Financial Impact of Improved Pressure Ulcer Staging in the Acute Hospital with Use of a New Tool, the NE1 Wound Assessment Tool

Article (PDF Available)inAdvances in skin & wound care 25(4):158-66 · April 2012with82 Reads
DOI: 10.1097/01.ASW.0000413597.20438.d2 · Source: PubMed
Abstract
The NE1 Wound Assessment Tool (NE1 WAT; Medline Industries, Inc, Mundelein, Illinois), previously called the N.E. One Can Stage, was shown to significantly improve accuracy of pressure ulcer (PrU) staging. Improved PrU staging has many potential benefits, including improved care for the patient and better reimbursement. Medicare has incentivized good care and accurate identification of PrUs in the acute care hospital through an additional payment, the Medicare Severity-Diagnosis Related Group (MS-DRG). This article examines the financial impact of NE1 WAT use on the acute care hospital relative to MS-DRG reimbursement. PrU staging accuracy with and without use of the NE1 WAT from previous data was compared with acute care hospital PrU rates obtained from the 2006 National Inpatient Sample. Hill-Rom International Pressure Ulcer Prevalence Survey data were used to estimate the number of MS-DRG-eligible PrUs. There are between 390,000 and 130,000 MS-DRG-eligible PrUs annually. Given current PrU staging accuracy, approximately $209 million in MS-DRG money is being collected. With the improved staging afforded by the NE1 WAT, this figure is approximately $763.9 million. Subtracting the 2 reveals $554.9 million in additional reimbursement that could be generated by using the NE1 WAT. There is a tremendous financial incentive to improve PrU staging. The NE1 WAT has been shown to improve PrU staging accuracy significantly. This improvement has the potential to improve the financial health of acute care hospitals caring for patients with PrUs.
Financial Impact of Improved Pressure Ulcer Staging
in the Acute Hospital with Use of a New Tool,
the NE1 Wound Assessment Tool
Daniel L. Young, PT, DPT; Jay J. Shen, PhD; Nancy Estocado, PT, BS, CWS; and Merrill R. Landers, PT, DPT, OCS
INTRODUCTION
Despite ongoing efforts to reduce the occurrence of pressure
ulcers (PrUs) in acute care hospitals, the problem persists. In
acute care hospitals, the average prevalence is more than 10%
but may be as high as 38% in some cases.
1–3
Current data
suggest that new PrU cases per year are in the range of 1 to 2.5
million people.
1,4,5
PrUs are not only a significant health issue
for the individual sufferer, but also a financial concern for the
entire healthcare system. In the United States, annual costs
associated with PrUs approach $11 billion, with the cost for
each PrU ranging from $500 to $70,000, depending on the
individual circumstances.
3,4
Because PrUs are often a prevent-
able condition, this represents a tremendous burden to indi-
viduals, hospitals, and the nation.
As the majority of patients with PrUs are older than 65 years
in the United States, Medicare has become the largest payer
for the care of individuals with a PrU.
1
Medicare has recently
made changes to its reimbursement policy f or PrUs to
incentivize good care. In the acute care hospital, it provides an
additional payment, called a Medicare SeverityDiagnosis
Related Group (MS-DRG), for the care of more severe PrUs
that are present on admission (POA). However, the MS-DRG is
not available if the PrU was a hospital-acquired condition
(HAC).
6
Thus, it has become financially important for hospitals
to correctly identify and define PrUs on admission and then
prevent the development of PrUs during the patients stay.
Correct identification of PrU severity involves assignment of
one of the stages defined by the National Pressure Ulcer
Advisory Panel (NPUAP).
7
The NPUAP has defined 4 separate
stages of PrU depending on the severity. To summarize, Stage I
presents as nonblanchable skin redness; Stage II is partial-
thickness loss of the dermis; Stage III is full-thickness skin loss
without exposure of bone, tendon, or muscle; and Stage IV is
ADVANCES IN SKIN & WOUND CARE & VOL. 25 NO. 4 158 WWW.WOUNDCAREJOURNAL.COM
ORIGINAL INVESTIGATION
Daniel L. Young, PT, DPT, is Assistant Professor, Department of Physical Therapy, School of Allied Health Sciences, and Jay J. Shen, PhD, is Associate Professor, Department of Health
Care Administration and Policy, School of Community Health Sciences, both at the University of Nevada, Las Vegas. Nancy Estocado, PT, BS, CWS, is Program Supervisor/Rehab
Therapy, Sunrise Hospital and Medical Center, Las Vegas, Nevada. Merrill R. Landers, PT, DPT, OCS, is Associate Professor, Department of Physical Therapy, School of Allied Health
Sciences, University of Nevada, Las Vegas. Dr Young has disclosed that he is/was a consultant/advisor to Medline Industries, Inc. Dr Shen has disclosed that he has no financial
relationships related to this article. Ms Estocado is the owner of NE Solutionz, LLC, and the NE1 Assessment Tool. Dr Landers has disclosed that he has no financial relationships related to
this article.
ABSTRACT
OBJECTIVE: The NE1 Wound Assessment Tool (NE1 WAT; Medline
Industries, Inc, Mundelein, Illinois), previously called the N.E. One
Can Stage, was shown to significantly improve accuracy of
pressure ulcer (PrU) staging. Improved PrU staging has many
potential benefits, including improved care for the patient and
better reimbursement. Medicare has incentivized good care and
accurate identification of PrUs in the acute care hospital through an
additional payment, the Medicare SeverityDiagnosis Related Group
(MS-DRG). This article examines the financial impact of NE1 WAT use
on the acute care hospital relative to MS-DRG reimbursement.
DESIGN: PrU staging accuracy with and without use of the NE1
WAT from previous data was compared with acute care hospital PrU
rates obtained from the 2006 National Inpatient Sample. Hill-Rom
International Pressure Ulcer Prevalence Survey data were used
to estimate the number of MS-DRGeligible PrUs.
MAIN RESULTS: There are between 390,000 and 130,000
MS-DRG eligible PrUs annually. Given current PrU staging
accuracy, approximately $209 million in MS-DRG money is being
collected. With the improved staging afforded by the NE1 WAT,
this figure is approximately $763.9 million. Subtracting the 2
reveals $554.9 million in additional reimbursement that could be
generated by using the NE1 WAT.
CONCLUSION: There is a tremendous financial incentive to
improve PrU staging. The NE1 WAT has been shown to improve
PrU staging accuracy significantly. This improvement has the
potential to improve the financial health of acute care hospitals
caring for patients with PrUs.
KEYWORDS: pressure ulcer staging, wound assessment tool,
reducing pressure ulcers
ADV SKIN WOUND CARE 2012;25:158 66
Copyright @ 2012 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
the same as Stage III but with the exposure of bone, tendon, or
muscle. They have also defined 2 additional categories relative
to PrU presentation that help to provide more clarity on the
state of the tissue. Suspected deep tissue injury (sDTI) is used to
describe a case where there is underlying tissue damage with-
out current loss of the overlying skin as evidenced by color,
temperature, or firmness changes. Unstageable is used when
the wound bed of a full-thickness wound is covered with
necrotic tissue, obscuring the deepest layer of involved tissue.
7
Medicare will pay the MS-DRG for Stages III and IV PrUs that
are POA. The MS-DRG is not available for Stage I or Stage II
PrUs, nor any PrU that is a HAC.
The ability of the average, nonexpert clinician (eg, nurse,
physical therapist, physician) to correctly stage a PrU is poor,
ranging from 23% to 58% correct.
8,9
This number drops to
as low as 20% correct when staging MS-DRG eligible PrUs
by nonexperts.
8
However, a recently developed tool, originally
called the NE One Can Stage but recently renamed the NE1
Wound Assessment Tool (NE1 WAT; Medline Industries, Inc,
Mundelein, Illinois), aided nonexpert clinicians in improving
staging accuracy from 35% correct without the tool to 71%
correct when using the tool for all types of PrUs and from
32% correct without the tool to 75% correct with the tool
on MS-DRG eligible PrUs, an improvement of greater than
100% in relative terms.
8
Evidence for the reliability of the
NE1 WAT was strong (intraclass correlation coefficient
(ICC)[3,1] = 0.794; 95% confidence interval, 0.673 0.873) for
different types of healthcare providers who may be involved in
PrU staging.
9
The NE1 WAT (Figure 1) is an L-shaped piece of
glossy paper with ruled inner edges and pictures and
descriptions of wounds on the body of it. The tool is designed
for placement on the patient_s intact skin bordering the
wound. A picture of the wound with the tool in place is then
taken to be included in the medical record. The tool guides the
clinician in determining the correct stage of PrU and in
measuring the wound dimensions.
The use of the NE1 WAT has the potential to improve re-
imbursement through improved accuracy of PrU staging and
subsequent collection of the MS-DRG when appropriate. Be-
fore such a statement regarding reimbursement could be used
to change practice at acute care hospitals, an analysis of the
costs relative to the benefit of the NE1 WAT would be bene-
ficial. Although the value of improved PrU staging may be
greatest in terms of improved care for the patient, this is not
the focus of this article. The primary goal of this article is to
examine the cost of the NE1 WAT relative to the potential
benefit in terms of the MS-DRG. Given the wide variety in
hospital size, this article also presents results for PrU rates and
impact of the NE1 WAT on hospitals of various sizes.
METHODS
The basic design of this study was to calculate the difference in
PrU reimbursement for the acute care hospital setting when
current PrU staging accuracy is compared with the improved
accuracy that the NE1 WAT affords. To achieve this, PrU stag-
ing accuracy data from the study of Young et al,
8
where the
validity of the NE1 WAT was tested, was used to compare with
historic data of PrU prevalence or volume. For staging without
the NE1 WAT (such as typical clinical practice), both a low
value (20%, worst accuracy for any discipline tested) and high
value (58%, best accuracy for any discipline tested) for accuracy
were used.
8
For staging with the NE1 WAT, the average accu-
racy (75%) for all clinicians was used.
8
The following were the
sources used to determine historic prevalence levels of PrUs:
& The 2006 National Inpatient Sample (NIS) that contains dis-
charge data from a stratified clustering sample of 20% of all
community hospitals in the United States
10
& The 2004 State Inpatient Data (SID)
11
of Nevada that contains
all discharges from community hospitals in the state. Both
NIS and SID data sets included diagnostic codes allowing the
data to be searched for numbers of patients with PrUs. The
Healthcare Cost and Utilization Project under the Agency for
Healthcare Research and Quality maintains these data sets
& The 2004 and 2006 American Hospital Association annual
survey data that included hospital characteristics
12
& Hill-Rom International Pressure Ulcer Prevalence survey data
13
The NE1 WAT is commercially available for purchase through
Medline. Pricing for the tool is determined based on the volume
of the purchase but averages close to $6. For the purpose of
this article and calculations, a price in excess of the maximum
cost for the tool was desired to ensure that even the smallest
purchases of the tool would still allow for a valid comparison to
these calculations. Following consultation with Medline Indus-
tries, the amount of $20 was then used as the per-unit price for
calculations used in this study. In addition, part of the meth-
odology involved estimating the number of PrUs that would be
eligible for the MS-DRG. The Hill-Rom data provided values for
the various proportions of different stages of PrUs (Figure 2).
Given that sDTI PrUs are full-thickness injuries and ‘‘evolution
may be rapid exposing additional layers of tissue even with
optimal treatment,’’ they were included with the Stage III and
IV numbers.
7
Also, unstageable PrUs are by definition full-
thickness and will be Stage III or Stage IV after debridement and
thus were included with the totals for Stages III and IV. This
number (39%) was then divided into thirds so that a high (39%),
mid (26%), and low (13%) value could be examined separately.
Finally, the exact value of the MS-DRG for each individual
facility will vary slightly based on the variables used by Medicare
to determine such payment; thus, an estimate of the MS-DRG
ADVANCES IN SKIN & WOUND CARE & APRIL 2012159WWW.WOUNDCAREJOURNAL.COM
ORIGINAL INVESTIGATION
Copyright @ 2012 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Figure 1.
THE NE1 WAT
Reprinted with permission from Medline.
ADVANCES IN SKIN & WOUND CARE & VOL. 25 NO. 4
160 WWW.WOUNDCAREJOURNAL.COM
ORIGINAL INVESTIGATION
Copyright @ 2012 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
at $2680 was used from an example on the Centers for Medicare
& Medicaid Services website.
6
Because the rate of PrUs in acute care hospitals appears to be
different based on hospital census or bed count, hospital size
was taken into account in the analysis. Examination of results
was conducted based on bed count in 100-bed increments.
National analyses were then made based on this division. On
preliminary analysis of the data, it was observed that Nevada
did not appear to follow the national trend on PrU rates for
different sizes of hospitals. Separate analysis of Nevada hospi-
tals was then conducted for comparison. Because there were so
few Nevada hospitals, they were split into 2 groups of less than
and greater than 100 beds, and statistical comparisons between
these groups were made using nonparametric Mann-Whitney
rank sum tests. As the NIS data provided for a much larger
sample of hospitals with different bed counts, these compari-
sons were made using parametric tests. Statistical analyses of
data based on hospital size were all performed using PASW18
(SPSS Inc, IBM, Chicago, Illinois).
Because the NE1 WAT would be used on every patient with
a PrU, the cost of using the tool is a straightforward calculation
whereby the number of patients with PrU diagnosis, given the
population and time frame of interest, can be multiplied by the
per-unit cost of $20. In this study, this was done for the United
States collectively, and the state of Nevada separately; it was
also calculated as a monthly value based on hospital bed count
and the average PrU rate for that size facility.
Both NIS and SID data sets did not contain the detail ne-
cessary to distinguish between numbers of patients with
different stages of PrUs. As previously mentioned, the Hill-
Rom data indicated that 39% of all acute care hospital PrUs
were greater than Stage II and thus eligible for the MS-DRG.
This number was then divided into thirds so that a high (39%),
mid (26%), and low (13%) value could be used for calculations.
Taking 39%, 26%, or 13% of the total PrUs observed yielded a
number that was then multiplied by the MS-DRG value to
obtain the maximum potential reimbursement (MPR
HorMor
L
). Because accurate unaided staging by the clinician for these
MS-DRGeligible PrUs appears to range from 20% to 58%
correct,
8
these percentages were then multiplied by the MPR to
obtain the actual reimbursement low (AR
L
) and the actual
reimbursement high (AR
H
) for each of the 3 MPR values. The
impact of the NE1 WAT on the MPR can be calculated by
multiplying the MPR by 75%, which was the staging accuracy
when the NE1 WAT was used on MS-DRG eligible PrUs,
9
yielding the potential reimbursement high, mid, or low (PR
Hor
MorL
). The difference between the PR and the AR is the
additional money that could be expected if the NE1 WAT were
used. The cost of the tool was subtracted from the PR in all
calculations (Figure 3).
The analysis for this study made some assumptions. First, the
assumption that all PrUs greater than Stage II were eligible for the
MS-DRG due to POA status. Some unknown percentage of these
PrUs are going to be HACs and thus ineligible. The percentage of
eligible PrUs was presented at different levels (high, mid, low),
offering comparison and examples for this unknown. Second, all
inaccuracy in staging was assumed to result in lost MS-DRG;
however, as an example, inaccurately staging a Stage IV PrU
as Stage III would not cause lost MS-DRG. Another assump-
tion was that all sDTIs would be eligible for the MS-DRG. It is
possible that an unknown percentage of these would not
progress into Stage III or IV. The final assumption is that all
patients with PrU would be covered by Medicare and thus
eligible for the MS-DRG. However, Medicare would not be the
payer for some unknown percentage of the PrUs included in
the calculations. Again, the inclusion of high, mid, and low, or
high and low values was done in places where assumptions
were made to indicate the range of possible values given these
assumptions.
RESULTS
The 2006 NIS data set revealed 204,247 cases of PrUs, which
gave a national estimate of approximately 1 million PrUs per
year in the United States, a figure supported by others as
well.
1,5
Using this number of total PrUs multiplied by the
cost of the NE1 WAT, the national cost for use of the tool
Figure 2.
NATIONAL DISTRIBUTION OF DIFFERENT STAGES OF PrUs
ADVANCES IN SKIN & WOUND CARE & APRIL 2012161WWW.WOUNDCAREJOURNAL.COM
ORIGINAL INVESTIGATION
Copyright @ 2012 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
would be $20 million. When the total number of PrUs was
multiplied by the estimates for the percentage that were
greater than Stage II (39%, 26%, and 13%), the numbers for
MS-DRGeligible PrUs in the United States were approx-
imately 390,000, 260,000, and 130,000 annually. This gives
MPR values (390,000, 260,000, and 130,000 multiplied by
$2680) of $1045.2 million, $696.8 million, and $348.4 million
annually. The national AR
L
($209 million) subtracted from the
PR
H
($763.9 million) gives $554.9 million in additional money
that would be collected if PrUs were staged using the NE1
WAT. National values for PR
H
,PR
M
, and PR
L
less either AR
H
or AR
L
amounts are shown in Table 1.
For Nevada in 2004, there were a total of 4951 PrUs. The
potential cost for all hospitals in the state to implement use of
the NE1 WAT would then be $99,020. When the total number
of PrUs was multiplied by the estimates for the percentage that
was greater than Stage II (39%, 26%, and 13%), the numbers
for MS-DRG eligible PrUs in Nevada were approximately
1931, 1288, and 644 annually. This gives MPR values (1931,
1288, and 644 multiplied by $2680) of $5.17 million, $3.45
million, and $1.73 million annually. The AR
L
($1.03 million)
subtracted from the PR
H
($3.78 million) gives $2.75 million in
additional money that would be collected if PrUs were staged
using the NE1 WAT. Nevada values for PR
H
,PR
M
, and PR
L
less
either AR
H
or AR
L
amounts are shown in Table 1.
Nationally, comparisons between hospitals of different sizes
(199 beds, 100 199 beds, 200 299 beds, 300 399 beds, 400
499 beds, z500 beds) were done using 1-way analysis of
variance. This test was performed for 8 different measures:
PrUs per bed per month (Figure 4), NE1 WAT cost per bed per
month (Figure 5), and the 6 different monthly, per bed, values
of additional money that could be collected if PrUs were staged
Figure 3.
CALCULATION FLOWSHEET
Table 1.
NATIONAL AND NEVADA MPR, PR, AND PROJECTED ADDITIONAL REIMBURSEMENT
MPR
H
MPR
M
MPR
L
PR
H
PR
M
PR
L
National $1,045,200,000 $696,800,000 $348,400,000 $763,900,000 $502,600,000 $241,300,000
Nevada $5,174,785.20 $3,449,856.80 $1,724,928.40 $3,782,068.90 $2,488,372.60 $1,194,676.30
Projected Additional Reimbursement
PR
H
-AR
H
PR
H
-AR
L
PR
M
-LR
H
PR
M
-LR
L
PR
L
-AR
H
PR
L
-AR
L
National $157,684,000 $554,860,000 $98,456,000 $363,240,000 $39,228,000 $171,620,000
Nevada $780,693.48 $2,747,111.86 $487,455.66 $1,798,401.24 $194,217.83 $849,690.62
Abbreviations: MPR
H, M, or L
, maximum potential reimbursement: high, medium, or low (theoretical value with 100% staging accuracy for eligible PrUs); PR, MPR
accuracy with use of NE1
WAT; PR
H
, potential reimbursement with NE1 WAT using the high estimate for eligible PrU proportion; PR
M
, potential reimbursement with NE1 WAT using the mid estimate for eligible PrU
proportion; PR
L
, potential reimbursement with NE1 WAT using the low estimate for eligible PrU proportion; AR, MPR
accuracy without using NE1 WAT; AR
H
, actual reimbursement using
the high estimate for unaided staging accuracy; AR
L
, actual reimbursement using the low estimate for unaided staging accuracy.
ADVANCES IN SKIN & WOUND CARE & VOL. 25 NO. 4
162 WWW.WOUNDCAREJOURNAL.COM
ORIGINAL INVESTIGATION
Copyright @ 2012 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
using the NE1 WAT (PR
H
AR
H
,PR
H
AR
L
,PR
M
AR
H
,
PR
M
AR
L
,PR
L
AR
H
,PR
L
AR
L
) (Table 2 and Figure 6).
There was a statistically significant difference among the means
for PrUs per bed per month, F
5,1017
= 20.929, P < .0001; NE1
WAT cost per bed per month, F
5,1017
=20.929,P <.0001;PR
H
AR
H
, F
5,1017
= 20.929, P < .0001; PR
H
AR
L
, F
5,1017
= 20.929,
P < .0001; PR
M
AR
H
, F
5,1017
= 20.929, P < .0001; PR
M
AR
L
,
F
5,1017
= 20.929, P < .0001; PR
L
AR
H
, F
5,1017
= 20.929, P < .0001;
and PR
L
AR
L
, F
5,1017
= 20.929, P < .0001. Tukey post hoc
analysis revealed that on all measures and between all groups,
only hospitals with 1 to 99 beds were different than hospitals
of larger sizes (Table 3). For comparisons between all but the
smallest hospitals, on all tested variables there were no sig-
nificant differences, P > .221.
For Nevada, there was a statistically significant difference in
the monthly PrU rate between the large (mean, 0.11 [SD, 0.04]
PrU per bed) and small (mean, 0.03 [SD, 0.03] PrU per bed)
hospitals, U = 14.00, z = 3.60, P < .0001. There was also a
difference in the monthly cost of using the NE1 WAT between
the large (mean, $0.68 [SD, $0.62] per bed) and small (mean,
$2.13 [SD, $0.80] per bed) hospitals, U = 14.00, z = 3.60, P <
.0001. Then as expected, a significant difference was also found
in the 6 different monthly, per bed, values of additional money
that could be collected if PrUs were staged using the NE1 WAT
(PR
H
AR
H
,PR
H
AR
L
,PR
M
AR
H
,PR
M
AR
L
,PR
L
AR
H
,PR
L
AR
L
), all with U = 14.00, z = 3.60, P < .0001
(Table 4).
DISCUSSION
The cost of the NE1 WAT compared with the potential increase
in revenue through MS-DRG payments is dramatic. Even using
a high estimate of $20 per unit for the cost of the NE1 WAT,
the difference between it and the MS-DRG is so large that it is
easily offset. Although there was a large difference between
PrU rates in small versus large Nevada hospitals, the NE1 WAT
is used only when a PrU is suspected, and so the per-bed cost
is also much less for small compared with large hospitals.
Although these data did not examine the benefit in terms of
improved patient outcomes, or reduced length of stay through
improved staging of PrUs, others have discussed improve-
ments from accurate PrU staging,
14 16
adding to the value of
the tool.
As has been previously mentioned, there is a need to
evaluate the impact of improved PrU staging through use of
the NE1 WAT on quality of care and other patient outcomes. It
is important to note that the NE1 WAT is used when a PrU is
suspected or already present. It does not function to prevent
the development of a PrU. Prevention measures and risk mea-
surement tools must be used in conjunction with the NE1
WAT. However, if PrUs are correctly identified and staged
earlier, it may be possible to see a reduction in the progression
of PrUs from less to more severe as the stage of the wound
guides treatment, including modalities, dressings, specialty
beds, and patient-positioning protocols.
14 16
This also ad-
dresses the potential concern for Medicare relative to increased
MS-DRG payouts to acute care hospitals if the NE1 WAT were
Figure 4.
NATIONAL MONTHLY AVERAGE PrU RATE PER BED
Figure 5.
NATIONAL MONTHLY AVERAGE COST OF USING THE NE1
WAT PER BED
ADVANCES IN SKIN & WOUND CARE & APRIL 2012163WWW.WOUNDCAREJOURNAL.COM
ORIGINAL INVESTIGATION
Copyright @ 2012 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
widely adopted. The increased payments would then have the
desired effect of improving PrU care in hospitals, subsequently
reducing costs for Medicare in care provided following acute
care hospital discharge.
As mentioned, the analyses for this study made some as-
sumptions on the data and necessitate caution when interpret-
ing the results. The assumption likely to have the greatest
impact on the results is the use of all PrUs greater than Stage II
as eligible for the MS-DRG due to POA status. Although
hospitals would prefer to report that all PrUs in their facilities
were POA, the truth is that some percentage is going to be
HACs. However, in these data, it would have taken only 37 of
the 4951 PrUs for the state of Nevada to cover the cost of the
NE1 WAT. And, all inaccuracy in staging was assumed to result
in lost MS-DRG, whereas some of this inaccuracy would not
have affected this reimbursement because both Stages III and
IV are eligible for the MS-DRG. However, this number is likely
to be quite small based on previous data.
8
Another assumption
was that all sDTIs would be eligible for the MS-DRG. The
Hill-Rom data indicated that these represented 11% of the
observed PrUs. The range of proportions offered in the analysis
would more than offset this number. One of the final assump-
tions was that all patients with PrUs would be covered by
Medicare and thus eligible for the MS-DRG. The Hill-Rom data
indicate that almost 65% of PrUs occurred in patients older
than 60 years, making nearly that many eligible for Medicare
coverage. Other studies support the assumption that the
majority of PrUs occur in older adults.
1
Another interesting finding in the authors’ data was the
significantly lower prevalence of PrUs in Nevada hospitals with
fewer than 99 beds. This is opposite the finding from the NIS
data where lower PrU rates were observed in the larger
hospitals. The Hill-Rom data do not have prevalence data
based on bed count, but they do have it based on census size, a
closely related metric. In their data, the trend was also opposite
that of Nevada, with the lower census counts correlating with
higher total PrU prevalence. The reason these opposite trends
were observe d is unknow n. Because reimburse ment and
regulation are similar throughout the nation, it is unlikely that
these factors caused the observed difference. It is most likely
that the observation was anomalous for the small sample and
time period and that trends over longer periods in the Nevada
hospitals would more closely reflect national trends. However,
hospital administrators should be cautious when applying
these data to their individual hospitals for budgeting and
planning, as it is clear that large differences may exist.
Table 2.
PROJECTED ADDITIONAL MONTHLY REIMBURSEMENT PER B ED WHEN USING THE NE1 WAT
PR
H
-AR
H
PR
H
-AR
L
PR
M
-AR
H
PR
M
-AR
L
PR
L
-AR
H
PR
L
-AR
L
1 99 Beds $50.33 $177.09 $31.42 $115.93 $12.52 $54.78
100 199 Beds $18.78 $66.09 $11.73 $43.27 $4.67 $20.44
200 299 Beds $13.62 $47.92 $8.50 $31.37 $3.39 $14.82
300 399 Beds $10.05 $35.38 $6.28 $23.16 $2.50 $10.94
400 499 Beds $6.56 $23.08 $4.10 $15.11 $1.63 $7.14
z500 Beds $3.95 $13.90 $2.47 $9.10 $0.98 $4.30
Abbreviations: MPR
H, M, or L
, maximum potential reimbursement: high, medium, or low (theoretical value with 100% staging accuracy for eligible PrUs); PR, MPR
accuracy with use of NE1
WAT; PR
H
, potential reimbursement with NE1 WAT using the high estimate for eligible PrU proportion; PR
M
, potential reimbursement with NE1 WAT using the mid estimate for eligible PrU
proportion; PR
L
, potential reimbursement with NE1 WAT using the low estimate for eligible PrU proportion; AR, MPR
accuracy without using NE1 WAT; AR
H
, actual reimbursement using
the high estimate for unaided staging accuracy; AR
L
, actual reimbursement using the low estimate for unaided staging accuracy.
Figure 6.
NATIONAL PROJECTED ADDITIONAL MONTHLY
REIMBURSEMENT PER BED WHEN USING THE NE1 WAT
(PR
H
-AR
H
)
Abbreviations: MPR
H, M, or L
, maximum potential reimbursement: high, medium, or low
(theoretical value with 100% staging accuracy for eligible PrUs); PR, MPR
accuracy with
use of NE1 WAT; PR
H
, potential reimbursement with NE1 WAT using the high estimate for
eligible PrU proportion; AR, MPR
accuracy without using NE1 WAT; AR
H
, actual
reimbursement using the high estimate for unaided staging accuracy.
ADVANCES IN SKIN & WOUND CARE & VOL. 25 NO. 4
164 WWW.WOUNDCAREJOURNAL.COM
ORIGINAL INVESTIGATION
Copyright @ 2012 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
This article was limited to an analysis of the acute care
hospital, and it would be valuable to examine the impacts of
improved PrU staging through use of this tool in other settings,
such as long-term acute care, rehabilitation, home health, and
long-term care. The Hill-Rom data indicate that the rates of
PrUs in long-term acute-care facilities are much higher than in
other facilities, and this may be a setting in which the earlier
and more accurate staging of PrUs combined with effective
protocols for treatment may have the largest impact on out-
comes and cost of providing care. In addition, there is a finan-
cial incentive for home health providers to accurately stage
PrUs as Medicare pays additional money for patients with
more severe PrUs, similar to the acute care hospital.
CONCLUSION
The difference between the cost of the NE1 WAT and the in-
creased reimbursement that comes from improved PrU staging
is substantial. When considered in light of the Medicare policy
for reimbursement of PrUs in acute care hospitals, accurate PrU
staging of patients on admission is essential. In Nevada, there
is a significant difference between hospitals with fewer than
99 beds and those with more than 99 beds in the prevalence of
PrUs. Regardless of PrU prevalence, the NE1 WAT is used only
when a PrU is present or suspected; thus, a lower prevalence
also lowers the facility cost for use of the tool proportional to
the PrU prevalence. The implementation of this tool is attrac-
tive for acute care hospitals because the improved accuracy in
PrU staging will result in increased reimbursement through the
MS-DRG.
&
Table 3.
POST HOC ANALYSIS FOR MONTHLY,
PER-BED RATES OF TESTED VARIABLES
Tested Variable Group Group Mean Difference SE
PrU rate 1 2 0.2001
a
0.0285
3 0.2328
a
0.0330
4 0.2554
a
0.0414
5 0.2776
a
0.0534
6 0.2941
a
0.0414
NE1 WAT cost in $ 1 2 4.00
a
0.57
3 4.66
a
0.66
4 5.11
a
0.83
5 5.55
a
1.07
6 5.88
a
0.83
PR
H
AR
H
in $ 1 2 31.54
a
4.49
3 36.71
a
5.21
4 40.27
a
6.52
5 43.77
a
8.43
6 46.38
a
6.52
PR
H
AR
L
in $ 1 2 111.00
a
15.81
3 129.17
a
18.32
4 141.71
a
22.95
5 154.01
a
29.65
6 163.19
a
22.95
PR
M
AR
H
in $ 1 2 19.70
a
2.81
3 22.92
a
3.25
4 25.15
a
4.07
5 27.33
a
5.26
6 28.96
a
4.07
PR
M
AR
L
in $ 1 2 72.66
a
10.35
3 84.56
a
12.00
4 92.77
a
15.02
5 100.82
a
19.41
6 106.83
a
15.02
PR
L
AR
H
in $ 1 2 7.85
a
1.12
3 9.13
a
1.30
4 10.02
a
1.62
5 10.89
a
2.10
6 11.54
a
1.62
PR
L
AR
L
in $ 1 2 34.33
a
4.89
3 39.95
a
5.67
4 43.83
a
7.10
5 47.64
a
9.17
6 50.48
a
7.10
Abbreviations: MPR
H, M, or L
, maximum potential reimbursement: high, medium, or low
(theoretical value with 100% staging accuracy for eligibl e PrUs); PR, MPR
accuracy
with use of NE1 WAT; PR
H
, potential reimbursement with NE1 WAT using the high
estimate for eligible PrU propor tion; PR
M
, potential reimbursement with NE1 WAT
using the mid estimate for eligible PrU proportion; PR
L
, potential reimbursement with
NE1 WAT using the low estimate for eligible PrU proportion; AR, MPR
accuracy
without using NE1 WAT; AR
H
, actual reimbursement using the high estimate for unaided
staging accuracy; AR
L
, actual reimbursement using the low estimate for unaided staging
accuracy.
Group 1 = 1 99 beds, group 2 = 100 199 beds, group 3 = 200 299 beds, group 4 = 300
399 beds, group 5 = 400 499 beds, group 6 = z500 beds.
a
P < .0001.
Table 4.
NEVADA PROJECTED ADDITIONAL
MONTHLY REIMBURSEMENT PER BED
WHEN USING THE NE1 WAT
n Mean SD
PR
H
AR
H
1 99 beds 12 $5.39 4.91
z99 beds 14 $16.81 6.29
PR
H
AR
L
1 99 beds 12 $18.97 17.29
z99 beds 14 $59.16 22.15
PR
M
AR
H
1 99 beds 12 $3.37 3.067
z99 beds 14 $10.50 3.93
PR
M
AR
L
1 99 beds 12 $12.42 11.32
z99 beds 14 $38.73 14.50
PR
L
AR
H
1 99 beds 12 $1.34 1.22
z99 beds 14 $4.18 1.57
PR
L
AR
L
1 99 beds 12 $5.87 5.35
z99 beds 14 $18.30 6.85
Abbreviations: MPR
H, M, or L
, maximum potential reimbursement: high, medium, or low
(theoretical value with 100% staging accuracy for eligible PrUs); PR, MPR
accuracy with
use of NE1 WAT; PR
H
, potential reimbursement with NE1 WAT using the high estimate
for eligible PrU proportion; PR
M
, potential reimbursement with NE1 WAT using the mid
estimate for eligible PrU proportion; PR
L
, potential reimbursement with NE1 WAT using
the low estimate for eligible PrU proportion; AR, MPR
accuracy without using NE1
WAT; AR
H
, actual reimbursement using the high estimate for unaided staging accuracy;
AR
L
, actual reimbursement using the low estimate for unaided staging accuracy.
ADVANCES IN SKIN & WOUND CARE & APRIL 2012
165WWW.WOUNDCAREJOURNAL.COM
ORIGINAL INVESTIGATION
Copyright @ 2012 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
REFERENCES
1. Whittington KT, Briones R. National Prevalence and Incidence Study: 6-year sequential
acute care data. Adv Skin Wound Care 2004;17:490-4.
2. Vangilder C, Macfarlane GD, Meyer S. Results of nine international pressure ulcer prevalence
surveys: 1989 to 2005. Ostomy Wound Manage 2008;54(2):40-54.
3. Cuddigan J, Berlowitz D, Ayello E. Pressure ulcers in America: prevalence, incidence,
and implications for the future. An executive summary of the National Pressure Ulcer
Advisory Panel monograph. Adv Skin Wound Care. 2001;14(4):208-15.
4. Kuhn BA, Coulter SJ. Balancing the pressure ulcer cost and quality equation. Nurs Econ
1992;10:353-9.
5. Reddy M, Gill SS, Rochon PA. Preventing pressure ulcers: a systematic review. JAMA
2006;296:974-84.
6. Overview hospital-acquired conditions (present on admission indicator). http://www.cms.gov/
HospitalAcqCond. Last accessed January 23, 2012.
7. National Pressure Ulcer Advisory Panel (NPUAP). http://www.npuap.org/pr2.htm. Last
accessed January 23, 2012.
8. Young DL, Estocado N, Landers MR, Black J. A pilot study providing evidence for the
validity of a new tool to improve assignment of National Pressure Ulcer Advisory Panel
stage to pressure ulcers. Adv Skin Wound Care 2011;24:168-75.
9. Lyder CH, Yu C, Emerling J, et al. The Braden scale for pressure ulcer risk: evaluating
the predictive validity in Black and Latino/Hispanic elders. Appl Nurs Res 1999;12(2):
60-8.
10. Introduction to the HCUP Nationwide Inpatient Sample (NIS), 2006. http://www.
hcup-us.ahrq.gov/db/nation/nis/NIS_Introduction_2006.jsp. Last accessed January 23,
2012.
11. The Healthcare Cost and Utilization Project. Overview of the State Inpatient Databases
(SID). http://www.hcup-us.ahrq.gov/sidoverview.jsp. Last accessed January 23, 2012.
12. American Hospital Association. Statistics and studies. http://www.aha.org/aha/resource-
center/Statistics-and-Studies/index.html. Last accessed January 23, 2012.
13. Hill-Rom, Inc. Hill-Rom International Pressure Ulcer Prevention Training. http://www.hill-
rom.com/usa/Info_IPUP.htm. Last accessed January 23, 2012.
14. Beeckman D, Schoonhoven L, Fletcher J, et al. EPUAP classification system for pressure
ulcers: European reliability study. J Adv Nurs 2007;60:682-91.
15. Nixon J, Thorpe H, Barrow H, et al. Reliability of pressure ulcer classification and diagnosis.
J Adv Nurs 2005;50:613-23.
16. Stotts NA, Rodeheaver GT, Thomas DR, et al. An instrument to measure healing in
pressure ulcers: development and validation of the Pressure Ulcer Scale for Healing
(PUSH). J Gerontol A Biol Sci Med Sci 2001;56(12):M795-9.
CALL FOR PAPERS
Advances in Skin & Wound Care is soliciting manuscripts on
a variety of topics, including original investigations,
clinical reviews, and innovative treatments.
Consult the journal’s Web site, www.woundcarejournal.com,
for the Author Guidelines.
Advances in
SKIN&
WOUND CARE
ADVANCES IN SKIN & WOUND CARE & VOL. 25 NO. 4 166 WWW.WOUNDCAREJOURNAL.COM
ORIGINAL INVESTIGATION
Copyright @ 2012 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
    • "Prevention rather than treatment of hospital-acquired pressure ulcers (HAPUs) has become the priority of United States hospitals since Medicare no longer pays for stage III or IV HAPUs [1,2]. Pressure ulcers are one of the most costly hospital-acquired conditions, resulting in $11 billion per year in direct and indirect costs [3,4]. The incidence varies with higher rates noted in intensive care units [5,6]. "
    [Show abstract] [Hide abstract] ABSTRACT: The study objective was to determine if hospitalized patients who are designated as self-turn would reposition themselves appropriately in the acute care setting. This was a prospective case series in a general practice unit of an 800-bed urban tertiary care hospital. Patients were instructed on the importance of mobility for pressure ulcer prevention and subsequently monitored on a continuous bedside pressure mapping device. Primary outcomes included intervals of inactivity and pressure ulcer incidence. During the 3-month study interval, only 2 patients had a documented 4-h interval without measurable repositioning. None of the 101 consecutive patients enrolled in the study developed pressure ulcers. General practice unit patients that are given proper instruction and designated as self-turn can reliably be considered low-risk for hospital acquired pressure ulcers. Based on our prospective study, patients designated as self-turn do reposition themselves.
    Article · Feb 2016
  • [Show abstract] [Hide abstract] ABSTRACT: Pressure-related intact discolored areas of skin (PRIDAS) are generally described as an area of nonblanching erythema (Stage I pressure ulcer) or deep tissue injury (DTI), but the validity of these definitions has not been tested. Preclinical studies and forensic observations have shown that skin temperature may help identify nonviable tissue. To investigate the effect of temperature difference between a PRIDAS and its adjacent intact skin and the subsequent development of skin necrosis, an observational, retrospective, correlational study was conducted. Data from all acute care hospital patients with an observed PRIDAS who received a skin integrity consult, including a skin temperature measurement of a PRIDAS site, were abstracted to ascertain if PRIDAS temperature correlated with the development of skin necrosis after 7 to 14 days and to examine the effect of additional patient variables on the progression or resolution of a PRIDAS. Skin temperatures were measured using a commercial, hand-held, infrared thermography camera, and the presence or absence of capillary refill was documented. Among the 85 patients studied, the difference between PRIDAS temperature and adjacent skin ranged from -3.2 ̊ C. to +3.0 ̊C. Of the 55 PRIDAS with a lower temperature at baseline than adjacent skin ("cool", average -1.2 ̊ C), 29 progressed to necrosis, compared to one of 30 PRIDAS with a higher temperature than adjacent skin ("warm", average + 1.2 ̊ C) (P <0.001). After adjusting for patient age, skin color, and PRIDAS site, the cool PRIDAS were 31.8 times more likely to progress to necrosis than the warm PRIDAS. Combining the presence/absence of capillary refill and PRIDAS temperature, 0% of 26 patients with signs of blanching and a warm PRIDAS versus 65% of 26 patients with a nonblanching and cool PRIDAS developed skin necrosis (P <0.001, Fisher exact test for the difference between the two combined values). Research examining the delayed appearance of DTI and large, multicenter, prospective validation studies are warranted. The current National Pressure Ulcer Advisory Panel definition of a Stage I pressure ulcer needs to be amended to reflect the strong relationship to DTI development.
    Article · Aug 2012
  • Full-text · Article · Jan 2013 · Ostomy/wound management
Show more

    Recommended publications

    Discover more