(generally smaller) trust or large hospitals on the order of £500,000 to £900,000 for rental of pressure-relieving equipment alone. 27
An economic evaluation was performed evaluating the implementation of new bed mattresses in a 650-bed hospital.24 The existing mattresses were all replaced for low-pressure foam mattresses. The evaluation consisted of calculating the cost after one year of implementation and calculating incidence and prevalence data. This change resulted in cost savings of £100 000 in the first year after implementation. Incidence and prevalence data were recorded but due to the lack of robust data collection methodologies and no case-mix adjustment and given the challenges of interpreting apparent trends in the data these data were not included. There remains considerable confusion regarding the effect on the prevention of PUs in this evaluation. 24
Finally, a cost-effectiveness analysis on pressure-relieving devices was performed in the United Kingdom.25 A decision-analytic model was constructed to evaluate different strategies to prevent or treat PUs. The strategies consisted of alternating pressure-relieving devices, mattress replacements, and mattress overlays compared with a standard hospital mattress (high-specification foam mattress) for the prevention and treatment of PUs in hospital patients. Three scenarios were evaluated: the prevention of PUs, the treatment of superficial ulcers, and the treatment of severe ulcers. Costs of the devices were obtained from manufacturers, whereas costs of treatment were obtained from the literature. The authors evaluated the results using £30,000 /QALY (quality-adjusted life year) as the decision-maker's cut off point (the current UK standard). In scenario 1 (prevention of PUs), the cost-effective strategy was the mattress overlay at 1, 4, and 12 weeks. In scenarios 2 and 3, the cost-effective strategy was the mattress replacement at 1, 4, and 12 weeks. Standard care was a dominated intervention in all scenarios. The authors concluded that alternating pressure mattress overlays may be cost- effective for the prevention of PUs, whereas alternating pressure mattress replacements appears to be cost-effective for the treatment of superficial and severe PUs. 25
Conclusions and implications for decision or policy making:
The data available specific to the acute and critical care population in the prevention of PUs is widely available. A total of 14 RCTs and 5 health economic analyses were published since 2000. Only two RCTs were not included in the 3 systematic reviews retrieved. Because the RCTs included in the systematic reviews were not evaluated as a whole, and because the comparison of the technologies or devices in each trial is often different than the other trials; it is not possible to draw sound conclusions at this time. Moreover, most of the RCTs have methodological issues such as low powered analysis due to small sample size and epidemiological bias. Overall only 2 recent RCTs (Jolley et al. and Theaker et al.) included in the Reddy report detected a significant reduction in the incidence of PUs; one was comparing specialized sheepskin overlay and standard hospital mattress, the other compared low-air-loss mattress versus alternating-pressure mattress, respectively. Another trial performed by Berthe et al. found a statistically significant difference between the median time for the occurrence of pressure sores between Kliniplot® mattress with the standard hospital mattress (p < 0.001). All the other RCTs showed no statistically significant difference in the incidence of PUs between foam mattresses, foam overlays, air filled sacs and low air loss surfaces.
On the other hand, the overall results from the systematic reviews which include RCTs going as far back as 1982 favor foam alternatives to the standard hospital foam mattress in reducing the incidence of PUs and favor the use of overlays in the operating room for reducing post-surgery PUs. There also seems to be evidence to support foam mattresses over standard hospital
Specialty Mattresses for Prevention of PUs in Acute and Critical Care