Pressure ulcers: guideline development and economic modelling

Aim. This paper presents the development process for clinical guidelines on the use of pressure-relieving devices (beds, mattresses and overlays), with emphasis on incorporating economic evidence. Background. Previous UK guidelines on the use of pressure-relieving devices to prevent pressure ulcers have not considered whether any recommendations made are cost effective. The routine inclusion of cost effectiveness evidence in guidelines is a recent policy development, and there has been little research into its potential role in the guideline process. Methods. We systematically reviewed the literature to assess both the clinical and cost effectiveness of pressure-relieving devices for prevention of pressure ulcers. Where there was sufficient evidence on the comparative clinical effectiveness between alternative devices, economic modelling was undertaken to assess comparative cost effectiveness. A guideline development group (comprising both clinicians and patient representatives) reviewed all the available evidence to formulate clinical practice guidelines and recommendations for further research. Results. Studies showed that caring for people vulnerable to developing pressure ulcers on high-specification foam mattresses compared with standard hospital mattresses significantly reduced their risk of developing a pressure ulcer. Cost effectiveness modelling indicated that, because of savings accruing through treating fewer pressure ulcers, high-specification foam mattresses are likely to cost less overall and are more effective. The resulting clinical practice guideline was uncompromising on the use of high-specification foam mattresses as the minimum provision in patients vulnerable to pressure ulcers. Significant weaknesses were identified in both the quality and availability of evidence for most of the other pressure relieving devices considered. Conclusions. Cost effectiveness assessment was an integral part of the guideline development process. It clarified the shortcomings of some of the clinical effectiveness evidence and helped in formulating pragmatic clinical practice recommendations.