Background: Pressure injuries (PIs) pose a substantial healthcare burden and incur significant costs worldwide. Several risk prediction tools to allow timely implementation of preventive measures and a subsequent reduction in healthcare system burden are available and in use. The ability of risk prediction tools to correctly identify those at high risk of PI (prognostic accuracy) and to have a clinically significant impact on patient management and outcomes (effectiveness) is not clear. We aimed to evaluate the prognostic accuracy and clinical effectiveness of risk prediction tools for PI and to identify gaps in the literature. Methods and findings: The umbrella review was conducted according to Cochrane guidance. Systematic reviews (SRs) evaluating the accuracy or clinical effectiveness of adult PI risk prediction tools in any clinical settings were eligible. Studies on paediatric tools, sensor-only tools, or staging/diagnosis of existing PIs were excluded. MEDLINE, Embase, CINAHL, and EPISTEMONIKOS were searched (inception to June 2024) to identify relevant SRs, as well as Google Scholar (2013 to 2024) and reference lists. Methodological quality was assessed using adapted AMSTAR-2 criteria. Results were described narratively. We identified 26 SRs meeting all eligibility criteria with 19 SRs assessing prognostic accuracy and 11 assessing clinical effectiveness of risk prediction tools for PI (4 SRs assessed both aspects). The 19 SRs of prognostic accuracy evaluated 70 tools (39 scales and 31 machine learning (ML) models), with the Braden, Norton, Waterlow, Cubbin-Jackson scales (and modifications thereof) the most evaluated tools. Meta-analyses from a focused set of included SRs showed that the scales had sensitivities and specificities ranging from 53% to 97% and 46% to 84%, respectively. Only 2/19 (11%) SRs performed appropriate statistical synthesis and quality assessment. Two SRs assessing machine learning-based algorithms reported high prognostic accuracy estimates, but some of which were sourced from the same data within which the models were developed, leading to potentially overoptimistic results. Two randomised trials assessing the effect of PI risk assessment tools (within the full test-intervention-outcome pathway) on the incidence of PIs were identified from the 11 SRs of clinical effectiveness; both were included in a Cochrane SR and assessed as high risk of bias. Both trials found no evidence of an effect on PI incidence. Limitations included the use of the AMSTAR-2 criteria, which may have overly focused on reporting quality rather than methodological quality, compounded by the poor reporting quality of included SRs and that SRs were not excluded based on low AMSTAR-2 ratings (in order to provide a comprehensive overview). Additionally, diagnostic test accuracy principles, rather than prognostic modelling approaches were heavily relied upon, which do not account for the temporal nature of prediction. Conclusions: Available systematic reviews suggest a lack of high-quality evidence for the accuracy of risk prediction tools for PI and limited reliable evidence for their use leading to a reduction in incidence of PI. Further research is needed to establish the clinical effectiveness of appropriately developed and validated risk prediction tools for PI.

Treatment of hard‐to‐heal wounds involves a holistic approach for choosing between available treatment options. However, evidence for informing these choices is sparse, introducing uncertainty into decisions about the optimum treatment pathways that reflect the vast heterogeneity in this patient population. This paper discusses the existing clinical and health economic literature in order to provide insight into sources of uncertainty in the evaluation of the holistic approach to management of the hard‐to‐heal wounds, and how this uncertainty can be appropriately reflected in research. We identified three key sources of uncertainty in the evaluation of chronic wound treatments, namely heterogeneity in aetiology and patient populations, heterogeneity in treatment pathways, and challenges around capturing all relevant outcomes. Reflecting these complexities requires sophisticated modelling of treatment sequencing and long‐term outcomes. The paper discusses how the scope specification, scenario analyses, and sensitivity analyses can be used to fully characterise analytical uncertainty.

The study aims to estimate the cost‐effectiveness of superabsorbent wound dressings compared to the standard‐of‐care (SoC) dressings mix for treatment of patients with moderate‐to‐highly exuding leg ulcers in the German healthcare settings. A model‐based cost‐effectiveness analysis was conducted from the German statutory health insurance perspective, following German specific and international recommendations of good research practice. An individual‐level (microsimulation) state‐transition model has been used with a cycle length of 1 week and time horizon of 6 months. Several comprehensive systematic reviews were conducted to inform all model inputs, including clinical parameters, efficacy, quality of life, resources utilisation, and cost inputs. In addition, primary data from two clinical trials were used. Based on this cost‐effectiveness analysis, using superabsorbent wound dressings instead of the SoC dressings of patients with moderate‐to‐highly exuding leg ulcers in Germany can lead to an improved healing rate of 2.57% (benefit ratio 1.08), improved health‐related quality of life of 0.152 quality‐adjusted life weeks, and total direct cost savings of €771 per patient in 6 months. Robustness of results was confirmed in sensitivity and scenario analyses.

Effective exudate management is key for optimal ulcer healing. Superabsorbent dressings are designed to have high fluid handling capacity, reduced risk of exudate leakage, fluid retention under compression, and to sequester harmful exudate components. This study aimed to systematically identify existing evidence for the clinical efficacy and cost‐effectiveness of superabsorbent dressings for the treatment of moderate‐to‐highly exudating chronic ulcers of various etiologies. The aim is focused on examining the ‘class’ effect of all superabsorbers, not any particular dressing. Clinical and cost effectiveness systematic reviews were conducted, searching Embase, MEDLINE, the Cochrane Library, and the Cumulative Index to Nursing and Allied Health Literature. The Cost Effectiveness Analysis Registry and Econ papers were also searched for the economic review. Outcomes of interest included ulcer closure, dressing properties, hospital‐ and infection‐related outcomes, safety, and economic outcomes. Fourteen studies were included in the clinical systematic review. Eleven were case series, with one randomised controlled trial, one retrospective matched observational study, and one retrospective cohort study. The studies investigated eight superabsorbent dressings and were heterogeneous in their patient population and outcomes. Superabsorbent dressings may result in favourable outcomes, including reductions in frequency of dressing change and pain scores. As most studies were case series, drawing firm conclusions was difficult due to absence of a comparator arm. The economic systematic review identified seven studies, five of which were cost‐utility analyses. These suggested superabsorbent dressings are a more cost‐effective option for the treatment of chronic ulcers compared with standard dressings. However, the small number and low quality of studies identified in both reviews highlights the need for future research.