Samantha Ketchin, Clinical Analyst Auckland DHB Investigating the Effect on Cost and Length of Stay (LOS) for Patients with Pressure Injuries (PI) Samantha Ketchin, Clinical Analyst Auckland DHB Healthy Communities, Quality Healthcare

Pressure Injuries Injury to skin/tissue caused by pressure and/or shear Patients experience: Pain Increased susceptibility to infection Delayed recovery Psychological distress Reduced quality of life

Organisational Priority Target: Reduce number of PIs by 20% Measure number of PI patients Implement changes in practice Measure again Identify benefits: Patient benefits Calculate increased hospital cost for PI patients Attribute cost saving to reduced prevalence N.B. Only costs associated with the patient’s hospital stay are covered in this presentation

Some Studies - Costs Bennett G, Dealey C & Posnett J (2003) £1000 (Grade 1) – £10,500 (Grade 4) Extra costs to treat patients with PI Calculated by: Time taken to heal (from other studies) Estimated costs for treatment Costs not solely associated with hospital stay Pappas S (2008) US$25 (Surgical Patients) - US$2400 (Medical Patients) Additional nursing costs for treating PI patients Study highlights limitations in attributing causality Padula W, Mishra M, Makic M, Sullivan P (2011) US$500 - $70,000 Additional hospital costs for treating PI patients Wide variation

Some Studies - LoS Cho, Ketefian, Barkauskas, Smith (2003) 1.84-fold increase in LoS Other studies mention but do not quantify increased LoS

The key question… Can we make reliable statements about hospital costs & LOS for PI patients using our own data?

ADHB Data Baseline audit (one day snapshot) of 1149 patients 75 patients with Pressure Injuries (PI) 55 patients acquired the PI during their hospital stay (HAPI) 3 patients excluded from analysis (unavailable diagnoses)

ADHB Study Identified control patients based on: Age bracket Specialty Main diagnosis (of presenting event) 2734 control patients identified Calculated LOS and costs for complete hospital stay Compared average LOS and costs with PI patients

Results Costs: Extra $39,045 per patient LOS: 3.1 times longer Published studies show: Costs: Extra $39,045 per patient LOS: 3.1 times longer Estimated Yearly Savings: Average cost per event calculated No. of discharge events in 2011 = 38,800 (29,927 patients) Approx. 6.7% with PI = 2600 20% of PIs = 520 20% reduction in PI: Bed days saved = 7,115 Cost saved = $12.4M Grade 4: £10,500 ($21,000) 1.9 times longer Doubts about data

Reasons to Question Too good to be true? Results do not align with those of published studies A number of issues identified

Variability of data Grade 1 Grade 2 Costs LOS

Health Status Assumption made about equal states of health in control and PI groups 50% of PI patients on cardiac ICU Should we add the ward as a criteria to identify control patients – and which of their wards should we use? Is primary diagnosis enough – should we use DRG and/or other measures?

Prevalence vs Incidence Prevalence = no. of cases at a given time (snapshot) = 6.7% Incidence = rate of new cases within a time period Extrapolating results to estimate yearly savings The European Pressure Ulcer Advisory Panel: pressure ulcer incidence is the most appropriate approach if the goal is to understand how the introduction of new protocols and interventions has affected the number of patients with pressure ulcers or to predict pressure ulcers or develop and evaluate risk assessment scales.

ADHB Yearly Calculations Calculation of number of PI patients in one year likely to be much lower than the 6.7% prevalence figure used

Calculating Incidence Time-consuming Requires data to be gathered over a period of time Potential to use coding to ascertain the number of PI patients in 1 year… but: Coding does not always indicate PI (only 14 audit PI patients had a coding of PI) Coding does not currently indicate whether hospital acquired Should we attempt to calculate incidence to estimate cost and LOS savings? Is prevalence a good means of demonstrating reduction?

Prevalence and Incidence European Pressure Ulcer Advisory Panel: Grade 1 pressure ulcers should be recorded as ‘warning signals’, but not included in the calculation of either prevalence or incidence rates. 75% of HAPIs are grade 1 (baseline audit) Should we include grade 1 PIs in our prevalence and incidence calculations?

Cost of Prevention Assess requirements Potential need for: Additional specialist equipment Additional resource Factor in these costs

Conclusion Current calculations are unreliable It’s hard to calculate the effect of PI on LOS and Cost: Many factors Many questions A lot of uncertainty Opportunities for research to improve validity of results Need clinical input into identification of control patients