The Burden of Pressure Ulcers in Spain

Disclosure: Joan Enric Torra i Bou, Lorena San Miguel, and John Posnett are paid employees of Smith & Nephew.

Today it is well known that pressure ulcers are an important problem for all healthcare systems.^1–3 However, there are still few published studies in the literature aimed at measuring the economic impact of this condition. A portion of these studies are based on general assumptions.⁴
Quantifying the cost of treating pressure ulcers provides information that helps highlight the magnitude of the problem. It also offers an incentive for clinicians, researchers, and managers to evaluate their clinical and nursing interventions, ensuring the most effective means are used to prevent and heal pressure damage. This type of analysis can also assist in identifying parameters, which have the greatest impact on overall costs.
This study was undertaken taking into account the importance of having reliable data to measure the size of the problem, and combined publicly available Spanish epidemiology data with national costs to produce cost estimates for treating patients with pressure ulcers throughout Spain.

Methods

A bottom-up costing approach was used to estimate expected weekly treatment cost per patient, expected cost per episode of care, and national costs of pressure ulcer treatment in Spain by ulcer grade and treatment setting.
Data on the number or pressure ulcers by grade and main care setting (hospital, primary care, or residential care) was derived from the 2nd National Prevalence Study of Pressure Ulcers carried out in Spain in 2005 by the National Group for the Advice and Study of Pressure and Chronic Ulcers (GNEAUPP).⁵
Data on expected time to heal by ulcer grade was taken from an analysis of questionnaires completed by a panel of experts. The panel consisted of the participants in the 2nd National meeting of Pressure Ulcer Commissions organized by the GNEAUPP in La Rioja, Spain in November 2005.
The questionnaires captured information on treatment protocols, expected time to heal (by ulcer grade, wound area, and care setting), time required to clean and dress the wound, incidence of local and systemic infection, length of stay, and percentage of ulcers healed in each treatment setting. The experts completed a total of 77 questionnaires: 26% from primary care centers, 66.2% from hospitals, and 7.8% from residential care centers.
Costs were estimated in 2 stages: (A) information on healthcare resources (dressings and other materials, nursing and medical time, hospital and residential bed-days) required to treat pressure ulcers by ulcer grade, and treatment setting was obtained from the clinical expert questionnaire; (B) information on the unit costs of resources in Spain in 2006 was derived from representative national sources or in cases where this was not possible from local sources.
An assumption was made that best practice was used. Best practice was defined as “moist wound healing,” which would include dressings that promote and maintain a moist wound environment and/or interact with the wound bed, such as foams, collagen, or silver dressings.
Traditional dressings, which are believed to be more expensive when considering overall cost of treatment, were described as “gauze-based dressings.”
Weekly treatment costs per patient and costs per episode include the cost of dressing changes, the cost of treating a wound infection, and the cost of additional hospital or residential care admission.
Cost of dressing changes (per week) = weekly frequency of dressing change* (cost of nurse time per change + cost of dressings and other materials per change). The cost of dressing changes includes nurse travel time for patients treated in primary care settings.
Expected cost of dressing changes per patient (per episode of care) = weekly cost* expected weeks of treatment required to heal the ulcer. Episode length is the time required to heal the ulcer and is dependent on the grade of ulcer.
Expected cost of infection (per patient) = probability of infection (local or systemic*) cost to resolve the infection. The probability of infection is dependent on ulcer grade and was obtained from expert opinion since no hard data was available.
Cost of additional length of stay in hospital or residential care. For the majority of patients treated in hospital or residential care it is assumed that the patient was not admitted for the care of their ulcer. In these cases, no additional costs are included. Additional costs for hospital or residential care are included (A) for patients treated mainly in hospital or residential care, the proportion of the total episode length for which the patient was admitted specifically for the care of their ulcer, or for which discharge was delayed; and (B) for patients treated in primary care who are transferred to hospital or residential care for part of their ulcer care.
The daily cost of a bed-day was estimated to be €350 ($469) in the hospital setting,⁷ and €52.37 ($70.18) in residential care.⁸

Results

Treatment cost per patient per week is shown in Table 1. The care setting is the one in which the majority of care is delivered. A patient may move between care settings during a treatment episode.
Treatment cost per week increases with grade of ulcer in all care settings and this is a result of a number of factors – frequency of dressing change and the time required for a dressing change both tend to be higher for more severe ulcers. In addition, patients with a more severe ulcer are more likely to receive treatment for infection. Weekly treatment cost ranges between €13 ([$17.42], Grade I ulcer treated in residential care) to €794 ([$1064], Grade IV ulcer treated in hospital). For Grade 1 ulcers, weekly cost is highest in primary care because of the additional time required for a nurse to travel to the patient’s home. The relatively high cost of treating a Grade II ulcer in residential care is because a significant proportion of patients in this setting (7.5%) are admitted to the hospital as part of their treatment.
Table 2 shows average expected cost to heal an ulcer, by grade of ulcer and by main care setting. Costs increase with grade of ulcer in all care settings. In primary care cost per patient ranges from €108 ($145) to heal a Grade I ulcer to €2868 ($3843) to heal a Grade IV ulcer. There are 2 reasons for this—it takes longer to heal a more severe ulcer while the incidence of infection is higher. Patients with a Grade III or Grade IV ulcer are also more likely to be admitted to hospital for all or part of their treatment.
In order to calculate the annual national cost of treating pressure ulcers in Spain, per patient cost estimates were combined with available epidemiological data. This was taken from the 2nd National study of pressure ulcer prevalence carried out by the GNEAUPP,⁵ which provided estimates of the total number of patients treated with a pressure ulcer in a given week by main care setting and by grade of ulcer.
This prevalence study covered 1.86% of the population over 14 years of age in Spain (at January 2005), 6.61% of all Spanish acute hospital beds and 4.05% of the 265,712 beds available in residential care. Extrapolation of survey evidence to provide an estimate for Spain as a whole was based on national census data and official statistics from residential institutions.^9–11 Results are shown in Table 3. The authors’ estimate suggests that approximately 53,000 patients with a pressure ulcer are being treated in Spain at any given point in time. The average (mean) number of ulcers per patient was 1.6, meaning 53,000 patients had a total of close to 85,000 ulcers.
Overall, 49.8% of patients were treated for the most part in primary care, 19.8% were treated mainly in hospitals, while 30.4% were treated primarily in residential care. The distribution of ulcers by grade of the most severe ulcer was: Grade 1 = 21.0%, Grade II = 36.5%, Grade III = 29.6%, Grade IV = 12.9%.
Assuming the prevalence remains stable through the year; the annual cost of pressure ulcer treatment in Spain was calculated by combining the number of patients treated on a weekly basis with the weekly cost, by grade of ulcer and main care setting. Results are shown in Table 4. The estimated total cost of treating pressure ulcers in Spain is €461 million ([$618 million] based on 2005 costs).
National costs can also be grouped by cost components as shown in Figure 1. The cost of dressings and other materials accounted for 15% of the total national cost of treatment. The cost of nurse time accounted for 19% of the total. Despite the fact that no more than 20% of patients were treated mainly in hospital, the cost of hospital care accounted for 45% of total cost. The remaining 21% represented any additional stay in residential homes due to the ulcer.

Discussion

As this study shows, the cost of treating pressure ulcers in Spain is significant to both the healthcare system and to society, amounting to approximately 461 million euro ($618 million), or 5% of total annual health care expenditure.¹²
Taking into account that patients may move between care sectors, almost half of all patients (49.8%) were treated mainly in primary care, 20% in hospital, and 30% in residential care. Treatment costs are dominated by the relatively small number of patients who require hospital treatment or whose stay in residential care is prolonged because of their ulcer.
The cost of dressings and other materials accounted for close to 15% of total cost (67 million euro, $90 million). The cost of nurse time accounts for roughly 19% (89 million euro, $119 million). Despite the fact that ulcer care is labor-intensive, patients who are hospitalized or whose discharge is delayed because of their ulcer dominate treatment costs. The cost of ulcer-related hospital or residential care admission accounted for 66% of the total cost (306 million euro, $410 million). This highlights the importance of avoiding infection and other complications, which may lead to hospitalization.
Treatment costs increase consistently with ulcer severity and this is partly because healing time is longer and partly because the incidence of infection is higher the more severe the ulcer. This also highlights the importance of preventing pressure damage in the first instance and preventing an ulcer from becoming more severe. Patients with more severe ulcers are also more likely to be admitted to hospital.
Historically, pressure ulcers have not been regarded as an important public health issue in Spain. When comparing their cost with the costs associated with other indications considered key targets for any developed healthcare system (eg, AIDS or type 2 diabetes), one can gain a better understanding of the true dimensions of the problem.
According to data on infection by HIV and AIDS in Spain, published in 2006,¹³ the annual cost of antiretroviral treatment amounted to 422 million euro ($565 million) in 2004, compared with the cost of pressure ulcers (assuming the most effective treatment (moist wound healing) at 461 million euro ($618 million).
The annual cost per patient treated for type 2 diabetes according to data from 2001, was €1305 ($1749).^14,15 This can be compared with an average annual cost to treat a patient with a pressure ulcer of between €1298 ($1739) and €1695 ($2271), depending on the type of treatment chosen (moist wound healing or traditional dressings).
In addition to the financial strain on the healthcare system, many published articles have shown that pressure ulcers present a significant associated morbidity and mortality, diminishing the quality of life for those who suffer from them.
Allman⁴ indicated that not only do hospital stays increase up to 5-fold when patients develop a pressure ulcer, but many patients with pressure ulcers experience pain due to their general health state, although many cannot express the pain that is generated from these ulcers. Systemic infection is a frequent complication associated with pressure ulcers and having a pressure ulcer significantly increases the probability of dying,^16–19 which ranges from 2 to 4 times higher among both elderly people¹⁷ and patients in intensive care.¹⁸ Estimates throughout Spain state that for each 100,000 deaths, more than 165 are directly related to pressure ulcers.²⁰ In the 1988, Hibbs²¹ presented the problem of pressure ulcers as a “pandemic under the sheets,” illustrating didactically the severity of the problem.
A limitation of the study is that it was based on questionnaires completed by a panel of experts and therefore was dependent on the accuracy of their responses. However, it is important to mention that the response rate was high (77 questionnaires), and that caregivers tend to give estimates of incidence rates from their own care settings that are lower than actual rates, so the estimations made in this study are conservative and the overall costs would most likely be higher.
Furthermore, the authors would have liked to include in their calculations measures of quality of life for the patients and their families/caregivers because it would offer a better and more complete understanding of the global nature of the problem. These data would have significantly complicated the study and it was decided to not include such data in the analysis.

Conclusion

Due to the personal impact of pressure ulcers on patients and caregivers, and their overall impact on healthcare costs, it is imperative to achieve more cooperation between healthcare professionals, patients, caregivers, and administrators in order to develop effective interventions, which could help minimize the suffering of thousands of patients.
Effective interventions are likely to include early prevention measures to protect skin integrity and avoid pressure damage, timely and accurate diagnosis linked to appropriate treatment (including treatment of associated underlying conditions, such as diabetes or poor nutrition), and use of effective wound care dressings consistent with the principles of moist wound healing.