Value of hospital resources for effective pressure injury prevention: a cost-effectiveness analysis



Hospital-acquired pressure injuries are localised skin injuries that cause significant mortality and are costly. Nursing best practices prevent pressure injuries, including time-consuming, complex tasks that lack payment incentives. The Braden Scale is an evidence-based stratification tool nurses use daily to assess pressure-injury risk. Our objective was to analyse the cost-utility of performing repeated risk-assessment for pressure-injury prevention in all patients or high-risk groups.


Cost-utility analysis using Markov modelling from US societal and healthcare sector perspectives within a 1-year time horizon.


Patient-level longitudinal data on 34 787 encounters from an academic hospital electronic health record (EHR) between 2011 and 2014, including daily Braden scores. Supervised machine learning simulated age-adjusted transition probabilities between risk levels and pressure injuries.


Hospitalised adults with Braden scores classified into five risk levels: very high risk (6-9), high risk (10-11), moderate risk (12-14), at-risk (15-18), minimal risk (19-23).


Standard care, repeated risk assessment in all risk levels or only repeated risk assessment in high-risk strata based on machine-learning simulations.

Main outcome measures

Costs (2016 $US) of pressure-injury treatment and prevention, and quality-adjusted life years (QALYs) related to pressure injuries were weighted by transition probabilities to calculate the incremental cost-effectiveness ratio (ICER) at $100 000/QALY willingness-to-pay. Univariate and probabilistic sensitivity analyses tested model uncertainty.


Simulating prevention for all patients yielded greater QALYs at higher cost from societal and healthcare sector perspectives, equating to ICERs of $2000/QALY and $2142/QALY, respectively. Risk-stratified follow-up in patients with Braden scores <15 dominated standard care. Prevention for all patients was cost-effective in >99% of probabilistic simulations.


Our analysis using EHR data maintains that pressure-injury prevention for all inpatients is cost-effective. Hospitals should invest in nursing compliance with international prevention guidelines.


cost-effectiveness; health services research; nurses.

© Author(s) (or their employer(s)) 2019. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.

Conflict of interest statement

Competing interests: None declared.


State transition diagram
Figure 1 State transition diagram of the Markov model. Patients are admitted to the hospital and determined to be one of five risk states for pressure injury using the Braden score. They then transition through different risk categories until they are safely discharged. Patients who develop a pressure injury (ie, Patient-Safety Indicator #3, PSI03) require acute and chronic care, and potentially surgery to safely exit the model, otherwise the pressure injury could be fatal. See this image and copyright information in PMC
Cost-effectiveness acceptability frontier
Figure 2 Cost-effectiveness acceptability frontier for three risk-assessment strategies related to pressure-injury prevention best practices from a US societal perspective: (a) standard care, (b) repeated risk assessment in all patients or (c) repeated risk assessment in high-risk patients according to the Braden Scale. QALY, quality-adjusted life-year. See this image and copyright information in PMC