Gunshot Injury Paraplegics—A Population Dying a Slow, Irreversible, and Expensive Death—A Viewpoint on Preventing Pressure Ulcers

To the Editor—Over the last 20 years, healthcare expenditure in the United States has been a subject of immense national interest. Given the increase in healthcare spending (>15% of the gross domestic product ¹ ), healthcare agencies are giving more attention to disease prevention in a variety of healthcare areas including infection prevention, antibiotic stewardship, and prevention of pressure ulcers.

While clinicians are very familiar with pressure ulcers in elderly bedridden patients, pressure ulcers are also a serious complication among spinal cord injury (SCI) paraplegics. The annual incidence of pressure ulcers in SCI paraplegics has been reported to be 23%. ² In the United States, most SCIs are an unfortunate result of gunshot injuries; this is especially true in metropolitan Detroit. Annually, a major tertiary-care hospital in Detroit treats 40–60 gunshot SCI paraplegic patients (GIPs) with pressure ulcers. ³ A recent study conducted at the Detroit Medical Center reported that 201 gunshot-SCI patients with pressure ulcers accounted for 395 admissions (including readmissions) between 2004 and 2008. During this study period, the cumulative median length of hospital stay per patient was 12 days (interquartile range, [IQR], 6–24 days), resulting in a mean adjusted cost of US$19,969 (±$6,639) per patient. ³

The number of GIPs is growing exponentially, ⁴ and GIPs with pressure ulcers are frequently admitted to the hospital, thus contributing significantly to hospital costs. The economic burden of treating pressure ulcers in this population is enormous but underappreciated. The annual cost of treating pressure ulcers in the United States in paraplegics with or without SCIs has reached a stunningly high $11 billion. ⁵ The estimated cost associated with healing a single pressure ulcer can reach $40,000. ⁵ Are government officials knowledgeable enough and aware of this enormous economic burden? Are healthcare professionals equipped to deal with this unfortunate patient population?

Let us consider the following scenarios of 2 gunshot SCI paraplegic patients at a tertiary-care hospital in Detroit: These 2 gunshot SCI paraplegic patients were admitted with pressure ulcers; both were male African Americans in their late 30s and belonged to low-education and low-income demographic groups. Despite their similarities in age and circumstance, their hospital costs were dramatically different. Costs for hospitalization for the first patient were moderate at $46,300, whereas the hospital costs for the second patient reached $262,168. The higher costs for the second patient resulted from an infected pressure ulcer: this patient was readmitted 3 times, and his treatment included several diagnostic procedures (including MRIs) and surgical interventions (ie, incision and drainage).

Development of a pressure ulcer in a paraplegic patient can be devastating socially, emotionally, and financially. An American soldier with a SCI is cared for in a very supportive environment. On the other hand, an African-American GIP residing in Detroit with low education, low income, and a poor support system has very limited resources to support his physical and mental health. Such destitute patients in the inner city are living slow but irreversible and expensive death sentences.

Through value-based purchasing, the Centers for Medicare and Medicaid Services (CMS) has begun to decrease payments to hospitals with excessive 30-day readmissions. The CMS will not provide hospitals added insurance reimbursement when pressure ulcers develop in the hospital. With the advent of these new regulations, what are we doing to prevent pressure ulcers in GIPs? In the last decade, both medical and surgical treatment modalities for pressure ulcers have progressed remarkably. However, there are major deficiencies in preventing pressure ulcers in GIPs.

Healthcare reforms should include more incentives for prevention and early intervention of pressure ulcers among GIPS. Public–private collaboration should incentivize providers to effectively manage care for GIPs. Special paraplegic health clinics should be set up. These clinics should utilize a large team of multidisciplinary healthcare professionals, including internists, psychiatrists, surgeons, wound care nurses, physical therapists, nutritionists, and social workers who can help improve the overall health of these patients.