Cost Reductions
Associated with
Declines in Pressure
Ulcers at MHA
Hospitals
Cambridge, MA
Bethesda, MD
Durham, NC
Atlanta, GA
April 17, 2011
Prepared for
Massachusetts Hospital
Association
Attn: David Smith
5 New England Executive Park
Burlington, MA 01803-5096
Prepared by
Michael Plotzke, PhD
Rajen Subramanian, PhD
Lauren Olsho, PhD
Contents
1. Introduction ................................................................................................................................ 2 2. Literature Review ...................................................................................................................... 3 2.1. Summary of Articles from Literature Review ................................................................ 3 2.2. Overview of Literature Review ...................................................................................... 9 3. Results ....................................................................................................................................... 13 3.1. Pressure Ulcers in MHA Hospitals Using the One Day Measure ................................ 14 3.2. Extrapolation of Pressure Ulcers and Cost Savings to an Annual Basis ...................... 19 4. Conclusion ................................................................................................................................ 23 Works Cited ........................................................................................................................................ 25 Appendix Tables ................................................................................................................................. 27 Appendix 2 – Articles Found in the Search That Weren’t Relevant ............................................. 32 Abt Associates Inc.
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1.
Introduction
The Massachusetts Hospital Association (MHA) previously contracted with Abt Associates Inc.
to analyze recent longitudinal trends in pressure ulcer rates in 70 acute care and 10 specialty care
hospitals. In the previous report, we found that the average acute care hospital pressure ulcer
prevalence rate dropped nearly 36 percent over the period, from 3.15 percent in 2007 to 2.04
percent in 2009, when looking at a weighted average that accounted for hospital size. The
average specialty hospital pressure ulcer prevalence rate dropped 44 percent over the period, from
3.43 percent in 2007 to 1.92 percent in 2009 when looking at a weighted average that accounted
for hospital size. This report extends that analysis by estimating cost reductions related to these
declines in pressure ulcer rates.
To obtain our cost reduction estimates, we combined our prior estimates of pressure ulcer rate
reductions in MHA hospitals with cost estimates derived from the literature. We conducted a
literature review to identify peer-reviewed articles and other published reports from industry
providing estimates of pressure ulcer costs in hospital settings. Our search identified three cost
estimates from two high-quality articles that appeared to be most generalizable to MHA hospitals.
The three incremental cost estimates reported in these two articles varied widely, ranging from
$2,728 to $22,124 per pressure ulcer1, reflecting important variations in pressure ulcer
measurement and estimation methodology. Our literature review also identified a number of
important moderating factors that can influence pressure ulcer costs.
We combined these three cost estimates with our previous estimates of the reductions in pressure
ulcers from 2007 to 2008, from 2008 to 2009, and from 2007 to 2009 to obtain estimates of cost
reductions. Considering only the pressure ulcers measured during the quarterly one day reporting
period, for acute care hospitals, estimates of reductions in cost ranged from $521,107 to $4.2
million over a two year period (from 2007 – 2009, using 2007 as the baseline year) depending on
the specific cost estimate used in the calculation. For specialty care hospitals, comparable
estimates of the two year cost reduction ranged from $68,208 to $553,107. Extrapolating the
findings from the quarterly one day reporting period to an estimate of the number of hospital
acquired pressure ulcers that occur on an annual basis, estimates of reductions in cost for acute
care hospitals ranged from $18.3 million to $148.3 million over a two year period (from 2007 –
2009, using 2007 as the baseline year), depending on the specific cost estimate used in the
calculation. For specialty care hospitals, comparable estimates of a two year cost reduction
ranged from $353,179 to $2.9 million.
The wide range of our cost reduction estimates for MHA hospitals reflects the wide variation
in cost estimates from the literature. However, it is important to note that even the most
conservative cost reduction estimates represent positive savings. Further, as noted in the
literature review, reduction in pressure ulcer rates results in benefits (such as improved
quality of life) that are not easily quantifiable (and therefore not included) in a cost savings
estimate.
1
Cost estimates reported in 2009 dollars.
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2.
Literature Review
Once per quarter, MHA collects information on a one-day census of hospital acquired pressure
ulcers in its member hospitals. This census does not provide information regarding costs
associated with those pressure ulcers. Because the pressure ulcer rates fell between 2007 and
2009, it is reasonable to expect that costs associated with pressure ulcers also fell during that
time. To estimate the reduction in costs associated with the declining pressure ulcer rate, we use
estimates from the literature on costs associated with pressure ulcers in hospital settings. We use
multiple estimates from the literature to form a range of possible values for the reduction in costs
associated with the declining pressure ulcer rate.
For this analysis, we performed a targeted literature review with the intention of finding between
6 and 10 articles that contained information on pressure ulcer costs. We focused on studies that
specifically examined pressure ulcer costs in hospitals. Below, we provide short summaries of
the most relevant articles found from the literature review. We then summarize the main points
from all the articles.2 One of the main findings from the literature review was the diversity of
cost estimates related to pressure ulcers. The range of estimates is the result of the unique nonhomogenous nature of pressure ulcers as well as different methodologies used by researchers to
measure costs. Because of this wide variation, it is not reasonable to identify a single study that
could be used as a gold standard for estimating costs associated with pressure ulcers. We
attempted to identify a variety of well done studies that covered an array of methods for
examining pressure ulcer costs in order to achieve a reasonable range of values related to pressure
ulcer cost.
2.1. Summary of Articles from Literature Review
Allman RM, Goode P, Burst N, Bartolucci A, and Thomas D. Pressure ulcer,
hospital complications, and disease severity: Impact on hospital costs and length of
stay. Advances in Wound Care 1999;12(1):22-30.
Allman et al. (1999) estimated the relationship between hospital acquired pressure ulcers (Stage II
or higher) and two primary outcomes: costs and length of stay (LOS). Unlike many other studies
measuring these relationships, these authors used multivariate linear regression to measure the
relationship between pressure ulcers and the outcomes while controlling for patient characteristics
that would bias the results such as severity of illness, comorbidities, nosocomial infections, and
other hospital complications. The authors performed this analysis using data from a prospective
cohort study of 286 patients admitted to a “tertiary care, urban, university teaching hospital.”
The authors found that patients with hospital acquired pressure ulcers have higher mean
unadjusted hospital costs compared to patients without pressure ulcers ($37,288 vs. $13,924 and
2
Note, we include Appendix 2 to document several articles we did review but were found not to be
relevant. Appendix 2 includes a short description of why an article was not included.
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LOS 30.4 vs. 12.8 days). In addition to having higher costs and an increased LOS, patients with a
hospital acquired pressure ulcer were also more likely to develop nosocomial infections and other
hospital complications. Because these other factors are also likely to increase costs, estimates not
accounting for these other patient characteristics will tend to overestimate costs attributable to
pressure ulcers alone.
The authors therefore performed two adjusted analyses that accounted for other predictors of
hospital costs and length of stay. We report results from both of these two analyses here; to
distinguish the two cost estimates below we will refer to the “first method” and the “second
method” of Allman et al.
The first analysis included only a limited set of controls for patient characteristics on admission.
Using that analysis, the authors found the cost and LOS of those who developed pressure ulcers
was still higher than for those that did not develop pressure ulcers ($14,260 vs. $12,382 and 16.9
days vs. 12.9 days). This represented an incremental cost associated with pressure ulcers of
$1,878, or $2,728 in 2009 terms.
The second analysis adjusts for admission characteristics as well as a wider range of patient
characteristics including hospital complications and nosocomial infections. The cost
specifications also included DRG-adjusted LOS as a predictor. In this second analysis, estimated
differences between those with hospital acquired pressure ulcers and those without were larger in
magnitude ($29,048 vs. $13,819 and 20.9 days vs. 12.7 days), but still lower than the unadjusted
comparison. This represented an incremental cost associated with pressure ulcers of $15,229 (or
$22,124 in 2009 dollars). The differences across these models indicate there is unexplained
variability correlated with pressure ulcer status and the outcome variables. This makes it difficult
to determine if one model provides superior results to another. However, it does give a range of
possible values that could be associated with pressure ulcers.
The authors conclude, “incident pressure ulcers are associated with substantial and significant
increases in hospital costs and length of stay.” The authors contend their study is the first to show
incremental costs of pressure ulcer treatment exist even after controlling for many other factors
correlated with both cost and the pressure ulcer incidence.
The authors argue these results are similar to others in the literature. Allman et al. cited
Alterescu’s (1989) work that found the mean variable costs of treating pressure ulcer in a hospital
was $1,300. Also, they cited other work (Inman, Sibbald, Rutledge 1993) showing the cost of
“treating Stage II pressure ulcers in hospitals was $1,886 in 1988 dollars.” The authors cite other
studies that find that mean charges for hospital patients with pressure ulcers is 5.3 times the
charges of other patients and the average LOS is 4.5 times longer (Allman, LaPrade, Noel et al
1986).
The authors suggest their results show that it is beneficial to develop prevention programs for
pressure ulcers as a means to decrease hospital costs and LOS. The benefits of reducing pressure
ulcers can also extend beyond the implications for a hospital’s finances. They cite a study in
which Medicare patients that developed pressure ulcers in the hospital had post-hospital discharge
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Medicare payments that averaged $13 more per day of survival compared to patients that did not
develop pressure ulcers (Allman, Damiano, Strauss 1996).
Russo CA, Steiner C, and Spector W. Hospitalizations Related to Pressure Ulcers,
2006. HCUP Statistical Brief #64. 2008, Agency for Healthcare Research and
Quality, Rockville, MD. http://www.hcup-us.ahrq.gov/reports/statbriefs/sb64.pdf.
This statistical brief released by the Agency for Healthcare Research and Quality uses
information from the Healthcare Cost and Utilization Project National Inpatient Sample (NIS).
The NIS gives information on a large nationally representative sample of inpatient hospital stays.
This is advantageous over other cost studies we reviewed which generally employed smaller
patient samples in limited geographic areas.
However, the NIS data have limitations for identifying hospital acquired pressure ulcers in
comparison to data collected via chart review. The authors state that if a discharge has a principal
diagnosis of pressure ulcer, this indicates the pressure ulcer was present on admission. If the
discharge has a secondary diagnosis of pressure ulcer, this indicates either that the pressure ulcer
developed during the course of the hospitalization, or that it was present on admission. The
authors look at differences in costs and lengths of stay between discharges with a primary,
secondary, or no diagnosis of pressure ulcers. The authors interpret the difference in costs
between discharges with a secondary pressure ulcer diagnosis and a patient with no pressure ulcer
diagnosis as the incremental cost of a hospital acquired pressure ulcer. Unlike Allman et al., they
did not attempt to adjust these estimates to control for other patient characteristics that might
affect costs.
For LOS, discharges with a principal diagnosis of pressure ulcer had on average a LOS of 14.1
days, discharges with a secondary diagnosis of pressure ulcers had on average a LOS of 12.7
days, and discharges with no diagnosis of pressure ulcers had a LOS of 5.0 days. The authors
found that a larger percentage of patients with pressure ulcer died in the hospital (4.2% for
primary diagnosis and 11.6% for secondary diagnosis) compared to those patients without
pressure ulcer (2.6%). Hospitals discharged a larger percentage of patients with pressure ulcers
(53.4% for primary and 54.5% for secondary) to long term care facilities compared to other
patients (16.2%).
The overall cost of hospitalization was greater for discharges with pressure ulcer ($16,800 for
principal and $20,400 for secondary) versus those without ($9,900). These findings show that the
incremental cost for patient with an incident pressure ulcer is equal to $10,500 ($20,400 - $9,900
= $10,500) or $11,370 in 2009 dollars. The average cost per day, however, was lower for
pressure ulcer discharges compared to discharges without pressure ulcer. Likely this occurred
because hospitals provided more intensive services over a shorter period of time for the
discharges that did not have pressure ulcers. It is important to note that individuals with pressure
ulcers tended to be older (65.3 for principal diagnosis and 71.9 for secondary diagnosis)
compared to those without pressure ulcers (61.5). This difference in age is likely partially
responsible for some of the relationships between costs/LOS and pressure ulcer incidence the
authors noted.
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Xakellis GC and Frantz R. The cost of healing pressure ulcers across multiple
health care settings. Advances in Skin & Wound Care 1996;9(6):18–22.
This article examined the cost of treating pressure ulcers across multiple settings. Its primary
focus was not on hospitals therefore its information was less useful than other articles from the
literature review. The authors found that the mean cost of treatment in a hospital of a pressure
ulcer was $2,242 ($3,690 in 2009 dollars) and the mean cost of treatment in a hospital per patient
was $3,663 ($6,029 in 2009 dollars).
Kumar RN, Gupchup GV, Dodd MA, Shah B, Iskedihan M, Einarson TR, and
Raisch DW. Direct health care costs of 4 common skin ulcers in New Mexico
Medicaid fee-for-service patients. Adv Skin Wound Care 2004;17(3):143-9.
These authors measure the costs associated with pressure ulcers (and other skin ulcers) for
Medicaid patients in New Mexico. They found that average annual hospital costs per patient with
pressure ulcers was $15,760 (standard deviation: $30,706) in 1998 using their sample of patients
in New Mexico. Adjusted to 2009 dollars this is equal to $24,451 (standard deviation: $47,640).
Note, these per year costs are quite different than the per visits costs of the previous studies.
It important to note that Medicaid costs may be quite different from costs associated with other
payors and therefore these results may not be generalizable. Because of this, we felt this article
was not appropriate to use in our analysis of MHA hospitals. However, the estimates these
authors have made fall in the broad range of possible values presented by other authors.
Beckrich K and Aronovitch SA. Hospital-Acquired Pressure Ulcers: A Comparison
of Costs in Medical vs. Surgical Patients. Nursing Economic$ 1999;17(5):263-71.
We used the Beckrich and Aronovitch article as a starting point in the literature review because
the authors themselves performed a literature review to construct estimates of pressure ulcer costs
to make cost estimates of pressure ulcer incidence in specific hospital settings. However, this
article relies on articles that were somewhat older so we did not use it in our estimates of pressure
ulcer costs associated with MHA hospitals.
The authors performed a literature review to determine the cost of hospital acquired pressure
ulcers. They indicated that costs of hospital acquired pressure ulcers varied along several
dimensions including: severity of the pressure ulcer (e.g., Stage I and II versus III and IV),
whether the ulcer occurred in medical patients or surgical patients, and the treatment options
pursued for the pressure ulcer (for example, surgical debridement, flap, graft, or less intensive
options). A major factor impacting the cost associated with hospital-acquired pressure ulcers was
LOS, as hospital acquired pressure ulcers tended to increase length of stay. The authors cited
previous research that showed LOS increased between two and five times due to pressure ulcers
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compared to the usual LOS of patients without pressure ulcers (Allman et al. 1986; Miller &
DeLozier 1994).
Authors note that a frequently cited estimate for the cost of healing pressure ulcers is between
$5,000 and $50,000 (Langemo, 1991; Perdue, 1989), but emphasized that this estimate was not
based on data.
Determining the cost of treating pressure ulcers depends on the extent of costs a researcher
considers. Beckrich and Aronovitch looked at one paper (Alterescu 1989) that only considered
direct costs of treatment for patients that developed hospital acquired pressure ulcers. That author
assumed other costs such as, “nursing time, overhead, and dietary” all would have occurred
regardless of whether a pressure ulcer developed and therefore were not relevant.
Beckrich and Aronovitch found that Alterescu (1989) estimated that on average it cost $1,300 to
heal a pressure ulcer. However, they emphasized many shortcomings of this finding including:
Alterescu generated a cost estimate using cases where pressure ulcers did not fully heal, the cost
estimate did not include the cost of treatment that continued after the hospital discharge, and the
cost estimate did not consider increased LOS. However, Beckrich and Aronovitch did admit that
increased LOS is only a small factor for Stage I and II pressure ulcers. Also, treatment options
(and therefore associated costs) are less variable for Stage I and II pressure ulcers. The authors
thought that the paper’s estimate of the cost per pressure ulcer was reasonable for Stage I and
Stage II pressure ulcers. Alterescu (1989) found the incremental “cost of Stage I and Stage II
ulcers was $86.50 excluding overhead, nursing time, or any costs associated with increased LOS.
It only includes the cost of dressings, ointments, specialty beds, ET nursing time, and related
items. In 1997 dollars this is equivalent to $125.50.”
Beckrich and Aronovitch found estimates from Miller and DeLozier (1994) for the cost of stage
III and IV pressure ulcers. Miller and DeLozier looked at pressure ulcers that were present on
admission, therefore the cost they measured are somewhat different than the costs of treating
hospital acquired pressure ulcers. Those authors found that the incremental charges (note, costs
were not used) of having a secondary diagnosis of pressure ulcer (and a primary diagnosis of hip
fracture) was $12,186 and LOS increased from 11.2 days to 22.2 days.
Beckrich and Aronovitch estimate nationwide and hospital specific costs associated with pressure
ulcers by multiplying estimates for the costs as discussed above by prevalence estimates by stage
and using a one day census of all US hospitals, and other adjustments. Using this calculation,
they find that hospitals annually incur on average between $400,000 and $700,000 ($599,542 and
$1,049,198 in 2009 dollars) in direct costs because of pressure ulcers.
The authors also tried to estimate costs associated with pressure ulcers in surgical patients. They
used information from one study (Aronovitch 1998) that examined surgeries that lasted more than
3 hours. In that study the total prevalence of pressure ulcers within 3 days of surgery was 8.5%.
Based on their analysis, they found in surgical cases lasting over 3 hours, the average cost
associated with pressure ulcers ranged from $170 to $340 ($254 to $510 in 2009 dollars). The
authors used that to estimate that hospitals with 100 or more beds would on average incur annual
costs on the range of $265,000 to $525,000 related to operating room acquired pressure ulcers.
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The authors note that hospital direct costs are not the only costs that are relevant when
considering costs associated with pressure ulcers. Hospitals and other health care facilities can
face lawsuits resulting from poor care that lead to pressure ulcers. Additionally, a newer concern
not mentioned by the authors is changes in CMS (and other insurers) payment policy that limit
payment for hospital acquired pressure ulcers. Beyond the hospital’s financial implications,
pressure ulcers also cause the patient’s quality of life to suffer.
Again, using estimates from the literature, Beckrich and Aronovitch estimate that hospitals face
incremental costs of $125 - $200 ($187 - $300 in 2009 dollars) for each Stage I and II pressure
ulcers and $14,000 to $23,000 ($20,984 to $34,474 in 2009 dollars) for each Stage III and Stage
IV pressure ulcer.
What the Experts Say About the Financial Implications of Pressure Ulcers.
http://www.sageproducts.com/documents/pdf/education/studies_articles/iad/20150b_W
hat_The_Experts_Say_About_The_Financial_Implications_of_Pressure_Ulcers.pdf.
This article and the next two articles provide literature reviews on costs associated with pressure
ulcers. Unlike the Beckrich and Aronovitch article, these articles don’t use the information from
the literature in a novel way to produce a new estimate of pressure ulcer costs. However, these
literature reviews do serve as a useful point of comparison for cost estimates from previous
articles. Also, these articles further demonstrate the broad range of costs associated with pressure
ulcers. This article is a fact sheet produced by Sage Products, a healthcare products firm. One
finding from the Sage Products literature review was particularly relevant. Robinson C, et al.
(2003) stated that the average hospital incurs between $400,000 and $700,000 a year on average
to treat pressure ulcers, which is typically non-reimbursable.
Kuhn BA and SJ Coulter. Balancing the pressure ulcer cost and quality equation.
Nursing Economic$ 1992;10(5): 353–9.
This older article reviews some literature on pressure ulcer cost and prevalence. Again, this type
of article provides useful context and a point of comparison to other articles found in the literature
review. The authors state that, “conservative national estimates show that 1.7 million patients
annually develop pressure ulcers with associated health care costs of $8.5 billion (Allman 1989).”
Also, “the costs associated with treating a single pressure ulcer can range from $5,000 to $40,000
(Maklebust, 1987).”
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Shoemake S and Stoessel K. The Clinical Issue – Pressure Ulcers in the Surgical
Patient: What the Experts Say About the Financial Implications of Pressure Ulcers.
Knowledge Network –Kimberly-Clark Health Care Education. Issue 1.
http://www.haiwatch.com/Upload/Tools/H0277-0701_CI_Pressure_Ulcer.pdf.
This article provides another literature review on the cost and treatment of pressure ulcer. It
produced similar findings as many of the other articles. The authors note that LOS can be
increased on average by 3.5 to 5 days (and could be as high as 15.6 days) for patients with
pressure ulcer (Aronovitch 1999; Price, Whitney, King, Doughty 2005; Allman, Good, Burst,
Bartolucci, Thomas 1999). The average cost associated with the pressure ulcer can range from
$5,000 to $60,000 with costs reaching as high as $90,000 for particularly severe pressure ulcers
(Sanders and Allen 2006). Sanders and Allen (2006) also found LOS increased by 6.5 days and
costs increased by $12,000 for patients with pressure ulcers. Insurers though did not typically
cover the increased cost, as average reimbursement from Medicare/Medicaid was only $1,600 per
patient, meaning the hospital was losing a substantial amount of money per pressure ulcer.
Although not a direct cost to the hospital, pressure ulcer incidence can also result in other
complications such as “bactermia, squamous cell carcinoma, sinus tract formation, osteomyelitis,
pyarthroses, amyloidois, and sepsis.” Additionally the authors stated there are emotional and
financial impacts the patients face such as, “pain, disfigurement, additional treatment, increased
hospital stay, loss of income, loss of independence and possibly even loss of life.”
2.2. Overview of Literature Review
Across the articles, there are many findings that show the difficulty in producing a single estimate
of the cost associated with pressure ulcers. There are many factors that influence the final cost
estimates. These include:
o
Factors influencing pressure ulcer costs:
o Pressure ulcer costs can cover individual pressure ulcers or multiple pressure
ulcers.
o The severity of a pressure ulcer (Stage I and II versus III and IV) has a large
impact on associated costs.
o Treatment options for a pressure ulcer may depend on the severity of the ulcer
and also characteristics of the hospital, both of which also impact the associated
costs of the pressure ulcer.
o Length of stay is major factor impacting the costs associated with a pressure
ulcer.
o Pressure ulcers may occur prior to the hospital stay or during the hospital
stay. Researchers examine both types and costs likely differ between the two.
o
Cost measurement:
o Different researchers consider different sets of costs when determining estimates
of pressure ulcer cost. Some researchers only consider direct costs of treatment
and assume hospitals would provide certain overhead items regardless of
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o
o
o
pressure ulcer status. Other authors argue that pressure ulcers lead to a longer
LOS and therefore overhead items should enter into the costs.
Pressure ulcer cost estimates may include only those costs incurred at the
hospital or may include those incurred at the hospital and after discharge.
Pressure ulcers can lead to other costs that go beyond the typical cost of care:
 Hospitals may incur lawsuits if they provide sub-par care that leads to a
pressure ulcer.
 Pressure ulcers reduce a patient’s quality of life, which the cost
calculations typically do not capture.
 Finally, hospitals may receive reduced payments from insurers if there
is a pressure ulcer that results from the hospital stay.
Methodological approaches:
o Many authors report unadjusted comparisons of patients with pressure ulcers
and those without to determine the incremental costs of pressure ulcers. The
most accurate incremental cost estimates would need to adjust those estimates to
account for those attributes that impact both the probability of having a pressure
ulcer and the overall cost of care in order to produce accurate incremental costs.
o In order to determine cost estimates, some authors study large administrative
databases while others look at a smaller set of providers (engaging in more
rigorous chart review). The downside to using administrative databases is that it
may be difficult to accurately measure costs associated with pressure ulcer or
whether a pressure ulcer is present on admission. However, looking at a smaller
set of providers may lead to biased estimates of cost if the providers are not
representative of a larger set of providers.
Because of these many differences in measuring costs associated with pressure ulcer, we look at a
range of estimates, using those that will work best with the data collected by MHA hospitals. In
Table 1, we summarize the cost estimates each article found. This table shows the broad range of
costs associated with pressure ulcers and the broad range of study and pressure ulcer
characteristics associated with those costs. As we later discuss, the cost estimates for Allman et
al. (1999) and Russo et al. (2006) seem to provide estimates that are most appropriate for the
MHA data. These estimates cover a wide range of costs that reflects the variability found in the
larger set of studies from the literature review. Table 2 more briefly summarizes several articles
cited by the authors of our literature review. These articles are typically older or are not as
relevant so were not directly included in the literature review. However, they bolster the results
of the literature review as their results are typically in line with the articles reviewed for this
report.
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Table 1: Summary of Estimates from the Literature on Costs Associated with Pressure Ulcers
Note: Bolded entries represent estimates used later in analysis
Authors
Year of
Data
Collection
Study
Population
Sample size
Data
Collection
Incremental
or Total
Costs
Articles Reviewed Directly (note, cost estimates are inflation adjusted to 2009 dollars)
Single urban
hospital.
Patients 55
years or
Allman,
older, had
Goode,
hip fracture
Chart
Burst,
1988 or confined
Incremental
286
review
Bartolucci,
1991
to bed for 5
and
days.
Thomas
Excluded
patients with
pressure
ulcer on
admission
Russo,
Steiner,
Spector
2006
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Nationwide
sample.
Patients 18
years or
older
Unweighted
sample size
not provided
Discharge
databases
Incremental
Control for
Patient
Characteristics
Costs
included
Estimate
Yes - age,
gender, race,
nosocomial
infections, MD
assessment,
nurse
classification
score
Charges
applied to a
cost to
charge ratio
●$2,728 per stay with
pressure ulcer
(first method)
●$22,124 per stay with
pressure ulcer
(second method)
No
Charges
applied to a
cost to
charge ratio.
No
physician
services
●$11,370 per stay with
pressure ulcer
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Table 1: Summary of Estimates from the Literature on Costs Associated with Pressure Ulcers
Note: Bolded entries represent estimates used later in analysis
Authors
Year of
Data
Collection
Study
Population
Sample size
Data
Collection
Incremental
or Total
Costs
Control for
Patient
Characteristics
Costs
included
Estimate
Articles Reviewed Directly (note, cost estimates are inflation adjusted to 2009 dollars)
Beckrich
and
Aronovitch
Xakellis and
Frantz
Kumar et al.
Used estimates from a review of literatures
1992
A long term
care facility in
the Midwest
1994 1998
New Mexico
Medicaid
beneficiaries.
Roughly half
the sample
were under
age 50
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Incremental
Used estimates from a literature
review
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Chart
review
Total
No
2,683
Medicaid
FFS claims
Total
No
12
Charges.
Physician
fees were not
included
Costs from
claims
(unclear if
these were
charges) for
hospital,
physician
visits, and
prescriptions
●Between $599,542 and
$1,049,198 annually on
average per hospital due
to pressure ulcers
● $187 - $300 per Stage I
and II pressure ulcer
● $20,984 to $34,474 per
Stage III and IV pressure
ulcer
● $3,690 per pressure
ulcer
● $6,029 per patient with
pressure ulcer
● $24,451 in annual
hospital costs per patient
with pressure ulcer
Table 2: Summary of Estimates Cited by Other Authors in the Literature Review
Authors
Estimate
Langemo (1991); Perdue
(1989)
$5,000 - $50,000 per pressure ulcer
Alterescu (1989)
$1,300 per pressure ulcer
Alterescu (1989)
Miller and DeLozier (1994)
$125.50 was the incremental cost of Stage I and Stage II ulcers (excludes overhead,
nursing, increased LOS)
$12,186 was the incremental charges associated with having a secondary diagnosis of
pressure ulcer
Inman, Sibbald, Rutledge
(1993)
Treating Stage II pressure ulcers in hospital equaled $1,886 in 1988 dollars
Sanders and Allen (2006)
Costs increased by $12,000 for patients with pressure ulcers
3.
Results
Based on the results from the literature review and also results from our previous study of
longitudinal trends in pressure ulcer rates, this section provides estimates of the cost reduction
associated with the recent decline in pressure ulcer rates at MHA member hospitals. We present
results separately for acute care hospitals and for specialty hospitals (using the same cost
estimates from the literature). It is important to note that our estimates of cost reductions
associated with pressure ulcer reductions are limited in a number of ways.
1. The pressure ulcer measures collected by MHA report the total number of patients with a
hospital-acquired stage II or greater pressure ulcer on the day of the prevalence
measurement. Hospitals collect and report this one-day measure on a quarterly
basis. Estimates from the literature examine costs associated with pressure ulcers for
specific stages, for a specific population of patients (e.g., surgical patients, Medicaid
patients), patients with multiple pressure ulcers, and pressure ulcers that aren’t
necessarily hospital acquired. As discussed previously, there are many factors that
influence the cost of a pressure ulcer. The MHA data are limited in that they only
provide a number for how many pressure ulcer events (covering a wider variety of
pressure ulcers) occurred. The MHA data do not provide the detail needed to determine
the many other factors associated with pressure ulcers that may influence costs. Even if
the MHA data did provide that detail, there are substantial differences in methodological
approaches to estimating costs in the literature, such that it would still be difficult to
properly account for the differences in our estimates. We present estimates of cost
reductions incorporating a range of incremental cost estimates from the literature, which
appropriately cover a plausible range of possible cost reductions.
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2. One pressure ulcer study we use was completed in 1999 and the other in 2006. We adjust
our estimates for inflation; however, the costs of treating a pressure ulcer may have
changed over time for reasons not related to inflation (e.g. improvements to pressure
ulcer treatment). We make no adjustments for these types of possible changes in
underlying costs.
Although there are many estimates of costs associated with pressure ulcers, we focus our analysis
on results from two papers, Allman et al. (1999) and Russo et al. (2006). We choose these two
papers because they appear to be the most complete and rigorous of the papers we reviewed. One
advantage of Russo et al (2006) is that the authors use a large nationwide sample to measures
costs. This data is somewhat similar to the pressure ulcer data collected by MHA in that it comes
from a broad range of hospitals. Allman et al. (1999) have a more focused review that relies on a
single hospital, but this was a beneficial article to include because the authors account for patient
variation that may impact pressure ulcers and costs. Of all the articles, Allman et al. (1999) most
carefully measured the incremental costs associated with hospital acquired pressure ulcers. Other
articles which were not used included hospital and non-hospital costs (Xakellis and Frantz 1996),
looked at a very specific population of patients (Kumar et al 2004), or used information on
pressure ulcer costs that was relatively old (Beckrich and Aronovitch 1999) compared to the two
articles we use.
3.1. Pressure Ulcers in MHA Hospitals Using the One Day
Measure
Table 3 provides the quarterly number of pressure ulcers collected during a single day of
measurement for MHA acute care hospitals for each of the hospital units for which MHA collects
data. We also present a combined count (adding together information from each individual unit)
and an annual total (adding together from the “combined” column over a four quarter period).
For each of the hospital units and the combined measures, the number of pressure ulcers has
fallen from the first reporting period to the last reporting period. By year, the number of pressure
ulcers overall has fallen from 675 in 2007, to 604 in 2008, to 484 in 2009 when considering just
the information collected during the one day measure.
Note that MHA hospitals did not report information on pressure ulcers for April through June of
2007 (marked in red in Table 3 – 6). As an estimate for what the April through June 2007
estimate would have been, we averaged together the results from April through June 2008 with
April through June 2009. We use this estimate to produce annual total costs of pressure ulcers
that are comparable across 2007, 2008, and 2009. This is a conservative estimate since pressure
ulcer rates were falling during this time and this method may produce a lower pressure ulcer rate
in 2007 than otherwise existed.
Finally, note that pressure ulcer reporting was optional in the 2nd and 4th quarter of each year and
therefore resulted in a reduced estimate of pressure ulcers compared to the 1st and 3rd quarters.
Abt Associates Inc.
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Table 3: Quarterly Number of Pressure Ulcers for MHA Acute Care Hospitals
(based on single day measure)
Time Period
Adult
Critical
Care
Adult
Step
Down
Adult
Medical
Adult
Surgical
Adult
MedicalSurgical
Combined
Annual
Total
Jan-Mar 2007
69
6
38
33
145
291
Apr-Jun 2007
27
6
16
11
32
91
Jul-Sep 2007
60
11
35
29
76
211
Oct-Dec 2007
23
6
15
5
33
82
Jan-Mar 2008
79
15
43
34
65
236
Apr-Jun 2008
16
4
21
13
31
85
Jul-Sep 2008
47
6
43
27
54
177
Oct-Dec 2008
25
13
22
7
39
106
Jan-Mar 2009
59
8
39
27
55
188
Apr-Jun 2009
37
8
11
8
32
96
Jul-Sep 2009
48
10
27
22
41
148
Oct-Dec 2009
13
3
8
4
24
52
Note: Shaded cells represent the optional reporting periods. No data from Apr-Jun 2007 was
reported but results are imputed from other rows of data.
675
604
484
MHA specialty care hospitals also show similar trends. The number of pressure ulcers in these
hospitals fell from 76 in 2007, to 59 in 2008, to 51 in 2009.
Table 4: Quarterly Number of Pressure Ulcers for
MHA Specialty Care Hospitals
(based on single day measure)
Time Period
Combined
Annual Total
Jan-Mar 2007
44
Apr-Jun 2007
7
Jul-Sep 2007
20
Oct-Dec 2007
5
76
Jan-Mar 2008
30
Apr-Jun 2008
4
Jul-Sep 2008
23
Oct-Dec 2008
2
59
Jan-Mar 2009
21
Apr-Jun 2009
10
Jul-Sep 2009
19
Oct-Dec 2009
1
51
Note: Shaded cells represent the optional reporting
periods. No data from Apr-Jun 2007 was reported but
results are imputed from other rows of data.
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We report the number of pressure ulcers instead of pressure ulcer rates because estimates of costs
from the literature typically provide the estimate by pressure ulcer or by patient. Abt’s previous
report provides rates and showed that the rates were also falling over time. Tables 5 and 6 show
the denominators for each measure for both the acute care hospitals and specialty care hospitals.
These tables show that the number of patients has increased slightly over time in acute care
hospitals. In specialty hospitals, the number of patients fell slightly from 2007 to 2008 and then
increased from 2008 to 2009. For acute care hospitals, pressure ulcer reductions do not seem to
occur because hospitals treat fewer patients in later years. For specialty care hospitals, there was
a decrease in patients from 2007 to 2008 and then a roughly 5% increase in patients from 2008 to
2009. However, that percentage increase is smaller than the corresponding percentage reduction
in pressure ulcers from 2008 to 2009 implying the reduction in pressure ulcers wasn’t solely
driven by reduced patient volume.
Table 5: Quarterly Number of Patients Eligible for the Pressure Ulcer Measure for MHA Acute
Care Hospitals
(based on single day measure)
Adult
Adult
Adult
Annual
Adult
Adult
MedicalCombined
Time Period
Critical
Step
Total
Medical
Surgical
Surgical
Care
Down
Jan-Mar 2007
996
376
1,455
939
3,919
7,685
Apr-Jun 2007
522
283
1,029
639
2,197
4,669
Jul-Sep 2007
900
346
1,598
1,017
3,567
7,428
Oct-Dec 2007
429
97
814
603
1,461
3,404
23,186
Jan-Mar 2008
987
464
2,038
1,686
3,450
8,625
Apr-Jun 2008
510
282
1,085
760
2,140
4,777
Jul-Sep 2008
853
416
1,846
1,212
2,994
7,321
Oct-Dec 2008
549
252
1,011
491
2,179
4,482
25,205
Jan-Mar 2009
925
476
1,852
1,039
3,403
7,695
Apr-Jun 2009
533
283
973
518
2,254
4,561
Jul-Sep 2009
905
474
1,805
1,075
3,337
7,596
Oct-Dec 2009
451
265
702
370
2,137
3,925
23,777
Note: Shaded cells represent the optional reporting periods. No data from Apr-Jun 2007 was
reported but results are imputed from other rows of data.
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Table 6: Quarterly Number of Patients Eligible for
the Pressure Ulcer Measure for MHA Specialty Care
Hospitals
(based on single day measure)
Time Period
Combined
Annual Total
Jan-Mar 2007
862
Apr-Jun 2007
367
Jul-Sep 2007
775
Oct-Dec 2007
375
2,379
Jan-Mar 2008
794
Apr-Jun 2008
275
Jul-Sep 2008
773
Oct-Dec 2008
301
2,143
Jan-Mar 2009
772
Apr-Jun 2009
458
Jul-Sep 2009
783
Oct-Dec 2009
251
2,264
Note: Shaded cells represent the optional reporting
periods. No data from Apr-Jun 2007 was reported but
results are imputed from other rows of data.
Using the annual number of pressure ulcers found in Tables 3 and 4 and results from the literature
review (Table 1), we are able to determine estimates of the costs associated with pressure ulcers
and reductions of these costs over time for the one day measure. We adjust the cost estimates
from the literature to be equivalent to 2009 dollars using the Medical Consumer Price Index
shown in Appendix 1.
To determine costs associated with pressure ulcers, we multiplied two parameters: (1) the annual
total number of patients with pressure ulcers reported by MHA hospitals (using the single day
measure) and (2) one of the estimates from the literature regarding the costs associated with
pressure ulcer. Table 7 (acute care hospitals) and Table 8 (specialty care hospitals) show these
results. Because of the range of cost estimates ($2,728 through $22,124), the range of costs
associated with pressure ulcers is large. For example, in 2007, MHA acute care hospitals
reported 675 pressure ulcers. Using findings from the literature, the estimate of costs associated
with pressure ulcers for MHA hospitals ranges from $1.8 million to $14.9 million using
information from the one day measure. In 2007 for specialty care hospitals, costs associated with
the 76 pressure ulcers ranged from $0.2 million to $1.7 million.
We then use those cost estimates to compute reductions in cost when looking across years.
Because the number of pressure ulcers has declined over time, the costs associated with pressure
ulcers using our simple approach have also declined over time. Table 9 (acute care hospitals) and
Table 10 (specialty care hospitals) show the reductions in cost associated with the reduction in
pressure ulcers. For example, Table 9 shows that between 2007 and 2008 the number of pressure
ulcers fell by 71 and this was associated with a decline in costs ranging between $193,710and
$1.6 million.
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Table 7: Annual Costs Associated with Pressure Ulcers in MHA Acute
Care Hospitals Using Estimates from the Literature
(based on single day measure)
Cost Per Pressure Ulcer Estimate
Year
Pressure
Ulcers
Allman,
Goode,
Burst
(1999)
Allman,
Goode,
Burst
(1999)
Russo,
Steiner,
Spector
(2006)
$2,728
$22,124
$11,370
2007
675
$1,841,608
$14,933,893
$7,674,928
2008
604
$1,647,898
$13,363,068
$6,867,639
2009
484
$1,320,501
$10,708,154
$5,503,207
Table 8: Annual Costs Associated with Pressure Ulcers in MHA
Specialty Care Hospitals Using Estimates from the Literature
(based on single day measure)
Cost Per Pressure Ulcer Estimate
Year
2007
2008
2009
Pressure
Ulcers
76
59
51
Allman,
Goode,
Burst
(1999)
Allman,
Goode,
Burst
(1999)
Russo,
Steiner,
Spector
(2006)
$2,728
$22,124
$11,370
$207,351
$160,970
$139,144
$1,681,446
$1,305,333
$1,128,339
$864,140
$670,846
$579,883
Table 9: Reduction in Annual Costs Associated with Pressure Ulcers in MHA Acute Care
Hospitals Using Estimates from the Literature
(based on single day measure)
Cost Per Pressure Ulcer Estimate
Russo,
Allman,
Allman,
Steiner,
Goode,
Pressure
Goode,
Spector
Burst
Years Examined
Ulcer
Burst (1999)
(2006)
(1999)
Reduction
Between 2007 and 2008
Between 2008 and 2009
Between 2007 and 2009
Abt Associates Inc.
71
120
191
$2,728
$22,124
$11,370
$193,710
$327,397
$521,107
$1,570,824
$2,654,914
$4,225,738
$807,289
$1,364,432
$2,171,720
18
Table 10: Reduction in Annual Costs Associated with Pressure Ulcers in MHA Specialty Care
Hospitals Using Estimates from the Literature
(based on single day measure)
Cost Per Pressure Ulcer Estimate
Russo,
Allman,
Allman,
Steiner,
Goode,
Pressure
Goode,
Spector
Burst
Years Examined
Ulcer
Burst (1999)
(2006)
(1999)
Reduction
$2,728
$22,124
$11,370
Between 2007 and 2008
Between 2008 and 2009
Between 2007 and 2009
17
8
25
$46,381
$21,826
$68,208
$376,113
$176,994
$553,107
$193,294
$90,962
$284,257
3.2. Extrapolation of Pressure Ulcers and Cost Savings to an
Annual Basis
As noted previously, the MHA pressure ulcer measure is based on a one day count (occurring
quarterly) of patients eligible to be included in the denominator of the measure and the number of
pressure ulcers in that population. The annual number of hospital acquired pressure ulcers for a
single hospital is likely to be much higher than summing the quarterly MHA measure for an
entire year because that measure does not count patients with a hospital stay or pressure ulcer
outside of the measurement period.
We estimate the annual number of hospital acquired pressure ulcers for MHA hospitals by
comparing the annual number of discharges in MHA hospitals to the number of patients MHA
hospitals record as eligible to be included in the pressure ulcer measure.
Table 11 shows that MHA acute care hospitals had 772,986, 767,511, and 776,264 discharges in
2007, 2008, and 2009 respectively.3 The actual number of recorded discharges is slightly higher,
however we adjust the number of discharges downward to exclude hospital stays where the
patient is under 18 years of age since the MHA pressure ulcer measure excludes patients under 18
years of age.4 We do not know the number of discharges by MHA hospitals for patients 18 years
or older. Instead, we reduce the total number of reported MHA discharges by 8.1%, which
corresponds to an estimate from the National Center for Health Statistics that 8.1% of hospital
discharges in 2007 (on a nationwide level) were pediatric.
The number of stays MHA hospitals reported as being eligible to be counted towards the measure
is also recorded in Table 11. We take the ratio of the annual number of non-pediatric stays to the
number of stays eligible to be counted towards the measure as shown in Table 11. We multiply
that ratio by the number of pressure ulcers recorded during the four single day reporting periods
3
Hospital specific discharge data is shown in Appendix Tables 2 and 3
National Center for Health Statistics. Health, United States, 2010: With Special Feature on Death and
Dying. Hyattsville, MD. 2011.
4
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for each year. Using this approach, we estimate that MHA acute care hospitals had 23,186,
23,205, and 23,777 hospital acquired pressure ulcers during 2007, 2008, and 2009 respectively.
Table 12 shows a similar approach for estimating the annual number of pressure ulcers in MHA
specialty hospitals. We estimate that MHA specialty hospitals had 2,379, 2,143, and 2,264
pressure ulcers during 2007, 2008, and 2009 respectively.
It is important to note that the ratio between the total annual discharges and the stays recorded in
the MHA pressure ulcer measure correspond to slightly different populations. While we make
assumptions to remove pediatric discharges, the pressure ulcer measure also excludes other
individuals from the measure. For example, some patients may refuse to be included in the
population or some patients may be too ill to be examined and included in the population
measure. Ideally, we would also exclude similar stays from the total annual discharge number.
However, we have no estimate of the percentage of patients excluded from the MHA single day
measure. This will cause us to overestimate the ratio of total discharges to stays in the MHA
measure causing our estimate of the annual number of pressure ulcers to be too high.
Based on the assumptions made in this approach, Tables 13 and 14 show the annual costs
associated with pressure ulcers when using this extrapolation of the MHA pressure ulcer measure.
Tables 15 and 16 show the reduction in annual costs using this extrapolated pressure ulcer
measure. We find the reduction in the two year (from 2007 – 2009, using 2007 as the baseline
year) costs for acute care hospitals using the extrapolated measures ranges from $18.3 million to
$148.3 million depending on the cost estimate used. For MHA specialty hospitals there is a
reduction in costs that ranges from $353,179 to $2.9 million over the two year period using the
extrapolated measure.
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Table 11: Estimate of Annual Number of Hospital Acquired Pressure Ulcers in MHA Acute Care
Hospitals
Ratio of
Annual
Discharges to
Discharges
Pressure
Ulcers
Stays During
During
Reported
Pressure
Pressure
Pressure
During
Ulcers
Ulcer
Ulcer
Reporting
Extrapolated
Total
Reporting
Reporting
Period
Period
to Entire Year
Year
Discharges
Period
2007
2008
2009
772,986
23,186
33.338
675
22,503
767,511
25,205
30.451
604
18,392
776,264
23,777
32.648
484
15,801
Table 12: Estimate of Annual Number of Hospital Acquired Pressure Ulcers in MHA Specialty Care
Hospitals
Ratio of
Annual
Pressure
Discharges to
Discharges
Ulcers
Stays During
During
Reported
Pressure
Pressure Ulcer Pressure Ulcer
During
Ulcers
Total
Reporting
Reporting
Reporting
Extrapolated
Year
Discharges
Period
Period
Period
to Entire Year
2007
2008
2009
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15,087
2,379
6.342
76
482
15,011
2,143
7.005
59
413
15,651
2,264
6.913
51
353
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Table 13: Annual Costs Associated with Pressure Ulcers (Extrapolated to Entire Year) in
MHA Acute Care Hospitals Using Estimates from the Literature
Cost Per Pressure Ulcer Estimate
Allman, Goode,
Burst
Allman, Goode,
Burst (1999)
(1999)
Russo, Steiner,
Spector (2006)
Year
Pressure
Ulcers
$2,728
$22,124
$11,370
2007
22,503
$61,389,446
$497,866,605
$255,864,369
2008
18,392
$50,174,064
$406,910,188
$209,119,908
2009
15,801
$43,106,418
$349,591,785
$179,662,746
Table 14: Annual Costs Associated with Pressure Ulcers (Extrapolated to Entire Year) in
MHA Specialty Care Hospitals Using Estimates from the Literature
Cost Per Pressure Ulcer Estimate
Allman, Goode,
Burst
Allman, Goode,
Burst (1999)
(1999)
Russo, Steiner,
Spector (2006)
Year
Pressure
Ulcers
$2,728
$22,124
$11,370
2007
482
$1,314,907
$10,663,861
$5,480,388
2008
413
$1,127,340
$9,142,694
$4,698,627
2009
353
$961,728
$7,799,589
$4,008,377
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Table 15: Reduction in Annual Costs Associated with Pressure Ulcers (Extrapolated to Entire Year)in MHA Acute
Care Hospitals Using Estimates from the Literature
Cost Per Pressure Ulcer Estimate
Allman,
Goode, Burst
(1999)
Russo,
Steiner,
Spector (2006)
Years Examined
Pressure
Ulcer
Reduction
Allman, Goode,
Burst (1999)
$2,728
$22,124
$11,370
Between 2007 and 2008
Between 2008 and 2009
Between 2007 and 2009
4,111
2,591
6,702
$11,215,382
$7,067,646
$18,283,028
$90,956,417
$57,318,403
$148,274,820
$46,744,462
$29,457,162
$76,201,623
Table 16: Reduction in Annual Costs Associated with Pressure Ulcers (Extrapolated to Entire Year) in MHA Specialty
Care Hospitals Using Estimates from the Literature
Cost Per Pressure Ulcer Estimate
Allman, Goode,
Burst (1999)
Allman,
Goode, Burst
(1999)
Russo,
Steiner,
Spector (2006)
Years Examined
Pressure
Ulcer
Reduction
$2,728
$22,124
$11,370
Between 2007 and 2008
Between 2008 and 2009
Between 2007 and 2009
69
61
129
$187,568
$165,612
$353,179
$1,521,167
$1,343,104
$2,864,272
$781,760
$690,250
$1,472,011
4.
Conclusion
Pressure ulcers in a hospital setting are costly. In addition to the increased direct care costs
associated with treatment, several forms of indirect costs can also occur. For example, these
could include increased length of stay, decreased quality of life for the patient, or reduced
reimbursements for the provider. Through a targeted review of the literature, it does not appear
that authors have achieved a consensus for the best approach to measure the magnitude of the
costs associated with pressure ulcers. Each article we reviewed had differences in the costs that
were included, the types of pressure ulcers studied, the patient population, provider
characteristics, and other confounding variables that may impact the cost associated with pressure
ulcers in a hospital setting. This is reflected in the rather broad range of estimates associated with
the cost per pressure ulcer. We picked two studies from the literature to represent the cost
estimates associated with pressure ulcers (Allman et al. 1999 and Russo et al. 2006). These
studies were chosen because the first controlled for a variety of patient characteristics when
measuring the incremental cost associated with pressure ulcers and the second examines a
nationwide population of hospital patients using a measure that is somewhat similar to the one
reported by MHA. The cost estimates from these two studies range from $2,728 to $22,124 per
pressure ulcer.
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MHA hospitals have seen a reduction in the number of pressure ulcers since 2007. Applying the
cost estimates from the literature to the hospital acquired pressure ulcer reduction using measures
collected quarterly during a single day, MHA acute care hospitals have experienced an estimated
decline in costs associated with pressure ulcers from $521,107 per year to $4.2 million over a two
year period (from 2007 – 2009, using 2007 as the baseline year), depending on the t specific cost
estimate used in the calculation. For specialty care hospitals, comparable estimates of the two
year cost reduction ranged from $68,208 to $553,107.
Because the MHA single day estimate may not capture many of the hospital acquired pressure
ulcer that occur during a year, we extrapolate the single day measure to create an annual estimate
of the number of hospital acquired pressure ulcers in MHA hospitals. Using that measure, we
find that MHA acute care hospitals have experienced an estimated decline in costs associated
with pressure ulcers from $18.3 million to $148.3 million over a two year period (from 2007 –
2009, using 2007 as the baseline year), depending on the specific cost estimate used in the
calculation. For specialty care hospitals, comparable estimates of annual cost reductions ranged
from $353,179 to $2.9 million per year.
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Allman RM, Damiano A, and Strauss M. Pressure ulcer status and post discharge resource
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Allman RM, Goode P, Burst N, Bartolucci A, and Thomas D. Pressure ulcer, hospital
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Allman RM, LaPrade CA, Noel LB, Walker JM, Moorer CA, Dear MR, et al. Pressure sores
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Beckrich K and Aronovitch SA. Hospital-Acquired Pressure Ulcers: A Comparison of Costs In
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Miller H and DeLozier J. Cost implications of the pressure ulcer treatment guideline. 1994.
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National Center for Health Statistics. Health, United States, 2010: With Special Feature on Death and
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Perdue R. Decubitus ulcers. Journal of the American Board of Family Practice 1989;2:43-48.
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Russo CA, Steiner C, and Spector W. Hospitalizations Related to Pressure Ulcers, 2006. HCUP
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Appendix Tables
We used the values shown in Appendix Table 1 to adjust the cost estimates from the literature
into 2009 dollars.
Appendix Table 1: Medical Care Consumer Price Index
(All urban consumers)
Year
Weight
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
Abt Associates Inc.
228.2
234.6
242.1
250.600
260.800
272.800
285.600
297.100
310.100
323.200
336.200
351.054
364.065
375.613
388.436
27
Appendix Table 2: MHA Acute Care Hospital Annual Discharges
(Note, estimates of discharges of patients 18 years and older were estimated using all
discharges and a nationwide estimate of pediatric discharges)
Hospital Name
2007
2008
2009
Anna Jaques Hospital
8,142
7,700
8,218
972
984
935
Baystate Franklin Medical Center
4,811
4,687
4,425
Baystate Mary Lane Hospital
1,719
1,728
1,673
Baystate Medical Center
38,608
38,197
38,164
Berkshire Medical Center - Berkshire Campus
11,655
11,758
11,384
2,524
2,438
2,325
Beth Israel Deaconess Medical Center - East Campus
40,039
41,895
40,973
Boston Medical Center - East Newton Campus
10,737
5,759
Boston Medical Center - Harrison Avenue Campus
18,724
23,669
30,265
Brigham and Women's Hospital
51,903
52,052
52,695
Cambridge Health Alliance - Cambridge Campus
7,018
6,978
7,242
Cambridge Health Alliance - Somerville Campus
4,732
4,102
2,338
Cambridge Health Alliance - Whidden Memorial Campus
5,589
4,607
4,261
16,830
16,985
17,177
6,727
6,447
6,409
Caritas Good Samaritan Medical Center - Brockton Campus
13,167
13,576
14,058
Caritas Holy Family Hospital and Medical Center
11,359
11,668
10,889
Caritas Norwood Hospital
12,991
12,527
12,778
5,968
6,336
5,874
Caritas St. Elizabeth's Medical Center
14,580
14,180
13,203
Children's Hospital Boston
17,330
17,870
18,348
Clinton Hospital
1,393
1,428
1,263
Cooley Dickinson Hospital
8,919
8,350
9,049
Athol Memorial Hospital
Beth Israel Deaconess Hospital - Needham
Cape Cod Hospital
Caritas Carney Hospital
Caritas Saint Anne's Hospital
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Appendix Table 2: MHA Acute Care Hospital Annual Discharges
(Note, estimates of discharges of patients 18 years and older were estimated using all
discharges and a nationwide estimate of pediatric discharges)
Hospital Name
2007
2008
2009
982
952
991
Emerson Hospital
9,091
8,901
8,893
Fairview Hospital
1,351
1,370
1,383
Falmouth Hospital
6,586
6,367
6,688
Faulkner Hospital
8,169
6,843
7,583
Hallmark Health System - Lawrence Memorial Hospital Campus
5,461
5,025
5,149
Hallmark Health System - Melrose-Wakefield Hospital Campus
11,341
10,803
10,238
3,160
2,983
3,727
839
815
840
Health Alliance Hospital -- Leominster Campus
7,895
7,528
7,995
Heywood Hospital
4,999
5,638
5,604
Holyoke Medical Center
7,700
7,550
7,139
Hubbard Regional Hospital
1,234
1,077
519
Jordan Hospital
11,725
10,812
11,768
Lahey Clinic -- Burlington Campus
20,267
21,049
21,596
Lawrence General Hospital
12,568
12,492
12,570
Lowell General Hospital
12,542
14,527
15,790
Martha's Vineyard Hospital
1,216
1,191
1,159
Massachusetts Eye and Ear Infirmary
1,205
344
1,305
Massachusetts General Hospital
50,131
50,450
50,765
Mercy Medical Center - Springfield Campus
12,624
12,519
12,610
4,243
4,172
4,134
11,109
10,480
10,552
4,739
4,279
4,807
Dana-Farber Cancer Institute
Harrington Memorial Hospital
Health Alliance Hospital -- Burbank Campus
Merrimack Valley Hospital
MetroWest Medical Center - Framingham Campus
MetroWest Medical Center - Leonard Morse Campus
Abt Associates Inc.
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Appendix Table 2: MHA Acute Care Hospital Annual Discharges
(Note, estimates of discharges of patients 18 years and older were estimated using all
discharges and a nationwide estimate of pediatric discharges)
Hospital Name
2007
2008
2009
Milford Regional Medical Center
9,357
9,173
8,892
Milton Hospital
4,550
4,481
4,540
Morton Hospital and Medical Center
7,971
7,647
7,816
14,464
14,165
14,407
660
637
620
Nashoba Valley Medical Center
2,271
1,914
1,791
New England Baptist Hospital
7,138
7,132
7,044
17,713
18,265
17,517
Noble Hospital
3,414
3,551
3,486
North Adams Regional Hospital
3,621
3,522
3,171
North Shore Medical Center, Inc. - Salem Campus
16,581
16,142
16,058
North Shore Medical Center, Inc. - Union Campus
6,041
5,682
5,393
Northeast Hospital Corporation - Addison Gilbert Campus
2,607
2,586
2,582
17,711
18,106
18,879
Quincy Medical Center
7,300
6,622
6,546
Saint Vincent Hospital
18,045
18,406
18,293
Saints Medical Center
8,112
7,329
6,302
Signature Healthcare Brockton Hospital
14,958
14,469
15,093
South Shore Hospital
23,329
24,402
25,784
Southcoast Hospitals Group - Charlton Memorial Campus
17,064
16,147
15,654
Southcoast Hospitals Group - St. Luke's Campus
18,299
18,575
18,233
Southcoast Hospitals Group - Tobey Hospital Campus
4,078
4,310
4,717
Sturdy Memorial Hospital
6,813
6,865
6,909
17,323
17,431
19,426
Mount Auburn Hospital
Nantucket Cottage Hospital
Newton-Wellesley Hospital
Northeast Hospital Corporation - Beverly Campus
Tufts Medical Center
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Appendix Table 2: MHA Acute Care Hospital Annual Discharges
(Note, estimates of discharges of patients 18 years and older were estimated using all
discharges and a nationwide estimate of pediatric discharges)
Hospital Name
2007
2008
2009
UMass Marlborough Hospital
3,728
3,570
4,157
UMass Memorial Medical Center - Memorial Campus
23,663
22,278
22,904
UMass Memorial Medical Center - University Campus
20,089
20,500
22,919
2,745
2,745
3,158
13,857
14,419
14,641
Total Discharges
841,116
835,159
844,683
Total Discharges - 18 and over
(Assuming a 8.1% Pediatric Discharge Rate)
772,986
767,511
776,264
UMass Wing Memorial Hospital
Winchester Hospital
Appendix Table 3: MHA Specialty Hospital Annual Discharges of Patients 18 and Older
(Note, estimates of discharges of patients 18 years and older were estimated using all discharges and a nationwide
estimate of pediatric discharges)
Hospital Name
2007
2008
2009
Rehab Hospital of the Cape and Islands
Spaulding Rehab
Shaughnessy-Kaplan
N.E. Sinai
HealthSouth New England Rehab Hospital
Hebrew Rehab
HealthSouth Rehab of Western Mass
Fairlawn
HealthSouth Braintree Rehab Hospital
Total Discharges
1,251
2,512
1,960
1,839
2,441
1,386
1,030
1,788
2,210
16,417
1,099
2,641
1,813
1,863
2,488
1,439
1,106
1,892
1,993
16,334
1,143
2,625
1,913
1,998
2,561
1,415
1,199
2,040
2,136
17,030
Total Discharges - 18 and over
(Assuming a 8.1% Pediatric Discharge Rate)
15,087
15,011
15,651
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Appendix 2 – Articles Found in the Search That
Weren’t Relevant
K Clever, G Smith, C Bowser, and K Monroe. Evaluating the Efficacy of a Uniquely
Delivered Skin Protectant and Its Effect on the Formation of Sacral/Buttock Pressure
Ulcers. 2002, 48(12),
Not relevant. Does not deal with costs. Did cite sources that stated, “Pressure ulcers tracked
across multiple healthcare setting cost, on average, between $1,119 and $10,185 to treat while the
management of severe wounds may cost as much as $55,000.”
Defloor, T, van Engelshoven, I, van Ramshorst, B, Buskens, E. Economic evaluation of
pressure ulcer care: a cost minimization analysis of preventive strategies. Nursing
Economics, 2009, 27:390-400, 415.
This article focused on Netherland hospitals and therefore not relevant to this analysis
KJ Inman, WJ Sibbald, FS Rutledge, BJ Clark. Clinical utility and cost-effectiveness of an
air suspension bed in the prevention of pressure ulcers
JAMA. 1993; 269(9):1139-1143.
Looks at cost-effectiveness of a very specific component of pressure ulcer treatment.
Javitz HS, Ward MM, Martens L. Major Costs Associated with Pressure Sores. J Wound
Care. 1998 Jun; 7(6):286-90.
Talks abut the cost drivers – but not the costs
Lapsley, HM and Vogels R. Cost and Prevention of Pressure Ulcers in an Acute Teaching
Hospital. International Journal [or Quality in Health Care, Vol. 8, No. 1, pp. 61-66, 1996.
http://intqhc.oxfordjournals.org/content/8/1/61.full.pdf
Not relevant – study takes place in an Australian hospital.
Lyder CH, Shannon R, Empleo-Frazier O, McGeHee D, White C.
Ostomy Wound Management. A comprehensive program to prevent pressure ulcers in
long-term care: exploring costs and outcomes. 2002 Apr; 48(4):52-62.
Only deals with long term care – Not Relevant.
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Kerstein MD, Gemmen E, van Rihswijk L., Lyder CH, Phillips T., Xaellis G, Golden K,
Harrington C. Cost and cost effectiveness of venous and pressure ulcer protocols of care.
Disease Management & Health Outcomes. 2001, 9(11): 651-636(-14)
Not Relevant – Contains no information on cost of treating pressure ulcer
K Whittington, M Patrick, and JL Roberts. A national study of pressure ulcer prevalence
and incidence in acute care hospitals. Journal of Wound Ostomy. 2000. Jul 27(4): 209 – 15.
Article only talks about pressure ulcer prevalence in hospitals – not relevant to cost issues.
Abt Associates Inc.
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