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ealth and economic literature is replete with discussions on how to provide cost-effective care under current fiscal and regulatory restraints. We are repeatedly told that cost effectiveness is defined not by the unit cost of a product or service but by the clinical outcome when a certain product or service is used in the course of patient care. A formula1 was developed seven years ago to assist clinicians in calculating the cost effectiveness of care. Prospective analyses2,3 of product usage, nursing time, and their associated clinical outcomes give us black and white evidence that more costly products can often be more clinically effective as well as cost effective in the long run. A recent large study4 in long-term care demonstrated that standardized care plans and products yield improved clinical outcomes at a reduced cost.
       Prevention is an area where many have difficulty in quantifying the "return on investment" for the resources used to prevent the development of pressure ulcers. Prior to the implementation of prospective payment in home health and long-term care, regulators required providers to take preventive measures but did not reimburse providers for the products and services needed to do so. In reality, preventive care was often overlooked. After all, due to the structure of the cost-based Medicare system at the time, providers were being paid to treat wounds rather than heal them or prevent the development of new ones.
       Under current payment and regulatory guidelines, providers are still expected and required to implement preventive measures for their patients. What has changed, however, is the fact that regulators now have the ability to evaluate the outcomes of care delivered by specific providers. Today, providers are held accountable and responsible for the development of pressure ulcers, skin problems associated with incontinence, or even peristomal skin irritation.
       One simply has to go online and review pending survey or litigation cases to understand how regulators and attorneys are looking at the care being provided. Did the facility or agency consciously invest time and staff to prevent the wound? Did the patient have this problem when admitted to the facility or agency? If not, what measures, if any, were taken to prevent it? Were patients evaluated for risk at admission, at regular intervals during the course of care, or when their clinical condition changed? Were suitable support surfaces used at the most clinically appropriate times? Does the organization have written skin care, incontinence, and pressure ulcer prevention protocols? Does the patient's medical record demonstrate that these protocols were understood by every member of the healthcare team and integrated into daily care? Does the organization have a formulary of preventive skin care products? Are they being used correctly on a regular basis?
       Cost issues related to prevention of chronic wounds have not been adequately quantified. How much does it really cost to prevent a pressure ulcer, a diabetic foot ulcer, or a venous leg ulcer in terms of supplies, nursing time, ancillary services, and patient education? The use of a nonreimbursed or highly expensive technology may be worthwhile from a cost standpoint rather than wasting precious time, prolonging patient suffering, and using "lower cost" noneffective interventions or interventions that have previously been used and failed to initiate healing or prevent wounds. Colburn5 suggests that healthcare professionals' long history of dedication to pain relief has historically been provided without expecting a cost saving, but that today, regulators and payers expect clinical and cost-efficacy data to be evident for prevention. We know what clinical interventions can prevent the development of costly chronic wounds. What we do not know is exactly how much it costs to do it or the most cost-effective way to do so.
       So what does cost-effective preventive wound care mean? Until it can be investigated further, it can be suggested that cost-effective preventive wound care means improved clinical and financial outcomes; a reduction in incidence; fewer triggers for surveys; less difficulties with families, attorneys, and surveyors; increased occupancy; an improvement in the reputation of the provider organization and its ability to compete; and an escalation of the overall fiscal health of the organization. It means more provider organizations will be able to keep their doors open to the thousands of patients who are going to need their care. What we do know for sure today is this is an area that requires further investigation and the generation of quality data that can be used by regulators and payers to establish coverage and payment policies. Avoiding the development of a preventable chronic wound is a basic patient right that deserves an adequate investment of time, resources, and caring.