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Cost-effectiveness of Cost-effectiveness of nutritional intervention on nutritional intervention on healing of pressure ulcershealing of pressure ulcers

Akinori HisashigeInstitute of Healthcare Technology

Assessment, Japan

Takehiko OhuraPressure Ulcers and Wound Healing

Research Center, Japan

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Pressure ulcer Pressure ulcer (stage III, medium size)(stage III, medium size)

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Pressure ulcerPressure ulcer (stage IV, large size) (stage IV, large size)

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Burden of Pressure UlcersBurden of Pressure Ulcers

　　　　　　　 Prevalence rateUS, UK, Can　　　 Hospitals 4.7 ～ 32.1%　　　 Nursing homes 4.6 ～ 20.7%　　　 Community care 4.4 ～ 33.0%Japan　　　 General hospitals 2.2 ～ 3.3%　　　 Long-term care 2.5%　　　 Nursing care 8.3%

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Economic burden of Pressure UlcersEconomic burden of Pressure Ulcers

Annual costs for treatment of pressure ulcers

UK £ 750 millionUS $ 3 billionAustraliaA$ 285 million 　　　

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Evidence for Nutritional Interventions Evidence for Nutritional Interventions on Pressure Ulcerson Pressure Ulcers

JAMA, 2006, 2008JAMA, 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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MethodsMethods 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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SubjectsSubjects

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Nutritional interventionNutritional interventionMean daily calorie per personMean 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)

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EffectivenessEffectiveness

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Prevalence of pressure ulcers

Pressure Ulcer Days

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Utility value for pressure ulcersUtility 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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Health state utilitiesHealth state utilitiesHealthy (reference state) 1.00Menopausal symptoms 0.99Side effects of hypertension treatment 0.95Mild angina 0.90Kidney transplant 0.84Moderate angina 0.70Hospital dialysis 0.56Severe angina 0.50Anxious/depressed and lonely much of the time 0.45Being blind or deaf or dumb 0.39 Hospital confinement 0.33Mechanical aids to walk and learning disabled 0.31Dead (reference state) 0

Confined to bed with severe pain -Unconscious -

Bed-ridden

Bed-ridden +

pressure ulcer

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Incremental effectiveness of Incremental effectiveness of nutritional intervention per personnutritional intervention per person

Effectiveness Intervention Control Incremental effectiveness (95% CI)

PUDs84.6 100.8 -16.2 (-8.7 ~ -23.7)

QALYs (x10 － 2 ）-2.00 -2.38 0.382 (0.205 ~ 0.559)

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CostsCosts

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Mean costs per patientMean costs per patient

Item Intervention Control

Nutritional management Total 905 891 Intervention period 773 695Wages Nurse 1,687 2,335 Physician 277 387 Others 40 545Drugs 99 174Dressing materials 100 138Consumables 45 66Mattress 58 66

Total cost per patient 3,718 4,602（ 95%CI ） (3,006 ~ 4,340) (4,117 ~ 5,008)

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Incremental cost of nutritional Incremental cost of nutritional intervention per personintervention per person

Intervention Control Incremental costs (95% CI)

Costs $

3,718 4,603 -881

(-1,285 ~ -478)

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Cost-Effectiveness of Nutritional Cost-Effectiveness of Nutritional InterventionIntervention

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Incremental cost-effectiveness of Incremental cost-effectiveness of nutritional interventionnutritional 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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Sensitivity AnalysisSensitivity Analysis

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Stochastic sensitivity analysisStochastic sensitivity analysis

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Qualitative sensitivity analysisQualitative sensitivity analysis

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Cost-effectiveneCost-effectivene ｓｓ ｓｓ of prevention and treatmentof prevention and treatment Russell, Health Aff, 28, 2009

QALY = quality-adjusted life-year

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ConclusionConclusion

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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Stochastic sensitivity analysisStochastic sensitivity analysis