Health care reorganization and quality of care: Unintended effects on pressure ulcer prevention

BACKGROUND. Health care reorganizations, with a change in focus from inpatient to outpatient care, are becoming increasingly frequent. Little is known regarding how reorganizations may affect risk-adjusted outcomes for those programs, usually inpatient, that lose resources as a result of the change in organizational focus. OBJECTIVES. To determine changes in risk-adjusted rates of pressure ulcer development over an 8-year period, the final 3 of which were characterized by a significant reorganization of the health care system. DESIGN. This was an observational study that used an existing database. SUBJECTS. Subjects were residents of Department of Veterans Affairs long-term care units between 1990 and 1997 who were without a pressure ulcer at an index assessment. MEASURES. The study examined risk-adjusted rates of pressure ulcer development, and proportions of new ulcers that were severe (stages 3 or 4) were calculated for successive 6-month periods. RESULTS. Between 1990 and 1994, risk-adjusted rates of pressure ulcer development declined significantly, by 27%. However, beginning in 1995, rates began to increase, and in 1997 they were similar to those in 1990. The proportion of new ulcers that were severe increased significantly over time (P = 0.01). CONCLUSIONS. The reorganization of the VA that began in 1995, with its emphasis on outpatient care, was associated with an increase in rates of pressure ulcer development. This highlights the need to carefully monitor the quality of care in programs that may be losing resources as a result of the reorganization.