Pressure injury in Australian public hospitals: a cost-of-illness studyKim-Huong Nguyen A D , Wendy Chaboyer B and Jennifer A. Whitty A C
A Centre for Applied Health Economics, School of Medicine and Griffith Health Institute, Griffith University, Qld 4131, Australia.
B NHMRC Centre of Research Excellence in Nursing, Research Centre for Health Practice Innovation, Griffith Health Institute, Qld 4215, Australia. Email: W.Chaboyer@griffith.edu.au
C School of Pharmacy, The University of Queensland, Brisbane, Qld 4072, Australia. Email: firstname.lastname@example.org
D Corresponding author. Email: email@example.com
Australian Health Review 39(3) 329-336 https://doi.org/10.1071/AH14088
Submitted: 3 June 2014 Accepted: 25 November 2014 Published: 2 March 2015
Objective Pressure injuries (PI) are largely preventable and can be viewed as an adverse outcome of a healthcare admission, yet they affect millions of people and consume billions of dollars in healthcare spending. The existing literature in Australia presents a patchy picture of the economic burden of PI on society and the health system. The aim of the present study was to provide a more comprehensive and updated picture of PI by state and severity using publicly available data.
Methods A cost-of-illness analysis was conducted using a prevalence approach and a 1-year time horizon based on data from the existing literature extrapolated using simulation methods to estimate the costs by PI severity and state subgroups.
Results The treatment cost across all states and severity in 2012–13 was estimated to be A$983 million per annum, representing approximately 1.9% of all public hospital expenditure or 0.6% of the public recurrent health expenditure. The opportunity cost was valued at an additional A$820 million per annum. These estimates were associated with a total number of 121 645 PI cases in 2012–13 and a total number of 524 661 bed days lost.
Conclusions The costs estimated in the present study highlight the economic waste for the Australian health system associated with a largely avoidable injury. Wastage can also be reduced by preventing moderate injuries (Stage I and II) from developing into severe cases (Stage III and IV), because the severe cases, accounting for 12% of cases, mounted to 30% of the total cost.
Additional keywords: opportunity cost, pressure ulcer, prevalence rate, treatment cost.
References State of Victoria. PUPPS 3: pressure ulcer point prevalence survey. Statewide report 2006. Melbourne: State Government of Victoria; 2006.
 Gallagher P, Barry P, Hartigan I, McCluskey P, O’Connor K, O’Connor M. Prevalence of pressure ulcers in three university teaching hospitals in Ireland. J Tissue Viability 2008; 17 103–9.
| Prevalence of pressure ulcers in three university teaching hospitals in Ireland.CrossRef | 18378140PubMed |
 Gorecki C, Brown JM, Nelson EA, Briggs M, Schoonhoven L, Dealey C, Defloor T, Nixon J. Impact of pressure ulcers on quality of life in older patients: a systematic review. J Am Geriatr Soc 2009; 57 1175–83.
| Impact of pressure ulcers on quality of life in older patients: a systematic review.CrossRef | 19486198PubMed |
 Nelson T. Pressure ulcers in Australia: patterns of litigation and risk management issues. Prim Intent 2003; 11 183–7.
 Vanderwee K, Grypdonck M, De Bacquer D, Defloor T. The identification of older nursing home residents vulnerable for deterioration of grade 1 pressure ulcers. J Clin Nurs 2009; 18 3050–8.
| The identification of older nursing home residents vulnerable for deterioration of grade 1 pressure ulcers.CrossRef | 19732245PubMed |
 Kottner J, Wilborn D, Dassen T, Lahmann N. The trend of pressure ulcer prevalence rates in German hospitals: results of seven cross-sectional studies. J Tissue Viability 2009; 18 36–46.
| The trend of pressure ulcer prevalence rates in German hospitals: results of seven cross-sectional studies.CrossRef | 19297160PubMed |
 Australian Commission on Safety and Quality in Health Care. Improvement guide standard 8: preventing and managing pressure injuries. Sydney: ACSQHC; 2012.
 Franks P. Pressure ulcers: cost to a nation, cost to an individual. Wound Manag 2007; 18–19.
 Russo A, Steiner C, Spector W. Hospitalizations related to pressure ulcers among adults 18 years and older, 2004. Healthcare Cost Util Proj 2008; 64 1–9.
 Mulligan S, Prentice J, Scott L. WoundsWest Wound Prevalence Survey 2011. Perth: Ambulatory care services, Department of Health; 2011. Available at: http://www.health.wa.gov.au/woundswest/docs/wound-prevalence-survey.pdf [verified 15 January 2015].
 Vanderwee K, Defloor T, Beeckman D, Demarre L, Verhaeghe S, Van Durme T, Gobert M. Assessing the adequacy of pressure ulcer prevention in hospitals: a nationwide prevalence survey. BMJ Qual Saf 2011; 20 260–7.
| Assessing the adequacy of pressure ulcer prevention in hospitals: a nationwide prevalence survey.CrossRef | 21209147PubMed |
 Gunningberg L, Stotts NA, Idvall E. Hospital-acquired pressure ulcers in two Swedish county councils: cross-sectional data as the foundation for future quality improvement. Int Wound J 2011; 8 465–73.
| Hospital-acquired pressure ulcers in two Swedish county councils: cross-sectional data as the foundation for future quality improvement.CrossRef | 21722316PubMed |
 Brem H, Maggi J, Nierman D, Rolnitzky L, Bell D, Rennert R, Golinko M, Yan A, Lyder C, Vladeck B. High cost of stage IV pressure ulcers. Am J Surg 2010; 200 473–7.
| High cost of stage IV pressure ulcers.CrossRef | 20887840PubMed |
 Brito PA, Generoso SDV, Correia MITD. Prevalence of pressure ulcers in hospitals in Brazil and association with nutritional status: a multicenter, cross-sectional study. Nutrition 2013; 29 646–9.
| Prevalence of pressure ulcers in hospitals in Brazil and association with nutritional status: a multicenter, cross-sectional study.CrossRef | 23466049PubMed |
 Vanderwee K, Clark M, Dealey C, Gunningberg L, Defloor T. Pressure ulcer prevalence in Europe: a pilot study. J Eval Clin Pract 2007; 13 227–35.
| Pressure ulcer prevalence in Europe: a pilot study.CrossRef | 17378869PubMed |
 Dealey C, Posnett J, Walker A. The cost of pressure ulcers in the United Kingdom. J Wound Care 2012; 21 261–266.
| The cost of pressure ulcers in the United Kingdom.CrossRef | 1:STN:280:DC%2BC38fnsVeguw%3D%3D&md5=135636e18fc57ae33d4d12c585adf1c1CAS | 22886290PubMed |
 Gunningberg L, Stotts NA. Tracking quality over time: what do pressure ulcer data show? Int J Qual Heal Care 2008; 20 246–53.
| Tracking quality over time: what do pressure ulcer data show?CrossRef |
 Shahin ESM, Dassen T, Halfens RJG. Incidence, prevention and treatment of pressure ulcers in intensive care patients: a longitudinal study. Int J Nurs Stud 2009; 46 413–21.
| Incidence, prevention and treatment of pressure ulcers in intensive care patients: a longitudinal study.CrossRef |
 Graves N, Birrell F, Whitby M. Effect of pressure ulcers on length of hospital stay. Infect Control Hosp Epidemiol 2005; 26 293–7.
| Effect of pressure ulcers on length of hospital stay.CrossRef | 15796283PubMed |
 House S, Giles T, Whitcomb J. Benchmarking to the international pressure ulcer prevalence survey J Wound Ostomy Cont Nurs 2011; 38 254–9.
| Benchmarking to the international pressure ulcer prevalence surveyCrossRef |
 Reddy M, Gill SS, Rochon PA. Preventing pressure ulcers: a systematic review. JAMA 2013; 296 974–84.
 Lyder CH, Wang Y, Metersky M, Curry M, Kliman R, Verzier NR, Hunt DR. Hospital-acquired pressure ulcers: results from the national medicare patient safety monitoring system study. J Am Geriatr Soc 2012; 60 1603–8.
| Hospital-acquired pressure ulcers: results from the national medicare patient safety monitoring system study.CrossRef | 22985136PubMed |
 Prentice J, Stacey M, Lewin G. An Australian model for conducting pressure ulcer prevalence surveys. Prim Intent 2003; 11 87–109.
 Graves N, Zheng H. The prevalence and incidence of chronic wounds: a literature review. Wound Pract Res 2014; 22 4–9.
 Asimus M, Li P. Pressure ulcers in home care settings: is it overlooked? Wound Pract Res 2011; 19 88–97.
 Asimus M, Li P, Kendall H. Pressure ulcer prevention interventions for community nursing patients. Wound Pract Res 2011; 19 19–22.
 Australian Wound Management Association. Pan Pacific Clinical Practice Guideline for the Prevention and Management of Pressure Injury. Perth: Cambridge Media Osborne Park, 2012.
 Allman R, Goode P, Burst N, Bartolucci A, Thomas D. Pressure ulcer, hospital complications and disease severity: impact on hospital costs and length of stay. Adv Wound Care 1999; 12 22–30.
| 1:STN:280:DyaK1M3lvVaisA%3D%3D&md5=5fafa8cdc29c9d9eb46b0a876d1ac5c0CAS | 10326353PubMed |
 Banks MD, Graves N, Bauer JD, Ash S. The costs arising from pressure ulcers attributable to malnutrition. Clin Nutr 2010; 29 180–6.
| The costs arising from pressure ulcers attributable to malnutrition.CrossRef | 19713015PubMed |
 Severens JL, Habraken JM, Duivenvoorden S, Frederiks CMA. The cost of illness of pressure ulcers in The Netherlands. Adv Skin Wound Care 2002; 15 72–7.
| The cost of illness of pressure ulcers in The Netherlands.CrossRef | 11984050PubMed |
 Bennett G, Dealey C, Posnett J. The cost of pressure ulcers in the UK. Age Ageing 2004; 33 230–5.
| The cost of pressure ulcers in the UK.CrossRef | 15082426PubMed |
 Graves N, Birrell FA, Whitby M. Modeling the economic losses from pressure ulcers among hospitalized patients in Australia. Wound Repair Regen 2005; 13 462–7.
| Modeling the economic losses from pressure ulcers among hospitalized patients in Australia.CrossRef | 16176454PubMed |
 Jackson T, Nghiem HS, Rowell D, Jorm C, Wakefield J. Marginal costs of hospital-acquired conditions: information for priority-setting for patient safety programmes and research. J Health Serv Res Policy 2011; 16 141–6.
| Marginal costs of hospital-acquired conditions: information for priority-setting for patient safety programmes and research.CrossRef | 21719478PubMed |
 State of Victoria. PUPPS 2 Pressure ulcer point prevalence survey: statewide report 2003. Melbourne: State Government of Victoria; 2003.
 State of Queensland. Patient safety: from learning to action 2012. Brisbane: Queensland Health; 2012.
 Antonio T, Conrad K. Clinical and economic improvements in pressure injury care at Ballarat Health Services. Wound Pract Res 2013; 21 4–10.
 Graves N, Zheng H. Modelling the direct health care costs of chronic wounds in Australia. Wound Pract Res 2014; 22 462–7.
 McEarlean B. South Australian pressure ulcer point prevalence survey report 2007. Adelaide: South Australia Department of Health; 2007.
 State of Victoria. VQC state wide PUPPS 2 report 2004: Pressure ulcer point prevalence survey. Melbourne: Metropolitan Health and Aged Care Services Division Victorian Government Department of Human Services; 2005.
 State of Queensland. 2012 Queensland bedside audit: inpatient report Gold Coast Hospital and Health Service. Queensland Health: Gold Coast; 2013.
 Pham B, Stern A, Chen W, Sander B, John-Baptiste A, Thein H-H, Gomes T, Wodchis W, Machado M, Carcone S, Krahn M. Preventing pressure ulcers in long-term care: a cost-effectiveness analysis. Arch Intern Med 2011; 171 1839–47.
| Preventing pressure ulcers in long-term care: a cost-effectiveness analysis.CrossRef | 21949031PubMed |
 Padula WV, Mishra MK, Makic MBF, Sullivan PW. Improving the quality of pressure ulcer care with prevention: a cost-effectiveness analysis. Med Care 2011; 49 385–92.
| 21368685PubMed |
 Australian Institute of Health and Welfare. Australian hospital statistics 2012–13. Health services series no. 54. Cat. no. HSE 145. Canberra: AIHW; 2014.
 Shemilt I, Thomas J, Morciano M. A web-based tool for adjusting costs to a specific target currency and price year. Evid Policy A J Res Debate Pract 2010; 6 51–9.
| A web-based tool for adjusting costs to a specific target currency and price year.CrossRef |
 Legood R, McInnes E. Pressure ulcers: guideline development and economic modelling. J Adv Nurs 2005; 50 307–14.
| Pressure ulcers: guideline development and economic modelling.CrossRef | 15811110PubMed |
 Australian Institute of Health and Welfare. Health expenditure Australia 2011–12. Health and welfare expenditure series no. 50. Cat. no. HWE 59. Canberra: AIHW; 2013.
 McNair PD, Jackson TJ, Borovnicar DJ. The US Medicare policy of not reimbursing hospital-acquired conditions: what impact would such a policy have in Victorian hospitals? Med J Aust 2010; 193 22–5.
| 20618109PubMed |
 Centres for Medicare and Medicaid Services. CMS final rule to improve quality of care during hospital inpatient stays. 2013. Available at: http://www.cms.gov/newsroom/mediareleasedatabase/fact-sheets/2013-fact-sheets-items/2013-08-02-3.html [verified 10 January 2015].
 State of Queensland. Activity based funding for Australian public hospitals: towards a pricing framework. Brisbane: Queensland Health; 2011.