Evaluation of AHRQ's On-Time Pressure Ulcer Prevention Program: A Facilitator-assisted Clinical Decision Support Intervention for Nursing Homes

Background: Pressure ulcers present serious health and economic consequences for nursing home residents. The Agency for Healthcare Research & Quality, in partnership with the New York State Department of Health, implemented the pressure ulcer module of On-Time Quality Improvement for Long Term Care (On-Time), a clinical decision support intervention to reduce pressure ulcer incidence rates. Objective: To evaluate the effectiveness of the On-Time program in reducing the rate of in-house–acquired pressure ulcers among nursing home residents. Research Design and Subjects: We employed an interrupted time-series design to identify impacts of 4 core On-Time program components on resident pressure ulcer incidence in 12 New York State nursing homes implementing the intervention (n = 3463 residents). The sample was purposively selected to include nursing homes with high baseline prevalence and incidence of pressure ulcers and high motivation to reduce pressure ulcers. Differential timing and sequencing of 4 core On-Time components across intervention nursing homes and units enabled estimation of separate impacts for each component. Inclusion of a nonequivalent comparison group of 13 nursing homes not implementing On-Time (n = 2698 residents) accounts for potential mean-reversion bias. Impacts were estimated via a random-effects Poisson model including resident-level and facility-level covariates. Results: We find a large and statistically significant reduction in pressure ulcer incidence associated with the joint implementation of 4 core On-Time components (incidence rate ratio = 0.409; P = 0.035). Impacts vary with implementation of specific component combinations. Conclusions: On-Time implementation is associated with sizable reductions in pressure ulcer incidence.