OPERATIONAL PERFORMANCE

Healthcare economics: costs of preventing versus treating skin breakdown

Discover why protecting fragile skin may help improve financial outcomes.

Clinicians work hard to protect patients from skin damage that may contribute to pressure injuries. But preventable pressure injuries/ulcers still occur. In fact, the number of other hospital-acquired conditions fell from 2014 to 2017, but hospital-acquired pressure injuries (HAPI) rose by 6 percent.

6% rise in HAPIs1

One of the reasons may be that preventive skin care is not always seen as having a strong financial incentive. That’s why, together with our Medline clinicians, we came up with an economic validation for prevention. One that you can share with leadership and value analysis teams to help them refocus on prevention initiatives.

Evaluating price of prevention and treatment

It’s a complex task to calculate the difference in costs between preventing patient skin breakdown and treating it. A lot of factors go into that number. To name a few:

  • Healthcare setting
  • Cost of goods
  • Cost of labor
  • Geography of facility
  • Third-party reimbursement levels, such as Medicare and Medicaid

We minimized these variables by looking specifically at data we gathered on incontinence care at a chain of nursing homes.

Incontinence has been associated with a higher risk of pressure injuries, so it tells an interesting story about prevention. “If the urine sits on the skin for a prolonged time, bacteria start to colonize and can have a negative impact on the skin integrity,” notes Margaret Halstead, Medline VP Health Economics and Market Access, Advanced Skin and Wound Care.

Instead of using exact numbers from each facility on how many residents were incontinent, we simplified our math by using Centers for Disease and Control research. It reveals that, on average, 76 percent of long-term nursing home residents are incontinent.2

Using our nursing home numbers, plus the CDC average helped predict estimated costs of prevention and treatment.

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Reference NPIAP guidelines

To determine what prevention of skin breakdown entails, we turned to the National Pressure Injury Advisory Panel guidelines.

As part of an overall prevention plan, the NPIAP recommends a skin care regimen that includes three key steps:3

  1. Cleanse with a pH-balanced foam cleanser
  2. Keep skin hydrated with moisturizer
  3. Protect skin from excessive moisture with a barrier product

“If you do that, most skin would never break down,” Halstead says.

For our calculation, we assumed three things:

  • Each nursing home had the national average of incontinent residents: 76% of census
  • “Prevention” costs were the sum of spend on cleanser, moisturizer, barrier and protectant
  • “Treatment” costs were the rest of the total spend on the line item of “skin care.”

Although we made it simple, we understand treatment—and associated costs—will vary widely. To give a ballpark, pressure injuries have been shown to cost healthcare facilities upwards of $150,000 per injury.4

$150,000 cost per pressure injury4

Connect skin care to cost savings

If each facility was following prevention best practices, we would assume that the total cost of skin care would go down per patient—and generally, that’s what the data confirmed.

In one instance, one facility in the chain with more than 450 residents spent a total of about $24,000 on skin and wound care; 57% of that was on skin care. Another, with less than 200 residents spent a total of over $30,000 and just 23% of that was on skin care.5

“My conclusion is, if you are putting money toward keeping the skin healthy, your overall spend seems to be less than if you were spending the majority of your money on treatment, after the fact,” Halstead notes.

However, this wasn’t always the case. Halstead attributes some of that discrepancy to education. “Part of it is training of the staff, using the right product at the right time.”

“If you are putting money toward keeping the skin healthy, your overall spend seems to be less.”
Margaret Halstead, Medline VP Health Economics and Market Access, Advanced Skin and Wound Care

Consider labor costs

It’s important to remember that the product spend doesn’t take into account the cost of the caregiver’s time to provide the prevention or treatment therapies. According to the Bureau of Labor and Statistics, the average hourly rate for a registered nurse is about $35, while a certified nursing assistant gets about $15 an hour.

Preventive skin care is typically done by the CNAs, while higher level nurses, such as RNs and wound care nurses are responsible for treatment therapies such as dressing changes. That could potentially add up to a big difference in cost.

However, Halstead explains the problem in this assumption: “If you have 100 patients in your nursing home and 76 percent are incontinent, then these people need their skin protected. So 76 residents need the skin care regimen performed four times a day. Four times to cleanse, a barrier each time you clean, and a moisturizer two times a day. Then you think of staffing, and the cost to do that if it takes 15 to 20 minutes per patient each time.” In other words, the labor time adds up.

How to calculate prevention spend

$ Total spend
(prevention products + labor cost to care for 1 patient in 1 day)

x

76% of facility census
(number of patients assumed to have incontinence)

In the end, Halstead says the cost of labor costs between prevention and treatment might not be so drastically different. Plus, Halstead points out that wound dressings are often covered by Medicare, meaning “the [prevention] incentive can be warped.” So what gives prevention a greater financial incentive than treatment?

Treatment costs are complicated

There are several challenges when it comes to calculating treatment costs, especially for long-term care and nursing homes. For one thing, Halstead stresses the cost of lawsuits in nursing-home related pressure injuries. According to data, 17,000 are filed each year, and it’s the second most common type of medical claim after wrongful death.4

 “Treatment costs a lot,” concludes Medline Divisional Manager Dionie Bibat, RN, MSN, CWOCN, adding, “There are a lot of non-financial factors that eventually add up to financial losses.”

Here are some of the factors that make treatment more expensive:

  • Longer length of stay
  • Increased readmissions
  • Increased patient pain, morbidity and mortality
  • Decreased patient quality of life
  • Lower nursing home satisfaction ratings
  • Education of nurses to provide treatment

Key takeaway

The economic factors of skin and wound care are complex. Research shows that, in addition to direct financial costs, treating a pressure injury can lead to indirect financial burdens for a facility and emotional costs for patients and family members. Preventing alterations in skin integrity may be as much a win for the bottom line as it is for patients and caregivers.

Read more about how you can help support prevention strategies:
How to prevent skin breakdown: why you need a holistic approach
Nurse leaders: Want to influence others to create a preventative culture? Here’s how
Are you doing comprehensive skin assessments correctly? Get the whole picture

References:

  1. Hospital Acquired Pressure Ulcers Prevention. (2020). Joint Commission Center for Transforming Healthcare. Available at https://www.centerfortransforminghealthcare.org/improvement-topics/hospital-acquired-pressure-ulcers-prevention/
  2. U.S. Department of Health and Human Services, Centers for Disease Control and Prevention. (2014, June). Prevalence of Incontinence Among Older Americans (Series 3, Number 36). National Center for Health Statistics
  3. National Pressure Injury Advisory Panel Prevention and Treatment of Pressure Ulcers/Injuries Clinical Practice Guideline, pages 84-85
  4. Preventing Pressure Ulcers in Hospitals. Content last reviewed October 2014. Agency for Healthcare Research and Quality, Rockville, MD. Available at https://www.ahrq.gov/patient-safety/settings/hospital/resource/pressureulcer/tool/index.html
  5. Data on file
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