Spetz, Joanne PhD, FAAN; Brown, Diane S. PhD, RN, CPHQ, FNAHQ, FAAN; Aydin, Carolyn PhD; Donaldson, Nancy DNSc, RN, FAAN
Hospitals face substantial costs associated with adverse patient events. Nurse executives are encountering growing pressure to reduce the incidence of adverse events, improve hospital finances, and improve patient outcomes.1,2 In October 2008, the Centers for Medicare and Medicaid Services (CMS) implemented a value-based purchasing (VBP) initiative aimed at reducing preventable, hospital-acquired conditions by eliminating payments for 11 conditions, including pressure ulcers (PUs) (CMS-1553-FC, CMS-1390-F).1,2 Private insurers are following suit. After the October 2007 CMS rule announcement, the BlueCross BlueShield Association announced that it would develop a program to end payments for services for certain hospital-acquired conditions.3 During 2013, CMS intends to fully implement VBP, in which hospitals will receive higher payments for achieving explicit performance goals.4
Most hospital-acquired PUs (HAPUs) are considered preventable,5 which is why they have been identified by the National Quality Forum (NQF) as a nurse-sensitive quality indicator and by CMS as 1 of the nursing-sensitive indicators that should be included in benchmarking registries.6 Moreover, HAPUs are mandatory reportable adverse events in some states, including California,7 and lead to increased morbidity and costs.8-14 Pressure ulcer treatment accounts for significant healthcare expenditures, with an estimated 2.5 million PUs treated each year in acute care hospitals in the United States.15 Interventions have been demonstrated as effective for HAPU prevention and management, but many nurse leaders believe that prevention measures are expensive and labor intensive, thus reducing support for investments in HAPU reduction programs.16-18In addition, to understand and track unit-level HAPU rates, hospitals need to invest in staffing and training to systematically conduct HAPU prevalence assessments, monitoring patient skin condition, and documenting the presence of early HAPUs (stage 1 and 2) and the more extensive HAPUs (stage 3 and 4). This article presents a simple model that can be used by nurse leaders to assess the potential cost savings that can be achieved from investments to prevent HAPU.
The national prevalence of HAPU has been estimated at 0.32% of hospital patients.19 The incidence of HAPU can be reduced through prevention, and the severity of HAPU can be mitigated with management of the condition and contributing factors.15,20,21 Interventions that have been demonstrated as effective for HAPU prevention include use of specially designed support surfaces, frequent repositioning of patients, attention to patient nutrition, and management of moisture and incontinence.15,22 Some aspects of nursing care are particularly important to preventing and treating PUs, including risk screening upon admission, systematic assessment and reassessments of individual risk factors along with skin inspections, implementation of a skin care regimen, and repositioning of patients.21-24 Many institutions also have certified and highly trained nurses in wound and ostomy continence to establish and implement their prevention and treatment programs.
The development of a PU can increase risk of mortality,8 induce pain,9 impair functional status,10 and decrease the quality of life.11 Moreover, PUs increase the duration of intensive care,12 total length of hospital stay,13,25 and treatment costs.14,26 The costs are significant for both the hospital and the patient; thus, investment in prevention activities may be beneficial from both clinical and financial perspectives.
Previous research has reported differing conclusions regarding whether programs to prevent HAPU are cost-effective. Specific interventions such as pressure-relieving mattresses25,27 and the use of dry polymer overlays on operating room tables14 have been found to be both cost-effective and cost-saving. Findings have been mixed from studies of integrated, multidimensional HAPU prevention programs. A study of quality improvement collaboratives to prevent PUs found that the project costs were greater than short-term savings from PU reduction.28 However, the authors of that evaluation noted that the long-term return on investment (ROI) could be positive. One analysis concluded that technical approaches to preventing HAPU, such as managing pressure and shearing forces through use of mattresses, were less expensive and resulted in greater cost minimization than staff-intensive interventions such as frequent patient turning and repositioning.16 More recently, a formal cost-effectiveness analysis that used decision modeling to measure the incremental costs and benefits of HAPU prevention found that prevention is cost-effective up to an additional investment of $821.53 per patient day.5
Nurse managers and executives have sufficient research-based evidence to consider implementing programs to reduce HAPUs, but they also need to establish that such programs will be clinically, financially, and strategically advantageous for their hospitals. The aim of this article was to provide a simple model to assess the cost savings associated with implementing nursing approaches to prevent HAPUs. Using data from the Collaborative Alliance for Nursing Outcomes (CALNOC) and the published literature, we assessed the degree of improvement in HAPU rates that is achievable based on CALNOC data and determined the financial savings associated with HAPU reduction. We then demonstrated how these data can be integrated into a calculation of the ROI for a program to reduce HAPUs. Our ROI framework is based on the Agency for Healthcare Research and Quality (AHRQ) Quality Indicators Toolkit, which provides clear instructions for estimating the ROI for quality improvement programs.29
Data and Methods
PU Rates and Improvements
Data on the prevalence of HAPUs were obtained from CALNOC, a not-for-profit, self-sustaining nursing-sensitive benchmarking registry. Collaborative Alliance for Nursing Outcomes supports hospital collection of data on nursing-sensitive structure, process, and outcomes for benchmarking and quality improvement planning.30-32 In 2012, 257 hospitals nationwide participated in CALNOC; 218 of these are in California, representing 60% of all general acute care hospitals in the state. The CALNOC database provides a convenience sample, with the number of participating hospitals increasing over time. Small and for-profit hospitals are under represented in the CALNOC data, with 15% of participants having fewer than 100 licensed beds in 2006, compared with 24% statewide.33
Monthly unit-level patient outcomes data are collected by CALNOC through a Web-based submission system.34 The dataset includes information about adult medical-surgical, critical care, step-down, and 24-hour observation units; pediatric and post–acute care units are also included in CALNOC but were excluded from these analyses. Hospitals are guided in their submissions through coding specifications, tutorials, and workshop training provided by CALNOC with the aim of ensuring a high level of data validity and reliability. Collaborative Alliance Of Nursing Outcomes is the cited measure developer of the NQF’s PU and restraint use prevalence measures, and the data submitted by hospitals on HAPU are of consistently high quality. Prevalence studies have been demonstrated to be more accurate than other methods of HAPU data collection; Gunningberg and Ehrenberg35 compared patient charts and a prevalence study and found that the patient records documented fewer than half of the PUs identified by skin examination.
Data on HAPU were extracted from the CALNOC database for 78 hospitals that contributed data every year from 2003 through 2010. These 78 hospitals collectively reported on 258,456 patients over the 8-year period. A single record per year was created for each of the hospitals by averaging the results of all studies conducted within the year, for a total of 624 records. As expected, the data indicate significant improvement in HAPU rates over time (see Table, Supplemental Digital Content 1, http://links.lww.com/JONA/A220). The hospitals that participate in CALNOC actively use the benchmarking data to develop, maintain, and modify quality improvement activities, and HAPU prevention has been a central area of work for many participating hospitals.
Cost of PU Treatment
A number of studies have documented the costs of treating PUs. However, some studies have reported only the total costs of care for a patient with PU, as opposed to the incremental costs associated with treating a patient with a PU versus a similar patient without a PU. For example, Brem et al36 reported that the average total costs for treating patients with stage 4 PUs was $127,185 but did not report how these costs compared with those for other patients. An additional difficulty in the literature is the aggregation of PUs, so that a single average cost is reported for all types of PU. The costs of treating a stage 4 PU are surely higher than those for a stage 1 PU, and to develop worthwhile ROI calculations, these costs should be distinguished.
We reviewed the literature and identified 3 studies that reported incremental costs associated with PU care, which are summarized in Table 1. The first 2 studies provided average incremental costs for PU by stage, based on data from England25 and Canada.27,37 A 3rd study provided estimates of incremental costs based on data from the United States, aggregating stages 1 and 2, and stages 3 and 4.5 These estimated costs are offset in the table to indicate they are averages of stages 1 and 2, and of stages 3 and 4. The Society of Actuaries published a comprehensive report on costs of adverse events but grouped all 4 stages of PUs in their reported cost estimate.19
Despite variation in the country from which data were obtained and the level of aggregation of the data, there is some consistency in the estimated incremental costs of PU treatment. The costs of treating stage 1 PUs are slightly more than $2,000,5,25 stage 2 PU costs are likely between $3,000 and $10,000,25,27,37 stage 3 costs range from $5,900 to $14,840,5,25,27,38 and stage 4 PU costs could be as high as $18,730 to $21,410.25,27,37 The Society of Actuaries estimated the overall average incremental cost at $10,700, which is near the average of the other cost estimates.19
Costs of PU Prevention Programs
Establishing an active program to prevent PUs involves both fixed costs and variable costs. Fixed costs are incurred regardless of the volume of patients. These costs include program management and the expertise of specialized personnel and can include the time of training of personnel, which might vary with the number of staff but will not directly change with fluctuations in patient volume. Variable costs are directly connected to the number of patients in the hospital and are often measured on a per-patient-day basis. These include rental costs of support surfaces, staff time for repositioning and mobilizing patients, and ointments and other supplies.
Table, Supplemental Digital Content 2, presents cost data from 3 published studies and estimates of the costs of CALNOC surveillance obtained from 2 hospitals that participate in CALNOC, http://links.lww.com/JONA/A221. Makai and colleagues28 implemented a PU prevention program among 25 teams in long-term care settings. This program involved substantial investment in training and management owing to the large number of organizations represented. Two of these fixed costs are likely to be incurred by hospitals as they launch HAPU prevention programs: staff training and management training. This study also reported an average of 48.21 minutes per patient day spent in prevention activities, which, in 2011 US dollars, would cost $50.13, on average, for wages and benefits.38
Other studies reported both costs and minutes of time required for prevention activities. Schuurman and colleagues16 identified the time and cost (in 2005 Euros) of repositioning patients, mobilization of patients, and ointments. They also determined the daily cost of using specific support mattresses. These costs totaled $13.31 per patient day, which is much lower than the $54.66 per patient day (in 2011 dollars) reported by Padula and colleagues.5
To monitor the success of HAPU prevention programs, regular data collection is necessary. We contacted 2 hospitals that participate in CALNOC to estimate the time required to conduct prevalence studies. There was consensus that initial training requires approximately 2 hours per nurse involved in the surveillance study and less than 1 hour of refresher training in subsequent years. If 10 nurses are involved in the study (1 nurse for each of 10 patient care units), the initial training costs would be $943.07 in wages and benefits. The time required for patient assessment and chart review was estimated at 3 minutes for simple cases to 14 minutes for the most complex cases. We used the higher time estimate to assign $11.00 per patient for variable surveillance costs. Note that our calculations assume that every patient admitted to the hospital is part of the surveillance study. In most hospitals, surveillance studies are conducted monthly or quarterly, and thus, only a subset of patients would be included. Thus, this component of cost is overestimated.
Method of Analysis
We used the AHRQ patient safety indicators toolkit as a guide for our ROI calculations.29 Return on investment is the ratio of the net returns from quality improvement activities versus the net investment in those activities. If the ROI ratio is greater than 1, then the quality improvement activity provides a positive net return, and is a cost-saving investment for the hospital.
We used the CALNOC data on improvements in HAPU rates (See Table, Supplemental Digital Content 1, http://links.lww.com/JONA/A220) and published literature (See Table, Supplemental Digital Content 2, http://links.lww.com/JONA/A221) to estimate the net returns from investment in HAPU prevention.39 These net returns are the incremental savings achieved by reducing HAPU rates. The estimated direct savings per patient for avoiding HAPU is the expected value of costs:
Equation (Uncited)Image Tools
We used the published literature to estimate the costs of HAPU prevention programs, including surveillance activities such as those used for CALNOC (see Table, Supplemental Digital Content 2, http://links.lww.com/JONA/A221). We tested the sensitivity of our ROI calculation to using higher or lower estimates of returns and costs. In a multiyear project, one would discount the returns and costs of future years, so that the initial investment is relatively more expensive than future investments or gains. This reflects the opportunity cost of the initial investment, which is the interest income that would have been received if the money had simply been invested or saved. For this analysis, we assumed the HAPU prevention activities occurred in 1 year.
Table 2 presents the results of the ROI calculation for variable costs, reflecting the ongoing costs of maintaining a HAPU surveillance and prevention program. For this analysis, we assumed that a hospital could achieve the same reduction in HAPU rates as observed between 2003 and 2010 among CALNOC participants (see Table, Supplemental Digital Content 1, http://links.lww.com/JONA/A220). All costs are in 2011 US dollars. In the baseline year, the expected cost of HAPU was $832.27 per patient, based on mean costs of HAPU treatment reported in the literature. Reducing HAPU rates to 2010 levels lowered costs to an expected level of $496.40 per patient, achieving a net savings in HAPU treatment costs of $335.87. The mean costs for HAPU surveillance and prevention are $208.36, based on an average hospital length of stay of 4.9 days.40 A comparison of the net savings from reduced HAPU treatment costs per patient and expenditures for surveillance and prevention produces an ROI ratio of 1.61 and net savings of $127.51 per patient.
We examined the sensitivity of our calculations to alternative costs of HAPU treatment and prevention. Table 3 presents the net savings from investment in HAPU prevention for each of the lowest, mean, and highest HAPU treatment and prevention costs. If HAPU treatment costs are at the mean or maximum of those reported in the literature, prevention provides a positive ROI even at the maximum prevention program cost. Only if HAPU treatment costs are at the minimum level reported in the literature is prevention more expensive—and only if prevention is greater than the minimum level.
These calculations do not include the fixed costs of training managers and staff to engage in surveillance and coordinate HAPU prevention activities. The estimated costs for 1st-time training before a CALNOC surveillance study are $943.07 (Table 1), and the costs for management and staff training for a prevention program is $4,526.72 (Table 1). If a hospital discharges 36 patients per year, the net savings from HAPU prevention are $4,590 ($127.51 × 36), which is greater than the initial training investment. Because nearly all hospitals discharge more than 35 patients annually, these fixed costs are negligible compared with overall potential cost savings.
This analysis demonstrates that HAPU surveillance and prevention can be not only cost-effective, as has been reported in the literature, but also cost saving for hospitals in most cases. A hospital’s direct savings achieved from HAPU surveillance and prevention programs will depend on the reduction in HAPU rates achieved, the historic costs of treating HAPU, and the amount spent on surveillance and prevention activities.
Our analysis is based on several assumptions. We assume that hospitals can achieve improvements in HAPU rates through active surveillance and prevention efforts. This is based on the experience of hospitals that participated in the CALNOC program from 2003 through 2010. These hospitals have demonstrated a long-term commitment to quality improvement, as represented by their participation in a nurse-sensitive outcomes registry. These hospitals may not represent the typical hospital, although all hospitals should have a focus on quality of care.
The data used to measure HAPU rates are from prevalence studies, and the quality of these data is dependent largely on the training and expertise of those conducting the study. Collaborative Alliance for Nursing Outcomes provides participating hospitals with consistent standards for identification of patients at risk and staging of PUs and with training resources for those engaged in surveillance. Hospitals and reporting organizations that support prevalence studies need to ensure that they provide clear guidelines and training, as well as clinical access to consultative nurses with advanced expertise in skin and wound care. As computerized healthcare documentation systems align around common data elements, HAPU prevalence may ultimately be extracted from real-time patient care documentation, in lieu of hospital-wide patient skin inspection. The need for nursing personnel to have adequate training and knowledge to properly identify and stage PUs will not be obviated by the development of electronic health records.
The costs of HAPU treatment and prevention are drawn from a variety of published sources, which brings uncertainty to the measurement of these costs.24 The costs of HAPU treatment and prevention will vary also with local costs of labor and equipment. Although the processes of HAPU prevention are noted in these studies, there likely is variation across organizations in implementation and activity definitions. Finally, this and previous economic analyses of HAPU have not included other variables that may have financial impact, such as the costs of regulatory fines for hospital-acquired conditions, the costs of market place position impacts for adverse publicity associated with regulatory fines, the costs of legal and malpractice consequences of HAPU, and the revenues to be gained from demonstrating comparably exemplary performance in HAPU prevention. The model presented here will demonstrate stronger accuracy when clinical and administrative leaders are able to identify and integrate costs and revenue savings associated with these other factors.
Conclusions and Implications for Nursing Administration
The sizeable reduction in mean HAPU rates among CALNOC hospitals demonstrates that active surveillance and performance improvement programs can lead to lower HAPU rates. The 1st step to enhancing quality of care is increasing understanding regarding which areas have opportunity for improvement. Surveillance programs such as that of CALNOC provide unit-level data, enabling nurse managers to make comparisons in their hospital, and benchmarking data, for external benchmarking. Comparison information can guide nurse managers to prioritize their quality improvement efforts and measure success.
A drop in HAPU rates results in lower morbidity and mortality for patients and also produces savings to hospitals. Nurse managers and executives have ample evidence-based data to develop and implement a HAPU prevention program. The ROI framework for calculating the costs and benefits of investing in HAPU prevention can be easily adapted to incorporate hospital-specific costs of prevention and treatment and guide nurse leaders to determine an appropriate level of investment in surveillance and prevention activities for this strategic investment.
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