M.E. Beth Smith, DO; Annette Totten, PhD; David H. Hickam, MD, MPH; Rongwei Fu, PhD; Ngoc Wasson, MPH; Basmah Rahman, MPH; Makalapua Motu’apuaka, BS; Somnath Saha, MD, MPH
Disclaimer: The findings and conclusions in this article are those of the authors, who are responsible for its content, and do not necessarily represent the views of AHRQ. No statement in this article should be construed as an official position of AHRQ, the U.S. Department of Health and Human Services, or the U.S. Department of Veterans Affairs.
Acknowledgment: The authors thank Robin Paynter, MLIS; Leah Williams, BS; Alexander Ginsburg, MA; Elaine Graham, MLS; Sujata Thakurta, MA; Bernadette Zakher, MBBS; Susan Carson, MPH; and AHRQ Task Order Officer, Christine Chang, MD.
Grant Support: By AHRQ (contract 290-2007-10057-I, Task Order 8). Dr. Saha is supported by the U.S. Department of Veterans Affairs.
Potential Conflicts of Interest: Disclosures can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M12-2182.
Requests for Single Reprints: M.E. Beth Smith, DO, Oregon Health & Science University, Mail Code BICC, 3181 Southwest Sam Jackson Park Road, Portland, OR 97239-3098; e-mail, email@example.com.
Current Author Addresses: Drs. Smith, Totten, Hickman, Fu, and Saha, Ms. Wasson, Ms. Rahman, and Ms. Motu’apuaka: Oregon Health & Science University, Mail Code BICC, 3181 Southwest Sam Jackson Park Road, Portland, OR 97239-3098.
Author Contributions: Conception and design: M.E.B. Smith, A. Totten, D.H. Hickam, N. Wasson, S. Saha.
Analysis and interpretation of the data: M.E.B. Smith, A. Totten, D.H. Hickam, R. Fu, N. Wasson, S. Saha.
Drafting of the article: M.E.B. Smith, D.H. Hickam, N. Wasson, B. Rahman, S. Saha.
Critical revision of the article for important intellectual content: M.E.B. Smith, A. Totten, D.H. Hickam, N. Wasson, S. Saha.
Final approval of the article: M.E.B. Smith, A. Totten, N. Wasson, B. Rahman, S. Saha.
Provision of study materials or patients: D.H. Hickam, N. Wasson, M. Motu’apuaka.
Statistical expertise: R. Fu, N. Wasson.
Administrative, technical, or logistic support: N. Wasson, B. Rahman, M. Motu’apuaka.
Collection and assembly of data: M.E.B. Smith, A. Totten, D.H. Hickam, N. Wasson, B. Rahman, M. Motu’apuaka, S. Saha.
Pressure ulcers affect as many as 3 million Americans and are major sources of morbidity, mortality, and health care costs.
To summarize evidence comparing the effectiveness and safety of treatment strategies for adults with pressure ulcers.
MEDLINE, EMBASE, CINAHL, Evidence-Based Medicine Reviews, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, Database of Abstracts of Reviews of Effects, and Health Technology Assessment Database for English- or foreign-language studies; reference lists; gray literature; and individual product packets from manufacturers (January 1985 to October 2012).
Randomized trials and comparative observational studies of treatments for pressure ulcers in adults and noncomparative intervention series (n > 50) for surgical interventions and evaluation of harms.
Data were extracted and evaluated for accuracy of the extraction, quality of included studies, and strength of evidence.
174 studies met inclusion criteria and 92 evaluated complete wound healing. In comparison with standard care, placebo, or sham interventions, moderate-strength evidence showed that air-fluidized beds (5 studies [n = 908]; high consistency), protein-containing nutritional supplements (12 studies [n = 562]; high consistency), radiant heat dressings (4 studies [n = 160]; moderate consistency), and electrical stimulation (9 studies [n = 397]; moderate consistency) improved healing of pressure ulcers. Low-strength evidence showed that alternating-pressure surfaces, hydrocolloid dressings, platelet-derived growth factor, and light therapy improved healing of pressure ulcers. The evidence about harms was limited.
Applicability of results is limited by study quality, heterogeneity in methods and outcomes, and inadequate duration to assess complete wound healing.
Moderate-strength evidence shows that healing of pressure ulcers in adults is improved with the use of air-fluidized beds, protein supplementation, radiant heat dressings, and electrical stimulation.
Agency for Healthcare Research and Quality.
National Pressure Ulcer Advisory Panel pressure ulcer stages.
Pressure ulcer stages I to IV and the 2 additional categories of suspected deep-tissue injury and unstageable are defined. National Pressure Ulcer Advisory Panel copyright; photos used with permission. National Pressure Ulcer Advisory Panel and European Pressure Ulcer Advisory Panel. Pressure Ulcer Prevention and Treatment: Clinical Practice Guideline. Washington, DC: National Pressure Ulcer Advisory Panel; 2009.
* Not pictured.
Analytic framework of pressure ulcer treatment strategies.
From reference 5.
Appendix Table 1. Stages of Pressure Ulcer Equivalency
Summary of evidence search and selection.
Full-text articles that were reviewed include additional studies identified through other sources, hand-searches of reference lists, peer review and public comment, scientific information packets, and gray literature searches. Quality-of-life outcomes and results related to histologic outcomes are in the full report (5) but not included in this article.
Table. Summary of Evidence of Benefits and Harms of Pressure Ulcer Treatment Strategies
Appendix Table 2. Summary of Evidence of Differences of Intervention Effectiveness
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Smith MB, Totten A, Hickam DH, et al. Pressure Ulcer Treatment Strategies: A Systematic Comparative Effectiveness Review. Ann Intern Med. 2013;159:39–50. doi: 10.7326/0003-4819-159-1-201307020-00007
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Published: Ann Intern Med. 2013;159(1):39-50.
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