5
Timeline on the Implementation of Quality Incentives ......................................................................22
Table 1
Government Programs that Penalize Providers for Pressure Ulcers and/ or Incentivizethe Prevention of Pressure Ulcers ........................................................................
.............................15 Box 1Clinical Advantages of a New Technology ........................................................................
................29 6Foreword
Few disease states ever present themselves to an attainable and near-term solution as pressure ulcers.
Pressure ulcers incidence can and should be reduced.Realizing a goal of preventing preventable pressure ulcers benets the millions of people worldwide who are affected
and to the tens of thousands who die from complications from pressure ulcers on an annual basis. Economic savings
through prevention, mostly accruing to public payers, extend to many tens of billions of Euro and Dollars annually.
These results are worthy and have been the lifelong work of legions of caregivers and academics globally.
This whitepaper is a call to action - a challenge - that extends well beyond the clinical community to provider
managers, quality and risk practitioners to healthcare policy makers. No matter how diligent and committed
caregivers are to the highest quality of care, unless systemic conditions that reward treatment and penalize
prevention are reversed, pressure ulcers will stubbornly persist.The temptation of provider managers and policy makers is to make a policy tweak here and another there: hire
quality nurses, add new reporting metrics, launch awareness campaigns or provide additional training.
These initiatives risk adding burden rather than addressing the systemic root causes of pressure ulcers. Do more"
alienates caregivers, adds stress to lean care organizations, and typically fail to inculcate long-term changes.
The return on investment is low.
A singular goal - preventing preventable pressure ulcers - when addressed systemically and collectively holds the
promise of compelling and sustaining pressure ulcer incidence near zero. Incentivizing prevention and creating
conditions intolerant of pressure ulcer incidence applied to the whole healthcare hierarchy, is the right strategy.
This whitepaper challenges caregivers to seek out and adopt new technologies capable of detecting tiss
ue damageearlier than visual inspection and risk scales can. We challenge provider managers to create institutional transparency
of the true costs of pressure ulcers and raise awareness within their organizations of the benets of a reduction in
incidence. Managers are able to drive localized policies and incentives to support front-line caregivers in this task. We
encourage policy makers to craft system-wide policies to drive consistency of detection protocols and to accelerate
policy moves towards rewarding prevention and penalizing incidence and subsequent treatment costs.With newly available technology and collective, systemic action, this is a disease state whose persistent incidence is
tantalizingly close to becoming a never event".Reynold W. (Pete) Mooney
Global Managing Director, Life Sciences and Health Care Deloitte Touche Tohmatsu Do Healthcare Systems Promote the Prevention of Pressure Ulcers? 7Executive Summary
Pressure ulcers represent a serious health problem to patients in acute as well as long-term health care.
According to the Joint Commission in the United States, "more than 2.5 million patients in United States (US)
acute care facilities suffer from pressure ulcers, and 60,000 die from pressure ulcer complications each year."
Pressure ulcers place a profound economic burden on healthcare sectors across Europe with estimates of between £1.4 and £2.1 billion for the United Kingdom (UK) and Germany in the magnitude of 1
.0 to 2.3 billion. For many this expenditure is considered avoidable and wasteful.In Belgium, France, Germany and the UK, 12.1%, 8.9%, 11.0% and 10.2% respectively of inpatients in hospital settings suffer from pressure ulcers. Care-setting specic studies have shown higher prevalence rates for both
hospital and long-term care settings across European countries.Pressure ulcer aetiology has been extensively studied. The causes of pressure ulcer prevalence beyond their aetiology are only recently being assessed and acted upon. Sadly the majority of cases are considered to be avoidable. Our research revealed systemic conditions, which create the conditions for the problem of pressure
ulcers to persist.Clinical practice has historically concentrated on pressure ulcer risk assessment and treatment. Health economic
policies have also historically tended towards treatment. Indeed in only one care setting studied there were
specic reimbursements for the costs of preventative care and only then in very modest amounts.Although the burden is high, the issue has until recently received unassertive attention from economists, politicians and clinicians. Selected countries in Europe and also the United States (US) have adopted policies
modestly focused on preventing pressure ulcers such as the UK"s Safety Thermometer. Thorough and detailed
prevention policies lack in most other countries.Current clinical assessment of pressure ulcers detection still relies on risk assessment scales and visual inspection of skin areas where pressure ulcers are most likely to occur: these methods are decades old, not evidence-based nor
standardised within or across countries.Contrary to common knowledge, costs for pressure ulcer treatment are not nanced as much as is assumed by healthcare providers. For example, in Germany an increase in Diagnosis-Related Group (DRG) payments occurs for
only 7.18% of patients incurring pressure ulcers (after some dened exclusions), while in the entire UK National
Health Service (NHS) it is 25.30%. Surprisingly, the awareness of the nancial impact of pressure ulcers on
hospital nancing appears to be low among stakeholders: providers are incurring more treatment costs and being
reimbursed less than they realize.To prevent most pressure ulcers - one of the most readily achievable hospital efciency targets according to many
clinicians - new strategies are needed to accelerate pressure ulcer detection and prevention. The opportunity for
new prevention strategies extend to national and European-wide health system managers and policy makers.
This situation requires a systemic response from policy makers and hospital managers alike. Pressure ulcer
management strategies need to become more effective and should be backed by focused healthcare policy
initiatives allowing for more research and the adoption of innovative methods to diagnose, prevent and manage
pressure ulcers. Additionally, innovative clinical practices to enable early detection would provide the most
favourable results both from a clinical and economic point of view.In 2012, the Applied Quality Improvement and Research (AQUA) Institute in Germany reported an overall national prevalence of 4.7%
which is far below the prevalence indicated by Lahmann et al. (2012). The overall prevalence of 4.7% consists of an incidence rate of 0.9%
and a prevalence rate of 3.8% including patients that were admitted to the hospital with pressure ulcers. (AQUA, (2012), DEK - Pfiege:
8Introduction
Pressure ulcers, commonly known as bedsores or decubitus ulcers, are areas of localised injury to the skin and/or
underlying tissue usually over a bony prominence, as a result of pressure or pressure in combination with shear.
The tissue injury is caused by the inability of the skin and the supporti ng structures to redistribute external pressurecausing alterations to the pressure gradient within the local vascular network. Approximately 70% of all pressure
ulcers occur over the sacral area, heels and buttocks 3 . Six stages 4,5 , have been identied, each characterizing wounds of differing severity of types of tissue damage 6 . In Europe however, only stages I to IV are considered 7Pressure ulcers present a serious problem to society, causing pain and mortality in patients and leading to increased
healthcare costs 8 . Across countries, prevalence rates of pressure ulcers are high within both hospital and long-term care settings 9, where patients and residents are often bedridden and restricted in their mobility and health status
10Although, the aetiology of pressure ulcers is increasingly understood, prevalence rates remain high. Commonly cited
peculiarities accounting for the high prevalence rates to occur are: No reliable and consistent measures to detect the earliest signs of pressure ulcers 11 Particular difculties in detecting stage I pressure ulcers in patients with dark skin tones 6Lean care organizations which are challenged by tight nursing care schedules and limited resources that have an
impact on stafng levels 12 Prevention strategies, which are not based on objective evidenceA level of scepticism of much of the existing evidence about prevention leading to inconsistent adoption. Existing evidence has to rely on subjective expert opinion and panel consensus given the limited a
vailability of technologies that might be capable of generating repeatable, veriable evidenceAccording to the World Union of Wound Healing Societies (WUWHS) and clinical experts, having appropriate
national policies and well-targeted local management standards in place could avert the preponderance of pressure
ulcer cases 13 . New technologies could optimise the diagnosis and management of pressure ulcers and reduce theseverity of the wounds, thereby minimising the associated nancial burden through reduced recovery times and
shorter lengths of inpatient stays.By providing a systematic, comparative assessment of the different national policies and incentives designed to curb
the increase in pressure ulcers and to reduce their impact on healthcare systems and providers, this report seeks to
raise the pressure ulcer debate beyond a narrowly focused discussion of aetiology to a strategic and management
level. 2 Gebhardt, K.S. (2002) Part 1. Cause of pressure ulcers. Nursing Times, 98 (11): 41 3Bates-Jensen, B.M. Pressure Ulcers: Pathophysiology, Detection, and Prevention." In Sussman, C. & Bates-Jensen, B.M. (Eds) Wound Care: A Collaborative Practice Manual for Health
Care Practitioners. Fourth Edition. Baltimore, Maryland: Lippincott Williams & Wilkins. 2012. 4In the EU, the term Grade" is most commonly used in place of Stage", a predominantly US-based term
5According to the National Pressure Ulcer Advisory Panel (NPUAP) (n.a.), the six stages are categorised as follows: (1) Stage I: non-blanchable erythema, (2) Stage II: Partial thickness; (3)
Stage III: Full thickness skin loss; (4) Stage IV: Full thickness tissue loss; (5) Unstageable/ unclassied: full thickness skin or tissue loss - depth unknown; (6) Suspected deep tissu
e injury- depth unknown 6NPUAP (n.a.). NPUAP Pressure Ulcer Stages/ Categories. [online] Retrieved February 2014, from: http://www.npuap.org/resources/educational-and-clinical-resources/
npuap-pressure-ulcer-stagescategories/ 7NPUAP (2009). International Guideline. Prevention of pressure ulcers: quick reference guide. [online] Retrieved February 2014, from: http://www.npuap.org/wp-content/uploads/2012/02/
Final_Quick_Prevention_for_web_2010.pdf
8Agency for Healthcare Research and Quality [AHRQ] (2011). 1. Are We Ready for This Change? Preventing Pressure Ulcers in Hospitals: A toolkit for Improving Quality of Care. Rockville,
MD: AHRQ (US) [online] Retrieved February 2014, from: http://www.ahrq.gov/professionals/systems/long-term-care/resources/pressure-ulcers/pressureulcertoolkit/putool1.html
9Vangilder, C, Amlung, S, Harrison, O. & Meyer, S. (2009). Results of nine international pressure ulcer prevalence surveys: 1989 to 2005. Ostomy Wound Management, 55(11): 39 -54
10Kuwahara, M, Tada, H., Mashiba, K., Yurugi, S., Iioka, H, Niitsuma, K, & Yasuda, Y. (2005). Mortality and recurrence rate after pressure ulcer operation for elderly long-term bedridden
patients. Annals of Plastic Surgery, 54(6): 629-32 11Gehin, C, Brusseau, E, Meffre, R, Schmitt, PM, Deprez, JF & Dittmar A. (2006). Which techniques to improve the early detection and prevention of pressure ulcers? Conference
Proceedings of the IEEE Engineering in Medicine and Biology Society, 1: 6057-60 12Hughes, R. G. (2008). Patient Safety and Quality: An Evidence-Based Handbook for Nurses. Rockville, MD: AHRQ (US)
13WUWHS (2008). Principles of best practice: Diagnostics and wounds. A consensus document. London: MEP Ltd
Do Healthcare Systems Promote the Prevention of Pressure Ulcers? 9Study Aims and Methodology
The aims of the study were to:
Identify the challenges that pressure ulcers pose to the clinical and political communities and the factors inuencing their prevalence Comparatively analyse the current status and shifting dynamics of pressure ulcer policies Assess the role of existing and potential nancial incentives and quality initiatives in improving outcomes of care Detail potential early detection technologies targeted at making pressure ulcer prevention possible The analysis focused on the hospital sector in four European countries: Belgium, France, Germany and the UK. Additional details of the US and other countries" systems are provided for analytical benet, but were not studied as extensively as the countries in focus.Extensive desk research was conducted to gain an
in-depth understanding of the implications of policy and care quality measures on the prevalence of pressure ulcers and the nancing of how pressure ulcers are managed in this area, covering both the hospital and long-term care (LTC) sectors in the four selected countries. Insights from a wide range of stakeholders - including leading academics, clinical staff, nursing care directors and payers - were collected through phone interviews of 30 to 60 minutes and face-to-face interviews of 120 and 150 minutes. On the basis of initial interviewees" suggestions, additional stakeholders were identied and their participation included. Response rates in the hospital sector were high in Belgium, Germany and the UK, while lower in France and in the LTC sector in general. In total, 42 EU wideexpert interviews were carried out.Interviews covered four main topics: Current care processes and organisation for patients
with pressure ulcers Reimbursement of prevention and treatment costs relating to pressure ulcers