The personal and health care costs of pressure ulcers (PUs) are substantial. PUs cause physical pain, emotional distress, and lower quality of life. Treatment of a Stage 4 ulcer averages more than $124,000 per patient (Brem et al., 2010). The prevalence of PUs among nursing home (NH) admissions has been reported to be 10% to 33% (Baumgarten et al., 2004; Brandeis, Morris, Nash, & Lipsitz, 1990; Capon, Pavoni, Mastromattei, & Di Lallo, 2007; Kiel, Eichorn, Intrator, Silliman, & Mor, 1994; Sternberg, Spector, Kapp, & Tucker, 1988; Zulkowski, 1998). Due to the difficulty in reliably identifying the least severe Stage 1 PUs (DeFloor & Schoonhoven, 2004), some studies exclude this stage (Baumgarten et al., 2004; Brandeis et al., 1990) or report Stage 1 results separately (Sternberg et al., 1988). Rates for Stage 2 to 4 PUs only among NH admissions show less variability and an upper bound that is half the rate including Stage 1 (10% to 13%) (Baumgarten et al., 2004; Brandeis et al., 1990; Sternberg et al., 1988). In the one study reporting the prevalence of PUs among NH admissions by stage, lower rates (2% to 3%) were documented among the more severe Stages 3 and 4 (Brandeis et al., 1990). Residents with at least one Stage 2 to 4 PU had 1.7 PUs on average (Baumgarten et al., 2004).
Two studies examined differences in PU prevalence of NH admissions by race: One compared White and all non-White races combined (Sternberg et al., 1988) and the other compared White and Black individuals only (Baumgarten et al., 2004). Both studies found that PU prevalence among minority admissions was approximately twice that of admissions among White adults. No studies to our knowledge have compared PU rates across all racial/ethnic categories of NH admissions. Racial/ethnic differences in PU prevalence have been found in cross-sectional groups of NH residents (new admissions as well as long-term residents). Among long-term NH residents who were considered to be at high risk for PUs, there was a higher prevalence of PUs among Black individuals compared to their White counterparts (Li, Yin, Cai, Temkin-Greener, & Mukamel, 2011). In five southwestern U.S. states with a large Hispanic population, the prevalence of PUs was greater among Hispanic NH residents than White residents and was associated with NH concentration of Hispanic residents (Gerardo, Teno, & Mor, 2009). These studies show the importance of examining the rate of PUs in the various race/ethnic groups as well as at NH and regional levels for a better understanding of this health problem.
Many individuals admitted to a NH are predicted to return to their homes (Keeler, Kane, & Solomon, 1981). Therefore, recognizing health problems that can be treated and cured, such as PUs, at admission to NHs is critical to increase the likelihood of a return to living in the community. The purpose of this article is to describe the prevalence of PUs among older adults at the time of their NH admission according to race/ethnicity at three levels of analysis: individual resident, NH, and area of the country (U.S. Census Bureau, n.d.).
Method
This study had a cross-sectional observational design. Minimum Data Set (MDS) records version 2.0 (years 2000–2002) and the 2000 U.S. Census tract data were used. The MDS is a record of the demographic, clinical, and functional status of NH residents; its validity and reliability have been established (Frederiksen, Tariot, & De Jonghe, 1996; Morris et al., 1997). The study cohort included all new admissions ages 65 and older to NHs affiliated with the same for-profit chain during the 3-year study period. All NHs were Medicare/Medicaid certified. The first full MDS record—the admission assessment—was analyzed. Demographic and clinical characteristics of this study’s admission cohort are reported elsewhere and have been shown to be highly similar to the population of admissions (ages 65 and older) to all Medicare/Medicaid-certified NHs in the United States during the same time period (Bliss et al., 2013).
MDS records provided demographic information and clinical data regarding the presence and stages of PUs. Race/ethnicity categories on the MDS were American Indian/Alaskan Native; Asian/Pacific Islander; Black, not of Hispanic origin; Hispanic; and White, not of Hispanic origin. NHs were classified according to their percentage of admissions of White individuals using previously published categories: <65% White, 65% to 84%, 85% to 94%, and ⩾95% White (Li et al., 2011). Prevalence was measured for three outcomes: (a) PUs Stages 1 to 4 individually as well as for Stages 2 to 4 together to compare findings with those of other published studies, (b) highest stage of all PUs present, and (c) average number of Stage 2 to 4 PUs per resident among those with at least one of these PUs. MDS records were de-identified, and the study was granted exempt status by the Institutional Review Board at the investigators’ university. The Census tract in which each NH was located was identified by the Minnesota Population Center at the University of Minnesota. For NH and regional analyses, data were summarized according to percentage of White NH admissions and by the nine U.S. Census (n.d.) divisions.
Results
Of the 111,640 NH admissions, the majority were White individuals followed by Black, Hispanic, Asian, and American Indian individuals. Women and residents ages 65 to 74 were the majority in all race and ethnic groups (Table 1). Approximately one third of Black, Hispanic, and American Indian admissions had a high school education, whereas nearly two thirds of White admissions had this level of education. The 457 NHs of the admissions were located in 29 states and all nine U.S. Census divisions.
At the level of individual admissions, 14% of NH admissions overall had a Stage 2, 3, or 4 PU, and 5% had a Stage 1 PU. The average number of Stage 2 to 4 PUs ranged from 1.9 to 2.4 per resident (Table 1). Black admissions had the highest prevalence of Stages 2 to 4 combined, followed by Hispanic admissions, and White admissions had the lowest prevalence. Hispanic admissions had the second greatest prevalence of the most severe PUs (Stages 3 and 4 combined = 11%). Blacks admissions had the highest prevalence of Stage 2, 3, or 4 PUs individually and the lowest prevalence of Stage 1 PUs. A Stage 2 PU was the most common highest stage among all racial/ethnic admission groups, with prevalence approximately two to three times that of the other stages. In terms of the highest stage of PUs present, the rate of Stage 1 PUs was lowest among Black admissions, and Stage 4 was lowest among White admissions. More Black admissions, followed by Hispanic, had a Stage 4 PU as the highest stage compared to the racial/ethnic groups.
At the NH level, an inverse trend was observed in the percentage of White admissions to a NH and the prevalence of some stages of PUs (Table 2). The greater the majority of White admissions, the lower the rates of Stage 4 PUs and Stages 2 to 4 combined. Similar to findings at the individual admissions level, Stage 1 PUs were least common and Stage 4 PUs were most common in NHs with the lowest percentage of White admissions.
The percentage of White admissions in NHs by Census division ranged from 74% to 97% (Table 3). Corresponding prevalence of PUs or highest stage of all PUs do not appear to be related to the percentage of White NH admissions within a Census division. The West North Central Census division, including North Dakota, South Dakota, Minnesota, Nebraska, Iowa, Kansas, and Missouri, has the lowest rates of both PU outcome variables, as well as the highest percentage White composition of its NHs, but this observation is not consistent within all divisions. The New England and West North Central divisions illustrate this point: 97% of admissions to NHs in both these divisions were White, yet the rate of Stages 2 to 4 PUs combined was 15% in the former and 11% in the latter (lowest of all Census divisions). The highest prevalence of PUs among NH admissions was in the Middle Atlantic division, which had the third highest percentage of White admissions.
Discussion
This is the first study to compare the prevalence of PUs among all racial and ethnic groups of NH admissions represented on the MDS. Our results extend the limited data available in the literature about racial/ethnic differences in PUs. Our finding of a PU rate among Black admissions that is 1.7 times higher than White admissions is consistent with that of Baumgarten et al. (2004), who reported an admission PU prevalence among Black individuals that was twice that of White admissions in Maryland NHs. Our results present new information that differences in the prevalence of Stages 2 to 4 PUs reported among a cross-section of NH residents as being Blacks > Hispanics > Whites (Gerardo et al., 2009) occur as early as at the time of admission. Our study adds that the admission prevalence of PUs among Asian and American Indian admissions was less than these other two minority groups. The 14% overall prevalence of Stages 2 to 4 PUs found in this study falls within the 10% to 20% reported in other studies examining all NH admissions (Brandeis et al., 1990; Kiel et al., 1994; Sternberg et al., 1988) with differences likely due in part to differences in sample size, national representation, and methods.
This is also the first study to examine the admission prevalence of PUs at the NH and regional levels. At the NH level, a higher prevalence of PUs was observed among NHs with a lower percentage of White admissions. This finding supports a similar association of a greater PU rate observed in Hispanic residents in NHs with greater concentrations of Hispanics (Gerardo et al., 2009). There was no consistent trend between PU prevalence and the percentage of White admissions to NHs by Census division.
Our results lend support to the suggestion that Stage 1 PUs in Black admissions may be underreported or underrecognized (Baumgarten et al., 2004; Lyder et al., 1999). Black NH admissions had the lowest prevalence of Stage 1 and the highest prevalence of Stage 2 PUs among all racial/ethnic groups. Similarly, the rate of Stage 1 PUs as the highest stage of PUs was lowest in Black admissions compared to other races/ethnicities. Darker skin presents challenges for detecting damage because “redness,” considered one of first signs of skin damage, can manifest as a purplish color or more subtle discoloration of usual skin tone and may be missed (Bennett, 1995).
Results of our study suggest the need for resources to assess and manage PUs from the time of admission and for NHs with higher percentages of minority admissions. Reports of lower levels of resources and care quality (Institute of Medicine [IOM], 2002; Smith, Feng, Fennell, Zinn, & Mor, 2007) in NHs with high minority concentrations suggest that higher rates of PUs among their admissions may further disadvantage these NHs. Clinical tools for assessing skin and skin damage, including PUs, that have been validated for use with dark-toned skin are lacking and are needed to help increase the awareness and ability of nursing staff to identify less severe skin pressure damage early. More intensive effort to assess for Stage 1 PUs among Black NH admissions that is supported by staff education and organizational policies is recommended.
Our findings encourage multivariate and multilevel analyses of factors that help explain admission differences in PUs among racial and ethnic groups, an important step toward achieving the IOM’s (2002) goal of improving equity and quality of health care. Comparative research of health care policies, health care system accessibility, as well as underlying functional and clinical differences of individuals may be necessary for more complete understanding of factors that are driving racial/ethnic-based differences in PU rates and to facilitate prevention (Smith, Feng, Fennell, Zinn, & Mor, 2008; Mor, Zinn, Angelelli, Teno, & Miller, 2004). Further investigation into whether the differences in PUs at NH admission noted may be an issue of health disparity is warranted.
Implications for Practice
Several important practice implications can be derived from this study. First, quality improvement efforts related to early detection of PUs at the time of NH admission, particularly in minority individuals, should include a careful skin assessment including observation of any existing skin damage conducted by the admitting nurse as well as the primary care provider, which may be a nurse practitioner. Second, because of the lack of valid and reliable clinical tools to assess early skin changes in dark-toned skin, emphasis should be given to developing processes for regularly monitoring skin in individuals who have or are at high risk for skin damage. Third, continuing education and staff development programs, as well as pre-licensure and advanced practice academic programs, need to incorporate content on differences in epidemiology of PUs at NH admission. This education will create awareness that minority groups have a higher risk for PUs and could lead to earlier diagnosis and intervention.
Limitations
A limitation of this study is use of a convenience sample of admissions to for-profit NHs that may not be representative of all U.S. NHs or admissions. However, 69% of all U.S. NHs are for profit (Centers for Medicare & Medicaid Services, 2012), and characteristics of our sample are similar to older adult admissions to all U.S. NHs during a similar time period (Bliss et al., 2013). Our sample is the largest, most diverse, and nationally representative of any that has investigated racial/ethnic differences in PUs among NH admissions to date. Secondary source data that were collected for regulatory rather than research purposes were used to determine PU prevalence. Findings may also be limited by variations in completion of MDS items about PUs among NHs.
Conclusion
Our study revealed racial- and ethnic-based differences in PUs among NH admissions. The prevalence of PUs in older Black and Hispanic adults admitted to NHs was greater than in Whites. The percentages of Stage 3 and 4 PUs were higher in all groups of minority admissions compared to White admissions. More PUs were observed among NHs with a lower percentage of White admissions. These findings suggest that NHs admitting higher percentages of older minority individuals need additional resources to assess and manage PUs starting at the time of admission. Efforts to reduce PUs in NHs must include a focus on PU prevention among older adults prior to NH admission.
References
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Demographics and Prevalence of Pressure Ulcers by Race/Ethnicity of Nursing Home Admissions
| n (%) |
|---|
| Variable | American Indian/Alaskan Native (n = 558) | Asian/Pacific Islander (n = 1,944) | Black, Not Hispanic (n = 9,580) | Hispanic (n = 1,956) | White, Not Hispanic (n = 97,594) |
|---|
| Female gender | 322 (58) | 1,168 (60) | 5,962 (62) | 1,108 (57) | 64,332 (66) |
| Age (years) | | | | | |
| 65 to 74 | 206 (37) | 290 (15) | 2,754 (29) | 582 (30) | 18,691 (19) |
| 75 to 84 | 212 (38) | 867 (45) | 3,923 (41) | 805 (41) | 43,282 (44) |
| 85+ | 140 (25) | 787 (40) | 2,903 (30) | 569 (29) | 35,621 (36) |
| High school education | 201 (36) | 1,024 (53) | 3,269 (34) | 610 (31) | 60,609 (62) |
| At least one pressure ulcer of this stage | | | | | |
| Stage 1 | 43 (8) | 194 (10) | 624 (7) | 135 (7) | 8,086 (8) |
| Stage 2 | 87 (16) | 281 (14) | 1,867 (19) | 302 (15) | 11,734 (12) |
| Stage 3 | 27 (5) | 69 (4) | 673 (7) | 121 (6) | 3,126 (3) |
| Stage 4 | 30 (5) | 75 (4) | 719 (8) | 95 (5) | 2,651 (3) |
| Stages 2 to 4 | 116 (21) | 356 (18) | 2,505 (26) | 414 (21) | 14,892 (15) |
| Highest stage of pressure ulcer | | | | | |
| Stage 1 | 25 (4) | 113 (6) | 271 (3) | 74 (4) | 4,842 (5) |
| Stage 2 | 52 (9) | 224 (12) | 1,207 (13) | 207 (11) | 8,442 (9) |
| Stage 3 | 15 (3) | 54 (3) | 381 (4) | 79 (4) | 2,026 (2) |
| Stage 4 | 24 (4) | 61 (3) | 596 (6) | 81 (4) | 2,053 (2) |
| Mean (SD) |
| Number of Stage 2 to 4 pressure ulcers per resident | 2.3 (2.1) | 1.9 (1.5) | 2.4 (2.2) | 1.9 (1.4) | 1.9 (1.6) |
Prevalence of Pressure Ulcers by Percentage of NH Admissions of White Older Adults
| n (%) Admissions of White Older Adults |
|---|
| Pressure Ulcer Stage | <65% (n = 11,865)a | 65% to 84% (n = 16,526)b | 85% to 94% (n = 27,994)c | ⩾95% White (n = 55,255)d |
|---|
| At least one pressure ulcer of this stage | | | | |
| Stage 1 | 966 (8) | 1,497 (9) | 2,833 (10) | 3,787 (7) |
| Stage 2 | 1,911 (16) | 2,352 (14) | 3,876 (14) | 6,133 (11) |
| Stage 3 | 702 (6) | 721 (4) | 1,084 (4) | 1,509 (3) |
| Stage 4 | 711 (6) | 697 (4) | 888 (3) | 1,275 (2) |
| Stages 2 to 4 | 2,605 (22) | 3,064 (19) | 4,906 (18) | 7,710 (14) |
| Highest stage of pressure ulcer | | | | |
| Stage 1 | 517 (4) | 853 (5) | 1,707 (6) | 2,249 (4) |
| Stage 2 | 1,283 (11) | 1,657 (10) | 2,776 (10) | 4,417 (8) |
| Stage 3 | 412 (3) | 467 (3) | 731 (3) | 945 (2) |
| Stage 4 | 574 (5) | 585 (4) | 721 (3) | 936 (2) |
| Mean (SD) |
| Number of Stage 2 to 4 pressure ulcers per resident | 2.2 (1.9) | 2.1 (1.7) | 2.0 (1.6) | 1.9 (1.5) |
Prevalence of Pressure Ulcers (PUs) According to Ascending Percentage of NH Admissions of White Older Adults within U.S. Census Divisions
| n (%) Admissions of White Older Adults |
|---|
| PU Stage | Mountain (n = 1,239, 74%)a | South Atlantic (n = 15,270, 78%)b | East South Central (n = 15,685, 81%)c | Pacific (n = 23,689, 84%)d | West South Central (n = 5,408, 85%)e | East North Central (n = 14,585, 92%)f | Middle Atlantic (n = 10,354, 95%)g | New England (n = 4,322, 97%)h | West North Central (n = 21,088, 97%)i |
|---|
| At least one PU of this stage | | | | | | | | | |
| Stage 1 | 28 (2) | 1,697 (11) | 1,320 (8) | 2,142 (9) | 344 (6) | 1,101 (8) | 1,098 (11) | 267 (6) | 1,086 (5) |
| Stage 2 | 115 (9) | 2,237 (15) | 2,111 (13) | 3,135 (13) | 671 (12) | 1,790 (12) | 1,756 (17) | 530 (12) | 1,927 (9) |
| Stage 3 | 20 (2) | 691 (5) | 527 (3) | 1,189 (5) | 142 (3) | 462 (3) | 471 (5) | 101 (2) | 413 (2) |
| Stage 4 | 27 (2) | 566 (4) | 861 (5) | 840 (4) | 136 (3) | 431 (3) | 392 (4) | 92 (2) | 226 (1) |
| Stages 2 to 4 | 143 (12) | 2,879 (19) | 2,819 (18) | 4,233 (18) | 814 (15) | 2,264 (16) | 2,179 (21) | 643 (15) | 2,311 (11) |
| Highest stage of PU | | | | | | | | | |
| Stage 1 | 22 (2) | 1,065 (7) | 717 (5) | 1,261 (5) | 197 (4) | 634 (4) | 653 (6) | 160 (4) | 617 (3) |
| Stage 2 | 84 (7) | 1,609 (11) | 1,436 (9) | 2,291 (10) | 498 (9) | 1,262 (9) | 1,268 (12) | 376 (9) | 1,309 (6) |
| Stage 3 | 14 (1) | 417 (3) | 308 (2) | 840 (4) | 98 (2) | 269 (2) | 306 (3) | 65 (2) | 238 (1) |
| Stage 4 | 26 (2) | 457 (3) | 711 (5) | 697 (3) | 123 (2) | 325 (2) | 273 (3) | 62 (1) | 142 (1) |
| Mean (SD) |
| Number of Stage 2 to 4 PUs per resident | 1.8 (1.3) | 2.0 (1.7) | 2.1 (1.9) | 1.9 (1.5) | 2.0 (1.8) | 2.0 (1.7) | 2.0 (1.7) | 1.8 (1.4) | 1.9 (1.6) |