Predictive and concurrent validity of the Braden Scale in long-term care: A meta-analysis Machelle Wilchesky, PhD 1,2,3 ; Ovidiu Lungu, PhD 1,4 1. Centre for Research in Aging, Donald Berman Maimonides Geriatric Centre, 2. Department of Medicine, Division of Geriatric Medicine, McGill University, 3. Centre for Clinical Epidemiology, Lady Davis Institute for Medical Research, Jewish General Hospital, 4. Department of Psychiatry, University of Montreal, Montreal, Quebec, Canada Reprint requests: Dr. Machelle Wilchesky, PhD, 5795 Avenue Caldwell, Montreal, Quebec, Canada H4W 1W3. Tel: 514-483-2121; Fax: 514-487-1086; Email: machelle.wilchesky@mcgill.ca Manuscript received: September 14, 2014 Accepted in final form: January 8, 2015 DOI:10.1111/wrr.12261 ABSTRACT Pressure ulcer prevention is an important long-term care (LTC) quality indicator. While the Braden Scale is a recommended risk assessment tool, there is a paucity of information specifically pertaining to its validity within the LTC setting. We, therefore, undertook a systematic review and meta-analysis comparing Braden Scale predictive and concurrent validity within this context. We searched the Medline, EMBASE, PsychINFO and PubMed databases from 1985–2014 for studies containing the requisite information to analyze tool validity. Our initial search yielded 3,773 articles. Eleven datasets emanating from nine published studies describing 40,361 residents met all meta-analysis inclusion criteria and were analyzed using random effects models. Pooled sensitivity, specificity, positive predictive value (PPV), and negative predictive values were 86%, 38%, 28%, and 93%, respectively. Specificity was poorer in concurrent samples as compared with predictive samples (38% vs. 72%), while PPV was low in both sample types (25 and 37%). Though random effects model results showed that the Scale had good overall predictive ability [RR, 4.33; 95% CI, 3.28–5.72], none of the concurrent samples were found to have “optimal” sensitivity and specificity. In conclusion, the appropriateness of the Braden Scale in LTC is questionable given its low specificity and PPV, in particular in concurrent validity studies. Future studies should further explore the extent to which the apparent low validity of the Scale in LTC is due to the choice of cutoff point and/or preventive strategies implemented by LTC staff as a matter of course. The development of pressure ulcers (PUs), or localized injuries to the skin and/or underlying tissue that are the result of pressure or pressure in combination with shear and/or friction, is a common complication associated with prolonged hospitalization. 1 Estimates of mean PU preva- lence across countries vary between 3 and 30%; 2–4 with marked differences depending on the target population and the type of healthcare setting in which the measurements are collected. PUs are associated with high mortality, mor- bidity, healthcare costs, and increased patient suffering. 2,5 International guidelines from the European/North-Ameri- can pressure ulcer advisory panel (EPUAP/NPUAP) acknowledge that PU development can largely be pre- vented, and recommend the routine use of PU risk assess- ment tools in all healthcare settings as part of a preventive strategy. 6 PUs pose a greater challenge for long-term care (LTC) institutions than for acute or general care settings for sev- eral reasons: LTC residents typically have longer lengths of stay, experience a range of mobility, lead a largely sed- entary lifestyle, and often suffer from serious chronic dis- eases that impact multiple systems such as mobility and nutrition, which predispose aging skin to increased vulner- ability. 7 For these reasons, PU prevention is often put forth as a high priority quality of care indicator in LTC, 8 and accurate risk assessment is essential to appropriately iden- tify residents who would benefit the most from prevention measures (e.g., specialized support surfaces, turning sched- ules, skin care products, massages, etc.). 9 PU risk can be assessed by means of clinical judgment, the use of risk assessment scales, or a combination of both. Given that these assessments can be made by indi- viduals with a wide range of clinical experience and exper- tise, availability of valid and standardized tools is necessary to ensure high inter-rater agreement. 2 The Bra- den Scale, 10,11 recommended by the NPUAP, 6 is the most frequently used risk assessment tool in North America. 12 The tool is comprised of six subscales that evaluate patients’ sensory perception, skin exposure to moisture, activity level, mobility, nutritional status, and level of fric- tion and shear. For each subscale, a score from 1 to 4 is assigned (except for friction and shear, which is scored from 1 to 3), and each score value is accompanied by detailed narrative descriptors that assist the rater in assess- ing the correct subscale level. The sum of the subscale scores constitutes the patient’s Braden Scale score, which 44 Wound Rep Reg (2015) 23 44–56 V C 2015 by the Wound Healing Society