An estimate of the potential budget impact of using prophylactic dressings to prevent hospital-acquired PUs in Australia

An estimate of the potential budget impact of using prophylactic dressings to prevent hospital-acquired PUs in Australia l Objective: To estimate the potential cost saving to the Australian health-care system of introducing the use of prophylactic dressings to prevent hospital-acquired pressure ulcers (PUs) for patients with a high-risk developing a PU. l Method: We estimated the costs of pressure ulceration based on conservative estimates of an incidence rate of 13% within 10% of the total admitted Australian patient population. Results from a recent large randomised control trial of prophylactic dressing used to prevent PUs in high-risk patients were then extrapolated to this population to derive a potential national cost/benefit calculation. l Results: Our estimate revealed that within the high-risk population of acute hospitals, more than 71,000 patients could be expected to develop a PU annually costing AU$77,800,000 ( 43,000,000). Whereas by implementing a national PU prevention initiative based on the use of prophylactic multilayer silicone foam dressings for high-risk patients, an annual saving of AU$34,800,000 ( 19,700,000) could be achieved, which represents a cost benefit of 55% to the Australian health-care system. l Conclusion: Our estimate of the potential cost benefit of implementing the use of prophylactic dressings to prevent hospital acquired PUs in high-risk patients uses conservative estimates of both the incidence rates of ulceration and of treatment costs. However, this is also based on one of the largest reported randomised control trials of this technique to prevent PUs. We believe that our modelling is robust yet requires replication in other countries with different health-care systems and costing structures. l Declaration of interest: There was no sponsorship of this study. The authors have no conflict of interest to declare. pressure ulcers; prevention; cost benefit; economic estimation; prophylactic dressing The prevention of hospital-acquired pressure ulcers (PUs) presents clinicians with an ongoing challenge. Despite significant advances in the prevention of pressure ulceration through the use of risk screening tools, advanced pressure redistribution surfaces (both static and dynamic) and the wide adoption of international PU prevention clinical guidelines, there remain groups of patients that continue to develop PUs whilst in acute care. 1 4 The development of a hospital-acquired PU exposes the patient to the risk of additional morbidity in highly vulnerable individuals such as the critically ill patient. Additionally, the patient will experience discomfort and pain and possibly be exposed to additional diagnostic tests and treatment that could have been avoided if the pressure injury was prevented. Apart from the physiological and personal impact of these avoidable wounds on the patient, there are significant additional costs to the health-care system. In Australia these costs have been estimated to exceed US$1.6 billion annually in the acute hospital sector. 5 While this figure is large for a country of 23 million people, it is consistent with cost estimates for comparable developed countries. 1 Recently, there has been an increased interest in the potential for the use of soft silicone multilayer dressings as a means of preventing PUs in high-risk patient populations. 6 Research in the area of PU prevention using wound dressing products has been sporadic over the past two decades, however, the development of more sophisticated composite dressings constructed of multiple layers of materials such as soft silicone foam have resulted in a renewed interest in the use of dressings as potential methods of reducing the incidence of PUs. The protective mechanisms underlying the effectiveness of these dressings appears to relate to the ability of the dressing to redistribute pressure, minimise shear force and to better manage microclimate. 7,8 Reports of the effectiveness of the use of multilayer silicone foam dressings in critically ill patients commenced with work by Brindle et al. 9,10 where N. Santamaria, 1 RN, PhD, Professor of Nursing Research; H. Santamaria, 2 BCom, Analyst; 1 Translational Research, University of Melbourne & Royal Melbourne Hospital, Level 6, Royal Melbourne Hospital, Parkville, Victoria 3050, Australia 2, TCI Capital Advisors,Collins Street, Melbourne 3000, Australia. Email: nick.santamaria@ mh.org.au 5 8 3

Table 1. Border trial pressure ulcer development by group Cases Intervention (n=161) Control (n=152) Patients who developed 5 20 0.001 pressure ulcer(s) Incidence rate (%) 3.1 13.1 Anatomical site Heel PU 5 19 0.002 Sacral PU 2 8 0.05 Total PU 7 27 0.002 Note: Each patient could develop a total of 3 pressure ulcers (1 sacrum and 2 heel) p cost benefit analysis of this study 12 revealed that there was a large cost benefit in favour of using these dressings to prevent pressure ulceration in these high-risk critically ill patients. This paper presents an estimate of the potential cost benefits to the Australian health-care system that could result from the use of this class of prophylactic dressings in high-risk patients in the acute care setting, based on an extrapolation of the costing methodology described by Santamaria et al. 12 to the annual acute patient population in Australian hospitals in 2013. 13 It should be noted that our calculations are based only on the cost benefit of the use of these dressings because these are the only dressings that have been used in large well-designed RTC, to date. they demonstrated a significant decrease in the incidence of sacral PUs using the Border Sacrum dressing (Mölnlycke Healthcare AB, Gothenburg, Sweden) applied prophylactically to a cohort of high-risk cardiac surgery patients. More recently Santamaria et al. 11 reported a large randomised controlled trial (RCT) of critically ill intensive care unit (ICU) patients (subsequently referred to as the Border Trial), where intervention group patients had the same dressings applied to the sacrum and the Mepilex Heel dressings to each heel and retained with Tubifast bandages on admission to the emergency department and maintained throughout the patients stay in ICU. Findings indicated significantly reduced incidence of both sacral and heel PUs compared to control group patients. A subsequent Table 2. The dressing costs associated with the Border Trial intervention group Intervention group (n=219) Frequencies of sacral dressing application/change 274 Unit price of Border Sacrum dressing $11.0 1 Sub-total: Cost of sacral dressings $3014 Frequencies of heel dressing application/change 465 Unit price of Heel dressing $9.0 Sub-total: Cost of heel dressings $4185 Tubular bandage (rolls) 10.0 Unit price of tubular bandage $9.9 2 Sub-total: Tubifast $99.0 Total dressing costs $7298 3 Average dressing costs $33.32 4 1. Unit price obtained from Mölnlycke Health Care AB. 2. Unit price obtained from the RMH hospital Supply and Logistic Department 3. Total dressing costs are the sum of dressings and bandage costs 4. Average dressing costs are the dressing costs divided by 219 patients Methodology This economic estimation was based on the RTC completed in Melbourne, Australia from April 2011 to December 2012. 12 Table 1 presents the PU incidence rates and anatomical sites in the control and intervention groups. From this data set, a wider lens was used to examine the potential economic benefits of using prophylactic dressings to prevent pressure ulceration in high-risk patients in public hospitals across Australia. To properly examine the acute care sector, annualised data for 2012 2013 has been used from the Australian Institute of Health and Welfare, 13 which is displayed as patient days 2012 2013. From this, a conservative estimate of 10% of total annual acute patients was considered to be high-risk based on published risk profiles of Australian acute hospital populations, 14 and this subgroup was the patient population on which our estimate was calculated. Our approach is conservative in estimating both the magnitude of the Australian at risk population and the associated costs. We intentionally underestimated the benefit as we believe that this method provides a greater degree of confidence in the potential benefit that may result from the use of these dressings to prevent pressure ulceration. Using the findings from the Border Trial cost benefit analysis, 12 a per-patient frequency coefficient of heel and sacral dressing changes was estimated, along with an estimated per patient coefficient factor for the number of tubular bandages used (Table 2). Additionally the total dressings costs is presented which is the sum of the dressing and bandage costs. The average dressing cost was then calculated by dividing the total dressing cost by the 219 patients in this group These per-capita estimates were then applied to the total number of patient days per Australian state to give us estimated totals for all three variables across Australia. The next phase of the estimate was concerned with the development of a cost function for the total 5 8 4

Table 3. Calculation of direct treatment costs of PUs from Border Trial ($AUD) Items Description Unit price ($) Material cost 1 Air mattress (BI-WAVE/ TRINOVA/CAIRWAVE) 11.88 18.75 (min max) 2 Air cushion (ROHO) 2.14 2 Orthotics boots 32.00 Silicone dressing (Mepilex Border) 8.40 Hydrocolloid dressing (Comfeel plus) 5.07 Transparent dressing (Tegaderm) 2.62 Fixation dressing (Bandage, Mefix, Tubifast) 0.53 10.9 (min max) Dressing pack 0.43 Sodium chloride irrigation 0.20 Gloves 0.47 Gauze 0.27 Nutritional supplements (Resource, Arginaid) 1.8 3.7(min max) Total material costs $65.81 84.95 1. All material cost information except for the air mattress/chair obtained from the hospital supply and logistic department 2. Information about daily rental cost for the air mattress/chair obtained from the mattress company that provided rental service to the hospital intervention process. Using the unit prices quoted in the Border Trial 12 for the sacrum and heel dressings, as well as the unit price for the tubular bandages, a state-by-state cost for each variable has been extrapolated. These state totals have been combined into a national total cost for each treatment variable. From this point, a practical application was pursued by using the above quantitative and economic estimates for the intervention process. A PU prevalence rate of 13% has been applied to the national 10% high-risk subgroup. This estimate is in line with the rate observed in the control group from the study. 12 While higher estimates of PU prevalence exist globally, 3 a more conservative estimate has been applied in this study to avoid overstating the potential economic benefit. From this 13% estimate, we arrive at a new subgroup of those high-risk patients who developed a pressure injury in acute care across Australia from 2012 2013. Using the Border Trial s cost benefit analysis 12 average treatment cost per ulcer of $1080.37 (Tables 3 and 4), we are able to combine this figure with the total pressure injury estimate to give a national estimate for treatment cost. It should be noted that the costs for the air mattress and air cushion are treated as a variable cost because of the large number of Australian hospitals that hire this equipment. Where hospitals have purchased this type of equipment it should be treated as a fixed cost and therefore omitted from the cost calculation. This process was then applied to a lower prevalence rate of 3%, which was observed in the Border Trial s intervention group. 12 The absolute risk reduction rate of 10% found between the two groups in the trial is again, a conservative measure, and therefore one that was adopted in our analysis. The lower rate of 3%, as a result of the use of prophylactic dressings, provides a new, smaller subgroup which is combined with the same average ulcer treatment cost as above. This figure is finally combined with the estimated total intervention cost to finalise the total cost of the new, lower subgroup. A comparison between the two groups provides an estimate of the Table 4. Average cost in the intervention and control groups ($AUD) Intervention (n=161) Control (n=152) Average treatment cost per ulcer 1 1082.37 1 1082.37 1 Weighted average treatment cost 33.55 2 141.79 3 Average dressing costs 33.32 Total average cost 66.87 4 141.79 1 The average cost of treating stage I, II and IV sacral and heel ulcers per episode of acute care 2 Multiplication of the average treatment cost per ulcer by the incidence rate of PUs in the intervention group (3.1%) 3 Multiplication of the average treatment cost per ulcer by the incidence rate of PUs in the intervention group (13.1%) 4 The sum of the weighted average treatment cost and the average dressing costs 5 8 6

References 1. National Pressure Ulcer Advisory Panel and European Pressure Ulcer Advisory Panel. Prevention and treatment of pressure ulcers: clinical practice guideline. Washington, DC: National Pressure Ulcer Advisory Panel, 2009. 2. Clark, M. The effect of a pressure-relieving wound dressing on the interface pressures applied to the trochanter. Decubitus 1990; 3: 3, 43 46. 3. Graves, N., Zheng, H. The prevalence and incidence of chronic wounds: a literature review. Wound Practice and Research 2014; 22: 1, 4-19. 4. Dealey, C., Brindle, C.T., Black, J. et al. Challenges in pressure ulcer prevention. Int Wound J 2013; doi: 10.1111/iwj.12107. 5. Graves N & Zheng H. Modelling the direct health care costs of chronic wounds in Australia. Wound Practice and Research 2014; 22: 1, 20 33. 6. Clark, M., Black, J., Alves, P. et al. Systematic review of the use of prophylactic dressings in the prevention of pressure ulcers. Int Wound J 2014; 11: 5, 460 471. 7. Call, E., Pedersen, J., Bill, B. et al. Enhancing pressure ulcer prevention using wound dressings: What are the modes of action? Int Wound J 2013; doi: 10.1111/iwj.12123. 8. Gefen, A. How do microclimate factors affect the risk for superficial pressure ulcers: A mathematical modeling study. J Tissue Viability 2011; 20: 3, 81 8. 9. Brindle, C.T. Outliers to the Braden Scale: Identifying High-risk ICU Patients and the Results of Prophylactic Dressing Use. World Council of Enterostomal Therapists Journal 2009; 30: 1, 11 8. 10. Brindle, C.T., Wegelin, J.A. Prophylactic dressing application to reduce pressure ulcer formation in cardiac surgery patients. J Wound Ostomy Continence Nurs 2012; 39: 2, 133 42. 11. Santamaria, N., Gerdtz, M., Sage, S. et al. A randomised controlled trial of the effectiveness of soft silicone multi-layered foam dressings in the prevention of sacral and heel pressure Table 5. 2012 2013 annual national estimates for intervention process State Patient days High risk 10% Estimated sacral Estimated heel Total changes Bandage rolls changes Changes NSW 1,716,789 171,679 291,854.30 496,152.31 788,006.61 10,300.74 VIC 1,429,453 142,945 243,006.50 413,111.05 656,117.55 8,576.70 QLD 1,044,011 104,401 177,481.70 301,718.89 479,200.59 6,264.06 WA 606,809 60,681 103,157.70 175,368.09 278,525.79 3,640.86 SA 413,756 41,376 70,339.20 119,576.64 189,915.84 2,482.56 TAS 106,358 10,636 18,081.20 30,738.04 48,819.24 638.16 ACT 94,712 9,471 16,100.70 27,371.19 43,471.89 568.26 NT 118,307 11,831 20,112.70 34,191.59 54,304.29 709.86 Total 5,530,195 553,020 940,134.00 1,598,227.80 2,538,361.80 33,181.20 NSW=New South Wales; VIC=Victoria: QLD=Queensland; WA=Western Austrailia; SA=Southern Austrailia; TAS=Tasmania: ACT =Australian Capital Territory; NT=Northern Territory Table 6. 2012 2013 financial estimates for cost of intervention process ($AUD) State Estimated sacral cost ($) Estimated heel cost ($) Estimated bandage cost ($) Total intervention cost ($) NSW 3,210,397.30 4,465,370.79 101,977.33 7,777,745.42 VIC 2,673,071.50 3,717,999.45 84,909.33 6,475,980.28 QLD 1,952,298.70 2,715,470.01 62,014.19 4,729,782.90 WA 1,134,734.70 1,578,312.81 36,044.51 2,749,092.02 SA 773,731.20 1,076,189.76 24,577.34 1,874,498.30 TAS 198,893.20 276,642.36 6,317.78 481,853.34 ACT 177,107.70 246,340.71 5,625.77 429,074.18 NT 221,239.70 307,724.31 7,027.61 535,991.62 Total 10,341,474.00 14,384,050.20 328,493.86 25,054,018.06 NSW=New South Wales; VIC=Victoria: QLD=Queensland; WA=Western Austrailia; SA=Southern Austrailia; TAS=Tasmania: ACT =Australian Capital Territory; NT=Northern Territory potential saving resulting from the use of the dressings based on the expected lower PU incidence rate. Results Table 5 presents the national estimates for the 10% subgroup of patients deemed to be at high-risk of PU formation and the resource utilisation for these patients is provided by state and nationally. In Table 6 we see the financial estimates of the costs of using the dressings. The estimated national PU treatment costs based on a 13% incidence rate within the 10% high-risk population of all acute hospital patients is presented in Table 7 indicating a national annual cost estimate of AU$77,814,393. A similar approach to that used in Table 7 for national PU treatment costs is presented in Table 8 but with an estimated reduction in PU incidence (from 13% to 3%) is seen but with the addition of the preventative dressing costs. In Table 9 we see the final estimate of the national annual cost benefit of using prophylactic dressing to prevent PUs in high risk patients Table 7. 2012 2013 national estimated cost for 13% incidence of pressure ulcers in high risk sub-group ($AUD) High risk 10% Pressure ulcer subgroup 13% Average treatment cost per ulcer ($) Estimated total treatment cost ($) 553,020 71,893 1,082.37 77,814,826.41 5 8 8

Table 8. 2012 2013 national estimated cost for 3% incidence of pressure ulcers in high risk subgroup ($AUD) High risk 10% Pressure ulcer Subgroup 3% Average treatment cost per ulcer ($) Discussion Our estimate of the potential cost benefit to the Australian acute health care sector of adopting the use of prophylactic dressings to reduce hospital-acquired PUs suggests a conservative annual saving of AU$34.8 million. This finding is based on the results of a large Australian RCT conducted with critically ill patients and a subsequent cost benefit analysis. 11,12 The patients in this study were all in the high risk band of PU risk stratification based on the Braden Scale. We believe that a conservative estimate of the number of patients that fall into this risk stratum in the Australian acute care sector would be at least 10% and as a consequence we believe that our extrapolation of the cost benefit to the acute care sector is justifiable. We have not included any staff costs in our calculations because these costs are fixed and hospitals would not decrease staff numbers as a result of decreasing PU rates. However, one could argue that because of the potential decrease in the number of patients who develop a PU, staff time would be optimised and therefore be used more efficiently due to the reduction in work load in managing these wounds. Similarly, we did not calculate the effect of the use of the prophylactic dressings on hospital length of stay. We acknowledge that the literature on pressure ulceration indicates that the development of these wounds contributes to increased patient length of stay, however we do not currently have accurate Australian data on this effect. Future research is required to clearly identify the effect of these wounds on patients pathways through the health system. In Australian acute care hospitals, patients with hospital-acquired PUs are often transferred to either the rehabilitation sector with an existing wound or alternatively the wounds are managed in the community by visiting nursing services. The study is limited to the acute care public hospital sector and due to our exclusion of the private sector, which is a growing health-care provider in Australia, we cannot generalise our findings to that sector as data on the risk profile of these patients is not generally available. Similarly, we have also excluded the residential aged care sector from our analysis due to the lack of any large well conducted trials of the use of prophylactic dressing to prevent pressure ulceration in this highly vulnerable population, consequently Estimated total treatment cost ($) Total intervention cost ($) Total cost ($) 553,020 16,591 1,082.37 17957600.67 25,054,018.08 43,011,618.75 we are unable to estimate the potential benefit to this large patient population. A further important limitation of our study is that it does not explore the issue of patient quality of life (QOL). While estimation of the impact on QOL of developing a PU was not an objective of our study, this area is important and should be included in future cost benefit research. There remains a large degree of uncertainty in the actual costs of pressure ulceration both in Australia and internationally. In Australia, we have seen Graves & Zheng 5 estimate the total cost of PUs in both hospital and residential care settings to be US$1.65 billion, however, as they note, with little certainty due to a reported standard deviation of US$1.05 billion. Similarly, when attempting to compare pressure ulceration costs internationally the problem is magnified due to differences in health-care systems structure and funding/reimbursement models. These systems may be public, private or composite type systems. Additionally, there are large variations and differences in staffing profiles, salary structures and purchasing systems that render international comparisons to our findings difficult. However, we believe that our methodology for deriving our cost benefit estimate is sound and as such we look forward to future work that may be conducted in other countries exploring the potential benefit of using multilayer silicone foam dressings to prevent PUs. Conclusion To conclude we would like to emphasise that whilst our work has focussed on the economic aspects and potential cost reduction of the use of multilayer silicone foam dressings to prevent hospital-acquired PUs, the real value in this emerging approach is in the potential to better safeguard vulnerable patients from an all too common, yet mostly preventable hospital adverse event. n Table 9. Comparison of costs between 13% and 3% pressure ulcer incidence in high risk sub-group ($AUD) Total Saving ($) Total Saving (%) 34,803,640.61 55% ulcers in trauma and critically ill patients: the border trial. Int Wound J 2013; doi: 101111/iwj12101 2013. 12. Santamaria, N., Liu, W., Gerdtz. M. et al. The cost-benefit of using soft silicone multilayered foam dressings to prevent sacral and heel pressure ulcers in trauma and critically ill patients: a within-trial analysis of the Border Trial. Int Wound J 2013; doi: 10.1111/iwj.12160. 13. Australian Institute of Health and Welfare (2014). Australian hospital statistics 2012 13. http://www.aihw. gov.au/workarea/ DownloadAsset. aspx?id=60129547000 (accessed October 2014) 14 Mulligan, S., Prentice, J., Scott, L. (2011) WoundsWest Wound Prevalence Survey 2011 State-wide. https://www. health.wa.gov.au/ WoundsWest/docs/ WWWPS_11_state_ report.pdf (accessed October 2014) journal of wound care vo l 2 3, n o 1 1, n ov e m b e r, 2 0 1 4 589