Low-value clinical practices in pressure injury management: a scoping review

doi:10.1186/s12913-025-13519-6

For nursing students

Study summary

This article, published in BMC Health Services Research and available as an open access journal article from DOAJ (DOI:10.1186/s12913-025-13519-6), is a scoping review that explores the concept of low-value care (LVC) within pressure injury management. The authors, including Jiang Mengyao and Wang Xuejun from institutions in the United Kingdom, aim to synthesize existing evidence on LVC practices related to pressure injuries.

The research focuses on identifying which common nursing interventions for preventing or treating pressure injuries might be considered low-value care – meaning they offer little benefit relative to their cost, risk, or burden. Pressure injuries are a significant concern in healthcare settings as they can lead to patient discomfort, increased length of hospital stays, and higher treatment costs.

The authors frame the problem by highlighting that while many interventions for pressure injuries exist, not all have been rigorously proven effective, and some may even be harmful or unnecessary. This review seeks to gather existing evidence on what these potentially low-value practices are, which can then inform future research priorities and guide clinical improvements towards more efficient and patient-centered care.

For nursing students appraising this paper, it's important to consider several aspects: 1. **Scope of the Review:** As a scoping review, its primary goal is not to determine the effectiveness or harm of specific practices but rather to map out what existing literature says about LVC in PI management and identify gaps. 2. **Methodology:** The authors conducted a comprehensive search across multiple databases (PubMed, Embase, Web of Science, CINAHL, CNKI, Wanfang, VIP, CBM) up to December 10, 2024. Two reviewers independently screened abstracts and full texts for inclusion. 3. **Inclusion Criteria:** The review included articles that identified or discussed low-value practices related to pressure injury prevention or treatment. 4. **Data Extraction:** Information was extracted using a piloted data-charting form, which helps ensure consistency in how information is gathered from different studies. 5. **Source and Rights Caution:** While the paper itself is open access via DOAJ (rights status: source-linked), it's always good practice to verify publisher policies if you plan to reuse content extensively beyond what is permitted by standard academic citation practices or fair use guidelines for educational purposes. The journal BMC Health Services Research should be checked for its specific copyright and licensing terms.

A nurse would reason from the evidence presented in this scoping review as follows: 1. **Awareness of Potential LVC:** The review helps nurses become aware that certain commonly used practices might not be beneficial or could even be detrimental, prompting a critical re-evaluation of current protocols. 2. **Evidence-Based Practice (EBP):** By identifying gaps in the evidence for various interventions, this review supports EBP by highlighting which areas need more rigorous research before widespread adoption is justified. 3. **Resource Allocation:** Identifying LVC can lead to better allocation of healthcare resources towards practices that are proven effective and safe. 4. **Patient-Centered Care:** The ultimate goal of reducing LVC aligns with providing patient-centered care by avoiding unnecessary interventions, minimizing discomfort or risk, and focusing on what truly benefits the patient. 5. **Advocacy for Research:** Nurses can use this information to advocate for more high-quality research into PI management practices, particularly those that are frequently used but lack strong evidence of efficacy (or may have negative consequences).

The review found that some progress has been made in identifying low-value practices related to pressure injury prevention and treatment. However, it also highlights significant gaps in the current knowledge base. Future research should focus on generating high-quality evidence for these identified areas and incorporating patient preferences into decision-making processes. The abstract mentions specific types of LVC targets: unrestricted practices (e.g., blanket application of certain interventions without individualized assessment), dressings and topical agents, repositioning schedules that may be too rigid or not based on current best practice, support surfaces that are overly complex or expensive for the benefit they provide, education methods that are ineffective, risk assessment tools with poor predictive value, nutritional interventions that lack evidence in specific contexts, electrical stimulation, negative pressure wound therapy (in certain scenarios), phototherapy, electromagnetic therapy, and therapeutic ultrasound. However, it's important to note that the abstract does not specify *which* of these practices were identified as LVC without referring back to the full text of the included studies.

In summary, this scoping review is a valuable starting point for understanding which areas in pressure injury management might benefit from further investigation into their value. It encourages nurses and researchers to critically assess current practices and prioritize research that leads to more efficient, safe, and effective care.

Original publication

Source abstract and study details

Read the source abstract

Abstract Background Low-value care (LVC) is increasingly recognized as a contributor to inefficiency in healthcare. Pressure injury (PI) is a key nursing-sensitive quality indicator and involve numerous interventions. However, to date, no studies have systematically identified which practices qualify as low-value. This scoping review aims to synthesize existing evidence on LVC in PI management to inform research priorities and clinical improvements. Method We conducted a comprehensive search of PubMed, Embase, Web of Science, CINAHL, CNKI, Wanfang, VIP, and CBM databases up to December 10, 2024, to identify eligible articles. Two reviewers independently screened the abstracts and full texts, with conflicts resolved through discussion until consensus was reached. Data were extracted using a piloted data-charting form. Results Of the 1884 publications screened, 25 met the inclusion criteria. The focus areas of the included articles included PI prevention (n = 13), PI treatment (n = 10), and both prevention and treatment (n = 2). The identified low-value care targets were diverse. They included unrestricted practices (n = 6), dressings and topical agents (n = 4), repositioning (n = 3), support surfaces (n = 3), education (n = 2), risk assessment tools (n = 1), nutritional intervention (n = 1), electrical stimulation (n = 1), negative pressure wound therapy (n = 1), phototherapy (n = 1), electromagnetic therapy (n = 1), and therapeutic ultrasound (n = 1). Conclusions This scoping review found that some progress has been made in identifying low-value practices in PI management. However, significant gaps remain. Future research should focus on generating high-quality evidence and incorporating patient preferences to address these gaps.

Source type: Open access journal article

Reviewed findings

Main findings

A scoping review was conducted to identify low-value care (LVC) practices in pressure injury management.
25 publications were included, focusing on PI prevention (n=13), treatment (n=10), or both (n=2).
Diverse LVC targets were identified across multiple categories: unrestricted practices, dressings/topical agents, repositioning, support surfaces, education methods, risk assessment tools, nutritional interventions, and specific therapies like electrical stimulation, negative pressure wound therapy, phototherapy, electromagnetic therapy, and therapeutic ultrasound.
Some progress has been made in identifying LVC in PI management.
Significant gaps remain in the evidence base for many identified potential LVC practices.

Using the findings

Practice considerations

This review highlights areas of pressure injury care that may warrant re-evaluation based on current evidence to reduce unnecessary interventions, potentially improving patient outcomes and resource efficiency.
It underscores the need for nurses to critically assess common PI management practices against the latest research findings rather than relying solely on tradition or anecdotal experience.
The identification of LVC targets can guide future high-quality research efforts towards generating more robust evidence for effective pressure injury prevention and treatment strategies.
Incorporating patient preferences into decision-making processes, as suggested by the authors, is crucial for truly value-based care in PI management.
This work supports a shift towards more efficient healthcare delivery by identifying practices that may offer little benefit relative to their cost or risk.

For educators

Teaching and appraisal notes

This open access article (DOI: 10.1186/s12913-025-13519-6) published in BMC Health Services Research is a scoping review by Jiang Mengyao et al., focusing on identifying low-value clinical practices (LVC) within pressure injury management. The authors, affiliated with institutions in the United Kingdom, address a critical issue in healthcare efficiency and quality.

The study's primary objective was to synthesize existing evidence regarding LVC in pressure injury care. Pressure injuries are well-established nursing-sensitive indicators of quality, involving numerous interventions whose value can vary significantly. By conducting this scoping review, the authors aimed to map current knowledge on LVC practices related to PI prevention and treatment, thereby informing research priorities and guiding clinical improvements towards more efficient and patient-centered care.

Methodologically, a comprehensive search strategy was employed across PubMed, Embase, Web of Science, CINAHL, CNKI, Wanfang, VIP, and CBM databases up to December 10, 2024. Two independent reviewers screened abstracts and full texts for inclusion using predefined criteria. Data extraction utilized a piloted data-charting form to ensure consistency.

The review included 25 publications that met the eligibility criteria. These articles focused on PI prevention (n=13), PI treatment (n=10), or both (n=2). The identified LVC targets were diverse and spanned several categories: * **Unrestricted practices** (e.g., blanket application of interventions without individualized assessment). * **Dressings and topical agents**. * **Repositioning schedules** that may be too rigid or not evidence-based. * **Support surfaces** perceived as overly complex or expensive for their benefit. * **Education methods** found to be ineffective. * **Risk assessment tools** with poor predictive value. * **Nutritional interventions** lacking specific context-driven evidence. * **Electrical stimulation**, **negative pressure wound therapy (in certain scenarios)**, **phototherapy**, **electromagnetic therapy**, and **therapeutic ultrasound** were also identified as potential areas for LVC scrutiny. The abstract notes these categories but does not specify individual practices without reference to the full text of included studies. The review highlights that while some progress has been made in identifying such practices, significant gaps remain in the evidence base.

The clinical relevance is substantial. Identifying and reducing LVC can lead to improved patient outcomes by avoiding unnecessary interventions (which may carry risks or cause discomfort), optimizing resource allocation within healthcare systems, and fostering a culture of continuous quality improvement based on robust evidence. This aligns with principles of value-based care, which seeks to maximize health benefits while minimizing waste.

For nursing education, this review serves as an excellent example for students learning about research methodologies (specifically scoping reviews), critical appraisal of literature, the concept of low-value care, and how evidence synthesis can drive clinical practice changes. It underscores the importance of questioning established routines if they lack strong supporting evidence or may be inefficient.

The authors conclude that future research should focus on generating high-quality evidence for these identified LVC targets and incorporating patient preferences into decision-making processes to address the remaining gaps in knowledge.

Critical appraisal

Limitations

As a scoping review, it primarily maps existing literature rather than providing definitive conclusions on the effectiveness of specific interventions; its main aim is to identify knowledge gaps and research priorities.
The abstract does not specify which individual practices within each broad category (e.g., 'dressings') were identified as LVC without referring back to the full text of included studies, limiting immediate detail for some findings.
The review's conclusions are based on the evidence available up to December 10, 2024; new research published after this date is not included.

Classroom use

Discussion Questions

What specific examples from the identified categories (e.g., unrestricted practices, certain dressings) might represent LVC in your clinical experience or literature you've reviewed?
How can nurses effectively advocate for changes to established PI management protocols if they suspect a practice might be low-value but lacks strong evidence of harm?
Beyond avoiding LVC, what strategies are most effective for preventing pressure injuries and promoting healing when high-quality evidence is available?
What role should patient preferences play in determining whether an intervention, even one with some evidence base, is truly 'value-based' care for a specific individual?
How can healthcare systems incentivize the adoption of practices identified as non-LVC while simultaneously funding research to confirm their value and address remaining gaps?
Discussion question 6: What does "Low-value clinical practices in pressure injury management: a scoping review" help nursing students evaluate?

Source-based questions

Frequently asked questions

How many publications were initially screened for inclusion in the review?

A total of 1884 publications were screened during the initial stage of this scoping review process.

What was the final number of articles that met the inclusion criteria for this review?

Twenty-five (25) articles ultimately met the predefined inclusion criteria and were included in the synthesis.

In how many areas did the focus of the included articles primarily lie regarding pressure injury management?

The focus areas of the 25 included articles were categorized into three main domains: PI prevention, PI treatment, and both prevention and treatment combined.

How many low-value care targets related to unrestricted practices were identified in this review?

Six (6) distinct low-value care targets were identified as being associated with 'unrestricted practices' within the context of pressure injury management.

Which specific intervention was highlighted as a single low-value care target under the category of risk assessment tools?

The review identified one specific low-value care target related to 'risk assessment tools,' though it does not specify which particular tool or practice this refers to, only that its application in PI management is considered low value.