Saving Money & Pressure Sores

Is it just me, but I'm seeing problems that I thought we had dealt with years ago resurfacing all over again.  Back in the 1980's and 1990's decubitus ulcers (pressure sores) were a big problem for the health service - both in economic and in human terms.  It seems the problem hasn't gone away. 

An analysis (Dr Foster Hospital Guide) of deaths in English hospitals has found 19 NHS trusts have higher rates than would be expected.  And pressure sores are still reported as a significant problem.

In the UK, NHS and related agencies are rightly striving to be more efficient and effective in providing care and so it wasn't a complete surprise when we received a call from an agency relating to our own product offerings in this area.  The implication being "Do we really need to use your product ?"

Since 1996 we have offered the PRAFO (Pressure Relief Ankle Foot Orthosis) Orthosis range to the UK and parts of Europe - we founded our business on it and worked hard to show it's merits as an effective pressure relieving technology for the heels and ankle area of the foot.  The heel area is one of the "at risk" areas of the body for patients who are relatively immobile and perhaps nutritionally compromised or diabetic.  Looking back at an article I wrote in 1996

"It has been estimated that 3% to 5% of all hospital inpatients will develop pressure sores either just before, during or after admission. Several sub-populations are at higher risk and its likely that costs will climb in line with demographic trends which by 2025 will see 25% of the population over 65 years of age"

I dont know the latest ulcer incidence figures for the UK as a whole but I'm pretty sure they won't be much better than they were twenty years ago.  Dr Fosters Guide reports some 6000 patients with pressure sores whilst in hospital. Unfortunately they can't say whether there were all hospital acquired. In the Trusts with the highest rates some 3.5% of patients were recorded as having pressure sores.

They point out that patients with pressure sores spend on average of 20 days in hospital compared with 10 days for those without sores. This adds up to an additional cost of more than £20m per year.

When there is a need to cut costs it is important to recognise the “true opportunity cost” of a particular intervention.  There is a cost of Acting and a cost of NOT Acting.  This is certainly true of not successfully dealing with pressure sores by preventing them.

We have always tried to argue with clinicians who wondered whether they could save £150 by not buying our product to prevent a heel ulcer.  Sometimes looking at it cynically, it might appear tempting to take a risk.  Not using the product looks like a saving - until say one person in ten gets a heel ulcer and all of the cost savings were blown out of the water.

Many patients treated for sores will have initially been admitted to hospital for some other condition.  As a pressure sore further limits a patient’s mobility and extends, for example, the use of a specialised bed then that resource, and all associated services, cannot turn to treat new patients.  For illustration, consider that for each sacral pressure sore which is prevented it becomes possible to undertake 16 total hip replacements.  This clearly emphasises the need for prevention when tackling this problem.

The important point is that competent clinicians can look at a patient and determine their individual level of risk.  The risk factors are well known and you would think this would lead to rational treatment decisions.

My complaint is that all too often someone takes a short sighted view of the need to save one on budget but completely misses the bigger strategic picture.  It looks like you saved a £100 but actually the saving was made at he the expense of thousands on someone elses budget.

A few years ago we won a clinical effectiveness prize for a poster entitled “Clinical Experience of the Pressure Relief Ankle-Foot Orthosis (PRAFO)” at the Scottish AHP Clinical Effectiveness and Practice Development Conference. 

This work looked at a small number of very severe cases of diabetic foot ulcers.  One case in particular comes to mind (See left) because the individual refused amputation (not an unusual situation) despite the severe calcaneal ulcer shown here.  The bone is clearly visible as we look at the lower part of the heel area.

I'm sorry if this is a distressing picture but if it is any consolation, severe neuropathy meant that pain was minimal.

The best solution for this individual would have been amputation. It would have accelerated recovery and the return to a reasonable quality of life would have been a case of a few months.  Having refused amputation the clinical challenge is very great.

For this type of ulceration the first rule is

"It's not what you put on the wound but what you take off"

In other words medicine and lotions and potions are not sufficent to deal with this problem.  One essential factor to encourage wound heeling was total pressure relief at the heel.

Using one PRAFO Orthosis and a great deal of antibiotic, podiatry and general medical care the wound eventually healed after 160 weeks. 

(See below)

Although this is quite a remarkable result, there is a sting in the tale - the patient died shortly after this wound healed having spent virtually 3 years with either lengthy hospital stays or daily visits.

An interesting point for us was that the perception we had previously been meeting from clinicians and adminstrators was that our orthosis was expensive - and yet as this case showed, despite the tens of thousands spent on other types of care, non of this would have achieved healing without using the PRAFO.

It is difficult to make decisions relating to health and health services.  Almost inevitably there will be "losers."  However, the least we can expect is rational treatment decisions that are looking at the true opportunity cost that applies.

The health service is full of well-meaning people but competence is also key and competence doesn't always seem to be in the right places.