Risk assessment for prevention of morbidity and mortality: lessons for pressure ulcer prevention

Medicine has changed from being a reactive process that attempts to alleviate disease only when it is clinically evident to a proactive one in which it is hoped that early intervention may reduce the impact of disease or even it developing at all. In moving the focus of treatment, this inevitably means that a greater number of individuals with lesser disease burdens are treated. The logical end-point of this process is to provide preventative measures for the entire population but this can only be done if the economic costs and negative effects of treatment are out-weighed by the benefits. In the case of pressure ulcers, it is self-evident that prevention is extremely beneficial to patients. However, the cost of some of the equipment used for prevention can be high, and therefore, the balance between the optimum level of provision, the purposes of prevention and the available funding becomes critical. Consequently a screening mechanism to better match susceptible patients with resources is essential. There are, however, many problems with such screening techniques. By looking at other specialties, we can see that it is vital to know the natural history of the disease: PSA testing reveals many men who would have died never having known they had prostate cancer, thus giving them years of worry and morbidity they would probably not previously have suffered; cardiovascular risk screening is so imprecise that risk estimates are of questionable utility; antenatal Down's syndrome risk screening is prone to data-related problems that can unexpectedly reduce the effectiveness of the test. In pressure ulcer screening, there are many tools currently in use, but few (possibly none) are really effective. Finally, this paper details some suggestions for future research to combine risk tests that may offer a prospect for improving ulcer risk screening tools.