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Quality of Care for Hospitalized Medicare Patients at Risk for Pressure Ulcers
Courtney H. Lyder, ND;
Jeanette Preston, MD, MPH;
Jacqueline N. Grady, MS;
Jeanne Scinto, PhD, MPH;
Richard Allman, MD;
Nancy Bergstrom, PhD;
George Rodeheaver, PhD
Arch Intern Med. 2001;161:1549-1554.
ABSTRACT
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Background No state peer review organization has attempted to identify processes
of care related to pressure ulcer prediction and prevention in US hospitals.
Objective To profile and evaluate the processes of care for Medicare patients
hospitalized at risk for pressure ulcer development by means of the Medicare
Quality Indicator System pressure ulcer prediction and prevention module.
Methods A multicenter retrospective cohort study with medical record abstraction
was used to obtain a total of 2425 patients aged 65 years and older discharged
from acute care hospitals after treatment for pneumonia, cerebrovascular disease,
or congestive heart failure. Six processes of care for prevention of pressure
ulcers were evaluated: use of daily skin assessment; use of a pressure-reducing
device; documentation of being at risk; repositioning for a minimum of 2 hours;
nutritional consultation initiated for patients with nutritional risk factors;
and staging of pressure ulcer. The associations between processes of care
and incidence of pressure ulcer were determined with Kaplan-Meier survival
analyses.
Results National estimates of compliance with process of care were as follows:
use of daily skin assessment, 94%; use of pressure-reducing device, 7.5%;
documentation of being at risk, 22.6%; repositioning for a minimum of 2 hours,
66.2%; nutritional consultation, 34.3%; stage 1 pressure ulcer staged, 20.2%;
and stage 2 or greater ulcer staged, 30.9%.
Conclusion These results suggest that US hospitals and physicians have numerous
opportunities to improve care related to pressure ulcer prediction and prevention.
INTRODUCTION
PRESSURE ULCERS continue to present a major health problem for hospitalized
older adults. Prevalence rates have ranged from 3.0% to 15.0% for those in
acute care hospitals.1 The elderly account
for approximately 70.0% of all pressure ulcers.2
When age is coupled with additional risk factors, the incidence of pressure
ulcers significantly increases.3 Although the
average cost to heal a pressure ulcer is relatively low (ranging from $5000
to $70 000, depending on the stage of pressure ulcer) compared with that
for other health conditions, it is conservatively estimated that the total
national cost for treating pressure ulcers is $1.3 billion annually and rising.4
The absence or presence of pressure ulcers is used by the US Health
Care Financing Administration (HCFA) survey and certification in long-term
care as one benchmark of quality care.5 This
is related to the interdisciplinary principles that guide both the prevention
and treatment of pressure ulcers. Pressure ulcers have also been associated
with in-hospital mortality when patient characteristics and severity of illness
are unadjusted in the regression models. Allman et al3
noted that hospitalized older adult patients with pressure ulcers were 2 times
more likely to die within 30 days after discharge. A study by Thomas et al6 also noted that in-hospital pressure ulcers were associated
with greater risk of death at 1 year after hospital discharge. Thus, pressure
ulcers can play an important role in predicting in-hospital mortality.
With the burgeoning older adult population and spiraling health care
costs, the prediction and prevention of pressure ulcers is paramount. Although
prediction tools and prevention strategies do not guarantee that every pressure
ulcer in hospitals will be prevented, HCFA is interested in ensuring that
optimal pressure ulcer prediction and preventive care is provided for Medicare
patients at risk for pressure ulcers. Before this study, no other state peer
review organization, to our knowledge, had attempted to identify processes
of quality care related to pressure ulcer prediction and prevention for hospitalized
older adult patients at risk for the development of pressure ulcers in US
hospitals. Thus, HCFA set out to assess the quality of hospital-based pressure
ulcer prediction and prevention care via performance of quality measures identified
as important by the literature and expert opinion. This report presents the
results of the Medicare Quality Indicator System (MQIS) pressure ulcer prediction
and prevention module.
METHODS
SELECTION OF QUALITY INDICATORS
The MQIS program was developed by HCFA to improve the quality of health
services to hospitalized Medicare beneficiaries. The hallmark of MQIS is the
development of quality indicators. These quality indicators are quantitative
measures used to monitor and evaluate processes of care. HCFA selected Qualidigm,
Middletown, Conn (the peer review organization for Connecticut), to develop
an MQIS pressure ulcer prediction and prevention module. The Qualidigm team
conducted an extensive literature review and reviewed Agency for Health Care
Policy and Research guideline 3 on the prediction and prevention of pressure
ulcers in adults to identify processes of care for consideration as quality
indicators by both local clinicians and national experts. The national expert
panel consisted of 3 of us (R.A., N.B., and G.R.). The national expert panel
provided invaluable feedback in assisting the Qualidigm team to identify quality
indicators for feasibility testing.
A series of pilot studies were conducted in Connecticut, New York, Pennsylvania,
Virginia, and Puerto Rico to ascertain the high correlates for pressure ulcer
quality indicators. The pilot studies were also conducted to refine the data
collection instrument, sampling strategies, and quality indicators before
national sampling. The final quality indicators were as follows: the proportion
of immobile patients with at least 1 other risk factor for the development
of a pressure ulcer, who received a daily skin assessment within 48 hours
of arrival; the proportion of bed- or chair-bound patients who were treated
with a pressure-reducing device within 48 hours of arrival; the proportion
of immobile patients with at least 1 other risk factor who were documented
as being at risk within 48 hours of arrival; the proportion of bed- or chair-bound
patients who were repositioned every 2 hours within 48 hours of arrival; the
proportion of patients weighing less than 80% of ideal body weight and/or
having a total lymphocyte count of 1.8 x 109/L or less and/or
albumin level less than 35 g/L who received a nutritional consultation within
48 hours of arrival; and the proportion of patients who acquired a stage 1,
stage 2, or greater pressure ulcer in whom the pressure ulcer was staged.
SAMPLE SELECTION
The sample was identified by HCFA from the Medicare National Claims
History File. This file contains patient records from all hospitals in the
United States; thus, it provides a rich repository of data for Medicare patients
throughout the country. HCFA identified a representative sample of patients
discharged from an acute care hospital (community and teaching) with a principal
diagnosis of pneumonia (International Classification of
Diseases, Ninth Revision, Clinical Modification [ICD-9-CM] codes 482.0-482.9, 485, 486, and 507), congestive heart failure
(ICD-9-CM code 428.0), or cerebrovascular accident
(ICD-9-CM codes 434.91 and 436). These 3 diagnoses
were selected because of a higher probability that older adults would be immobile
for a period of their hospitalization. Additional inclusion criteria included
a length of stay of 5 days or longer, immobility, or the need for assistance
with ambulation. From January 1, 1996, to December 31, 1996, 2425 potential
cases were selected. The optimal number of patients was derived from power
calculations of an SD for compliance of 0.5 and an  of .05.
After the cases were procured, the exclusion criteria were applied.
Patients were excluded if they had a principal diagnosis of pressure ulcer
(ICD-9-CM code 707.0), stage 2 to 4 pressure ulcer
on admission, or age younger than 65 years.
DATA COLLECTION
Hospitals from across the United States were requested to provide copies
of the medical records of the identified cases, which were forwarded to 1
of 2 clinical data abstraction centers (DynKePRO, York, Pa, and FMAS, Rockville,
Md) to ensure a representative sample of the US Medicare population. Trained
medical abstractors collected the data from the submitted records by means
of the electronic data collection instrument. Any duplicate or unrequested
cases were deleted. The  statistics were calculated for the inclusion
criteria, exclusion criteria, clinical characteristics, and performance of
quality indicators. Data element reliability was continuously tested and improved
by reabstracting random samples of cases and determining reasons for abstraction-reabstraction
disagreements before finalization of the data collection instrument that was
used in the national study. The statistics ranged from 0.83 (mobility
on admission) to 1.0 (length of stay) for confirmation of inclusion and exclusion
criteria and from 0.60 (documented at risk) to 0.87 (turn every 2 hours) for
quality indicators, indicating moderate to excellent interrater reliability.
DATA ELEMENTS
Two categories of variables were used in this study: inclusion and exclusion
criteria indicators and process of care indicators. Both the inclusion and
exclusion criteria and process of care indicators were previously listed.
Demographic and clinical characteristic and risk factor variables usually
associated with pressure ulcers were collected from the medical records. Demographic
variables included prearrival setting, age, race, sex, and discharge disposition.
Clinical characteristic and risk factor variables included bladder and bowel
incontinence, serum albumin level less than 35 g/L, motor deficit, abnormal
skin hydration, wound drainage, stay in a specialty care unit (ie, intensive
care unit), comatose state, less than 80% of ideal body weight, and total
lymphocyte count of 1.8 x 109/L or less.
DATA ANALYSIS
On receipt of the data, logic and consistency checks for inclusion and
exclusion criteria were run on both claims and abstracted data elements. Descriptive
statistics were used to describe the sample. Compliance with each quality
indicator was determined by calculating the proportion of patients in the
study set who adhered to the quality indicator within 48 hours of arrival
to the hospital. The use of 48 hours was based on several studies that demonstrated
occurrence of pressure ulcers between admission and 48 hours after hospitalization.7-8 Moreover, 48 hours was selected to
ensure that hospitals would have ample time to complete the admission process.
To evaluate the association between quality indicator compliance and
the development of pressure ulcers during a 3-week period, a Kaplan-Meier
survival analysis was conducted. The log-rank test was used to determine significant
differences in the stratification of the survival distributions.
Two outcome measures were established for this study. The first outcome
measure was compliance with the quality indicators and the second was the
development of pressure ulcers. Because of the sample size, all pressure ulcers
(stages 1-4) were truncated to provide adequate power to evaluate this outcome.
Although there is a wide variance in defining the stage 1 pressure ulcer,9 it was included in the analysis because treatment
must be implemented for all 4 stages of ulceration.
RESULTS
CASE SELECTION
A total of 2425 potential pressure ulcer cases were abstracted. Of these
patients, the majority had a length of stay of 5 days or longer (n = 2355)
and were immobile or required assistance to ambulate (n = 1923). Of the 2425
in the sample, 257 were excluded because of age younger than 65 years (n =
35) or admission to the hospital with a pressure ulcer of stage 2 or greater
(n = 222). (Some of these 257 patients had already been excluded based on
length of stay and their mobility status.) No patients were excluded because
of the principal diagnosis of pressure ulcer (ICD-9-CM
code 707.0). Therefore, the final study sample was composed of 1803 patients.
The majority of patients had a principal diagnosis of pneumonia (n = 1029)
or cerebrovascular accident (n = 582). The mean length of stay for patients
was 10.2 days (range, 5-66 days).
PATIENT CHARACTERISTICS
The prearrival hospital data (Table
1) showed that most patients came from home, followed by skilled
or intermediate facilities or other facilities or long-term care hospitals.
The mean age for the sample was 79.8 years, with the majority of patients
being aged 75 to 84 years. The sample was predominantly white. There were
more women than men. The majority of patients were discharged to home (n =
924), skilled or intermediate care facilities (n = 581), and other facilities
or long-term care hospitals (n = 150). For patients at high risk (>3 risk
factors), in-hospital mortality accounted for 8.1% (n = 146) of the sample.
Clinical characteristics and risk factors for pressure ulcers (Table 2) showed that the majority of patients
in the sample were bed or chair bound and had had at least 1 stay in a specialty
intensive care unit. A large proportion of the sample had a nutritional impairment.
Urinary incontinence and fecal incontinence were not a major clinical problem
for the sample. Moreover, the presence of coma, abnormal skin hydration or
dry skin, wound drainage, and hip fractures were not prevalent in this sample.
Patients had at least 2 risk factors (n = 609), with the majority (659) having
3 or more risk factors.
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Table 2. Clinical Characteristics and Risk Factors*
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INCIDENCE AND PREVALENCE
One hundred sixty-four patients had a preexisting stage 1 pressure ulcer
on arrival to the hospital; of these, 32 (19.5%) progressed to a stage 2 pressure
ulcer or greater. A total of 317 patients acquired a pressure ulcer of any
stage while in the hospital; 238 patients developed at least 1 stage 1 pressure
ulcer. Thus, the incidence of stage 1 pressure ulcers was 13.2%. Thirty-eight
(16.0%) of the patients with a stage 1 pressure ulcer progressed to a more
advanced stage. One hundred ten patients developed at least 1 stage 2 or greater
pressure ulcer during their hospital course, yielding an incidence rate of
6.1% for the more advanced pressure ulcers. Three patients (2.7%) with a stage
2 or greater pressure ulcer progressed to a more advanced stage.
COMPLIANCE WITH QUALITY INDICATORS
The compliance varied depending on the quality indicator (Table 3). Compliance was 94.0% on quality indicator 1 (daily skin
assessment), 7.5% on indicator 2 (use of a pressure-reducing device), 22.6%
on indicator 3 (documentation of being at risk), 66.2% on indicator 4 (repositioning),
34.3% on indicator 5 (nutritional consultation), 20.2% on indicator 6a (staging
of stage 1 ulcer), and 30.9% on indicator 6b (staging of stage 2 ulcer).
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Table 3. Quality Indicator (QI) Compliance*
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QUALITY INDICATOR COMPLIANCE AND PRESSURE ULCER DEVELOPMENT
The relationship between quality indicator compliance and pressure ulcer
development was studied for quality indicators 2 through 5 for a 3-week period
(Table 4). The research team determined
from clinical experience and the literature that 3 weeks would be an appropriate
amount of time to capture pressure ulcer prevention measures for any given
hospitalized patient who had an extended stay. In general, older patients
with longer stay had higher incidence rates of pressure ulcers. In fact, the
Kaplan-Meier analysis showed a total incidence rate of pressure ulcer of 32%
at 21 days (Table 4). Because
skin assessment (quality indicator 1) had a high compliance rate (94.0%),
it was excluded from the bivariate analysis. Patients who received a pressure-reducing
device (quality indicator 2) within 48 hours of arrival to the hospital had
a higher incidence of pressure ulcer development during week 1, with no statistical
differences noted for weeks 2 and 3. Patients who were documented at risk
for pressure ulcers (quality indicator 3) had a significantly higher incidence
of pressure ulcer development during the 3-week period. Moreover, patients
who were turned every 2 hours (quality indicator 4) also had a significantly
higher incidence of pressure ulcer development during the same 3-week period.
The implementation of a nutritional consultation (quality indicator 5) was
associated with a lower incidence of pressure ulcer development, although
this association was not statistically significant.
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Table 4. Cumulative Incidence of Pressure Ulcer by Hospital Days Stratified
by Quality Indicator Compliance*
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COMMENT
The results of this national quality-of-care study demonstrated that
there are numerous opportunities for improvement in both the prediction and
prevention of pressure ulcers in hospitalized Medicare beneficiaries. Overall,
the incidence rate of stage 2 or greater pressure ulcers was 6.1%, which appears
to be much lower than that reported by other hospital pressure ulcer studies.
These studies have reported incidence rates of pressure ulcers between 8.1%
and 12.9%,1, 10 which suggests
that health care providers in hospital settings are implementing prevention
strategies. Thus, there appears to be a decrease in the incidence rate of
stage 2 or greater pressure ulcers in hospitals subsequent to 1996. Another
explanation for lower rates of stage 2 or greater pressure ulcers may be underascertainment.
No studies could be found for comparison that used methods similar to those
in this study. However, many studies that use abstraction as the major method
of data collection are vulnerable to misclassification of pressure ulcers
or nonrecording of preventive measures in the medical records. This study
showed that 19.5% of older adults hospitalized with a stage 1 pressure ulcer
progressed to a stage 2 or greater pressure ulcer. Moreover, of older adult
patients who developed a stage 1 pressure ulcer while in the hospital, 16.0%
progressed to a stage 2 or greater ulcer. Although the incidence rate was
lower than that in other reported studies, the findings suggest the need for
hospital staff to remain vigilant in identifying older adults at risk and
implementing prevention strategies.
The failure of this study to significantly associate prevention strategies
with the decreased incidence of pressure ulcers illustrates the multivariate
nature of pressure ulcer development. It is possible that we did not measure
the appropriate constructs necessary to capture the process-outcome link.
This appears to be highly unlikely, because the quality indicators selected
were based on current literature, which appeared to have excellent face validity.
Numerous research studies suggest that process-outcome links are extremely
difficult to identify. These results clearly underscore the multivariate causal
pathway to pressure ulcer development and the lack of good evidenced-based
research in pressure ulcer prevention.
Quality indicator compliance within 48 hours varied greatly depending
on the process of care profiled. Daily skin assessment (quality indicator
1) was the only quality indicator with a high compliance rate (94.0%) within
48 hours of hospitalization. This is probably related to the general practice
of nursing staffs completing a general skin assessment as part of the hospital
admission intake assessment. Independent of daily skin assessments, the hospital
compliance rates were relatively low. The percentage of bed- or chair-bound
older adults receiving a pressure-reducing device (quality indicator 2) within
48 hours was very low, at 7.5%. Given the potential for a pressure ulcer to
develop within a relatively brief period, patients at risk must be identified
and appropriate pressure-reducing devices implemented. The lack of documentation
(22.6%) of patients at risk (quality indicator 3) and the low proportion (66.2%)
repositioned every 2 hours (quality indicator 4) demonstrate the need for
hospitals to increase both prediction and prevention strategies. This is consistent
with the findings of Bergstrom et al,10 who
demonstrated that when risk assessments were not conducted, written orders
for turning were less likely to occur. Moreover, the low proportion (34.3%)
of nutritionally compromised patients who received a nutritional consultation
suggests that greater emphasis must be placed on completing nutritional assessments,
especially in light of the large proportion of patients (76.2%) identified
to be nutritionally compromised in this study. This action would not be as
likely to be missed if formal risk assessments were completed. Research studies
have demonstrated that older patients with low dietary intake of protein and
low serum albumin levels are more likely to be at risk for the development
of pressure ulcers.10 Thus, if older adults
are identified as being nutritionally compromised and appropriate nutritional
supplements are introduced, a decrease in the incidence of pressure ulcers
may result.
The results from this study also suggest that, for Medicare beneficiaries,
extended stays longer than 7 days in the acute care hospital greatly increase
the incidence of pressure ulcers. Clearly, the majority of patients who spend
extended stays in the acute care setting are most likely the sickest, accounting
for more than 30% of the pressure ulcer incidence. Hospitals and physicians
must remain vigilant in the prevention of pressure ulcers in patients with
longer stays. Clearly, these patients provide the physician with not only
a greater opportunity to use preventive measures but, if an ulcer develops,
ample time to treat and heal the pressure ulcer.
An interesting finding in this study was the inability to demonstrate
an association between quality indicator compliance and a decreased incidence
of pressure ulcer development. In fact, older adults who received a pressure-reducing
device (quality indicator 2) and/or were documented at risk (quality indicator
3) and/or were turned every 2 hours had a higher incidence of pressure ulcer
development. These results suggest that, although the patients were treated
with pressure-reducing devices, we did not evaluate the quality of products
used. It is conceivable that the support surfaces used did not truly reduce
pressure. The research team had no mechanisms established to guarantee that
patients documented to be turned every 2 hours were actually turned. The study
was also unable to capture prevention strategies (or lack thereof) used before
admission to the hospital unit. These inverse relationships may also be attributed
to the lack of appropriate risk adjustments or the study's inability to capture
confounding variables. Thus, the ulcerations may have been developing before
arrival on the unit. The study did not capture decision processes used by
the hospitals to determine which older adults received prevention strategies.
It is conceivable that hospital staff implemented prevention strategies on
the most vulnerable patients too late or without sufficient prevention strategies,
accounting for the inverse relationship. Of interest, the use of a nutritional
consultation was associated with decreased incidence of pressure ulcers, although
the difference was not statistically significant. This finding does not suggest
that a nutritional consultation is equated with the patient actually receiving
nutritional supplementation; rather, it suggests a nutritional consultation
may sensitize the staff that the older adult is at risk for pressure ulcer
development. This finding suggests, however, that nutrition may play a significant
role in pressure ulcer prevention.
This study had several limitations. First, because of the retrospective
nature of the study, we were unable to capture observational data. Patients
may have received additional prevention strategies that were not captured
on the data collection instrument. The inability to identify prevention strategies
used (or not used) and the time from processing until the patient arrived
on the hospital unit were not captured. Thus, it is possible that the pressure
ulcer occurred independent of arrival to the hospital unit. To this end, the
study was dependent on chart compliance by the hospitals. The lack of an effective
risk adjustment model also limited the study, and the research team could
not identify an effective risk adjustment instrument. The Charlson Comorbity
Index11 and the Acute Physiology and Chronic
Health Evaluation II score12 have been used
to adjust for risk in previous pressure ulcer studies; however, they were
not designed for pressure ulcer risk adjustment nor validated in a frail elderly
population. These instruments were designed and validated for use in critical
care to predict mortality; thus, their use in pressure ulcer prediction and
prevention studies is questionable. The low rate of compliance with the quality
indicators may be attributed to the negative associations. Finally, the low
incidence (6.1%) of pressure ulcer development greatly limited the statistical
power that could be applied to causal modeling, thereby explaining our inability
to completely evaluate the process-outcome association. A further limitation
of our study was the inclusion of stage 1 pressure ulcers, since a large variation
exists in defining this ulcer. The literature notes that there is no standard
definition for the stage 1 pressure ulcer as compared with other ulcers.9 Thus, it is possible that some clinicians may have
improperly classified the stage 1 pressure ulcer.
In summary, this study examined the quality of care delivered to older
adults at risk for pressure ulcer development in hospitals throughout the
United States. We identified numerous opportunities for hospitals and physicians
to improve the prediction and prevention of pressure ulcers. Our findings
also suggest that nutritional consultation may prevent pressure ulcer development
by sensitizing the physician and staff that the patient is at risk for pressure
ulcer development.
AUTHOR INFORMATION
Accepted for publication October 23, 2000.
This study was supported by contract 500-96-P549 from HCFA, US Department
of Health and Human Services, Baltimore, Md.
We thank the following individuals and organizations for contributing
their time and expertise toward the creation of the MQIS pressure ulcer module:
Qualidigm: Darcey Ahearn, RN; Kelly Forsyth. Regional validation peer review
organizations: New York Peer Review Organization; DynKePRO; Puerto Rico Quality
Improvement Professional Research Organization, Inc; and Virginia Health Quality
Center. Staff at HCFA: Mary Pratt, MSN, RN; Tim Cuerdon, PhD; Cindy Wark,
MS, RN; Heidi Gelzer, RN.
The content of this publication does not necessarily reflect the views
or policies of the US Department of Health and Human Services, nor does the
mention of trade names, commercial products, or organizations imply endorsement
by the US government. The authors assume full responsibility for the accuracy
and completeness of the ideas presented.
Corresponding author and reprints: Courtney H. Lyder, ND, Yale University
School of Nursing, 100 Church St S, PO Box 9740, New Haven, CT 06536 (e-mail: Courtney.Lyder{at}Yale.edu).
From Qualidigm, Middletown, Conn (Drs Lyder, Preston, and Scinto and
Ms Grady); Section of Geriatric Nursing, Yale University School of Nursing,
New Haven, Conn (Dr Lyder); University of Connecticut Center on Aging, Farmington
(Dr Preston); Section of Geriatric Medicine, University of Alabama School
of Medicine, Birmingham (Dr Allman); University of Nebraska Medical Center
College of Nursing, Omaha, and University of Texas–Houston, Health Sciences
Center, Center on Aging (Dr Bergstrom); and Department of Surgery, University
of Virginia School of Medicine, Charlottesville (Dr Rodeheaver).
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