EUROPEAN PRESSURE ULCER ADVISORY PANEL

EPIDEMIOLOGY, PREVENTION AND TREATMENT OF PRESSURE ULCERS IN HUNGARIAN HOSPITALS; 1992-1998. PART 2
Dr László Gulácsi, President, Hungarian Wound Healing Society

This article follows from Part 1 of Dr Gulacsi's report published in Vol 3 (1) of the EPUAP Review. For the convenience of readers the abstract is reprinted to establish the context of the article.

Abstract

Objectives: This project held three objectives: (1) Within patients nursed in acute care hospitals and considered to be at risk of pressure ulcer (PU) development, what was the baseline prevalence and incidence of PU. (2) To establish the current patterns of preventive and treatment interventions and to investigate the economic burden imposed by the prevention and treatment of PU within the hospital population. (3) To improve the quality of both PU prevention and treatment through the creation, dissemination and implementation of quality assurance programmes in hospitals.

Design: Data were collected from several sources: (1) Retrospective PU data gathered during the quality assurance activities undertaken within 17 (COMAC/QA/HSR Programme) and 20 (BIOMED/PECO Programme) general public hospitals between 1992 and 1997 (*). (2) Retrospective national data describing the prevalence of PU between 1993 and 1998. (3) Retrospective chart review to identify PU management across 1,200 adult patient records drawn from 7 hospitals in 1994. (4) Analysis of the national financial reimbursement of the in-hospital PU cases in 1994. (5) Prospective active surveillance of 705 adult patients in one county hospital. (6) Prospective active surveillance of 2,702 adult patients along with the costing of 100 PU patients (1,350 PU patient-days). (7) Changing PU prevention and treatment practices through the use of clinical protocols and guidelines.

Main results: (1) The actual prevalence of pressure ulcers is estimated to be 16-27 fold higher (3.7%-5.7%) than the officially published rate (0.18-0.21%) in Hungary. (2) On average 1.0%-2.5% of the direct costs of PU treatment, along with the estimated one to five days prolonged hospitalisation are reimbursed under the current DRG financing mechanism. (3) As a result of this four-year PU study and quality assurance intervention, the Hungarian Wound Healing Society was created in 1997 in order to improve the quality of patient care through education, training, creating, disseminating and implementing guidelines and conducting surveillance in the field of prevention and treatment of PU.

Conclusion: (1) In order to monitor the true incidence and prevalence of PU active surveillance has to be established. (2) Both the prevention and appropriate treatment of pressure ulcers are in the economic interest of the hospitals reimbursed under the current DRG mechanism, because they are not reimbursed for any additional costs incurred by the PU patients. (3) Appropriate PU surveillance and documentation, including risk assessment, PU guidelines, PU costing and disease forecast tools have to be implemented, in addition disease-specific PU quality of life tools have to be created, if health care professionals and managers want opinion leaders, media and financing organisations to be on their side. (4) Incidence and prevalence of pressure ulcers can be decreased by appropriate prevention and treatment.

This study was part of the 'Concerted Action Programme on Quality Assurance in European Hospitals (COMAC/HSR), 1992-1994, and part of its follow-up programme, the 'Cooperation in Science and Technology with Central and Eastern European Countries and with the New Independent States of the Former Soviet Union, Les Pays d'Europe Centrale et Orientale (BIOMED/PECO)' of the the European Union, DG XII, between 1994-1997, and This study was performed under the aegis of the Hungarian Society for Quality Assurance in Health Care and the Hungarian Wound Healing Society.

The author express special thanks to European Union, DG XII., the Dutch Ministry of Health, Welfare and Sport, the Hungarian Ministry of Health and Mölnlycke Health Care for funding the study.

Section numbering follows from Part 1 of this article.

2. The epidemiology, prevention and treatment of PU in Hungary (continued)

2.4 Phase 4: The reimbursement of hospitals for the care of patients with PU, 1994

According to the Centre of Healthcare Information, Ministry of Health, Hungary, 3,710 PU cases were recorded into medical records and reported to the Centre in 1994. Overall 2.115 million patients episodes were reimbursed in 1994 giving a prevalence of PU cases of 0.18%.

Economic incentives can be important as levers to improve the quality of care and to decrease unnecessary resource utilisation. According to the economic analysis of Phase 4, nationally in 1994, the extra payment approximated only between 1-2.5% of the cost of treating PU cases in hospitals. This result shows that under the DRG system there are explicit financial incentives for hospitals to perform effective PU prevention given the high, and largely non-reimbursed costs of their treatment.

2.5 Phase 5: Active prospective surveillance and risk assessment of 705 adult patients in one county hospital during 1995

In 1995, the fate of 705 consecutive patients newly-admitted to four medical departments (3 active and 1 chronic) in one large county hospital was followed. At admission their current vulnerability to PU was documented using the Norton Scale with one nurse performing all assessments. The main aim of the study was to investigate any differences in both the distribution of patient age and PU occurrence between the acute and chronic care departments and secondarily to explore the sensitivity and specificity of the Norton Scale. The recruited subjects' were largely elderly with 454 (64.4%) over 60 years old. Only 17 (2.4%) were under 30 years old with the remaining 234 (33.2%) falling between 30 and 60 years. The prevalence of PU differed between the acute (prevalence 2.9%) and chronic (prevalence 19.6%) departments. Overall, 40 patients (5.7%) were found to present with PU. Subjects were divided into two groups; Group A (at risk; Norton Score at admission 5-14, n=189, 16.8%) and Group B (risk free Norton Score of at least 15 at admission, n=516, 73.2%). In Group B 3 subjects presented with PU (0.6%). Group A subjects were then divided into two further groups; Group C (medium risk, Norton Score at admission 13 or 14, n=52, 7.4%) and Group D (high risk, Norton Score at admission 12 or less, n=137, 19.4%). Eight patients in Group C (15.4%) and 29 from Group D (21.2%) presented with PU.

2.6 Phase 6: The cost of PU care based upon the fate of 100 adult in-patients with PU within one county hospital

In 1996, 100 consecutive patients with PU were recruited across 15 departments of one county general hospital. These patients either presented with PU at the time of admission (n=49) or developed their ulcers during their stay (n=51). The objective of the study was to define, and cost, the care allocated to patients with, or at risk of, PU. The direct hospital costs associated with PU prevention and treatment was collected by micro-costing. Data collection was structured using a standard instrument that recorded the location and grade of PU, the patient's diagnoses, progress and other clinical circumstances, and finally any medical devices and nursing procedures allocated to help prevent or treat PU. All data was completed by a trained, specialist surveillance nurse. Patients were eligible for recruitment if they had a PU at the time of admission to hospital or developed a PU during their stay. All eligible patients had to be aged eighteen years or older, and admitted to one of the following specialities - Medical I-III, Surgery, Traumatology, Neurology, Urology, Oncology, Medical intensive, Surgical intensive, Central admitting, Chronic medical, Acute Psychiatry, Chronic Psychiatry and Rehabilitation.

The specialist nurse who completed all patient assessments and who recorded all drug, device and medical investigation related to PU prevention and treatment was trained before the study began. On each participating ward, the nurse who first identified the presence of a PU informed the specialist nurse who then completed the resource utilisation data collection form daily. Upon admission to the study, a Norton Scale was completed and all body sites were observed to record the distribution of PU. The Norton Score was re-calculated upon any significant changes in the patient's health status and was also recorded at the time of discharge from hospital. The specialist nurse was monitored weekly by the hospital's nursing director.

2.5.1 PU incidence and prevalence

During the six-month duration of the investigation 2,711 patients were admitted to the participating departments. Of these, 100 (3.7%) patients had PU with 41 patients presenting with PU at the time of admission. New PU developed in 59 subjects admitted to hospital without PU. The average age of the PU patients was 78.2 years with only 19 aged under seventy. The 100 PU patients presented with 308 co-morbidities (3.08 per patient). Of the 100 patients with PU, 73 died during their stay in hospital (mean age 77.15 years, mean length of stay (LOS) 37.4 days), and these patients had an average of 3.18 co-morbidities each. The remaining 27 patients discharged alive (mean age 68.2 years, mean LOS 27.5 days) from hospital had fewer co-morbidities (2.77 per patient). Among the live discharges, 3 patients experienced complete healing of their PU, the remainder either showed some or no improvement in the status of their PU. The average age of the patients who died during the hospitalisation was 77.15 years, whereas the average age of those discharged home was 68.2 years. The reduced age of the patients discharged alive is consistent with other studies. Michocki et al (1976) reported an approximate four-fold increase in the probability of death following the development of a PU among elderly patients. The advanced age of the patients with PU has also been reported by others. Walldorf (1986) reported an annual incidence of PU in hospital of 3% with 96% of all affected patients being over 65 years, with 36% over 85 years old.

The 100 patients with PU presented with 178 ulcers, with wounds located at the left and right aspects of each anatomical location treated as a single PU. The mean size of the encountered PU was 425.5 square cm, and 74% of PU classed as Grade 2 or more severe. The majority of PU (89%) were located caudal to the apex of the iliac prominence.

Overall the total cost of PU treatment among the 100 patients (1,350 PU patient days) was 721,164 HUF, an average of 534HUF per patient day. While the 100 subjects were followed for 1,350 patient days, this period excluded a) time spent in hospital prior to the start of the study and b) time passed in medical departments other than the participating specialities. Overall, the 100 PU patients remained in hospital for 2,287 days at an estimated total cost of 1,072,934 HUF, an increase of 351,770 HUF above the study costing (based on a total of 1,350 patient days). Table 8.15 illustrates the size and cost of treatment of the encountered PU by their severity. Both the mean size and cost per day of treatment increased as PU became more severe.

The presented costs related only to those directly incurred in PU prevention and treatment. Additional costs that may be incurred through any prolongation of the stay in hospital due to having a PU were not included. Such hidden costs include hotel services and overheads. The estimated total hospital cost incurred by the 100 PU patients was 9,703,868 HUF. Presently the extent to which (if any) a PU extends LOS is unknown. However any extension of LOS due to pressure ulcers will be costly; for example in medical department I., a 1% increase in LOS would cost 7,155 HUF.

2.5.2 Estimating the burden and cost of PU at the national level

In 1996, 2,250,000 people were admitted to hospital in Hungary. From the results of the current study, the estimated national prevalence of PU in 1996 was 3.7% (78,000 PU patients). This should be contrasted with the information available through the Centre for Healthcare Information, Ministry of Welfare, which reported 4,139 PU patients in 1996 (national prevalence 0.18%). It is suggested that, based on the current investigation, a 3% (n=66,700 PU patients) to 5% (n=113,000 PU patients) can be expected within Hungarian hospitals.

During 1996 the total reimbursement for PU patients was 24,844,514 HUF with a PU related DRG creep of only 12,499 HUF. If hospitals had adopted excellent disease classification coding practices then PU reimbursement would have only increased by 0.05%. However, the reimbursement was based upon the data reported to the Centre for Health-care Information, an estimated under-reporting of 78,020 cases of PU patients! If hospitals had reported the likely true number of PU patients the estimated national reimbursement would have been 522,491,500 HUF. This calculation assumes that the distribution of PU by main nursing diagnosis, complication and co-morbidity was constant in both the reported and estimated populations. When calculating the cost of PU, the cost elements can be grouped into two categories: a) Direct costs of PU treatment amounting to 837,135,650 HUF in 1994 (cost estimated from sample population data), and b) Indirect costs of hospitalisation among patients who have PU among other diagnoses. This estimation clearly depends upon the daily cost of hospital care within different medical specialities. A one-day prolongation of LOS due to PU would cost 330,708,150 HUF (national level, 1996 costs). While there is no information upon the effect of PU on LOS in Hungary, it is more widely speculated that PU may extend LOS by five days.

Assume that the prolonged LOS represents:

• One day per PU patient: In this scenario the additional cost due to the prolonged hospital stay would be 330,708,150 HUF, and the total costs of all PU patients would reach 1,167,843,800 HUF. In 1996 the total PU patient reimbursement to hospitals was 24.844.514 HUF suggesting that only 2.5% of the total cost of caring for PU patients in hospital was reimbursed by the Health Insurance Fund.
• Five day per PU patient: In this perhaps worst-case scenario the additional cost due to the prolonged hospital stay would be 1,653,540,700 HUF, and the total costs of all PU patients would reach 2,490,676,300 HUF. If this extension of LOS was accepted then in 1996, only 1% of the total costs of caring for patients with PU in Hungarian hospitals was reimbursed by the Health Insurance Fund. These scenarios both assume that the costs of hospital care increase in a linear relationship with the extended LOS.

2.7 Phase 7: Changing PU prevention and treatment practices through the use of clinical protocols and guidelines, 1997-1998

One central effect of the overall study was to make health professionals aware that guidelines and local protocols on PU prevention and treatment were required to reduce local practice variations and so improve the quality of care. Consensus building conferences were organised with the participation of the hospitals involved in earlier stages of the study. These events resulted in the creation of Hungarian guidelines for PU prevention and treatment, based upon several published international PU guidelines (The Dutch Consensus Prevention of Bedulcers CBO, 1985; National Pressure Ulcer Advisory Panel, 1995; European Pressure Ulcer Advisory Panel, 1998). Draft versions of the PU prevention and treatment guidelines were provided for comment through various multidisciplinary meetings involving nurses, physicians (surgeons, dermatologists, orthopaedists, intensive care specialists, etc) and the medical and nursing directors of Hungarian hospitals. The final versions were published in medical and nursing journals under the aegis of the Hungarian Wound Healing Society, and the Hungarian Society for Quality Assurance in Health Care. These guidelines were generally accepted and widely implemented across Hungarian hospitals. The Hungarian PU prevention and treatment guidelines are slightly modified versions of the European Pressure Ulcer Advisory Panel's PU prevention (1998) and treatment (1999) guidelines.

3. Discussion and conclusion

The relatively high number of study participants, patients, professionals and organisations, the high level of willingness of participation and the high completion rate suggest that we have now sufficient experience in this area to make some general conclusions about the current situation and possible future development of quality assurance in Hungary. Various quality measures were used in the presented study associated with structure, process and outcome. Results show that both structure and process quality improved. 'intermediate' outcome was assessed.

This project hold three main goals: a) to develop the baseline prevalence and incidence of PU in Hungarian hospitals; b) to establish the current patterns of preventive and treatment interventions and to investigate the economic burden imposed by the prevention and treatment of PU; and c) to improve the quality of both PU prevention and treatment through the creation, dissemination and implementation of quality assurance programmes in hospitals.

a) Prevalence and incidence of PU in Hungarian hospitals
The actual prevalence of pressure ulcers according to the Hungarian study presented in this chapter, is estimated to be 16-27 fold higher (3.7%-5.7%) than the officially published rate (0.18-0.21%) by the Centre for Healthcare Information Ministry of Health in Hungary. Compared with the international literature on PU prevalence the number of officially reported PU cases is very low, due to various methodological problems including misclassification, incompleteness and inaccuracy of data collection, unchecked and mainly self-reported data.

Baseline PU prevalence and incidence data is needed to properly evaluate the effect of any PU quality assurance initiative. This requires the availability of trained staff and a standardised approach to data collection.

b) Current patterns of preventive and treatment interventions and the economic burden of PU
The second aim of the study was to establish the current patterns of preventive and treatment interventions and to investigate the economic burden imposed by the prevention and treatment of PU. The study showed that there was a widespread local variation in the current patterns of preventive and treatment interventions among hospitals and hospital departments. One consequence of the wide practice variations was that it was practically impossible to identify either the results (outcomes) or the costs of different interventions. It is likely that these differences in nursing practice may result in differences in the recorded incidence of PU.

The level of knowledge about PU was meagre and pressure ulcers were seldom viewed as a major problem in the hospitals. It was frequently unclear who is responsible for the prevention and treatment of pressure PU in the hospitals, the quality of PU care was depending in a large extent on personal initiatives. Practice guidelines and protocols were not created, disseminated and implemented in the hospitals. When PU quality assurance programmes began in Hungary it was widely accepted that PU were almost non-existent and that this disease and its economic burden were not important. In contrast, according to the study presented in this chapter, the total cost of all PU patients would reach the level of 1,167-2,490 million HUF annually, which is 0.4-0.8% of the total health care budget in Hungary. Reliable PU prevention and treatment cost information can be obtained through micro-costing. On average 1.0%-2.5% of this direct costs of PU treatment are reimbursed under the current DRG financing mechanism. Economic incentives for creating better quality nursing care are required, while at present the cost of 'poor quality care' are not identifiable.

c) To improve the quality of PU prevention and treatment
Another aim of the study was to improve the quality of both PU prevention and treatment through the creation, dissemination and implementation of quality assurance programmes in hospitals. PU prevention and treatment technologies were often used inappropriately due to the lack of practice guidelines. Practice guidelines were required to decrease the use of ineffective interventions or those with low cost-effectiveness. One important result of the overall study was to make health professionals aware that guidelines and local protocols on PU prevention and treatment are required to reduce local practice variations and improve the quality of care. The study resulted in the creation of Hungarian guideline for PU prevention and treatment, based upon several published international PU guidelines such as: The Dutch Consensus Prevention of Bedulcers CBO (1985), National Pressure Ulcer Advisory Panel (1995) and the European Pressure Ulcer Advisory Panel (1998). This guideline was widely disseminated and implemented among Hungarian hospitals. The importance of the continuous education for all staff involved in PU prevention and treatment was recognised as well. Training for 'Pressure Ulcer Nurses' was provided and a 350 member large professional society on PU prevention and treatment was created (Hungarian Wound Healing Society).

This study provided evidences that the structure and process quality were improved as a result of this project. International literature shows that there is a direct link between structure and process quality and outcome in the field of PU prevention and treatment. Based on this conclusion from the literature and some indirect evidences from this study it seems to be fair to conclude that the outcome of the PU prevention and treatment was also improved. The project probably had a Hawthorn effect as well, where the quality of nursing care was improved purely by the fact the study was being performed.

3.1 General conclusions and recommendations
Based upon the officially available data by the Centre for Healthcare Information Ministry of Health in Hungary, on PU epidemiology in Hungarian hospitals policy and decision makers might fail to prioritise PU initiatives due to the apparently low prevalence of the condition. It would appear that some form of quality assurance activity has to be in place in order to identify the extent of the burden of any particular problem area. Overall, this seven-phase study has demonstrated that effective quality assurance programmes can be established to tackle PU prevention and treatment. PU quality assurance programmes along with practice guidelines can be created through consensus of the relevant health care professions. The implementation of such programmes can improve the quality of nursing care even during a time of transition within the Hungarian health care system.

This programme provided direct evidence that quality assurance in the field of prevention and treatment of pressure ulcers can be implemented and used and the effectiveness of health care services can be improved in a group of Hungarian hospitals. In contrast, no empirical data of good quality have been yielded by the quality assurance studies presented in this thesis, concerning the question: 'Do quality assurance initiatives in Hungary contribute to cost containment?' Cost containment is a very difficult issue to be discussed in the Hungarian health care system, due to the lack of agreement on the meaning of quality and cost, and because no standardised costing mechanisms are implemented in the Hungarian hospitals in general, and as part of quality assurance programmes in particular.

Full References to Parts 1 and 2

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• Gulácsi L, Jakab Zs, Szloboda I (1993) Pressure Scores; A quality circle investigation, Health Management Review 31,5, 425-449
• Haalboom JRE, van Everdingen JEE, Cullum N (1997) Incidence, prevalence and classification, in: Parish LC, Witkowski JA, Crissey JT (1997) The decubitus ulcer in clinical practice, Springer: 12-23
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• Jakab Zs, Gulácsi L (1993b) Prevention and Treatment of Bedulcers in a Group of Hungarian Hospitals, The Nurse 5,6, 33-59.
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• Michocki RJ (1976) The problem of pressure ulcers in a nursing home population: statistical data, Journal of the American Geriatric Society 24, 323-326.
• National Pressure Ulcer Advisory Panel, (1995), Pressure Ulcer Healing: Controversy to Consensus, Assessment methods and Outcomes, Springhouse Corporation.
• Pressure Ulcer Treatment Guidelines (1999) European Pressure Ulcer Advisory Panel, Oxford.
• Pressure Ulcer Prevention Guidelines (1998) European Pressure Ulcer Advisory Panel, Oxford.
• The Dutch Consensus Prevention of Bedulcers (1985) CBO, Utrecht.
• Treatment of Pressure Ulcers Guideline Panel, (1994) Treatment of pressure ulcers, Rockville: Department of Health and Human Services, Agency for Health Care Policy and Research. Clinical Practice Guideline No 15. Publication No. 95-0653.