Redistribution Mattresses to Improve Prevention of Pressure Ulcers

Results of a cost-effectiveness analysis of evidence-based strategies to prevent pressure ulcers in long-term care [Arch Intern Med. 2011;171(20):1839-1847] show a clinical and economic benefit of using pressure redistribution foam mattresses for all long-term care residents, with some evidence also suggesting the cost-effectiveness of improving prevention with perineal foam cleansers and dry skin emollients.

The adverse health effects and high cost of pressure ulcers, particularly in residents living in long-term care facilities, have led to a number of strategies to improve prevention. A description of the cost implications of these different strategies is lacking.

To examine the cost-effectiveness of current prevention practices, investigators compared 4 quality improvement strategies that have some evidence-based support. These strategies included (1) replacing all standard mattresses in long-term care facilities with pressure redistribution mattresses, (2) providing daily oral nutritional supplements to high-risk residents with recent weight loss, (3) applying a skin emollient daily to dry skin of high-risk residents, and (4) replacing soap and water with a foam cleanser for high-risk residents who require bladder and/or bowel incontinence care. The primary outcomes of the study were assessment of the lifetime risk of stage 2 to 4 pressure ulcers, quality-adjusted life-years (QALYs), and lifetime costs expressed in 2009 Canadian dollars and calculated according to the perspective of a single healthcare payer.

To assess these outcomes, the study used a Markov model to simulate pressure ulcer–related health events whose likelihoods depended on the effectiveness of prevention. Key inputs used in the model included data from a population-based cohort of <8000 residents from 89 long-term care facilities in Ontario, Canada, that showed a 2.6% incidence of stage 2 to 4 pressure ulcers over 3 months. All patients included in this cohort had a full assessment that included physical functioning, cognition, nutritional status, skin health, incontinence, and at least 1 reassessment every 3 months or when health status changed.

Other inputs used in the model included data from a survey of 34 long-term care facilities; survey results found that standard mattresses are used in the majority of long-term beds (55%), and soap and water comprise care of incontinence in 50% of all care episodes.

Cost inputs included the base cost for nursing and personal care adjusted to reflect individual care. The mean weekly cost attributable to additional care was $106 for stage 2 ulcers and $128 for stage 3 and 4 pressure ulcers. Incremental costs of each of the 4 preventive strategies were included. The study found that on average the cost of the strategies averaged $11.66 per resident per week.

All the strategies reduced the lifetime risk of developing a pressure ulcer. Two strategies minimally improved QALYs: replacing all standard mattresses in long-term care facilities with pressure redistribution mattresses (strategy 1) reduced the mean lifetime cost by $115 per resident and replacing soap and water with a foam cleanser for high-risk residents who require bladder and/or bowel incontinence care (strategy 4) reduced the mean lifetime cost by $179 per resident. For strategy 2 (providing daily oral nutritional supplements to high-risk residents with recent weight loss) and strategy 3 (applying a skin emollient daily to dry skin of high-risk residents), the cost per QALY gained was about $78,000 and $7.8 million, respectively.

Overall, the study found that, if up to $50,000 is paid for 1 QALY gained, the probability that improving prevention is cost-effective is 94% for strategy 4, 82% for strategy 1, 43% for strategy 3, and 1% for strategy 2. Limitations of the study include inclusion of data from acute care patients, data obtained from older trials, and lack of repositioning strategies. Based on these results, the study supports the use of pressure redistribution mattresses for long-term care residents based on the clinical and economic improvements of this strategy to prevent pressure ulcers.

Although the study also suggests improved prevention and cost-effectiveness with perineal foam cleansers and dry skin emollients, clinical evidence remains limited and therefore no firm conclusions can be made.