Presence of new or worsened bedsores tied to poorer outcomes in inpatient rehab facilities

BUFFALO, N.Y. -- A new study from the University at Buffalo has shown that the presence of new or worsened bedsores is an effective indicator of the quality of care for rehab patients.

The study is the first to examine whether this metric is, in fact, is associated with outcome of care in inpatient rehabilitation settings. New or worsened bedsores is a quality metric instituted as part of the Patient Protection and Affordable Care Act (ACA). The ACA requires that medical institutions be evaluated on their quality of care.

Bedsores, also known as pressure ulcers, cost the U.S. health care system between $9.1 billion and $11.6 billion per year, according to the U.S. Department of Health and Human Services' Agency for Healthcare Research and Quality, the lead federal agency charged with improving the safety and quality of the nation's health care system.

Previous studies have shown an association between the presence of bedsores and a variety of outcomes for patients in acute care hospitals and long-term care facilities. However, the association between pressure injury development and rehabilitation outcomes hasn't been examined previously.

Margaret DiVita, who conducted the research as a doctoral student in epidemiology at UB, is now an associate professor at SUNY Cortland. Using data from the Uniform Data System for Medical Rehabilitation, she examined the records for nearly 500,000 Medicare patients discharged between January 2013 and September 2014 -- after this mandated measure of quality was implemented. The study was published in the Archives of Physical Medicine and Rehabilitation.

"We looked at how good a proxy measure of quality the new or worsened pressure ulcer measure was, in particular to see if it was associated with poorer outcomes for rehabilitation patients. We found that it was indeed associated with lower quality outcomes: less gain in function during treatment, and lower likelihood of leaving rehab to go to a community setting," said Jo Freudenheim, the paper's senior author and chair of the Department of Epidemiology and Environmental Health in the UB School of Public Health and Health Professions.

"The focus of this paper is on an important question for the regulation of medical care. How do you measure whether someone is getting good care? In this case we were focused on the inpatient rehab facilities," Freudenheim said. "We looked at one of the ways that quality is measured as part of the ACA--whether patients get a new pressure ulcer during their stay or, if they have one already, if it gets worse during their stay."

While outcomes were poorer for those with new or worsened pressure ulcers, more than half of these patients were able to be discharged to a community setting. "A pressure injury prior to admission or greater likelihood of developing worse pressure injury are not appropriate grounds for denial of access to inpatient rehabilitation care," the researchers write.

Compared to the control group, patients with a new or worsened bedsore tended to have a lower change score on the Functional Independence Measure (FIM), a basic indicator of patient disability, and to have, on average, longer rehabilitation stay. In this study, about 1 percent of patients experienced new or worsened bed sores during their rehabilitation stay.

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The study, which was published in the August issue of the print journal, was made available online in April 2018 ahead of peer-review.

In addition to DiVita and Freudenheim, co-authors on the paper include Carl Granger, a professor in the Department of Neurology in the Jacobs School of Medicine and Biomedical Sciences at UB; Richard Goldstein, an assistant professor of pediatrics at Harvard Medical School; and Paulette Niewczyk, associate professor of health promotion at Daemen College in Buffalo.

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