Health Policy & Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA.
Armstrong Institute for Patient Safety and Quality, Johns Hopkins Medicine, Baltimore, Maryland, USA.
BMJ Qual Saf. 2019 Feb;28(2):132-141. doi: 10.1136/bmjqs-2017-007505. Epub 2018 Aug 10.
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.
Cost-utility analysis using Markov modelling from US societal and healthcare sector perspectives within a 1-year time horizon.
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.
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).
Standard care, repeated risk assessment in all risk levels or only repeated risk assessment in high-risk strata based on machine-learning simulations.
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.
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.
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.
医院获得性压力性损伤是局部皮肤损伤，可导致较高的死亡率，并造成巨大的经济负担。护理最佳实践可预防压力性损伤，其中包括耗时且复杂的工作，且这些工作缺乏支付激励。Braden 量表是一种基于证据的分层工具，护士每天使用它来评估压力性损伤风险。我们的目的是分析对所有患者或高危人群进行压力性损伤预防的重复风险评估的成本-效用。
使用 Markov 模型，从美国社会和医疗保健部门的角度，在 1 年的时间内进行成本-效用分析。
使用 2011 年至 2014 年期间从学术医院电子健康记录（EHR）中获取的 34787 例患者的纵向数据，包括每日 Braden 评分。监督机器学习模拟风险水平和压力性损伤之间的年龄调整后的转移概率。
Braden 评分分为 5 个风险水平的住院成年人：极高危（6-9）、高危（10-11）、中危（12-14）、有风险（15-18）、低危（19-23）。
标准护理，对所有风险水平进行重复风险评估，或仅根据机器学习模拟对高危人群进行重复风险评估。
压力性损伤治疗和预防的成本（2016 年美元）以及与压力性损伤相关的质量调整生命年（QALY），根据转移概率进行加权，以计算 10 万美元/QALY 支付意愿的增量成本效益比（ICER）。单变量和概率敏感性分析测试了模型的不确定性。
从社会和医疗保健部门的角度来看，对所有患者进行预防可获得更多的 QALY，但成本更高，分别相当于 ICER 为 2000 美元/QALY 和 2142 美元/QALY。Braden 评分<15 的患者的风险分层随访优于标准护理。对所有患者进行预防在>99%的概率模拟中具有成本效益。
我们使用电子健康记录数据进行的分析表明，对所有住院患者进行压力性损伤预防具有成本效益。医院应投资于护理人员遵守国际预防指南。
