ORIGINAL INVESTIGATION

Cost-effectiveness Analysis of Nutritional Support

for the Prevention of Pressure Ulcers in
High-Risk Hospitalized Patients
Haitham W. Tuffaha, PhD; Shelley Roberts, PhD; Wendy Chaboyer, PhD;
Louisa G. Gordon, PhD; and Paul A. Scuffham, PhD

ABSTRACT
OBJECTIVE: To evaluate the cost-effectiveness of nutritional
support compared with standard care in preventing pressure
ulcers (PrUs) in high-risk hospitalized patients.
DESIGN: An economic model using data from a systematic
literature review. A meta-analysis of randomized controlled trials
on the efficacy of nutritional support in reducing the incidence of
PrUs was conducted.
PATIENTS: Modeled cohort of hospitalized patients at high risk of
developing PrUs and malnutrition simulated during their hospital
stay and up to 1 year.
INTERVENTIONS: Standard care included PrU prevention
strategies, such as redistribution surfaces, repositioning, and skin
protection strategies, along with standard hospital diet. In
addition to the standard care, the intervention group received
nutritional support comprising patient education, nutrition goal
setting, and the consumption of high-protein supplements.
MAIN OUTCOMES MEASURES: The analysis was from a healthcare
payer perspective. Key outcomes of the model included the average
costs and quality-adjusted life years. Model results were tested in
univariate sensitivity analyses, and decision uncertainty was
characterized using a probabilistic sensitivity analysis.
MAIN RESULTS: Compared with standard care, nutritional support
was cost saving at AU $425 per patient and marginally more
effective with an average 0.005 quality-adjusted life years gained.
The probability of nutritional support being cost-effective was 87%.
CONCLUSIONS: Nutritional support to prevent PrUs in high-risk
hospitalized patients is cost-effective with substantial cost
savings predicted. Hospitals should implement the
recommendations from the current PrU practice guidelines and
offer nutritional support to high-risk patients.

KEYWORDS: nutritional support, pressure ulcer prevention, costeffectiveness

ADV SKIN WOUND CARE 2016;29:261Y7

INTRODUCTION
The National Pressure Ulcer Advisory Panel (NPUAP) defines a
pressure ulcer (PrU) as a localized injury to the skin, usually over
a bony prominence as a result of pressure alone or in combination
with shear and/or friction.1 Although PrUs are mostly preventable,
they remain common with an estimated prevalence ranging from
4% to 38% in acute care hospitals and from 6% to 48% in longterm-care facilities.1Y5 Pressure ulcers are associated with increased
morbidity and mortality, as well as substantial healthcare costs.
Hospital-acquired PrUs cost between $500 and $70,000 per patient
and up to $11 billion every year in the United States, driven by the
high cost of treatment and the extended length of stay for the affected patients.6 At an average 5 to 8 days_ additional length of stay
per patient, a study from the United Kingdom estimated that
hospital-acquired PrUs result in 3000 to 4800 excess bed-days at
an annual cost of U3.36 million.7
Risk factors for PrUs include limited or restricted mobility, older age,
malnutrition, and comorbidities that affect skin integrity by reducing blood perfusion and tissue oxygenation (eg, diabetes).1-8 Considering the huge burden of PrUs, it is important to assess hospitalized
patients for these risk factors and implement effective interventions to prevent the occurrence or reduce the severity of this complication. International clinical practice guidelines recommend
various strategies to prevent PrUs, such as encouraging mobility
and frequent patient repositioning, appropriate support surfaces,
1,2,9
good skin care, and nutritional assessment and support if required.

Haitham W. Tuffaha, PhD, is a Research Fellow, Centre for Applied Health Economics, School of Medicine, Griffith University, Queensland, Australia. Shelley Roberts, PhD, is a Research Fellow,
School of Allied Health Sciences, Griffith University, Queensland, Australia. Wendy Chaboyer, PhD, is Professor and Director, National Health and Medical Research Council (NHMRC) Centre of
Research Excellence in Nursing Interventions for Hospitalised Patients Centre for Health Practice Innovation, Griffith University, Gold Coast, Australia. Louisa G. Gordon, PhD, is Principal Fellow,
Centre for Applied Health Economics, School of Medicine, Griffith University, Queensland, Australia. Paul A. Scuffham, PhD, is director, Population and Social Health Research Program, and Professor, Health Economics, Griffith University, Queensland, Australia. Dr Tuffaha has disclosed that he is the recipient of a doctoral scholarship through the NHMRC Centre for Research Excellence
in Nursing Interventions for Hospitalised Patients. Dr Gordon has disclosed that she was a consultant to the Prostate Cancer Foundation of Australia; her insitutition is the recipient of a grant fom
Australia_s NHMRC; and she has received funding for conference travel expenses from the Ministry of Health Singapore. Dr Scuffham has disclosed that he serves as a consultant to and has various contracts with Australia_s Department of Health; and is the investigator of grants with Australia_s National Health and Medical Research Council and the Australian Research Council. The
remaining authors have disclosed they have no financial relationships related to this article. Submitted August 28, 2014; accepted in revised form October 21, 2014.
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ORIGINAL INVESTIGATION

Hospitalized patients at high risk for PrUs (eg, older patients

with restricted mobility) are at increased risk of malnutrition,
with an estimated prevalence of 10% to 60%.10,11 Because balanced nutrition is associated with better skin integrity and reduced tissue breakdown, the occurrence of PrUs can increase
with inadequate nutritional intake.1,2,9,12 One study found that
malnourishment was significantly associated with the presence
of PrUs, with at least twice the odds of developing an injury in
hospitalized patients.10
A number of randomized controlled trials (RCTs) have investigated the efficacy of nutritional support in preventing PrUs.13Y18
Although having small samples and of low quality, these studies
have shown that nutritional support, mainly in the form of oral
high-protein supplements, reduces the incidence of PrUs in
high-risk patients. Based on this, current clinical practice guidelines call for a comprehensive nutritional assessment and nutritional support offered to patients at high risk of PrUs and
malnutrition.1,2,9 Nevertheless, there is cost associated with providing nutritional support, and therefore, it is essential to assess
the cost-effectiveness of this intervention. An Australian study
found that nutritional support resulted in cost savings in hospitalized
high-risk patients; however, that study did not include a complete
cost-effectiveness analysis of all incremental costs and benefits.19 A
cost-effectiveness analysis from Canada concluded that nutritional
supplements were not cost-effective in preventing PrUs in residents
of long-term-care facilities20; nevertheless, it is uncertain whether
these results are generalizable to hospitalized patients.
The aim of the authors_ study was to perform a full costeffectiveness analysis of nutritional support intervention in
preventing PrUs in high-risk hospitalized patients. This is a
modeling study using best available evidence to estimate costs
and outcomes for a cohort of high-risk hospitalized patients.

METHODS
Study Population and Interventions
The study population included hospitalized patients at high
risk of PrUs and malnutrition. The mean age of the modeled
patient cohort was 70 years. Patients were deemed to be at
high risk for a PrU if they had any type of mobility restriction.
This included requiring mobility aids or assistance to be mobile,
and the presence of equipment that restricts patient mobility.
Patients were identified as being malnourished or at nutritional
risk using a valid and reliable nutritional assessment tool (eg, the
Subjective Global Assessment).21 Standard care included regular
PrU risk assessment, standard hospital diet, redistribution surfaces, repositioning, and skin protection strategies.1,2 In addition
to the standard care, the intervention group received nutritional
support comprising patient education, patient self-monitoring
of oral intake, nutrition goal setting, and the consumption of an
ADVANCES IN SKIN & WOUND CARE & VOL. 29 NO. 6

additional 1000 to 2000 kJ/d.19,21,22 The provision of the additional

kilojoules equates to approximately 2 to 3 nutritious snacks or
commercial oral high-protein (ie, at least 30% energy as protein)
supplements per day.19,23

The Economic Model

The authors constructed a health state transition Markov model
(Figure 1) in TreeAge Pro 2013 (TreeAge Software Inc,
Williamstown, Massachusetts).23 The model duration was 1 year
with a 1-day cycle length (ie, the model runs for 365 cycles). The
authors chose this cycle length and model duration to reflect the
changes in PrU status based on daily nursing assessment and to
allow for sufficient time for wound healing. Simulated patients
start the model as newly hospitalized individuals with intact skin
and receive the standard PrU prevention care or the standard care
plus nutritional support. Patients who remained hospitalized
could develop a grade 1 PrU, which is defined by the NPUAP
as superficial erythema without skin breakdown (ie, closed
wound).1 A closed wound can either heal, remain the same,
or deteriorate to an open wound (ie, NPUAP Stages II to IV);
Stage II is partial-thickness loss of dermis presenting as a shallow
open ulcer; Stage III is full-thickness tissue loss but with no bone,
tendon, or muscle exposure; and Stage IV is full-thickness tissue
loss with exposed bone, tendon, or muscle.1 The authors grouped
PrU grades in a closed wound state and an open wound state to
simplify the model. Patients move sequentially between intact
skin, closed wound, and open wound health states mimicking
the natural progress of the condition. Patients who developed a
PrU of any grade would receive the appropriate treatment (eg,
wound dressing, debridement, and/or pain management) and
continue to receive prevention strategies to avoid additional ulcers. Furthermore, patients could die or be discharged at any time
in the model; however, the model allowed for the treatment of
open wounds for discharged patients in the ambulatory setting.
Key outcomes of the model included the average costs, qualityadjusted life years (QALYs), and the percentage of patients with
PrUs in each group.

Data Input and Sources

Transition Probabilities. Transition probabilities reflect the
chance of patient movement between the health states of the
model. Healing, death, and discharge rates were estimated
from a systematic literature review. The authors considered
these rates to be constant over time and converted rates to
probabilities (probability = 1 j ejratetime). The authors assumed that the 2 groups have the same transition probabilities
except for the probability of developing PrUs. Table 1 summarizes transition probabilities between the modeled health states
and their sources.

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ORIGINAL INVESTIGATION

Figure 1.
MARKOV MODEL STRUCTURE

To obtain information on the relative effectiveness of nutritional support, the authors systematically searched the literature for
RCTs evaluating oral nutritional support in comparison with
standard care in preventing PrUs. The authors identified 5 RCTs:
(Delmi et al13 [1990]; Ek et al14 [1991]; Bourdel-Marchasson
et al15 [2000]; Houwing et al [2003]16; and Olofsson et al17
[2006]); in addition, 1 study (Hartgrink et al,18 [1998]) included
patients on enteral tube feeding (Table 2). The patients included
in the identified studies were older than 65 years, chronically hospitalized (ie, admitted for 92 weeks), and at risk of malnourishment
but not necessarily malnourished. The authors performed a metaanalysis of the 5 studies on oral nutritional support (Figure 2).
The individual studies were small and did not show a significant
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effect; however, in the meta-analysis, nutritional support significantly reduced the incidence of PrUs with a relative risk (RR) of
0.83 (confidence interval, 0.71Y0.96) compared with standard
care.22 Including the tube feeding study by Hartgrink et al18 gave
a similar estimate (RR, 0.84; confidence interval, 0.74Y0.96).
Utilities. Similar to health-related quality of life (QOL) scores,
the utilities for the health states in the model were based on
EuroQoL 5D-3L scores. These scores range from 0 to 1, with
0 meaning worst state or death and 1 for best possible health.
Utility weights were based on the preferences of the Australian
population. The authors set the background utility value for
nonhospitalized patients between 65 and 74 years of age (ie,
the health state of being discharged) at 0.82, based on a study

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ORIGINAL INVESTIGATION

Table 1.

BASE CASE MODEL ESTIMATES AND SOURCES

Description

Base Case Estimate

SE or Range

Distribution

Source

Transition estimates and probabilitiesa

Average length of stay

21 d

Excess length of stay from PrUs

Hospital mortality
Background mortality
RR of mortality from PrUs
Probability of developing PrU with standard care

8 days
0.07
0.0008
1.5 (log = 0.42)
0.35

4
0.05Y0.10

F
Uniform

0.21 (log = 0.25)

0.02

Log normal
A

RR of PrU with nutritional support

0.81 (log = j0.2)

0.06 (log = 0.076)

Log normal

0.35
0.24
0.12

0.03
0.03
0.01

A
A
A

The average length of stay in the trials

included in the authors_ meta-analysis
Allman et al,34 1999; Graves et al,39 2005
Scott et al,35 2011
Australian Bureau of Statistics36
Isaia et al,37 2010
From the control arm of the meta-analysis
of nutritional support in preventing PrUs
From the meta-analysis of nutritional
support in preventing PrUs
Bourdel-Marchasson et al,15 2000
Bourdel-Marchasson,15 2000
Brandies et al,38 1990

0.52
0.82
0.29
0

0.02
0.01
0.2
0

A
A
F
-

Hawthorne et al,25 2001

Clemens et al,24 2014
Essex et al, 200926
Assumed

AU
AU
AU
AU
AU

AU
AU
AU
AU
AU

F
F
F
F
F

Australian Hospital Statistics36

Padula et al,6 2011
Banks et al,17 2013
Dealey et al,7 2012
Dealey et al,7 2012

Probability closed wound heals

Probability closed wound worsens to open wound
Probability open wound heals
Utilities
Utility for hospitalization with intact skin
Utility discharged with intact skin
Disutility from PrUs
Utility of death
Daily costs
Hospitalization
High-risk prevention
Oral nutritional support
Closed wound treatment
Open wound treatment

$950
$90
$17
$103
$226

$300
$45
$8.5
$52
$113

Abbreviations: PrU, pressure ulcer; RR, relative risk; SE, standard error.
a
Probabilities: 3 weeks, converted in the model to daily probabilities using the following equation: 1jexp (ln (1 j probability) / 21).

from Clemens et al.24 Hospitalized patients in the same age

group and with intact skin had utility values of 0.66 based on
Hawthorne et al.25 The disutility from PrUs (ie, reduction in
QOL compared with intact skin) was 0.29, from Essex et al.26 The
authors_ base case assumption was that the improvement in

QOL would be a result of the reduction in the incidence of PrUs;

however, Hoekstra et al27 have reported that nutritional support
could also improve the QOL in hospitalized patients regardless of
their PrU status; therefore, the authors included the possible gains
in QOL from nutritional support in the authors_ sensitivity analysis.

Table 2.

SUMMARY OF THE IDENTIFIED RANDOMIZED CONTROLLED STUDIES ON NUTRITIONAL

SUPPORT IN THE PREVENTION OF PRESSURE ULCERS
Study
Oral nutritional supplements studies
Bourdel-Marchasson et al,15 2000
Delmi et al,

13

1990

Ek et al,14 1991
Houwing et al,

16

2003

Population

Intervention

Control

Outcomes

Follow-up

Critically ill older adults

Standard diet plus

oral supplements
Standard diet plus
oral supplements
Standard diet plus
oral supplements
Standard diet plus
oral supplement
Standard diet plus high
oral protein drinks

Standard diet

PrU incidence

2 wk

Standard diet

PrU incidence

2Y4 wk

Standard hospital diet

PrU incidence

9 wk

Standard hospital diet

4 wk

Normal postoperative
care

PrU incidence,
mortality
PrU incidence,
length of stay

Standard diet with

tube feeding

Standard diet

PrU incidence

Older adults with hip fractures

Long-term medical care residents
hospitalized for 93 wk
Older adults with hip fracture

Olofsson,17 2007

Femoral neck fracture patients

Enteral tube feeding studies

Hartgrink,18 1998

Older adults with hip fracture

16 wk

2 wk

Abbreviation: PrU, pressure ulcer.

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Figure 2.
META-ANALYSIS OF RANDOMIZED CONTROLLED TRIALS
ON NUTRITIONAL SUPPORT IN THE PREVENTION OF
PRESSURE ULCERS

Costs. The cost-effectiveness analysis was from the perspective of the State Department of Health in Queensland, Australia.
Results were presented in Australian dollars (AU $). Costs estimated in other currencies and price years were converted to
2014 Australian dollars using the CCEMG-EPPI-Centre Cost
Converter web-based tool.28 Resources considered in the study
included those for hospitalizations, PrU prevention, and PrU
treatment. Hospitalization cost was for a public hospital bed in
Queensland, Australia, at AU $950 per patient day.29 The cost
of PrU prevention per day was AU $90, estimated from Padula
et al6 (US $55 [2010]). The cost components of ulcer prevention
included risk assessment, supportive surfaces, repositioning,
and moisture and incontinence management.6 The authors set
the cost of nutritional support at AU $17 per day. This was based
on the study by Banks et al,19 which estimated the staff time to
provide nutritional support at 0.40 hours per day, that is, AU
$13 for AU $32/hour registered nurse, and the cost for the commercial nutritional supplements at AU $4 per day. The authors
estimated the cost of treating PrUs from the study by Dealey
et al,7 which used a bottom-up methodology, based on the daily
resources required to deliver protocols of care reflecting good

clinical practice in the United Kingdom. The daily cost of treating

a closed PrU was AU $103 (U43 [2011]), and the weighted average
daily cost for open wound management (Stages IIYIV) was AU
$226 (U94 [2011]), including the cost of surgery and wound infection treatment.7
Analyses. The model aggregated the probabilities and values
assigned to the health states and generated mean expected values
for costs and effects. Costs and effects were not discounted because the time horizon of the model was 1 year. The authors calculated the incremental cost-effectiveness ratio, which is the
incremental effectiveness (ie, the difference in effectiveness between the 2 groups) divided by the incremental cost. For this
analysis, the authors set the willingness to pay per QALY gained
at AU $50,000.30 To address the uncertainty in the authors_ results, they performed 1-way sensitivity analyses in which they
varied key parameters through a range of plausible values (using
the 95% confidence, values reported in the literature, or T50%)
and observed changes to the base case estimates. In addition, to
characterize the uncertainty surrounding data estimates, the authors conducted a probabilistic sensitivity analysis whereby multiple sets of parameter values were randomly sampled (10,000
times) from a prioriYdefined probability distributions.31 In general,
the authors assigned A distribution to transition probabilities and
utilities, F distribution to costs and length of hospital stay, and
log-normal distribution to RR.32

RESULTS
Over a 1-year duration, the estimated mean cost for the nutritional
support was AU $33,687 compared with AU $34,112 for standard
care, with an average cost saving from nutritional support of AU
$425 (Table 3). Compared with standard care, nutritional support
is estimated to result in an average 0.005 QALY gained (0.694 vs
0.689 QALY). The authors_ model estimated that approximately
15% of the patients would have PrUs in standard care compared
with 11% in the nutritional support group. The probabilistic sensitivity analysis showed that the probability of nutritional support
being cost-effective was 87%. The probability of nutritional support being cost-effective across a range of willingness-to-pay
thresholds is presented in Figure 3. In the 1-way sensitivity analysis, the results were sensitive to the RR of PrUs with nutritional
support, the probability of developing PrUs with standard care,

Table 3.

RESULTS OF THE COST-EFFECTIVENESS ANALYSIS

Nutritional support
Standard care

Cost

Incremental Cost

Effect (QALY)

Incremental Effectiveness

ICER

AU $33,687
AU $34,112

AU $425

0.694
0.689

0.005

Dominatesa

Abbreviations: ICER, incremental cost-effectiveness ratio; QALY, quality-adjusted life year.

a
Nutritional support is less costly and more effective.

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Figure 3.
PROBABILITY OF EACH INTERVENTION BEING
COST-EFFECTIVE ACROSS A RANGE OF
WILLINGNESS-TO-PAY THRESHOLDS

nutritional support cost, and the average length of hospital stay

(Table 4).

DISCUSSION
The authors_ study showed that nutritional support intervention
for high-risk hospitalized patients was cost-effective in preventing
PrUs. Effectively identifying high-risk patients and supporting them
nutritionally were more effective and less costly than standard care.
The cost saving from nutritional support was driven by avoiding

the downstream costs of wound management and extended hospitalization. Expectedly, implementing nutritional support at a national
level would result in substantial cost savings. For an estimated hospitalized high-risk population of 20,000 each year,29 the authors calculate the annual cost savings for all public hospitals in Queensland
to be approximately AU $8.5 million (AU $425  20,000). The
expected cost savings could be greater if additional benefits from nutritional support were included in the analysis. For instance, the authors assumed that the 2 groups have the same rate of wound
healing; however, individual small studies showed a trend toward
improved PrU healing with high-protein nutritional supplements
when compared with a standard diet.22,33 Furthermore, in the base
case analysis, the improvement in QOL scores was only from
avoiding PrUs; nevertheless, hospitalized patients offered nutritional
support might have improved QOL compared with other patients.28
The authors_ estimates are in line with the study by Banks et al,19
which found that implementing nutritional support intervention
for at-risk patients in Queensland public hospitals would avoid
2900 cases of PrUs every year, releasing 12,400 bed-days at AU
$5.4 million saved in opportunity costs. However, that analysis
did not capture the incremental utility of the intervention, which
possibly underestimated the overall benefits of nutritional support.
A Canadian study by Pham et al20 assessed the cost-effectiveness
of oral nutritional supplements in preventing PrUs in residents of
long-term-care facilities, obtaining effectiveness evidence from a
meta-analysis of 4 RCTs. In that study, nutritional support was not
cost-effective, with an incremental cost of $731 and 0.0001 QALY
gained.20 Nutritional support was costly because there was no cost

Table 4.

ONE-WAY SENSITIVITY ANALYSIS

Estimate
Base case
Base case estimates (Table 1)
Relative risk of PrU with nutritional support; base = 83%
Low
71%
High
96%
Probability of PrU with standard care; base = 34%
Low
17%
High
50%
Nutritional support cost; base = AU $17
Low
AU $8
High
AU $24
Length of stay (excess stay); base = 21 d (8 d)
Low
7 d (4 d)
High
35 d (12 d)
Hospitalization cost per day; base = AU $950
Low
AU $600
High
AU $1300
Utility gain from nutritional support included; base = 0
Improved quality-of-life scoresa

Incremental Cost

Incremental Effectiveness (QALY)

ICER

AU $425

0.005

Nutritional support dominates

AU $1110
AU $270

0.008
0.001

Nutritional support dominates

AU $233,714

AU $8
AU $812

0.003
0.007

Nutritional support dominates

Nutritional support dominates

AU $699
AU $243

0.005
0.005

Nutritional support dominates

Nutritional support dominates

AU $160
AU $477

0.002
0.007

Nutritional support dominates

Nutritional support dominates

AU $355
AU $531

0.005
0.005

Nutritional support dominates

Nutritional support dominates

AU $425

0.02

Nutritional support dominates

Abbreviations: ICER, incremental cost-effectiveness ratio; PrU, pressure ulcer; QALY, quality-adjusted life year.
a
From Hoekstra et al27; nutrition improved quality-of-life score by 0.145 in 3 months.

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saving from avoiding excess length of stay in the hospital for

residents of long-term-care facilities. In addition, that study
relied on local data on QOL, namely, the Resident Assessment
InstrumentYMinimum Data Set and not EuroQoL 5D-3L scores,
and did not include excess mortality attributable to PrUs, which
probably reduced the QALYs gained from the intervention.20
Finally, the patients included in the Canadian study were not
at the same level of PrU and malnourishment risk as the patients
in the RCTs included in the meta-analysis. This is obvious from
the very low incidence of PrUs used by Pham et al20 at 0.68% per
week, rendering the prevention strategy not cost-effective because
there were very few PrUs to prevent at the onset.
In the absence of national PrU data on the incidence, healing
rate, mortality, and QOL, the authors had to estimate these inputs from the published literature and make assumptions when
necessary. The information in the literature on these important
parameters was also limited, and there appears a need for more
research in this area. Another limitation is that the authors had
to adopt certain cost estimates from other countries (eg, the costs
of treating and preventing PrUs); however, the authors referred
to studies from Western Europe and North America where PrU
management and its associated costs may be reasonably comparable to the Australian setting.
In conclusion, the authors_ model estimates that investing in
nutritional support as an intervention to prevent PrUs in highrisk hospitalized patients is cost-effective with substantial cost
savings predicted. Hospitals should implement the recommendations from the current PrU practice guidelines and offer nutritional support to high-risk patients.

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