Effectiveness and Costs of Pressure Ulcer Treatment and the Quality of Life of Patients With Pressure Ulcers Receiving Home-Based and Institutional Care

Quality of Life Questionnaire assessment will be conducted using the EQ-5D-5L - a standardized generic instrument for measuring health-related quality of life across five domains: mobility, self-care, usual activities, pain/discomfort, and anxiety/depression, together with a self-rated health visual analogue scale (EQ VAS) or QOL-AD (Quality of Life in Alzheimer's Disease) - a validated questionnaire designed to assess quality of life in individuals with dementia. The questionnaire will be presented in a version for the patient and a caregiver.

The index scores range from roughly -0.59 to 1 (higher = better outcome), and EQ VAS scores range from 0 to 100 (higher = better health) Assessment will be conducted before the start of the study and then after 6 and 12 weeks of the study (the end of the study).

Planimetry - a quantitative method used to measure the surface area of pressure ulcers (cm²) to monitor wound healing over time. Measurements will be performed every two weeks. If the pressure ulcer heals before the end of the 12th week, the date of healing will be recorded in the documentation. The surface area of the pressure ulcer will be measured using planimetry. First, a waterproof marker will be used to trace the contours of the pressure ulcer on a transparent, soft, non-stretchable film, which will be placed directly on the pressure ulcer after disinfection. Next, the contour of the pressure ulcer will be transferred to a transparent, rigid film, and the surface area of the defect will be measured using a planimeter (Mutoh Kurta XGT, Altek, USA). The planimeter will be connected to a computer equipped with special C-GEO software (version 4.0, Nadowski SoftLine, PL), which allows for the calculation of pressure ulcer surface area and data storage.

Newcastle Satisfaction with Nursing Scale (NSNS) - a validated instrument used to evaluate patients' experiences of and satisfaction with the quality of nursing care received during hospitalization or other healthcare services.

NSNS is used in clinical studies on the quality of nursing care in various medical facilities. It allows for the assessment of patient satisfaction with nursing care and fits perfectly with the study's objective, which concerns pressure ulcer management, where daily care, dressing changes, pressure ulcer prevention, and interpersonal relationships with staff are key. It can be used in both home care and inpatient settings.

The questionnaire uses clear and straightforward language, making it suitable for older adults.

Transformed scores on both subscales range from a minimum of 0 to a maximum of 100, where higher scores mean a better outcome.

Assessment will be conducted before the start of the study and then after 6 and 12 weeks of the study (end of the study).

In long-term care, the following costs will be taken into account primarily:

• Personnel costs (nursing, care, and rehabilitation services).
• Basic medical supplies and standard dressings (e.g., gauze, bandages, sterile compresses).
• Medications from the reimbursement list.
• Patient meals and accommodations.

In home care (long-term nursing home care), the following costs will be taken into account primarily:

• Community nurse visits (nursing services costs).
• Basic dressings and medical supplies costs.
• Nursing procedures (dressing changes, measurements, patient and family education).

In both types of care, the following will also be taken into account:

• Costs of specialized dressings and care products.
• Transport costs for a home care nurse
• Rental costs of pressure-relief equipment (e.g., alternating pressure mattresses).
• Working time of non-medical caregivers.
• Additional diagnostics and specialist consultations.

The costs will be added up and calculated.

NPIAP/EPUAP Classification System is used to classify pressure ulcers according to their severity (Stages I-IV) based on the depth of tissue damage and clinical characteristics.

A stage I pressure ulcer is characterized by non-blanching redness of the skin without skin disruption. A stage II pressure ulcer has partial loss of dermal thickness, while a stage III pressure ulcer has complete loss of skin thickness. A stage IV pressure ulcer is characterized by extensive tissue destruction, exposing muscles, tendons, and even bone (with the possibility of lesions extending deeper into these structures).

The international NPIAP/EPUAP Classification System grades the severity of pressure ulcers (bedsores) based on the depth of soft tissue damage and anatomical tissue loss. The staging values run from Stage 1 (minimum) to Stage 4 (maximum), where higher scores mean a worse outcome and more profound tissue destruction. A physician will assess the severity of the pressure ulcer.

Mini Nutritional Assessment (MNA) - a validated screening tool used to evaluate nutritional status in older adults through dietary assessment, anthropometric measurements, general health evaluation, and functional assessment.

The scale allows for a maximum of 30 points, and the results are interpreted as follows: 24-30 points - adequate nutrition, 17-23.5 points - risk of malnutrition, <17 points - malnutrition.

Geriatric Depression Scale (GDS-30) - a 30-item self-report questionnaire designed to screen for depressive symptoms in older adults and assess their severity.

The following are assessed: emotional well-being, interest in life, energy and motivation, self-esteem, and feelings of hopelessness or sadness. The results are interpreted as follows: 0-9 points - no depression or depression unlikely, 10-19 points - mild to moderate depression (deepening diagnostics is recommended), 20-30 points - severe depression (referral to a psychiatrist and possible treatment should be initiated).

Mini-Mental State Examination (MMSE) - a widely used cognitive screening test that assesses orientation, memory, attention, language, and visuospatial abilities to identify cognitive impairment.

The assessment will be performed by a physician. This scale assesses six areas of cognitive function: orientation in time (date, day of the week, month), orientation in place (name of the patient's location, floor of the building, city, province), memorization (repeating given words), concentration and counting, recall (repeating given words after a few minutes), language and executive functions (naming objects, repeating sentences, understanding instructions, reading, writing, drawing). The results are summed and interpreted as follows: 27-30 points - no cognitive impairment, 24-26 points - mild cognitive impairment, 18-23 points - moderate cognitive impairment, ≤17 points - significant impairment (suspected dementia).

Barthel Index - an instrument used to evaluate a patient's level of independence in activities of daily living (ADLs), including feeding, bathing, dressing, toileting, transfers, mobility, and continence.

The patient's independence is assessed during activities such as eating, transferring (e.g., from bed to a chair), dressing, using the toilet, washing and grooming, climbing stairs, mobility (moving a distance of 50 meters), and controlling urine and stool. The results are interpreted as follows: 0-20 points - complete dependence (patient requires full care), 21-60 points - significant dependence (significant assistance with most activities), 61-90 points - moderate dependence (assistance with some activities), 91-99 points - minimal dependence (little assistance or supervision), 100 points - complete independence (patient performs all activities independently).

Waterlow Scale - a comprehensive pressure ulcer risk assessment tool that considers multiple patient-related factors, including age, body build, mobility, nutritional status, continence, skin condition, and comorbidities.

It assesses the following risk factors for pressure ulcers: patient age, gender (female patients receive additional points), body composition (height and weight; BMI), skin condition (e.g., presence of pressure ulcers, dry, moist, or damaged skin), mobility, urinary and/or fecal incontinence, appetite and nutrition, neurological disorders (e.g., paralysis, stroke, multiple sclerosis), acute and chronic diseases (e.g., diabetes, heart failure, cancer, respiratory diseases), medications (e.g., steroids, chemotherapy), and previous surgical procedures (major surgeries lasting >2 hours). Each factor is assigned a specific number of points and ≥20 points means high risk of pressure ulcers.

Braden Scale - a validated tool used to assess the risk of pressure ulcer development by evaluating six domains: sensory perception, skin moisture, physical activity, mobility, nutrition, and friction/shear.

The Braden Scale is one of the most commonly used tools for assessing the risk of pressure ulcers in elderly patients, particularly those who are chronically ill, immobilized, or hospitalized. This scale assesses six areas of pressure ulcer risk: sensory perception (the patient's ability to respond to pressure-induced discomfort), skin moisture (exposure of the skin to moisture, e.g., sweat, urine, feces), activity (level of physical activity, e.g., walking, lying down), mobility (the ability to change and control body position), nutrition (nutrition type and quality), and friction and shear forces (the effect of body movement relative to the ground). The maximum score is 23, and the lower the score, the greater the risk of pressure ulcers