Cost-effectiveness of nutritional intervention on healing of pressure ulcers

1. Cost-effectiveness of
nutritional intervention on
healing of pressure ulcers
Akinori Hisashige
Institute of Healthcare Technology
Assessment, Japan
Takehiko Ohura
Pressure Ulcers and Wound Healing
Research Center, Japan
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2. Pressure ulcer
(stage III, medium size)
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3. Pressure ulcer
(stage IV, large size)
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4. Burden of Pressure Ulcers
Prevalence rate
US, UK, Can
Hospitals 4.7 ～ 32.1%
Nursing homes 4.6 ～ 20.7%
Community care 4.4 ～ 33.0%
Japan
General hospitals2.2 ～ 3.3%
Long-term care 2.5%
Nursing care 8.3%
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5. Economic burden of Pressure Ulcers
Annual costs for treatment of
pressure ulcers
UK £ 750 million
US $ 3 billion
Australia A$ 285 million
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6. Evidence for Nutritional Interventions
on Pressure Ulcers
JAMA, 2006, 2008
 Prevention
Dietary supplementation: maybe beneficial
5 RCTs
One high quality trial: effective
Other trials: not effective
 Healing
Nutritional supplementation: maybe beneficial
7 RCTs
One high quality trial: effective
Other trials: mixed results
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7. Methods
 Design: cost-effectiveness analysis
 Perspective: societal (≒hospital)
 Clinical evidence: RCT
 Intervention: nutritional supplementation (targeted
energy goal)
 Duration: 16 weeks (12-week observation + 4-week
follow-up)
 Effectiveness: PUDs, QALYs
 Costs: direct costs (indirect costs, not included)
 Economic measure: Cost per QALY gained
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8. Subjects
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9. Nutritional intervention
Mean daily calorie per person
Intervention Control t p
During observation (12w)
1,384 (166) 1,092 (162) 6.226 .0000
Follow-up (4W)
1,142 (238) 1,094 (188) .851 .4019
Kcal: Mean (SD)
The goal energy for intervention =
Basal Energy Expenditure x active factor (1.1) x stress factor
(1.3-1.5) 9

10. Effectiveness
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11. Prevalence of pressure ulcers
Pressure Ulcer Days
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12. Utility value for pressure ulcers
 Design: cross-sectional survey
 Subjects: 227 members of Japanese Society of
Pressure Ulcers
 Method: TTO (time trade-off), group interview
 Results:
Utility for bed-ridden 0.39
Utility for bed-ridden + pressure ulcer
0.30
Utility for pressure ulcer － 0.086
(SD) (0.012)
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13. Health state utilities
Healthy (reference state) 1.00
Menopausal symptoms 0.99
Side effects of hypertension treatment 0.95
Mild angina 0.90
Kidney transplant 0.84
Moderate angina 0.70
Hospital dialysis 0.56
Severe angina 0.50
Anxious/depressed and lonely much of the time 0.45
Being blind or deaf or dumb 0.39 Bed-ridden
Hospital confinement 0.33
Mechanical aids to walk and learning disabled 0.31 Bed-ridden
Dead (reference state) 0 +
pressure ulcer
Confined to bed with severe pain -
Unconscious - 13

14. Incremental effectiveness of
nutritional intervention per person
Effectiveness Intervention Control Incremental effectiveness
(95% CI)
PUDs
84.6 100.8 -16.2 (-8.7 ~ -23.7)
QALYs (x10 － 2 ）
-2.00 -2.38 0.382 (0.205 ~ 0.559)
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15. Costs
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16. Mean costs per patient
Item Intervention Control
Nutritional management
Total 905 891
Intervention period 773 695
Wages
Nurse 1,687 2,335
Physician 277 387
Others 40 545
Drugs 99 174
Dressing materials 100 138
Consumables 45 66
Mattress 58 66
Total cost per patient 3,718 4,602
（ 95%CI ） (3,006 ~ 4,340) (4,117 ~ 5,008) 16

17. Incremental cost of nutritional
intervention per person
Intervention Control Incremental costs
(95% CI)
Costs $
3,718 4,603 -881
(-1,285 ~ -478)
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18. Cost-Effectiveness of Nutritional
Intervention
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19. Incremental cost-effectiveness of
nutritional intervention
Incremental cost-effectiveness ratio (95% CI)
Cost ($) per PUD decreased
-11 (-816 ~ 559)
Cost ($) per QALY gained
-38,726 (-2926,499 ~ 3096,049)
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20. Sensitivity Analysis
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21. Stochastic sensitivity analysis
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22. Qualitative sensitivity analysis
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23. Cost-effectivene ｓｓ of prevention and treatment
Russell, Health Aff, 28, 2009
QALY = quality-adjusted life-year
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24. Conclusion
 Nutritional intervention on healing
pressure ulcers is cost saving with
health improvement.
 Further studies are required to
determine whether this is a cost-
effective intervention for widespread
use.
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25. Stochastic sensitivity analysis
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