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Improving Healthcare Quality in the United States: A Message for World Wide Pressure Injury Day

November 21 marks the 7th annual World Wide Pressure Injury Prevention Day, which raises awareness for the global elimination of preventable pressure injuries. Although pressure injuries are both common and often have severe consequences on patient health, they are infrequently discussed in national medical media coverage. As a result, there has been a strong push among experts for greater education and awareness to aid in reducing the prevalence of pressure injuries.

What is a pressure injury?

Pressure injuries, more commonly referred to as bedsores, are areas of localized skin and tissue damage caused by prolonged or intense pressure. These injuries are most likely to occur over boney prominences such as elbows, heels, and shoulder blades. Pressure injuries begin as areas of skin break down and can progress to the point where muscle, and even bone, is exposed if left untreated.

Burden of Pressure Injuries in the United States

Pressure injuries are estimated to occur in greater than 2.5 million people in the United States annually, according the The Agency for Healthcare Research & Quality. Anyone can suffer from a pressure injury, but they most commonly occur in elderly individuals, those who have reduced mobility, those who have poor circulation to the skin due to circulatory disorders, and undernourished/low weight individuals. Depending on the severity of the pressure injury, each wound costs between $20,900 and $151,700 to treat, which results in an annual estimated burden of somewhere between 9.1 and 11.6 billion dollars on the United States healthcare system. Sadly, an estimated 60,000 individuals die in the United States every year as a direct result of a severe pressure injury. Therefore, reducing pressure injuries is an important step towards improving health care quality. 

What can be done to reduce pressure injuries?

Severe pressure injuries are known to be preventable with adequate medical care and are therefore considered an important indicator of the care quality provided by a healthcare facility. Adequate care to prevent pressure injuries includes effective skin care, sufficient nutrition, and repositioning a patient to redistribute pressure away from any one area of the body.

On a higher level, the impact of pressure injuries is thought to be under-reported and research focused on further dissecting factors that cause and worsen pressure injuries, identifying better prevention methods, and fully understanding the scope of the problem is a key step towards eliminating this public health crisis. 

Public reporting and efforts to reduce pressure injuries

Within the United States, the Centers for Medicare & Medicaid Services (CMS) exists as the largest single payer for healthcare delivery.  Data on a number of healthcare quality indicators, including pressure injuries, are collected by CMS to evaluate how successfully facilities are treating their patients. These data, including pressure injury data, are publicly reported by CMS for 7 different settings, including the 3 facilities (Inpatient Rehabilitation Facilities, Skilled Nursing Facilities/Nursing Homes, Long-Term Care Hospitals) that RTI, under contract with CMS, has developed quality measures for to assess the incidence of new or worsened pressure injuries. RTI’s quality measurement work on pressure injuries has generated profound impacts on how pressure injury data is collected across care settings and enabled analyses that have furthered our understanding of what populations are most affected by this issue.  

In 2014, Congress passed the Improving Medicare Post-Acute Care Transformation (IMPACT) Act of 2014 to improve care quality in post-acute care (PAC) settings, partially through the alignment of quality measures across setting types, targeting skin integrity as a priority domain. Aligned measures allow for standardized assessment of quality, which in turn enable meaningful comparisons that have the ability to highlight where resources can best be focused to reduce pressure injuries. For example, using aligned data items from facility-based PAC settings, RTI has identified health disparities in pressure injuries, which include increased risk for males and African American patients. Recent analyses currently in press in Advances in Skin and Wound Care using aligned data items have also confirmed common risk factors across PAC settings—including advanced age, urinary, bowel and joint incontinence, low BMI, and functional limitation—and have contributed to discussion of complex relationships between high BMI and pressure injuries.

As part of the work to respond to the IMPACT Act of 2014, RTI developed a new pressure injury quality measure, “Changes in Skin Integrity Post-Acute Care: Pressure Ulcer/Injury”. This measure was implemented in 2018 and updated the previous PAC measures to include aligned data collection items across PAC settings that more accurately assess patient pressure injury outcomes by including unstageable injuries. This new quality measure also simplifies and reduces the pressure injury data items required to be collected by PAC providers, thereby reducing provider burden. Through our pressure injury quality measure development work, RTI has aligned measures across PAC programs, addressed high-impact health care needs to improve patient outcomes, and increased the understanding of pressure injury burden to support the provision of quality care to reduce the incidence of pressure injuries in PAC settings. 

Learn more about RTI's work involving quality measures in health care settings.

Disclaimer: This piece was written by Julie Seibert (Senior Research Public Health Analyst), Daniel Barch (Researcher), and Elissa Scherer to share perspectives on a topic of interest. Expression of opinions within are those of the author or authors.