Pressure ulcers: risk factors and the power of policy

By | May 5, 2016

qualityMedical Care has recently published two papers on the topic of pressure ulcers — costly, painful, largely preventable infections associated with poorer quality care.

In the first, from researchers at the University of Manitoba, York University, and the University of British Columbia, lead author Malcolm Doupe, PhD and colleagues focus on the risk of developing stage 1 or higher pressure ulcers among newly admitted nursing home residents. The authors found that transferring from a hospital to a nursing home, compared to transferring from the community, was associated with more than a 2-fold risk of developing a pressure ulcer. This association held when the researchers included interaction terms accounting for multimorbidity in the models.

This finding is important for several reasons. First, about half of all new nursing home admissions are transfers from acute-care hospitals in Manitoba. Second, there is currently no policy in Manitoba that requires hospitals to treat pressure ulcers before discharging patients. Given that evidence-based pressure ulcer prevention methods are well established, the high prevalence of pressure ulcers in this population (9.2% in this study) gives pause.

Those evidence-based prevention practices are the subject of the second recent article on pressure ulcers, published in the May issue of Medical Care. Headed by William V. Padula, PhD, MS, MSc of the Johns Hopkins Bloomberg School of Public Health, a team of researchers from Hopkins as well as the University of Chicago, the University of Colorado, and Dartmouth looked at the longitudinal impact of CMS nonpayment policies, and the subsequent quality improvement efforts at academic medical centers, on rates of stage 3 and higher hospital-acquired pressure ulcers, or HAPUs.

HAPU rates

Smoothed locally weighted regression of aggregate quarterly weights and scatterplot of hospital-level hospital-acquired pressure ulcers (HAPU) rates relative to all hospitalized patients according to Agency for Healthcare Research and Quality PSI-03 inclusion criteria, while noting Centers for Medicare and Medicaid Services (CMS) nonpayment policy during October 2008. Gray dots indicate quarter when CMS nonpayment policy was established in October, 2008. Source: Padula WV et al. Are Evidence-based Practices Associated With Effective Prevention of Hospital-acquired Pressure Ulcers in US Academic Medical Centers? Medical Care. 54(5):512-518, May 2016. doi: 10.1097/MLR.0000000000000516

CMS began their policy of not paying for the extra costs associated with treating hospital-acquired pressure ulcers in 2008. In October 2014, they extended this policy by adding a 1% reimbursement penalty for hospitals in the worst-performing quartile of hospital-acquired condition rates.

Rates of stage 3 and higher hospital-acquired pressure ulcers in the US were on the decline even before CMS enacted these policies: from a spike of 7% in 2004 to 4.5% as of 2012. But Padula and colleagues found that, from 2007 through 2012 in a sample of 55 US academic medical centers, stage 3 and higher hospital-acquired pressure ulcers dropped by 11.3 cases per quarter on average. Hospitals that updated their prevention protocols saw additional average rate reductions of 1.2 fewer cases per quarter. The rate was nearly 0% by the end of the study period.

The fall in the rate of hospital-acquired pressure ulcers in this sample of hospitals was almost entirely attributable to the change in reimbursement policies: the power of policy in action. The CMS policy change is an excellent example of using financial incentives to improve patient safety. More research is needed to understand whether these successes can be broadened and built upon to improve quality even further–not just in hospitals, but in every care setting.

For more about cross-setting pressure ulcer prevention quality measures, visit CMS.

Lisa Lines

Lisa Lines

Health services researcher at RTI International
Lisa M. Lines, PhD, MPH is a health services researcher at RTI International, an independent, non-profit research institute. She is also an Instructor in Quantitative Health Sciences at the University of Massachusetts Medical School. Her research focuses on quality of care, care experiences, and health outcomes among people with chronic illnesses; emergency department utilization; and person-centered care and patient-centered medical homes, among other topics. She is co-editor of TheMedicalCareBlog.com and serves on the Medical Care Editorial Board. She also serves as chair of the APHA Medical Care Section's Health Equity Committee. In 2015, Dr. Lines was appointed to a 3-year term on the National Quality Forum's Neurology Standing Committee. Views expressed are the author's and do not necessarily reflect those of RTI or UMass Medical School.
Lisa Lines
Lisa Lines

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About Lisa Lines

Lisa M. Lines, PhD, MPH is a health services researcher at RTI International, an independent, non-profit research institute. She is also an Instructor in Quantitative Health Sciences at the University of Massachusetts Medical School. Her research focuses on quality of care, care experiences, and health outcomes among people with chronic illnesses; emergency department utilization; and person-centered care and patient-centered medical homes, among other topics. She is co-editor of TheMedicalCareBlog.com and serves on the Medical Care Editorial Board. She also serves as chair of the APHA Medical Care Section's Health Equity Committee. In 2015, Dr. Lines was appointed to a 3-year term on the National Quality Forum's Neurology Standing Committee. Views expressed are the author's and do not necessarily reflect those of RTI or UMass Medical School.