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Received: 19 October 2020    Revised: 4 January 2021    Accepted: 31 January 2021

DOI: 10.1002/nop2.792

REVIEW ARTICLE

Predictive validity of the braden scale for pressure injury risk

assessment in adults: A systematic review and meta-­analysis

Can Huang1,2  | Yuxia Ma1,3 | Chenxia Wang4 | Mengyao Jiang1 |

Loretta Yuet Foon1 | Lin Lv1,4 | Lin Han1,4

1
Evidence-­Based Nursing Center, School of
Nursing, Lanzhou University, Lanzhou, China Abstract
2
Department of Endocrinology, The First Aim: Pressure injuries are common adverse events in clinical practice, affecting the
Hospital of Lanzhou University, Lanzhou,
well-­being of patients and causing considerable financial burden to healthcare sys-
China
3
The First Clinical Medical College, Lanzhou
tems. It is therefore essential to use reliable assessment tools to identify pressure
University, Lanzhou, China injuries for early prevention. The Braden Scale is a widely used tool to assess pres-
4
Nursing Department, Gansu Provincial sure injury risk, but the literature is currently lacking in determining its accuracy. This
Hospital, Lanzhou, China
study aimed to evaluate the accuracy of the Braden Scale in assessing pressure injury
Correspondence risk.
Lin Han, Evidence-­Based Nursing Center,
School of Nursing, Lanzhou University, Design: Systematic review and meta-­analysis.
Lanzhou, China. Methods: Articles published between 1973–­2020 from periodicals indexed in the
Email: [email protected]
PubMed, EMBASE, CINAHL, Web of Science and the Cochrane Library were se-
Funding Information lected. Two reviewers independently selected the relevant studies for inclusion. Data
This study has been funded by the National
Nature Science Foundation of China (Grant were analysed by the STATA 15.0 and the RevMan 5.3 software.
Nos. 71663002 and 71704071), the Fund Results: In total, 60 studies involving 49,326 individuals were eligible for this meta-­
of China Medical Board (#20-­374), the
National Scientific Research Training Plan of analysis. The pooled SEN, SPE, PLR, NLR, DOR and AUC were 0.78 (95% CI: 0.74
Gansu Provincial Hospital (19SYPYA-­4), the to 0.82), 0.72 (95% CI: 0.66 to 0.78), 2.80 (95% CI: 2.30 to 3.50), 0.30 (95% CI: 0.26
Research Funds for the School of Nursing
of Lanzhou University (LZUSON202002), to 0.35), 9.00 (95% CI: 7.00 to 13.00) and 0.82 (95% CI: 0.79 to 0.85), respectively.
the Natural Science Foundation of Gansu Subgroup analyses indicated that the AUC was higher for prospective design (0.84,
Province (20JR10RA603) and the Health
Industry Scientific Research Project of 95% CI: 0.81 to 0.87), mean age <60 years (0.87, 95% CI: 0.84 to 0.90), hospital (0.82,
Gansu Province (GSWSKY2017-­65). 95% CI: 0.79 to 0.86) and Caucasian population (0.86, 95% CI: 0.82 to 0.88). In addi-
tion, 18 was found to be the optimal cut-­off value.
Conclusion: The evidence indicated that the Braden Scale had a moderate predictive
validity. It was more suitable for mean age <60 years, hospitalized patients and the
Caucasian population, and the cut-­off value of 18 might be used for the risk assess-
ment of pressure injuries in clinical practice. However, due to the different cut-­off val-
ues used among included studies, the results had a significant heterogeneity. Future
studies should explore the optimal cut-­off value in the same clinical environment.

KEYWORDS

pressure ulcer, risk assessment, sensitivity and specificity, systematic review

This is an open access article under the terms of the Creative Commons Attribution License, which permits use, distribution and reproduction in any medium,
provided the original work is properly cited.
© 2021 The Authors. Nursing Open published by John Wiley & Sons Ltd.

Nursing Open. 2021;00:1–14.  |

wileyonlinelibrary.com/journal/nop2     1
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2       HUANG et al.

1 |  I NTRO D U C TI O N Risk assessments tools are generally used to assess the risk
of developing PIs, such as the Norton Scale, the Waterlow Scale
Pressure injuries (PIs), also known as decubitus ulcers, ischaemic and the Braden Scale. The ideal risk assessment tool must ac-
ulcers, bedsores, pressure sores and pressure ulcers, are localized curately identify individuals at risk, as well as those not at risk.
damage to the skin and underlying soft tissue usually over a bony The Norton Scale is the first structured risk assessment tool for
prominence or related to a medical or other device (NPUAP, 2016). predicting PIs, but it lacks the part of friction shear, which may
Individuals who are at high risk are those characterized by multiple result in the occurrence of PIs (National Pressure Ulcer Advisory
risk factors that affect both the mechanical boundary conditions and Panel and Alliance, 2014). Although it was also developed to as-
the susceptibility and tolerance of the individual (National Pressure sess senile patients at risk of developing PIs, the Waterlow Scale
Ulcer Advisory Panel and Alliance, 2014). However, most PIs can cannot accurately identify those individuals who are not at risk,
be prevented if effective measures including systematic skin ex- with the specificity of 32.9% (Serpa et al., 2009). The Baden Scale
amination, risk assessment, bed and chair support surfaces, repo- is based on six common risk factors including sensory function,
sitioning and mobilization, and nutritional support are implemented moisture, activity, mobility, nutrition, shearing force and friction.
(Bredesen et al., 2015). Risk assessment is a central component of PI A summative score reveals the level of risk where lower values are
prevention (Coleman et al., 2013, National Pressure Ulcer Advisory indicative of higher risk (Kelechi et al., 2013). Due to the ease of
Panel and Alliance, 2014), so it is important to use a valid and reliable use and interpretation of the point system, the Braden Scale has
assessment tool to identify high-­risk patients and implement appro- quickly gained popularity among practitioners. However, in order
priate interventions for the prevention of PIs. to reflect the population characteristics and the medical culture
Since the early 1960s, a variety of risk assessment tools have of the country, the Braden Scale has been re-­verified by different
been developed with over 50 scales currently to determine the risk researchers in the past 30 years. The sensitivity and specificity of
of PIs, such as the Norton Scale, the Waterlow Scale and the Braden it showed a wide range of differences from 50%–­100% depend-
Scale (Shi et al., 2019). The Braden Scale is the most common around ing on the research subjects or conditions (Chou et  al.,  2013),
the world due to its ease of use with wider risk factor incorpora- and the cut-­off point differed as well (Cowan et al., 2012). Some
tion (e.g. moisture and sensory perception) when compared to other studies (Chen et  al.,  2016; Pancorbo‐Hidalgo et al.,  2010; Park
scales (National Pressure Ulcer Advisory Panel and Alliance, 2014). et al., 2016) found that the Braden Scale offered the best balance
However, it has been used in different population clinical settings, between sensitivity and specificity. But a systematic review (Wei
with a variety of re-­verification results. In order to take appropri- et  al.,  2012) revealed that the Braden Scale could not be used
ate measures and prevent PI development early, practitioners must alone in assessing PIs’ risk in surgical patients. As a result, there
ascertain whether the Braden Scale can accurately identify the risk is no consensus on predictive validity of the Braden Scale among
of PIs. different studies.
Given the importance of risk assessment for PI prevention, prac-
titioners have used the Braden Scale in different population and clin-
2 |  BAC KG RO U N D ical settings. However, it is unclear whether the Braden scale can
accurately identify the risk of PIs in practice. The purpose of this
PIs are one of the most frequently occurring adverse events in hos- study was to determine predictive validity of the Braden Scale and
pitalized patients worldwide (Li et al., 2020, National Pressure Ulcer to explore the suitable population and optimal cut-­off value through
Advisory Panel and Alliance, 2014), which prolong hospital stay, a diagnostic method oriented meta-­analysis. Understanding the
increase medical expenses, decrease quality of life and result in in- predictive validity, applicable population and optimal cut-­off value
creased nosocomial infection, disability, morbidity and mortality (Al is beneficial for practitioners to identify the risk of PIs and take pre-
Mutairi & Hendrie,  2018; Aloweni et  al.,  2019; Amir et  al.,  2017; ventive measures early.
Coleman et al., 2013; Ferris et al., 2019; Jackson et al., 2019; Mallow
et al., 2013). The prevalence of PIs remains unacceptably high, ranging
from 1.1%–­26.7% in the hospital setting and 6%–­29% in the com- 3 | D E S I G N
munity setting (Graves & Zheng,  2014). It has been estimated that
the annual cost of treating PIs is $26.8 billion in the United States We conducted a systematic review and meta-­analysis. The study
(Padula & Delarmente,  2019), €334.86 million to €2.59 billion in was performed in accordance with the guidelines from the Cochrane
Europe (Severens et al., 2002) and A$983 million in Australia (Nguyen Handbook for Systematic Reviews of Diagnostic Test Accuracy
et al., 2015). A recent study noted that the cost of PI prevention was from the Cochrane Collaboration (Macaskill et al., 2010) and
more cost-­effective than that of PI treatment across all clinical settings Preferred Reporting Items for Systematic Review and Meta-­analysis
(Demarré et al., 2015). For these reasons, PI prevention is of great im- (PRISMA) (Moher et  al.,  2009). Our study protocol was registered
portance. An essential component of preventive strategies is the risk with the International Prospective Register of Systematic Reviews
assessment of PI development in the individual. (PROSPERO) (CRD42020142181).
HUANG et al. |
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4 | M E TH O DS each of the included studies. It contains four domains: patient selec-
tion, index test, reference standard, and flow and timing, classifying
4.1 | Search strategy the methodological quality as having a low, high or unclear risk of
bias. Two reviewers independently rated the applicability and risk of
The digital databases including PubMed, EMBASE, Web of Science, the bias, and any conflict was resolved by a third reviewer.
Cochrane Library and the Cumulative Index of Nursing and Allied Health
(CINAHL) were searched, from inception of each database to July 2020.
In addition, we explored the bibliographies of relevant reviews in order 4.6 | Statistical analysis
to identify other potentially eligible studies. The literature search terms
and strategies used are available in supplementary appendix 1. All statistical analyses were performed using STATA 15.0 (Stata,
College Station, TX, USA) and Review Manager 5.3 software
(Cochrane Collaboration, Oxford, UK). The bivariate meta-­a nalysis
4.2 | Inclusion and exclusion criteria model was selected to calculate the pooled sensitivity (SEN), speci-
ficity (SPE), positive likelihood ratio (PLR), negative likelihood ratio
The eligible studies must meet the following criteria: (a) patients were (NLR), diagnostic odds ratio (DOR) and their corresponding 95%
18 years of age or older and had no PIs at time of admission; (b) the confidence intervals (95% CIs) (Reitsma et al., 2005). Furthermore,
Braden Scale was used to identify the risk of PIs; (c) studies directly the summary receiver operator characteristic (SROC) curve was
provided true positive (TP), false positive (FP), false negative (FN) and constructed and the area under the curve (AUC) was calculated
true negative (TN) for predicting PIs’ risk or with data available regard- to quantify the diagnostic power (Jones & Athanasiou,  2005).
ing these statistics; (d) the definition and classification of PIs were pro- With respect to the value, a value of 0.5 was deemed informative,
duced by one of the accepted standards, such as the National Pressure 0.5 < AUC≤0.7 was considered less accurate, 0.7 < AUC≤0.9 was
Ulcer Advisory Panel (NPUAP), the European Pressure Ulcer Advisory thought to be moderate, 0.9 < AUC<1 was deemed very accurate,
Panel (EPUAP), the Agency for Health Care Policy and Research and AUC = 1 was considered a perfect test (Greiner et al., 2000).
(AHCPR), the International Classification of Diseases, Ninth Revision Heterogeneity was analysed by I2 statistics. ≤25%, 25%<I2 ≤ 75%
(ICD-­9), and the Bergstrom and others; and (e) the cross-­sectional and > 75% indicated respectively low, moderate and high hetero-
study and the cohort study were included. geneity between studies (Higgins et al., 2003). Subgroup analysis
Exclusion criteria were as follows: (a) studies failed to obtain a and sensitivity analysis were used to identify the sources of het-
complete data; (b) letter, comment and meeting abstract; and (c) du- erogeneity. Subgroup analysis was performed under the follow-
plicate publications. ing covariates: (a) study design (prospective vs. retrospective); (b)
mean age (<60  years vs. ≥60  years); (c) setting (hospital vs. non-­
hospital); (d) ethnicity (Asian population vs. Caucasian population);
4.3 | Study selection and (e) reference standard (authoritative vs. non-­authoritative). In
addition, we used Deeks’ funnel plot to assess any potential publi-
Two reviewers independently screened titles and abstracts for cation bias (Deeks et al., 2005).
eligibility with the consistent accomplishment of a pilot literature
selection. The full text was read if the abstract and title cannot be
determined for inclusion. In case of disagreement, a third reviewer 5 | R E S U LT S
resolved the conflict between them.
5.1 | Search results

4.4 | Data extraction A total of 6,441 publications were identified in our initial search. 4,215
studies remained after removing duplications. After scanning titles and
Two reviewers extracted data into a spreadsheet independently and abstracts, 71 studies were identified for further examination. By re-
resolved any discrepancies through discussion to reach a consensus. viewing the full text of the remaining articles, 11 studies with insuf-
For each study included, the following information was extracted: first ficient data or no relevance to the diagnosis were rejected. Finally, a
author, publication year, country, study design, age, gender, sample total of 60 studies were included in this review (Table 1). The detailed
size, cut-­off value, reference standard, TP, FP, TN and FN. screening process is presented in Figure 1.

4.5 | Quality assessment 5.2 | Study characteristics

The Quality Assessment of Diagnostic Accuracy Studies Ⅱ The baseline characteristics of these included studies are shown
(QUADAS-­Ⅱ) (Whiting et al., 2011) was used to assess the quality of in Table  1. In total, 49,326 individuals were involved in this
TA B L E 1   Characteristics of the included studies
|

Study Gender Sample

4      

Author/year Country design Setting Age (year) (female/male) size Cut-­off TP FP FN TN

Lim et al., (2019) Singapore R Ward 68 ± 17.1 80/119 199 ≤17 68 25 32 74

Limaserrano et al., (2018) Spain P ICU 63.74 ± 16.12 129/206 335 ≤12 21 82 6 226
Han et al., (2018) Korea R ICU 62.37 ± 14.32 223/377 600 ≤16 242 131 58 169
Chen et al., (2017) China R Ward 60.5 ± 15.6 962/1563 2,525 ≤14 63 727 13 1722
Deng et al., (2017) China R ICU 58 ± 17 119/349 468 ≤16 70 80 24 294
Roca-­Biosca et al., (2017) Spain P ICU 59.34–­62.92 NR 295 ≤12 34 168 7 86
Šáteková et al., (2017) Czech Republic P LTCF 73.89 ± 10.12 NR 100 ≤15 12 40 2 46
Roa Díaz et al., (2017) Colombia P Ward ≥18 407/531 938 ≤18 43 361 5 529
Griswold et al., (2017) USA R ICU 48.3 ± 18.2 743/1917 2,660 ≤12 50 1,299 11 1,299
Jin et al., (2015) Korea R ICU 62.66 ± 17.98 NR 965 ≤18 615 87 92 171
Kumari et al., (2015) Indian P Ward ≥18 NR 100 ≤17 23 0 8 69
García-­Díaz et al., (2015) Spain P LTCF 82.3 ± 10.07 99/254 353 ≤15 34 85 6 200
Freitas and Alberti, (2013) Brazil P LTCF 82.5 ± 12.1 126/57 183 ≤18 37 56 0 90
Hyun et al., (2013) USA R ICU 58.7 ± 15.2 3317/4473 7,790 ≤13 5,901 124 1655 110
Cowan et al., (2012) USA R ACU 71.0 ± 10.6 7/206 213 ≤18 65 34 35 79
Fromantin et al., (2011) France P Ward 16–­89 434/148 582 ≤18 26 100 3 453
Costa and Caliri, (2011) Brazil P ICU ≥18 NR 53 ≤14 19 18 1 15
Serpa et al., (2011) Brazil R ICU 60.9 ± 16.5 24/48 72 ≤13 6 11 2 53
Cho and Noh, (2010) Korea R ICU 62.33 ± 15.5 282/433 715 ≤13 32 355 10 318
de Souza et al., (2010) Brazil P LTCF 76.6 ± 9.2 129/104 233 ≤17 27 48 10 148
Feuchtinger et al., (2010) Germany P ICU 62.0 ± 12.1 22/31 53 ≤16 20 19 6 8
Chan et al., (2009) China P ACU 82.2 ± 7.35 167/30 197 ≤16 12 64 6 115
Kim et al., (2009) Korea P ICU 58.1 ± 1.2 74/145 219 ≤14 37 54 3 125
Tannen et al., (2008) Netherlands P LTCF 81.2 ± 10.2 7301/2797 10,098 ≤18 2,337 3,591 834 3,336
Oh et al., (2007) Korea P Ward 51.1 885/997 1882 ≤18 4 114 0 1764
Lahmann et al., (2006) Germany P LTCF 81.9 ± 12.2 3843/1003 4,846 ≤20 406 2,507 268 1665
Tannen et al., (2006) Germany P LTCF 84.6 ± 8.0 2873/626 3,499 ≤20 243 1853 25 1,378
Sanada et al., (2006) Indonesia P ICU 50.9 ± 17.0 33/72 105 ≤12 28 32 7 38
Lahmann et al., (2005) Germany P LTCF 83.6 NR 1,347 ≤20 149 712 8 458
Defloor and Grypdonck, (2005) Belgium P LTCF 84.6 ± 7.9 1403/369 1772 ≤16 160 724 27 861
Jalali and Rezaie, (2005) Iran P Ward 60 130/100 230 ≤16 39 0 35 156
HUANG et al.

(Continues)
TA B L E 1   (Continued)

Study Gender Sample

HUANG et al.

Author/year Country design Setting Age (year) (female/male) size Cut-­off TP FP FN TN

Kwong et al., (2005) China P ACU 54.1 ± 16.9 176/253 429 ≤14 8 118 1 302
Seongsook et al., (2004) Korea P ICU 62 48/64 112 ≤16 34 57 1 20
Cho et al., (2004) Korea P Ward 55.3 ± 15.8 1555/2339 3,894 ≤16 94 248 15 3,524
Marrie et al., (2003) Canada R Ward 61.0 ± 18.0 90/98 188 ≤16 35 33 11 109
Lee, (2003) Korea P ICU 54.1 18/48 66 ≤16 26 14 4 22
Bergstrom and Braden, (2002) USA P LTCF 19–­99 NR 825 ≤18 74 165 32 554
Schoonhoven et al., (2002) Netherlands P Ward 67.2 ± 14.8 NR 2,190 ≤18 105 628 136 1,321
Bergquist and Frantz, (2001) USA R LTCF 78.78 ± 8.38 1070/641 1696 ≤19 75 604 32 985
Halfens et al., (2000) Netherlands P Ward 60.9 ± 18.3 153/167 320 ≤20 34 82 13 191
Lewicki et al., (2000) USA P Ward 62 ± 11.59 83/254 337 ≤14 9 26 7 295
Hagisawa and Barbenel, (1999) Japan P Ward NR NR 275 ≤16 5 0 7 263
Bergstrom et al., (1998) USA P LTCF 63 ± 16 94/161 255 ≤18 49 52 12 142
Goodridge et al., (1998) Canada P Ward 78.6 ± 8.5 NR 330 ≤19 22 134 10 164
Lyder et al., (1998) USA P Ward 71.0 ± 6.5 21/15 36 ≤16 5 0 9 22
Schue and Langemo, (1998) USA R Ward 69.2 ± 10.9 0/170 170 ≤18 33 50 13 74
Pang and Wong, (1998) China P Ward 45–­92 54/52 106 ≤18 19 32 2 53
Baldwin and Ziegler, (1998) USA P ICU 31.7 ± 10.9 20/16 36 ≤10 10 1 1 24
Olson et al., (1998) Canada P Ward 54.8–­62.4 NR 128 ≤16 9 19 2 98
Watkinson, (1997) UK P Ward 82.7 68/24 92 ≤16 14 18 1 59
Capobianco and McDonald, (1996) USA P Ward 66.9 ± 19.3 32/18 50 ≤18 10 6 4 30
Harrison et al., (1996) Canada P ACU 60.0 ± 19.0 362/376 738 ≤19 147 176 72 343
VandenBosch et al., (1996) USA P Ward 67 ± 13.8 54/49 103 ≤17 17 30 12 44
Ramundo, (1995) USA P LTCF NR NR 48 ≤18 7 27 0 14
Braden and Bergstrom, (1994) USA P LTCF 75.9 ± 9.45 73/29 102 ≤18 22 19 6 55
Barnes and Payton, (1993) USA P AVU 50–­90 178/183 361 ≤16 16 32 6 307
Salvadalena et al., (1992) USA P Ward 72.0 ± 13.0 63/34 99 ≤16 8 24 12 55
Choi and Song, (1991) Korea P Ward 54.1 57/89 146 ≤16 13 8 3 122
Langemo et al., (1991) USA P LTCF 66 NR 25 ≤18 4 7 3 11
Bergstrom et al., (1987) USA P ICU 58.5 ± 14.5 32/28 60 ≤16 20 13 4 23

Note: Abbreviations: ACU, acute care unit; ICU, intensive care unit; LTCF, long-­term care facility; TP, true positive; FP, false positive; FN, false negative; TN, true negative; R, retrospective; P, prospective;
and NR, no report.
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6       HUANG et al.

F I G U R E 1   Flow diagram of article of

selection

F I G U R E 2   Study quality assessment results

meta-­analysis, whose mean age ranged from 31–­8 4  years. These 5.3 | Results of risk of bias
studies were published between 1987–­2019. 45 studies were per-
formed in hospitals and 15 in long-­term care facilities (LTCF). Of all The risk of bias and applicability were assessed. In the risk of bias, a
studies, 47 were prospective and 13 were retrospective in nature. low risk of patient selection was shown in 11 (18%) studies, and 39
Among these studies, 41 studies were performed in Caucasian pop- (65%) studies were observed to have low risk in terms of the index
ulations, while 19 studies were conducted in Asian populations. The test. Reference standard in 58 (97%) studies were judged to have
cut-­off point showed a wide range between 10–­20 out of the total a low risk of bias, and 50 (83%) studies belonged to low risk in the
score of 23. domain of flow and timing. In applicability, 44 (73%) studies were
HUANG et al. |
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F I G U R E 3   Sensitivity and specificity of included studies

deemed to be low risk in the patient selection, 51 (85%) studies in the 5.6 | Subgroup analyses
index test and 58 (97%) studies in the reference standard. Details
regarding risk of bias and applicability are summarized in Figure 2. In order to explore possible heterogeneity factors, we performed
subgroup analyses based on study design (prospective vs. retrospec-
tive), mean age (<60 years vs. ≥60 years) (Matsumoto et al., 2018),
5.4 | Predictive validity of the Braden Scale setting (hospital vs. LTCF) and ethnicity (Asian population vs.
Caucasian population). The pooled diagnostic parameters for sub-
The pooled SEN was 0.78 (95% CI: 0.74 to 0.82), and the pooled SPE group analyses are summarized in Table 2.
was 0.72 (95% CI: 0.66 to 0.78) (Figure 3). The pooled PLR and NLR
were 2.80 (95% CI: 2.30 to 3.50) and 0.30 (95% CI: 0.26 to 0.35),
respectively, which yielded a DOR of 9.00 (95% CI: 7.00 to 13.00). In 5.7 | Sensitivity analysis and publication bias
addition, the SROC AUC was 0.82 (95% CI: 0.79 to 0.85) (Figure 4).
I2 values in SEN and SPE reached 96.10% (c2 = 1512.52, p <.05) and We carried out sensitivity analysis to assess the result reliability in
99.17% (c2 = 7820.13, p <.05), respectively. Figure 5. The goodness of fit and bivariate normality showed that the
included studies had only minimal influence on the overall estimates.
Influence analysis and outlier detection identified eight outlier stud-
5.5 | Threshold effect ies. After excluding these outlier studies, the SEN increased from
0.78–­0.79, the SPE dropped from 0.72–­0.70, the PLR decreased
Visual inspection of forest plots and SROC curves, as well as from 2.80–­2.60, the NLR showed no change from 0.30–­0.30, the
Spearman's correlation of 0.334 (p =.009), suggested the presence DOR decreased from 9.00–­8.00, and the AUC showed no change
of a threshold effect to some extent. The pooled results of different from 0.82–­0.82, which suggested that the random-­effects bivariate
cut-­off points are shown in Table 2. model was robust for the calculation of the pooled estimates. Finally,
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8       HUANG et al.

that the Braden Scale might be more suitable for PI risk assessment.
The reasons are shown as follows: (a) a good assessment tool was
high in both SEN (true-­positive rate) and SPE (true-­negative rate),
which was generally unavailable in clinical settings (Park et al., 2015).
PI risk assessment was a screening inspection that preferred a higher
sensitive tool rather than a higher specific tool. When the AUC was
the same, the higher SEN was better in identifying the risk of PIs,
which was beneficial to taking PI preventive interventions in time;
and (b) risk assessment tools of PIs were based on its risk factors. The
Braden Scale included more factors than the Waterlow Scale and the
Norton Scale, such as restricted mobility, limited sensory perception
and excess moisture. They are important factors that lead to the de-
velopment of PIs. Considering that preventive measures are more
cost-­effective than therapeutic measures for PIs (Zarei et al., 2019),
it is suggested that nursing staffs apply the Braden Scale to identify
factors that impact on an individual's risk in clinical practice.
Given the significant heterogeneity among included studies,
we carried out threshold analyses. Spearman's correlation of 0.334
(p =.009) suggested the presence of a threshold effect to some ex-
F I G U R E 4   Summary receiver operating characteristic curve tent. Threshold effect occurs when different cut-­off values are used
to define a positive test result in different studies, affecting the re-
Deeks’ funnel plot asymmetry test was used to assess the potential ported sensitivity and specificity of the test (Mahmood et al., 2019).
publication bias. The funnel plot (Figure 6) was not fully symmetrical, In this meta-­analysis, the cut-­off value ranged from 10–­20, which
suggesting publication bias may exist in this meta-­analysis (p <.05). indicated that the cut-­off value might be the primary reason of sig-
nificant heterogeneity. Moreover, we conducted cut-­off-­stratified
analyses according to the values ≤15, 16, 17, 18 and ≥19. Compared
6 |  D I S CU S S I O N with other cut-­off values, 16 and 18 were better in SEN (0.75 and
0.82), SPE (0.85 and 0.70) and AUC (0.84 and 0.83), which were also
This meta-­analysis included 60 studies involving 49,326 patients. widely used in clinical practice nowadays. As a result, it seemed that
The pooled SEN, SPE, PLR, NLR, DOR and AUC were 0.78, 0.72, the cut-­off value of 18 might be the best choice. The possible reason
2.80, 0.30, 9.00 and 0.82, respectively. Subgroup analyses indicated was that a risk assessment tool for PIs was not a diagnostic tool for
that the Braden Scale was more accurate in assessing the risk of PIs the incidence of PIs but instead a screening tool assessing the risk
for mean age <60 years, hospitalized patients and Caucasian popula- of PIs. The cut-­off value of 18 had a higher SEN than that of 16.
tion. When the cut-­off value was 18, the Braden Scale was the most However, in view of the characteristics in the specific clinical setting,
effective in identifying PIs’ risk. whether the value of 18 can be treated as the optimal cut-­off was
The results indicated that the probability of a positive result was unknown. Future studies could explore this issue among different
78% when the Braden Scale was used to assess a person who actually populations, such as medical, surgical, critical and elderly patients.
developed PI, and the probability of a negative result was 72% when In addition, it is necessary to conduct multi-­centre, large-­sample
the Braden Scale was applied to assess a person who did not actually studies in order to verify the effectiveness of 16 and 18 in PI risk
develop PI. The pooled PLR and NLR were also calculated in order assessment.
to evaluate the diagnostic accuracy in clinical level. The pooled PLR Based on the subgroup analyses, we found that results showed a
value was 2.80, suggesting that the probability of PI in a person with higher level of accuracy among prospective studies (AUC: 0.84) than
a positive test was 2.80-­fold higher than that in a healthy individual. retrospective design (AUC: 0.78), which may be attributed to more
By contrast, the pooled NLR indicated that the probability of not rigorous design in the prospective studies. Although there was no
having PI in a person with a negative test was 30%. Meanwhile, DOR significant difference in the AUC (0.87 vs. 0.81) between the young
demonstrated a high level of overall accuracy. DOR, which is found and middle-­aged population and the elderly, the pooled SEN and
by dividing PLR by NLR, can range from 0–­infinity, and a higher DOR SPE of the young and middle-­aged population were 0.83 and 0.78,
represents higher accuracy (Deeks,  2001). Finally, the AUC (0.83) while those of the elderly were 0.77 and 071. Based on these, we
showed that the Braden Scale had a moderate predictive validity for found that the Braden Scale was more accurate in the young and
PI risk assessment. In addition, compared with the Waterlow Scale middle-­aged population than in elderly. The possible reason was
(0.75) and the Norton Scale (0.55) (Park & Lee,  2016), the Braden that older people developed chronic diseases due to their declined
Scale had a higher SEN. Based on the results above, it was suggested physiological reserve (Jaul, 2010), which was not considered in the
HUANG et al. |
      9

TA B L E 2   Summary results of meta-­analysis

n SEN (95% CI) SPE (95% CI) PLR (95% CI) NLR (95% CI) DOR (95% CI) AUC (95% CI)

Total 60 0.78 (0.74–­0.82) 0.72 (0.66–­0.78) 2.80 (2.30–­3.50) 0.30(0.26–­0.35) 9.00 (7.00–­13.00) 0.82 (0.79–­0.85)
Outlier excluded 52 0.79 (0.76–­0.82) 0.70 (0.64–­0.74) 2.60 (2.20–­3.10) 0.30 (0.26–­0.35) 8.00 (6.00–­11.00) 0.82 (0.78–­0.85)
Study design
Prospective 47 0.80 (0.74–­0.84) 0.75 (0.67–­0.82) 3.20 (2.40–­4.30) 0.27 (0.22–­0.33) 12.00 (8.00–­18.00) 0.84 (0.81–­0.87)
Retrospective 13 0.77 (0.73–­0.81) 0.65 (0.58–­0.71) 2.20 (1.80–­2.60) 0.36 (0.30–­0.43) 6.00 (5.00–­9.00) 0.78 (0.75–­0.82)
Mean age
<60 16 0.83 (0.79–­0.87) 0.78 (0.68–­0.85) 3.70 (2.50–­5.50) 0.22 (0.16–­0.28) 17.00 (10.00–­31.00) 0.87 (0.84–­0.90
≥60 44 0.77 (0.71–­0.81) 0.71 (0.62–­0.79) 2.70 (2.10–­3.40) 0.33 (0.28–­0.39) 8.00 (6.00–­11.00) 0.81 (0.77–­0.84)
Setting
Hospital 46 0.76 (0.72–­0.80) 0.77 (0.69–­0.84) 3.40 (2.50–­4.50) 0.31 (0.26–­0.36) 11.00 (7.00–­16.00) 0.82 (0.79–­0.86)
ACU 5 0.68 (0.62–­0.74) 0.74 (0.63–­0.83) 2.60 (1.70–­4.10) 0.43 (0.33–­0.56) 6.00 (3.00–­12.00) 0.72 (0.67–­0.75)
ICU 17 0.83 (0.79–­0.86) 0.59(0.49–­0.68) 2.00 (1.60–­2.50) 0.29(0.23–­0.37) 7.00 (4.00–­10.00) 0.83 (0.79–­0.86)
Wards 24 0.71 (0.64–­0.78) 0.87 (0.78–­0.93) 5.60 (3.20–­9.80) 0.33 (0.26–­0.42) 17.00 (9.00–­33.00) 0.83 (0.80–­0.86)
LTCF 14 0.84 (0.77–­0.90) 0.58 (0.51–­0.66) 2.00 (1.70–­2.40) 0.27 (0.18–­0.39) 8.00 (5.00–­12.00) 0.77 (0.74–­0.81)
Ethnicity
Asian 19 0.80 (0.74–­0.85) 0.84 (0.67–­0.93) 4.90 (2.40–­10.10) 0.24 (0.19–­0.30) 20.00 (10.00–­4 3.00) 0.82 (0.79–­0.86)
Caucasian 41 0.77 (0.72–­0.82) 0.68 (0.61–­0.73) 2.40 (2.00–­2.80) 0.33 (0.27–­0.40) 7.00 (5.00–­10.00) 0.86 (0.82–­0.88)
Cut-­off
≤15 15 0.79 (0.76–­0.82) 0.66 (0.55–­0.75) 2.30 (1.70–­3.20) 0.31 (0.25–­0.40) 7.00 (4.00–­12.00) 0.80 (0.76–­0.83)
16 19 0.75 (0.67–­0.82) 0.85 (0.70–­0.93) 5.00 (2.50–­10.20) 0.29 (0.23–­0.37) 17.00 (8.00–­36.00) 0.84 (0.80–­0.87)
17 4 0.69 (0.61–­0.76) 0.86 (0.50–­0.97) 4.90 (1.00–­25.00) 0.36 (0.23–­0.55) 14.00 (2.00–­103.00) 0.73 (0.69–­0.77)
18 15 0.82 (0.73–­0.89) 0.70 (0.62–­0.77) 2.70 (2.10–­3.60) 0.25 (0.16–­0.39) 11.00 (6.00–­20.00) 0.83 (0.79–­0.86)
≥19 7 0.78 (0.65–­0.87) 0.54 (0.44–­0.63) 1.70 (1.40–­2.00) 0.41 (0.26–­0.65) 4.00 (2.00–­7.00) 0.67 (0.63–­0.71)

Note: Abbreviations: SEN, sensitivity; SPE, specificity; PLR, positive likelihood ratio; NLR, negative likelihood ratio; DOR, diagnostic odds ratio; AUC,
area under the curve; 95% CIs, 95% confidence intervals; ACU, acute care unit; ICU, intensive care unit; LTCF, long-­term care facility.

Braden Scale. Moreover, oxygenation and perfusion situations that 6.1 | Strengths and limitations
do not exist in the Braden Scale may also affect PI development in
elderly people (Iranmanesh et al., 2012). An additional finding was The strengths of this meta-­analysis included the large number of
that the Braden Scale had a higher diagnostic accuracy in the hos- patients retained in the quantitative synthesis. Furthermore, this is
pital than in the LTCF (AUC, 0.82 vs. 0.77). Such result correlated the first meta-­analysis on the overall accuracy of the Braden Scale
with some published studies (Park et al., 2015; Wei et al., 2020), but for identifying PI risk. In addition, we performed threshold analy-
different from another study (Wei et al., 2012). The small number of ses and cut-­off-­s tratified analyses, and identified the optimal cut-­
selected studies might contribute to the difference. Further studies off value, which played an important role in determining the risk of
with an increased number of studies could clarify the inconsistency PIs. More importantly, sensitivity analysis was performed in order
issue among studies. Moreover, compared with its use in the acute to find outlier studies. After removing the outliers and performing
care unit (AUC: 0.72, SEN: 0.68, SPE: 0.74) and intensive care unit the same analyses for the remaining studies, we found that the
(AUC: 0.83, SEN: 0.83, SPE: 0.59), the Braden scale was more suit- overall parameters of diagnostic accuracy did not change signifi-
able for use in the general wards (AUC: 0.83, SEN: 0.71, SPE: 0.87). cantly, which suggested that the random-­effects bivariate model
The reason was that some other risk factors for PIs in the acute care was robust for the calculation of the pooled estimates. However,
unit and intensive care unit including emergency environment, se- there are still several limitations. First, we have implemented a
dation, vasoactive agents, mechanical ventilation, incontinence and comprehensive systematic literature review, yet the language of
oedema were not found in the Braden Scale. In terms of ethnicity, the included studies was limited to English and Chinese, which
the Braden Scale demonstrated higher diagnostic accuracy in the might lead to publication bias. Second, because the cut-­off value
Caucasian population than in Asian population (AUC, 0.86 vs. 0.82). of 16 was only found in the 4 original studies, the pooled param-
Taking cultural difference into account, the Braden Scale, which was eters in the systematic review had a limited interpretation. Future
developed in the United States, might be more suitable to Caucasian studies should conduct more original researches to compare the
population. effectiveness of 18 with that of 17.
 |
10       HUANG et al.

F I G U R E 5   Sensitivity analysis results.

a Goodness of fit; b bivariate normality; c
influence analysis; and d outlier detection

F I G U R E 6   Deek's funnel plot

asymmetry test for identifying publication
bias

6.2 | Implication for practice patients and Caucasian population, compared with mean age
≥60 years, long-­term care facility and Asian population. Meanwhile,
The Braden Scale is more suitable to identify the risk of PI for mean the cut-­off value of 18 afforded the best choice in SEN and AUC,
age <60 years, hospitalized patients and the Caucasian population. It and could be recommended for use in clinical practice. Future stud-
appears that 18 is the optimal cut-­off value in clinical practice. ies should explore the optimal cut-­off in the specific environments.

AC K N OW L E D G E M E N T S
7 |  CO N C LU S I O N The authors declare that they have no known competing finan-
cial interests or personal relationships that could have appeared
The Braden Scale has a moderate predictive validity for PI risk as- to influence the work reported in this paper. This study has been
sessment, and it is more suitable for mean age <60 years, hospitalized funded by the National Nature Science Foundation of China (Grant
HUANG et al. |
      11

Nos. 71663002 and 71704071), the Fund of China Medical Board Nursing & Health, 17(6), 459–­470. https://doi.org/10.1002/nur.47701​
70609
(#20-­374), the National Scientific Research Training Plan of Gansu
Bredesen, I. M., Bjøro, K., Gunningberg, L., & Hofoss, D. (2015). The
Provincial Hospital (19SYPYA-­4), the Research Funds for the School prevalence, prevention and multilevel variance of pressure ulcers in
of Nursing of Lanzhou University (LZUSON202002), the Natural Norwegian hospitals: A cross-­sectional study. International Journal
Science Foundation of Gansu Province (20JR10RA603) and the of Nursing Studies, 52(1), 149–­156. https://doi.org/10.1016/j.ijnur​
stu.2014.07.005
Health Industry Scientific Research Project of Gansu Province
Capobianco, M. L., & McDonald, D. D. (1996). Factors affecting the pre-
(GSWSKY2017-­65). dictive validity of the Braden Scale. Advances in Wound Care: The
Journal for Prevention and Healing, 9(6), 32–­36.
C O N FL I C T O F I N T E R E S T Chan, W. S., Pang, S. M. C., & Kwong, E. W. Y. (2009). Assessing pre-
The authors declare no conflict of interest. dictive validity of the modified Braden scale for prediction of
pressure ulcer risk of orthopaedic patients in an acute care set-
ting. Journal of Clinical Nursing, 18(11), 1565–­1573. https://doi.
AU T H O R C O N T R I B U T I O N S org/10.1111/j.1365-­2702.2008.02757.x
C.H., Y.M., L.H.: Study design. C.H., Y.M., M.J.: Data collection. C.H., Chen, H.-­L ., Cao, Y.-­J., Zhang, W., Wang, J., & Huai, B.-­S. (2017). Braden
Y.M., C.M.: Data analysis. C.H., Y.M., M.J., C.W., L.H.: Manuscript scale (ALB) for assessing pressure ulcer risk in hospital patients: A
validity and reliability study. Applied Nursing Research, 33, 169–­174.
writing and revisions for important intellectual content.
https://doi.org/10.1016/j.apnr.2016.12.001
Chen, H. L., Shen, W. Q., & Liu, P. (2016). A meta-­analysis to evaluate the
DATA AVA I L A B I L I T Y S TAT E M E N T predictive validity of the braden scale for pressure ulcer risk assess-
The data used to support the findings of this study are available from ment in long-­term care. Ostomy Wound Manage, 62(9), 20–­28.
Cho, I., & Noh, M. (2010). Braden Scale: Evaluation of clinical usefulness
the corresponding author on reasonable request.
in an intensive care unit. Journal of Advanced Nursing, 66(2), 293–­3 02.
https://doi.org/10.1111/j.1365-­2648.2009.05153.x
ORCID Cho, M., Park, I., Kim, K., Woo, K., Joo, Y., Jeong, E., & Park, M. (2004).
Can Huang  https://orcid.org/0000-0002-3740-4872 Evaluation of predictive validity for the pressure ulcer risk assess-
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Lin Han  https://orcid.org/0000-0001-7821-5253
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