08/08/11

A national effort since 2002 to reduce pressure ulcers among at-risk nursing home residents appears to have had little effect among black Americans, while the prevalence of such wounds in the overall nursing home population declined, according to a study published in JAMA. The authors found the disparity related to higher pressure ulcer rates in nursing homes with the highest proportions of black residents.

Since late 2002, national, state, and local initiatives have sought to improve the overall quality of nursing home care, in part by reducing pressure ulcers. Yue Li, PhD, of the University of Iowa, Iowa City, and colleagues analyzed the pressure ulcer prevalence in nursing homes by race and site of care between 2003 and 2008. The sample for the observational cohort study consisted of 2.1 million white and 346,808 black residents who required extensive or total staff assistance, were in a coma, or were malnourished. The study covered 12,473 certified nursing homes in the United States.

The high-risk black residents were 6 years younger (76 years vs. 82 years) and more likely to be male (33% vs. 26%) than the whites. The black residents were more likely to have had a stroke or diabetes but less likely to have had dementia and musculoskeletal disease.

The results in the July 13 issue of JAMA included:

--Of all high-risk patients assessed during the study period, 10.5% of whites and 15.9% of blacks had stage 2, 3, or 4 pressure ulcers. By pressure ulcer stages, prevalences were 2.1% of whites vs. 1.2% of blacks (stage 1), 6.6% of whites vs. 7.7% of blacks (stage 2), 1.5% of whites vs. 2.7% of blacks (stage 3,) and 2.4% of whites vs. 5.5% of blacks (stage 4).

--Pressure ulcer rates decreased overall from 2003 through 2008 but remained consistently higher in black residents: 16.8% in 2003 to 14.6% in 2008, vs. 11.4% percent in 2003 to 9.6% in 2008 for whites (95% confidence interval).

--In nursing homes with populations of 35% or more black, the black residents had a pressure ulcer rate of 15.5% in 2008, while the rate was 8.8% among white residents in facilities with less than 5% black residents. Residents in homes with high black populations had at least a 30% increased risk of pressure ulcers than residents in homes with no or only a small percentage of black residents (JAMA 2011;306:179-86).

"Given the widespread racial disparities in nursing home care, it is imperative to close the gap beyond industry-wide improvements," the authors said. "The first key step would be understanding why these disparities exist before appropriate efforts can be made to eliminate them."

The researchers found that facilities with the highest proportion of black residents tended to have lower staffing levels of registered nurses and certified nurse assistants, be large and for profit, and be urban. They pointed out that "care for minority residents is concentrated among a small number of nursing homes" that may be financially disadvantaged by caring for predominantly Medicaid patients.

The study has several limitations, the researchers said. First, they focused on the prevalence of pressure ulcers and racial disparities, so the data may not be generalized to other outcome and care disparities in nursing homes. Second, they had limited ability to account for variations in resident and site-of-care characteristics, meaning that pressure ulcer disparities may partially be mediated by unmeasured factors. Third, the study could not distinguish the effects of various quality improvement initiatives.

In an editorial accompanying the report, researchers Nancy Bergstrom, PhD, RN, and Susan D. Horn, PhD, said that the overall rate of pressure ulcers among high-risk nursing home residents in the United States has declined, thanks to various quality initiatives. Yet the prevalence consistently remains higher in black residents, said Dr. Bergstrom, with the Center for Aging, School of Nursing, University of Texas Health Science Center, Houston, and Dr. Horn, with the International Severity Information Systems, Salt Lake City.

That at-risk black residents are more likely to be younger and male, and to have a history of diabetes and stroke, is consistent with earlier reports that men and residents with more severe illness or disability have a higher rate of pressure ulcers on admission to nursing facilities, they said.

About half the disparity shown in the current study relates to the proportion of black people residing in a nursing facility, the commenters noted. "These findings suggest that disparities in pressure ulcer care may be related to both individual and system issues," they said, "and thus it is important to examine the changes in pressure ulcer care over time as well as the differences that may exist across systems."

Databases should include information on new pressure ulcers, rather than just the existence of pressure ulcers, said Dr. Bergstrom and Dr. Horn. Otherwise, residents with pre-existing wounds, such as those admitted from a hospital, still appear in nursing homes’ rates.

Additional research is needed to accurately identify the causes of racial disparity in the incidence of pressure ulcers, they said. For example, high staff turnover may undermine care, as may management decisions to use or not use technologies such as high-density viscoelastic foam mattresses and disposable briefs and to turn patients every 4 hours.

They cited as one limitation of the report by Dr. Li and colleagues the use of public databases that consider prevalence rather than incidence to define quality of care and racial disparities. Incidence of ulcers more accurately reflects quality of care and improvements. Also, it is important to separate superficial (stage 2) ulcers from full-thickness (stages 3 and 4) ulcers when evaluating quality improvement.

By establishing the causative factors in pressure ulcer rates, nursing facilities will be able to make sure that all residents achieve appropriate care, said Dr. Bergstrom and Dr. Horn.

None of the authors reported any conflict of interest. Dr. Bergstrom and Dr. Horn reported receiving some support for their research from Kinetic Concepts, which makes devices for treating pressure ulcers and other wounds.CfA

Jeffrey S. Eisenberg is a freelance writer based in Philadelphia.