Value of hospital resources for effective pressure injury prevention: A cost-effectiveness analysis

William V. Padula, Peter J. Pronovost, Mary Beth F. Makic, Heidi L. Wald, Dane Moran, Manish K. Mishra, David O. Meltzer

Research output: Contribution to journalArticlepeer-review

17 Scopus citations


Objective Hospital-acquired pressure injuries are localised skin injuries that cause significant mortality and are costly. Nursing best practices prevent pressure injuries, including time-consuming, complex tasks that lack payment incentives. The Braden Scale is an evidence-based stratification tool nurses use daily to assess pressure-injury risk. Our objective was to analyse the cost-utility of performing repeated risk-assessment for pressure-injury prevention in all patients or high-risk groups. Design Cost-utility analysis using Markov modelling from US societal and healthcare sector perspectives within a 1-year time horizon. Setting Patient-level longitudinal data on 34 787 encounters from an academic hospital electronic health record (EHR) between 2011 and 2014, including daily Braden scores. Supervised machine learning simulated age-adjusted transition probabilities between risk levels and pressure injuries. Participants Hospitalised adults with Braden scores classified into five risk levels: very high risk (6-9), high risk (10-11), moderate risk (12-14), at-risk (15-18), minimal risk (19-23). Interventions Standard care, repeated risk assessment in all risk levels or only repeated risk assessment in high-risk strata based on machine-learning simulations. Main outcome measures Costs (2016 $US) of pressure-injury treatment and prevention, and quality-adjusted life years (QALYs) related to pressure injuries were weighted by transition probabilities to calculate the incremental cost-effectiveness ratio (ICER) at $100 000/QALY willingness-to-pay. Univariate and probabilistic sensitivity analyses tested model uncertainty. Results Simulating prevention for all patients yielded greater QALYs at higher cost from societal and healthcare sector perspectives, equating to ICERs of $2000/QALY and $2142/QALY, respectively. Risk-stratified follow-up in patients with Braden scores <15 dominated standard care. Prevention for all patients was cost-effective in >99%of probabilistic simulations.conclusion Our analysis using EHR data maintains that pressure-injury prevention for all inpatients is cost-effective. Hospitals should invest in nursing compliance with international prevention guidelines.

Original languageEnglish (US)
Pages (from-to)132-141
Number of pages10
JournalBMJ Quality and Safety
Issue number2
StatePublished - Feb 1 2019


  • cost-effectiveness
  • health services research
  • nurses

ASJC Scopus subject areas

  • Health Policy


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