Pressure injuries (PIs), also known as pressure ulcers (PUs),1 typically result from prolonged periods of uninterrupted pressure on the skin and underlying tissue. While mostly preventable,2 PIs severely impair patient quality of life and often lead to increased morbidity, mortality, and costs. In the United States, 2.5 million cases of PIs are treated annually at a cost of $11.6 billion to the health care system.3 The risk of acquiring a PU within the first 2 weeks of hospitalization is 9%,4 and patients with a PU have a 4-day longer median length of stay (LOS), a 5-fold higher mortality rate, and an average of $17 000 in additional incremental charges for a hospital admission.5
To encourage hospital quality improvement (QI), the Centers for Medicare & Medicaid Services (CMS) and US health insurers have enacted nonpayment policies for hospital-acquired conditions (HACs), including PIs, placing financial responsibility solely on hospitals.6-8 As a requirement of the 2005 Deficit Reduction Act to eliminate payments for treating high-cost and high-volume preventable adverse events during a hospital stay, the Hospital-Acquired Conditions Present on Admission (HAC POA) provision was mandated in 2008.9 With 257 412 cases of preventable PIs reported by the CMS in 2007, hospital-acquired PIs (HAPIs), regardless of stage and whether hospital-acquired or POA, were identified among conditions for which the CMS would no longer provide payment.10
In a separate measure that strives to tie payment to performance, the Affordable Care Act established the Hospital-Acquired Condition Reduction Program (HACRP). Beginning in 2015, the HACRP requires the CMS to lower inpatient reimbursement by 1% for the lowest quartile of hospitals with highest HAPI rates as measured by HAC scores,11 a policy projected to save Medicare $350 million annually.12 The HAC score is calculated based on data in 2 domains, with the first domain consisting of the CMS Recalibrated Patient Safety Indicator (PSI) 90 (CMS PSI 90) with PU rate accounting for 5% of the PSI 90 composite.11 The second domain is comprised of the National Healthcare Safety Network health care-associated infections measures. For domain 1 and domain 2, the CMS applies a weight of 15% and 85%, respectively, to determine the Total HAC Score.11 To put this into perspective, 1384 of the 5534 US hospitals will have had a Medicare payment reduction as part of the HACRP in 2018.13
In addition, PIs have legal implications. The passage of the Omnibus Budget Reconciliation Act in 1987 (OBRA-87) saw an increased risk of malpractice lawsuits in the United States, with more than 17 000 lawsuits related to PIs annually.3 The OBRA-87 set federal standards of care for health care providers, making it easier for claimants to prove negligence in the handling of PIs.14 In 2005, the verdict in a PI lawsuit favored plaintiffs in 87% of cases with a median settlement of $1.06 million.15
Thus, when considering the impact of PIs on hospital revenue, not only should the costs of treatment be considered but also the loss of reimbursement, risk of litigation, and increased patient mortality that would impact hospital performance metrics. The calculator herein was developed to assess the current financial burden of PIs and the potential cost avoidance and savings derived through the implementation of QI initiatives (including the use of a digital wound management system) in helping reduce PIs.