Higher Prevalence of Pressure Ulcers in Black High-Risk Nursing Home Residents Related to Care Site

Among nursing home residents at high risk for pressure ulcers, black residents had higher prevalence rates than white residents from 2003 through 2008, with the disparity largely related to the higher rates among nursing homes that disproportionately serve black residents, according to a study in the July 13 issue of JAMA.

Pressure ulcers are a common health problem among nursing home residents and substantially increase morbidity, mortality, and the cost of care, the authors write. A variety of nursing home quality improvement programs have been implemented during the last decade but their implications for racial disparities on quality are unknown.

Yue Li, PhD, of the University of Iowa, Iowa City, and colleagues analyzed the trend of pressure ulcer prevalence in nursing homes by race and site of care from 2003 through 2008. The study included data on pressure ulcer rates in 2.1 million white and 346,808 black residents of 12,473 certified nursing homes in the United States who were considered at high risk of developing pressure ulcers. Nursing homes were categorized according to their proportions of black residents.

The researchers found that pressure ulcer rates decreased overall from 2003 through 2008 among high-risk residents of nursing homes, but black residents showed persistently higher pressure ulcer rates than white residents. The pressure ulcer rate among black residents decreased from 16.8 percent in 2003 to 14.6 percent in 2008 and the rate among white residents decreased from 11.4 percent in 2003 to 9.6 percent in 2008. Despite the lowered pressure ulcer rates over time for both races, racial disparity remained relatively unchanged.

Analysis indicated that more than half of the risk-adjusted disparity between black and white residents in pressure ulcer rates for each year was found between sites rather than within sites of care. Black residents in the nursing home facilities with the highest concentrations of black residents had the highest pressure ulcer rate (15.5 percent in 2008), which was about 7 percent higher than the rate for white residents in facilities with lowest concentrations of black residents (8.8 percent in 2008), which was the lowest among all groups. Residents of both races and in nursing homes with the highest concentrations of blacks had at least a 30 percent increased risk-adjusted odds of pressure ulcers compared with residents in nursing homes caring for none or only a small percentage of black residents.

Nursing home facilities with higher concentrations of black residents had higher rates of pressure ulcers for both black and white residents compared with nursing homes with lower concentrations of black residents. Nursing homes with higher concentrations of black residents tended to have lower staffing levels of registered nurses and certified nurse assistants and to be larger for-profit and urban facilities. These facilities may be more financially disadvantaged when caring for patients predominantly receiving Medicaid, the authors write.

Given the widespread racial disparities in nursing home care, it is imperative to close the gap beyond industry-wide improvements. The first key step would be understanding why these disparities exist before appropriate efforts can be made to eliminate them. Given that nursing home care for minority residents is concentrated among a small number of nursing homes, understanding how outcomes vary as a function of site of care can inform targeted interventions, the researchers write.

The authors add that their findings suggest several policy implications. Importantly, future quality initiatives such as the renewed Centers for Medicare & Medicaid Services quality improvement organization program could consider incorporating disparity-eliminating efforts.

Nancy Bergstrom, PhD, RN. of the University of Texas Health Science Center, Houston, and Susan D. Horn, Ph.D., of the International Severity Information Systems, Salt Lake City, comment on the findings of this study in an accompanying editorial, "Racial Disparities in Rates of Pressure Ulcers in Nursing Homes and Site of Care." Among other points, the authors raise the issue that databases should include information on new, or incident pressure ulcers, rather than just the existence of a pressure ulcer because otherwise a resident admitted from a hospital with a preexisting pressure ulcer appears in the nursing homes pressure ulcer rates.

Additional research is needed to accurately identify the causes of black and white differences in the incidence of pressure ulcers in nursing facilities. Individual characteristics, staffing, and system changes such as mattresses and disposable briefs can all affect pressure ulcer risk and rates and help explain disparities. Establishing the causative factors in pressure ulcer rates will be important to help to ensure that all nursing facility residents receive appropriate care.

References: JAMA. 2011;306[2]211-212 and  JAMA. 2011;306[2]179-186.