title: Explaining the national differences in pressure ulcer prevalence between the Netherlands and Germany--adjusted for personal risk factors and institutional quality indicators.
abstract: BACKGROUND
  Pressure ulcers have a known impact on quality of life as well as on morbidity and mortality of the persons affected. Remarkable differences in pressure ulcer prevalence between the Netherlands and Germany have been found during the last 6 years. This study explores to what extent the individual risk of the population and quality indicators of the institutions can explain the variation in national prevalence.
  
  
  METHODS
  Data of a binational multi-centred cross-sectional study in 103 hospitals (n = 21,378 patients) and 129 nursing homes (n = 15,579 residents) were analysed using random effects regression models to calculate the differences in national prevalences within the nursing homes and hospitals, adjusted for personal risk for pressure ulcer and quality indicators.
  
  
  RESULTS
  The prevalence of pressure ulcers among the at-risk group (Bradenscore <or=20) in nursing homes was 30.8% in the Netherlands and 8.3% in Germany [OR: 4.9 (CI 95%: 4.2-5.7)]. In hospitals, the prevalence among the at-risk group was 26.1% in the Netherlands and 21.2% in Germany [OR: 1.3 (CI 95%: 1.2-1.5)]. After adjusting for individual risk factors (age, gender, Bradenscore) as well as for quality structures (use of prevention and treatment protocols, experts groups, information leaflets, nurses training, central pressure ulcer statistics and regular updating of protocols), the chance of developing a pressure ulcer was 6.05 times higher (CI 95%: 4.0-9.2) in a Dutch nursing home than in a German nursing home. Within the hospitals, the OR for Dutch patients was 2.03 (CI 95%: 1.4-3.0).
  
  
  CONCLUSIONS
  A remarkable national variation exists in pressure ulcer prevalence and nursing practice. Neither the populations vulnerability for pressure ulcers nor pressure ulcer management as measured in this study could explain this national variation. Therefore, other risk factors should be taken into consideration. Additionally, it is possible that quality indicators are implemented in differing ways with varying levels of effectiveness. Therefore, further research is needed to examine prospectively and in more detail the reality of care within facilities in both countries.
authors.affiliation: Department of Nursing Science, Charité-Universitätsmedizin Berlin, Berlin, Germany. antje.tannen@charite.de
authors.forename: Antje
authors.initials: A
authors.lastname: Tannen
authors.forename: Ekkehart
authors.initials: E
authors.lastname: Dietz
authors.forename: Theo
authors.initials: T
authors.lastname: Dassen
authors.forename: Ruud
authors.initials: R
authors.lastname: Halfens
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D003430:Cross-Sectional Studies; D005260:Female; D005858:Germany / Q000453:epidemiology; D006761:Hospitals; D006801:Humans; D008297:Male; D009426:Netherlands / Q000453:epidemiology; D009735:Nursing Homes; D003668:Pressure Ulcer / Q000453:epidemiology* / Q000209:etiology; D019984:Quality Indicators, Health Care; D012307:Risk Factors; D011795:Surveys and Questionnaires