Low-tech, inexpensive interventions for bedsores could benefit long-term care residents

Researchers at the University of Toronto have found that low-tech, inexpensive interventions for bedsores could improve health for long-term care residents and reduce health-care costs for the facilities that house them.

For all long-term care residents, pressure reduction foam mattresses were cost-effective 82% of the time compared to standard mattresses, with average savings of $115 per resident, the researchers showed. Foam cleansers for incontinence care would be cost-effective 94% of the time compared to soap and water, saving an average of $179 per resident.

The clinical benefits of foam cleansers for bedsores, or "pressure ulcers," however, require confirmation through more research, the team noted.

"These results provide specific evidence to support practice guidelines, which recommend reducing risk factors and improving skin health to prevent pressure ulcers," said Ba' Pham, lead author on the study and a senior research associate with the Toronto Health Economics and Technology Assessment (THETA) Collaborative. "We encourage all providers of long-term care to consider these changes," said Pham, who is completing his doctorate at U of T's Department of Health Policy, Management and Evaluation.

The Archives of Internal Medicine published the study in its current online edition.

In Ontario, there are approximately 72,000 long-term care residents in 89 facilities. As part of their study, the researchers conducted a phone survey with directors of care at 26 of those facilities, and found that only half their beds have pressure reduction foam mattresses. As well, roughly half of incontinence-care cleanings were performed with soap and water rather than foam cleansers.

This slow uptake of quality improvements in pressure ulcer care in Ontario may be connected to the condition's low profile relative to other diseases. "It's one of those diseases that's kind of silent," said Prof. Murray Krahn, principal investigator on the study who is a Professor in the Department of Medicine and the Faculty of Pharmacy at U of T, and Director of THETA.

"Unlike HIV or breast cancer, there are no advocacy groups marching for pressure ulcers. The patients are seniors with co-morbidities and low mobility in long-term care," said Krahn.

Compounding the condition's visibility problem is that it doesn't belong to a particular clinical group. Patients are cared for by nurses, surgeons, infectious disease specialists, general practitioners and internists, so no one group is well-positioned to champion the cause effectively.

Yet, the disease burden for pressure ulcers is huge. From 5% to 10% of all residents in long-term care facilities have pressure ulcers, and a study published this year in the journal Health Affairs, cited by Pham and Krahn, pegged their treatment costs in all health-care settings-including hospitals and home care-at $3.3 billion U.S. annually. "We've estimated, crudely, that the economic burden for pressure ulcers is similar to diabetes. It's absolutely enormous," said Krahn.

The researchers also evaluated two other strategies for dealing with pressure ulcers: emollients to reduce dry skin, and oral nutritional supplements. They found some evidence that emollients were moderately cost-effective, and that supplements were not cost-effective, although both have been associated with clinical benefits.

Krahn attributes the range and strength of the study's results to the policy-oriented research model for pressure ulcers developed by his colleagues. "It's the work of about 15 people over two years looking at Ontario-specific data, and it's by far the best model in the world in this area," said Krahn.

That model, said Krahn, has produced a very clear message: "There's something relatively easy that can be done about pressure ulcers that will have a relatively large impact."