European Journal of Clinical Nutrition (2013) 67, 4246

& 2013 Macmillan Publishers Limited All rights reserved 0954-3007/13

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ORIGINAL ARTICLE

Cost effectiveness of nutrition support in the prevention of

pressure ulcer in hospitals
MD Banks1,2, N Graves2, JD Bauer3,4 and S Ash2
BACKGROUND/OBJECTIVES: This study estimates the economic outcomes of a nutrition intervention to at-risk patients compared
with standard care in the prevention of pressure ulcer.
SUBJECTS/METHODS: Statistical models were developed to predict cases of pressure ulcer avoided, number of bed days gained
and change to economic costs in public hospitals in 20022003 in Queensland, Australia. Input parameters were specified and
appropriate probability distributions fitted for: number of discharges per annum; incidence rate for pressure ulcer; independent
effect of pressure ulcer on length of stay; cost of a bed day; change in risk in developing a pressure ulcer associated with nutrition
support; annual cost of the provision of a nutrition support intervention for at-risk patients. A total of 1000 random re-samples were
made and the results expressed as output probability distributions.
RESULTS: The model predicts a mean 2896 (s.d. 632) cases of pressure ulcer avoided; 12 397 (s.d. 4491) bed days released and
corresponding mean economic cost saving of euros 2 869 526 (s.d. 2 078 715) with a nutrition support intervention, compared with
standard care.
CONCLUSION: Nutrition intervention is predicted to be a cost-effective approach in the prevention of pressure ulcer in at-risk
patients.
European Journal of Clinical Nutrition (2013) 67, 4246; doi:10.1038/ejcn.2012.140; published online 10 October 2012
Keywords: pressure ulcer; nutrition support; cost effectiveness

INTRODUCTION
Pressure ulcer, while gaining increased attention from health-care
decision makers, remains a large problem. Reported prevalence in
the acute setting ranges between 10 and 20%,1,2 and incidence
rates between 4 and 10%.2,3 The annual cost of treating pressure
ulcer in the United Kingdom was estimated to be d1.42.1 billion
in 2004, equivalent to approximately 4% of the total NHS budget,4
and in the United States for the same time period it was estimated
to be US$2.23.6 billion.1 Studies show that systematic efforts at
education, heightened awareness of pressure ulcer prevention
and specific interventions by multidisciplinary teams can reduce
the incidence of pressure ulcer.5 Despite this evidence, more
action is required to prevent pressure ulcer.2
A large part of the cost attributable to pressure ulcer is the
prolonged length of stay in the hospital to treat them. The
economic opportunity cost of prolonged hospital stay is that beds
are not available for use to other patients.6 In an Australian study,
the opportunity cost of hospital beds lost to pressure ulcer in
20012002 was estimated to be a median of Australian dollars
(AU$) 285 million.7
Previous findings indicate malnutrition is significantly associated with having pressure ulcer (odds ratio (OR) 2.6; 95%
confidence interval (CI) 1.83.5, Po0.001)8 and the mean
economic cost of pressure ulcer attributable to malnutrition in
Queensland (Australia) public hospitals in 20022003 was AU$13
million (euros 7 million).9 Whether investing in the prevention of
pressure ulcer through nutrition intervention is cost effective is an
interesting question not yet addressed in literature.

Nutrition interventions have been found to reduce the

incidence of pressure ulcer in patients at risk of developing
pressure ulcer.1014 Meta-analysis of intensive nutrition support in
the prevention of pressure ulcers (5 randomized controlled trials
(RCTs), n 1325 patients) revealed a significantly lower incidence
of pressure ulcer development in at-risk patients compared with
standard care (OR 0.74, 95% CI 0.620.88, 5 RCTs, n 1325).15
An economic model was developed to predict the cost of
pressure ulcer attributable to malnutrition in Queensland
(Australia) public hospitals in 20022003.9 The aim of the
analysis reported here is to extend this model to estimate
changes to economic outcomes arising from an intensive nutrition
support intervention targeted at patients with high risk of
developing pressure ulcer, compared with standard nutrition
care. The outcomes estimated are changes to the number of cases
of pressure ulcer arising, the number of bed days released and the
change to related economic costs.
MATERIALS AND METHODS
The perspective of the economic analysis model was from the health-care
provider in the Australian acute care setting, considering the input costs of
providing an intensive nutrition support intervention to patients at risk of
developing pressure ulcer; and output opportunity cost of bed days
released (that is, bed days not occupied by patients with pressure ulcer) for
the period of the financial year 20022003. A complete cost effectiveness
analysis was not possible, as the model utilizes previously published
studies that do not provide patient level data to determine health benefit
as quality-adjusted life years. However, an economic modeling framework

1
Department of Nutrition & Dietetics, Royal Brisbane & Womens Hospital, Herston, Queensland, Australia; 2Institute of Health and Biomedical Innovation, Queensland University
of Technology, Kelvin Grove, Queensland, Australia; 3The Wesley Hospital & Wesley Research Institute, Toowong, Queensland, Australia and 4School of Human Movement Studies,
University of Queensland, St Lucia, Queensland, Australia. Correspondence: Dr MD Banks, Department of Nutrition & Dietetics, Royal Brisbane & Womens Hospital, Herston
QLD 4029, Queensland, Australia.
E-mail: merrilyn_banks@health.qld.gov.au
Received 27 February 2012; revised 12 July 2012; accepted 3 September 2012; published online 10 October 2012

Cost effectiveness of nutrition in preventing pressure ulcer

MD Banks et al

43
was used to predict potential changes to the incidence of pressure ulcers,
subsequent bed days related to pressure ulcer, and related economic
(opportunity) costs saved. The results will provide useful economic
information to health services decision makers.

Economic model
The data from a meta-analysis of intensive nutrition support in the
prevention of pressure ulcers15 was applied to the Queensland public
hospital population in 20022003 to determine if an intensive nutrition
support intervention provided to patients at risk of developing pressure
ulcer, would have been a cost-effective approach to reduce the incidence
of pressure ulcer, compared with the standard nutrition care.
If an intensive nutrition support intervention had been implemented in
Queensland public hospitals in 20022003, the annual economic cost of
pressure ulcer becomes a function of the cost of providing the intervention
to all patients at risk of developing pressure ulcer for the year, less the
opportunity cost savings for a reduction in bed days related to a reduction
in the incidence of pressure ulcer for the year. A diagrammatic
representation of the input parameters and model to determine the
economic outcomes of reducing the incidence of pressure ulcer with an
intensive nutrition support intervention is shown in Figure 1.
A probabilistic sensitivity analysis was undertaken whereby probability
distributions rather than fixed values are used to describe each input
parameter. Samples are drawn at random from these distributions to
generate an empirical distribution of the results. The advantage is that
uncertainty arising from a large number of variables is simultaneously
included and propagated forward to the results. This indicates the degree
of confidence that can be attached to decisions made from the results.16

Input parameter data and sources

The methods used and values determined for several input parameters
have been described previously9 and are summarized in Table 1. These
include: the number of relevant discharges (parameter A); the incidence
rate for pressure ulcer (parameter B); the independent effect of pressure
ulcer on length of stay (parameter C); and the cost of a bed day (parameter
D). The methods used and values determined for the other input
parameters are described next. These include: change in risk in developing
pressure ulcer associated with nutrition support (parameter E) and the
annual cost of providing an intensive nutrition support intervention to
patients at risk of pressure ulcer (parameter F).
Parameter E. The input parameters for determining the change in risk of
developing a pressure ulcer with intensive nutrition support was determined
from the OR of 0.74 and corresponding 95% CIs (0.620.88) determined in
the meta-analysis by Stratton et al.15 of intensive nutrition support in the
prevention of pressure ulcers. The s.e. of the OR was calculated backwards
from the 95% CI, where 95% CI OR1.96 " s.e. Rearranged, s.e. 95%
CI # OR/1.96. The s.e. value was calculated to be 0.066.
Parameter F. The input parameters for the annual cost of provision of
intensive nutrition support to at-risk patients was determined to include:

Table 1.

(i) the annual cost of extra staffing resources to ensure at-risk patients
receive and consume the required nutrition, and (ii) the annual cost of
additional food and/or commercial nutritional supplements. Details of how
these input parameters were determined are provided in Supplementary
Appendix 1, available in Supplementary Information.
Costs were estimated based on the following: the proportion of
malnourished patients represented patients at risk of developing pressure
ulcer requiring intensive nutrition support with a subset of malnourished
patients already receiving nutrition support; additional nutrition support
was considered to be additional food or commercial nutritional products
provided over and above standard hospital food, however, where patients
may have required total enteral tube nutrition support this would replace
similar food costs and so does not need to be considered; malnourished
patients require extra staffing resources for encouragement, assistance
and monitoring to ensure the receipt and consumption of the required
nutrition support.
The lowest and highest costs per annum based on a combination of the
lowest and highest staff numbers were calculated and are presented in
Table 2.

The economic cost of pressure ulcer in Queensland public hospitals

2002/2003 if an intervention of intensive nutrition support was provided to all
at risk patients is a function of:

$ F - (A*B*C*D*E)

Where * indicates multiplication; - subtraction; and A, B, C, D, E and F

represent the following input parameters:

A = number of relevant discharges

B = incidence rate for pressure ulcer
C = independent effect of pressure ulcer on length of stay
D = cost of a bed day to the Queensland public health system
E = change in risk of developing a pressure ulcer associated with intensive
nutrition support
F = cost of provision of intensive nutrition support to at risk patients

Figure 1. Diagrammatic representation of the model to determine

the economic outcomes of reducing the incidence of pressure ulcer
with an intensive nutrition support intervention.

Values for input parameters used in economic model

Input parameter

Data

Source

Type of distribution fitted

A: number of relevant discharges

241 415

Fixed value

B: incidence of PU

81 cases from 1747

individuals (4.6%)
4.31 (95% CI 1.856.78) days
s.e. 1.26 days
$611$1008

Health Information
Services
Graves et al.3

Beta distribution

Graves et al.3

Gamma distribution

17

AIHW

Uniform distribution

OR 0.74 (95% CI 0.620.88)

s.e. 0.066

Stratton et al.15

Lognormal distribution of
odds ratio.

$3 767 752$5 470 075

Determined (see Table 2)

Uniform distribution

C: independent effect of PU on
mean excess LOS
D: cost of a bed day in Queensland
public hospital
E: change in risk in developing a PU
associated with intensive nutrition
support
F: annual cost of the provision of an
intensive nutrition support
intervention for at-risk patients

Statistics used
for distribution

a 81
b 1666
a 11.7
b 0.37

Abbreviations: AIHW, Australian Institute of Health and Welfare; CI, confidence interval; LOS, length of stay; OR, odds ratio; PU, pressure ulcer.

& 2013 Macmillan Publishers Limited

European Journal of Clinical Nutrition (2013) 42 46

Cost effectiveness of nutrition in preventing pressure ulcer

MD Banks et al

44
Table 2.

Costing model of provision of an intensive nutrition support intervention in Queensland public hospitals in 20022003

Item

Frequency

Value/annum

Annual low cost

Annual high cost

Additional nutrition/nursing support staff

Additional food/nutritional supplements
Total

7995 FTE
678 patients per day

$41 428$44 555

$2$5/day " 365 $730$1825

$3 272 812
$ 494 940
$3 767 752

$4 232 725
$1 237 350
$5 470 075

Abbreviation: FTE, full-time equivalent.

Table 3.

Means.d.
MinMax

Cases of
pressure
ulcer
avoided

Bed days
released

Economic costs (savings)

2896632
10825585

12 3974491
380740 873

# $5 373 645$3 892 727

# $24 671 651$ 2 761 398

Cases of Pressure Ulcers Avoided versus Cost

5,000,000
0
Economic Cost ($)

Predicted mean, variance and range values for cases of

pressure ulcer avoided, bed days released and associated economic
cost (savings) with intensive nutrition support intervention for
patients at risk of pressure ulcer in Queensland public hospitals
20022003

1,000

2,000

3,000

4,000

5,000

6,000

-5,000,000
-10,000,000
-15,000,000
-20,000,000
-25,000,000

Abbreviations: Max, maximum value; Min, minimum value.

-30,000,000

Figure 2. Cost effectiveness plane: cases of pressure ulcer avoided

versus economic cost.

The addition of a high and low value for each of the parameters of extra
staffing and extra food/nutrition was determined to provide an overall
high and low value for the annual cost of providing an intensive nutrition
support intervention (see Table 2).

A total of 1000 samples were drawn at random from each distribution,

using Microsoft Excel and Visual Basic Programming language, to generate
an empirical distribution of the outputs. Probability distributions for
specified input parameters were assigned according to standardized
methodology for statistical modeling.16 The values and distributions for
the parameters A, B, C and D were used as described previously.9
Information on values and distributions for parameters E and F can be
found in Supplementary Appendix 2 available in Supplementary
Information.
Cost values were determined in Australian dollars (AU$) and then
converted to euros as at 1 January 2003. The exchange rate on this date
was AU$1 0.534 euros (www.oanda.com).

RESULTS
Table 3 shows the mean, variance and ranges for the number of
cases of pressure ulcer avoided, bed days released and associated
economic costs if an intensive nutrition support intervention
had been implemented for at-risk patients in Queensland public
hospitals in 20022003.
The mean number of bed days released was 12 397 (s.d. 4491),
which was 0.52% of patient bed days in Queensland Health in
20022003.
Scatter plots of the cases of pressure ulcer avoided versus
economic cost and associated bed days released from cases of
pressure ulcer avoided versus economic cost are illustrated in
Figures 2 and 3, respectively. These scatter plots represent cost
effectiveness planes, where the desired outcomes (number of
pressure ulcers avoided (Figure 2) and number of bed days
released (Figure 3)) are represented on the x-axes and economic
costs on the y-axes. Each data point represents a possible output
from the model, and the overall distribution demonstrates the
likelihood of the output result.
Overall there were 951 of the 1000 samples where the
economic cost is a negative value, indicating a 95.1% chance
that implementing an intensive nutrition support intervention is
European Journal of Clinical Nutrition (2013) 42 46

5,000,000
0
0
Economic Cost ($)

Method of evaluation

Cases of Pressure Ulcers Avoided

Bed Days Released from Pressure Ulcer

Avoided versus Cost

5.000 10,000 15,000 20,000 25,000 30,000 35,000 40,000

-5,000,000
-10,000,000
-15,000,000
-20,000,000
-25,000,000
-30,000,000

Bed Days Released from Pressure Ulcer Avoided

Figure 3. Cost effectiveness plane: bed days released from cases of

pressure ulcer avoided versus economic cost.

overall cost saving, while reducing the cases of pressure ulcer and
related hospital bed days. The model predicts mean economic
opportunity for cost savings of AU$5 373 645 (s.d. $3 892 727)
(euros 2 869 526 s.d. 2 078 715) if an intensive nutrition support
intervention had been implemented in Queensland public
hospitals in 20022003.
DISCUSSION
The economic modeling undertaken for this study predicts that a
substantial number of cases of pressure ulcer could have been
avoided, had an intensive nutrition support intervention been
provided to all at-risk patients in Queensland Health in 20022003.
This corresponds to a substantial number of patient bed days that
could have been used for purposes other than patients staying in
hospital for an extended period of time with pressure ulcers.
Importantly, there were no predicted additional cases of pressure
ulcer or bed days lost to pressure ulcer from this model, with the
minimum number of cases and bed days saved being 1082 and
3807, respectively (see Table 2 and related Figures 2 and 3).
The economic cost of implementing an intensive nutrition
support intervention for at-risk patients was predicted to be
& 2013 Macmillan Publishers Limited

Cost effectiveness of nutrition in preventing pressure ulcer

MD Banks et al

45
overall cost saving with a mean value of approximatelyAU$5.4
million (euros 2.9 million), despite input costs of between
approximately AU$3.85.5 million (euros 22.9 million).
Importantly, the model chosen predicted a 95.1% chance of
being economically cost saving, while reducing the incidence of
pressure ulcers and releasing valuable bed days for use by other
patients. Of course, evaluation of the implementation of such an
intervention is required to test whether the economic outcomes
predicted are accurate. This research can be considered to be
hypothesis generating while also providing useful information for
decision making.
No published studies were located investigating the economic
outcomes of nutrition intervention for comparative purposes.
A few studies have investigated the cost effectiveness of
alternative types of pressure-relieving surfaces1820 and although
a comparison of economic outcomes cannot be made due to
different methodological approaches, they appear to indicate that
the prevention of pressure ulcers is overall associated with
significant positive economic outcomes. Graves et al.7 discussed
the need for more studies that estimate the changes in cost and
health benefits that would arise from competing strategies to
reduce the risk of pressure ulcers.
Economic cost savings in this study do not represent actual
monetary savings, rather the opportunity costs of patient bed
days not available for alternative use. Potential cost savings of
treatment and care or broader patient burden issues associated
with pressure ulcers have also not been considered. The value to
the public health system of increased throughput is considered
the most relevant factor here, but the additional costs saved from
avoided cases of pressure ulcer with respect to treatment would
also be substantial. Other potential benefits of an intensive
nutrition intervention in this patient population have also not
been considered, such as potential reduction in other complications and improvement in recovery.
The cost of the modeled intensive nutrition intervention was
between AU$3.8 million and AU$5.5 million (euros 22.9 million)
(20022003 prices), representing a substantial investment in
nutritional care in the Queensland public hospital system at this
time. The nutrition support intervention was chosen to provide
additional food or commercial supplements to patients who were
at nutritional risk and unlikely to be receiving additional nutrition
supplements. It also included additional nutrition/nursing support
staffing to encourage and assist patients to consume the required
nutrition, although this task could possibly be achieved within
existing resources with a change in care models and emphasis on
importance of patients achieving nutritional intakes. This model of
staffing was chosen based on the results of a study where the
intensive nutrition intervention resulted in significantly improved
intake (62% achieved X75% of requirements) compared with
patients receiving standard nutrition care (36% achieved X75% of
requirements).21 However the most effective way of spending
funds to ensure optimal nutrition care is not clear at this stage and
requires further investigation.
Economic analysis of the impact of nutrition intervention has
been undertaken in a few studies indicating substantial economic
benefits.22,23 Stratton et al.6 estimated mean cost savings of
between d352 and d8179 per patient if nutritional supplements
were provided to patients at nutritional risk. However, a review
of the economic literature related to nutrition support found
many studies were inadequately designed and collected only
rudimentary figures associated only with the cost of the nutrition
intervention, rather than considering the wider economic benefits,
such as an associated decrease in length of stay or reduction
in infectious complications post-operatively.24 Most studies also
failed to make even a minimal allowance for uncertainty by the
use of sensitivity analysis, nor did the authors take advantage of
the stochastic nature of the data to present measures of precision
such as CIs. This review highlights a lack of evidence related to
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costs and effects of different types of nutrition intervention. On

the contrary, this present study uses sound economic analysis
methodology to determine the economic outcomes of nutrition
intervention in a medical condition for which poor nutritional
status is a risk.
Limitations of this study mainly relate to the information used
for the input parameters.9 The economic estimates rely on effect
estimates from a meta-analysis of five studies, limitations of which
are detailed by Stratton et al.15 However, confidence in the results
of the meta-analysis is supported by the results of the individual
studies, all of which reported a decreased incidence of pressure
ulcer with nutritional support. A lack of significance of the
individual studies is most likely to be due to small sample sizes,
with the increased power of the meta-analysis arising mostly from
pooling of the data. Therefore, the findings of the meta-analysis
despite some methodological limitations is considered robust, and
given the heterogeneity of subjects and settings included,
applicable to large proportions of patients considered to be at
risk for pressure ulcer development. Another limitation of this
study was the assumption that patients at risk of developing
pressure ulcer were also considered to be at risk of, or
malnourished and hence would benefit from intensive nutrition
support. Stratton et al.15 determined that although the nutritional
status of all subjects at risk of pressure ulcer in the studies
included in the meta-analysis were not specifically assessed or
done in a standardized way, data available for subjects indicated a
majority would have been at risk of being, or malnourished. There
are many factors associated with being at risk of malnutrition that
are also factors for being at risk of pressure ulcer, such as age,
functional capacity, diagnoses and severity of illness, so this
assumption is considered reasonable. The assumption that the
prevalence of malnutrition is equivalent to the prevalence of
nutritional risk may have also underestimated the number of
patients at nutritional risk and hence the number of patients who
might have benefited from nutritional support. There were also a
number of other assumptions made regarding developing the
model for costing of the intensive nutrition support intervention,
which may be considered limitations, however as discussed
previously, the modeled costs represented a substantial
investment in nutrition support that could be spent in alternate
ways. In fact, the current predicted economic savings allow
substantial scope for even more funds to be spent, if necessary, on
the nutrition support intervention and it still remains cost
effective.
While this study utilizes data and predicts outcomes from
almost a decade ago, intensive nutrition intervention for patients
at risk of pressure ulcer in the public hospital population of
Queensland (Australia) is still not routine, and so although
parameter inputs may have subsequently changed, including
escalating costs and increasing hospital waiting lists, the overall
findings of this study remain applicable.
CONCLUSION
This economic modeling study predicts that investment in
intensive nutrition support to patients at risk of pressure ulcer
will realize substantial opportunity cost savings for the health
system with respect to the prevention of pressure ulcer, which
improves patient outcomes.
CONFLICT OF INTEREST
The authors declare no conflict of interest.

ACKNOWLEDGEMENTS
This research was supported by a grant from the Royal Brisbane & Womens Hospital
Research Foundation.

European Journal of Clinical Nutrition (2013) 42 46

Cost effectiveness of nutrition in preventing pressure ulcer

MD Banks et al

46
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Supplementary Information accompanies the paper on European Journal of Clinical Nutrition website (http://www.nature.com/ejcn)

European Journal of Clinical Nutrition (2013) 42 46

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