Cost-effectiveness of closed-incision negative pressure therapy in primary total joint arthroplasty: a break-even analysis.

OBJECTIVE: Surgical site complications (SSCs) are the leading cause of unplanned emergency department visits and readmissions following total joint arthroplasty (TJA). The use of closed-incision negative pressure therapy (ciNPT) has shown promise in reducing SSC occurrence. However, no study has evaluated the cost-effectiveness of ciNPT in primary TJA. The purpose of this study was to calculate the break-even absolute risk reduction (ARR) of SSCs, the break-even treatment cost of SSCs, and the break-even cost-of-use for ciNPT, based on existing literature to assess the cost-effectiveness of ciNPT in primary TJA. METHOD: Relevant values for ARR, infection treatment cost and intervention cost were obtained via literature review. A break-even analysis was conducted to investigate the cost-effectiveness of ciNPT use in primary TJA, as well as to derive the ARR, infection treatment cost (Ct) and intervention protocol cost (Cp) values at which ciNPT use becomes cost-effective. RESULTS: The values derived from the literature review were as follows: Cp=$160.76 USD; Ct=$5348.78 USD; ARR=0.0375. The break-even ARR was calculated to be 3.0%, the break-even Cp was calculated to be $200.58 USD, and the break-even Ct was calculated to be $4286.93 USD. The ARR of ciNPT use was greater than the calculated break-even ARR. CONCLUSION: This analysis demonstrated that ciNPT use in primary TJA was cost-effective. By examining the difference between the calculated break-even Cp and the Cp reported in the literature, the cost saved per patient treated with ciNPT can be calculated to be $39.82 USD.

Preoperative Opioid Use Disorder is Associated with Longer Length of Stay, Infection Rate, and Healthcare Expenditure Following Primary Shoulder Arthroplasty.

Recent research efforts have focused on the complications and outcomes associated with opioid use disorder (OUD). However, there is a lack of evidence on the associated risks respective to each primary shoulder arthroplasty procedure. After separating patients by total shoulder arthroplasty (TSA) and reverse shoulder arthroplasty (RSA) and matching to controls, our study demonstrated significant association with longer LOS in both groups, higher risk of SSI and PJI in the TSA group, PJI in the RSA group, and higher costs regardless of procedure. Efforts to appropriately recognize OUD, optimize patients pre-operatively, and apply targeted surveillance postoperatively should be made. (Journal of Surgical Orthopaedic Advances 33(2):117-121, 2024).

Long-term Health Outcomes and Health System Costs Associated With Surgical Site Infections: A Retrospective Cohort Study.

OBJECTIVES: To examine the association between surgical site infections (SSIs) and hospital readmissions and all-cause mortality, and to estimate the attributable health care costs of SSIs 1 year following surgery. BACKGROUND: SSIs are a common postoperative complication; the long-term impact of SSI on health outcomes and costs has not been formally evaluated. METHODS: This retrospective cohort study included all adult patients who underwent surgery at the 1202-bed teaching hospital in Ottawa, Ontario, Canada, and were included in the National Surgical Quality Improvement Program database between 2010 and 2015. The study exposure was postoperative SSI. The study outcomes included hospital readmission, all-cause mortality, and health care costs at 1 year (primary) and at 30 days and 90 days (secondary) following surgery. RESULTS: We identified 14,351 patients, including 795 patients with SSIs. Our multivariable analyses that accounted for competing risks demonstrated that at 1-year following the index date, superficial and deep/organ space SSIs were significantly associated with an increase in hospital readmission [hazard ratio (HR) = 1.63, 95% confidence interval (95% CI) 1.39-1.92 and HR = 3.49, (95% CI 2.76-4.17, respectively) and all-cause mortality (HR = 1.35, 95% CI 1.10-1.98 and HR = 2.21, 95% CI 1.44-2.78, respectively]. At 1 year after surgery, patients with superficial and deep/organ space SSIs incurred higher health care costs C$20,648 (95% CI) C$16,980- C$24,112and C$53,075 (95% CI) C$44,628- C$60,936), than non-SSI patients. CONCLUSION: SSIs, especially deep/organ space SSI, contribute to adverse health outcomes and health care costs across the entire year after surgery. Our findings highlight the importance of effective prevention/monitoring strategies targeting both short- and long-term consequences of SSI.

The Role of Autologous Flap Reconstruction in Patients with Crohn's Disease Undergoing Abdominoperineal Resection.

BACKGROUND: Patients with symptomatic Crohn's disease who undergo abdominoperineal resection can experience impaired postoperative wound healing. This results in significant morbidity, burdensome dressing changes, and increased postoperative pain. When abdominoperineal resection is performed for oncological reasons, autologous flap reconstruction is occasionally performed to optimize wound healing and reconstruction outcomes. However, the role of flap reconstruction after abdominoperineal resection for Crohn's disease has not been established. OBJECTIVE: This study examines the utility of flap reconstruction in patients with symptomatic Crohn's disease undergoing abdominoperineal resection. We hypothesize that patients with immediate flap reconstruction after abdominoperineal resection will demonstrate improved wound healing. DESIGN: This study is a retrospective chart review. SETTINGS: Eligible patients at our institution were identified from 2010 to 2018 by using a combination of Current Procedural Terminology, International Classification of Diseases, Ninth Revision, and International Classification of Diseases, Tenth Revision codes. PATIENTS: Of 40 adult patients diagnosed with Crohn's disease, 20 underwent abdominoperineal resection only and 20 underwent abdominoperineal resection with flap reconstruction. INTERVENTIONS: Immediate autologous flap reconstruction was performed after abdominoperineal resection. MAIN OUTCOME MEASURES: The primary outcomes measured were the presence of postoperative perineal wounds and postoperative wound care burden. RESULTS: Patients in the abdominoperineal resection with flap reconstruction group demonstrated significantly worse preoperative disease traits, including fistula burden, than patients in the abdominoperineal resection only group. A lower number of patients tended to be associated with a persistent perineal wound in the flap group at 30 days (abdominoperineal resection with flap reconstruction = 55% vs abdominoperineal resection only = 70%; p = 0.327) and at 6 months (abdominoperineal resection with flap reconstruction = 25% vs abdominoperineal resection only = 40%; p = 0.311) postoperatively. There was also a trend toward a lower incidence of complications in the flap group. Patients in the abdominoperineal resection with flap reconstruction group tended to experience lower postoperative pain than patients in the abdominoperineal resection only group. LIMITATIONS: This retrospective cohort study was limited by its reliance on data in electronic medical records, and by its small sample size and the fact that it was a single-institution study. CONCLUSIONS: In select patients who have severe perianal fistulizing Crohn's disease, there may be a benefit to immediate flap reconstruction after abdominoperineal resection to lower postoperative wound care burden without significant intraoperative or postoperative risk. In addition, flap reconstruction may lead to lower postoperative pain. See Video Abstract at http://links.lww.com/DCR/B416. EL ROL DE LA RECONSTRUCCIN CON COLGAJO AUTLOGO EN PACIENTES CON ENFERMEDAD DE CROHN SOMETIDOS A RESECCIN ABDOMINOPERINEAL: ANTECEDENTES:Los pacientes con enfermedad de Crohn sintomática que se someten a una resección abdominoperineal pueden experimentar una curación posoperatoria deficiente de la herida. Esto da como resultado una morbilidad significativa, cambios de apósito molestos y un aumento del dolor posoperatorio. Cuando se realiza una resección abdominoperineal por razones oncológicas, ocasionalmente se realiza una reconstrucción con colgajo autólogo para optimizar los resultados de la curación y reconstrucción de la herida. Sin embargo, no se ha establecido la función de la reconstrucción con colgajo después de la resección abdominoperineal para la enfermedad de Crohn.OBJETIVO:Este estudio examina la utilidad de la reconstrucción con colgajo en pacientes con enfermedad de Crohn sintomática sometidos a resección abdominoperineal. Presumimos que los pacientes con reconstrucción inmediata con colgajo después de la resección abdominoperineal demostrarán una mejor curación de la herida.DISEÑO:Revisión retrospectiva de expedientes.MARCO:Los pacientes elegibles en nuestra institución se identificaron entre 2010 y 2018 mediante una combinación de los códigos de Terminología actual de procedimientos, Clasificación internacional de enfermedades 9 y Clasificación internacional de enfermedades 10.PACIENTES:Cuarenta pacientes adultos diagnosticados con enfermedad de Crohn que se someten a resección abdominoperineal solamente (APR-solo = 20) y resección abdominoperineal con reconstrucción con colgajo (APR-colgajo = 20).INTERVENCIÓN (ES):Reconstrucción inmediata con colgajo autólogo después de la resección abdominoperineal.MEDIDAS DE RESULTADOS PRINCIPALES:Presencia de herida perineal posoperatoria y carga de cuidado de la herida posoperatoria.RESULTADOS:Los pacientes del grupo APR-colgajo demostraron rasgos de enfermedad preoperatoria significativamente peores, incluida la carga de la fístula, en comparación con los pacientes del grupo APR-solo. Un número menor de pacientes tendió a asociarse con una herida perineal persistente en el grupo de colgajo a los 30 días (APR-colgajo = 55% vs APR-solo = 70%; p = 0.327) y 6 meses (APR-colgajo = 25% vs APR-solo = 40%; p = 0.311) postoperatoriamente. También hubo una tendencia hacia una menor incidencia de complicaciones en el grupo APR-colgajo. Los pacientes del grupo APR-colgajo tendieron a experimentar menos dolor posoperatorio en comparación con el grupo APR-solo.LIMITACIONES:Estudio de cohorte retrospectivo basado en datos de historias clínicas electrónicas. Tamaño de muestra pequeño y estudio de una sola institución.CONCLUSIONES:En pacientes seleccionados que tienen enfermedad de Crohn fistulizante perianal grave, la reconstrucción inmediata del colgajo después de la resección abdominoperineal puede beneficiar a reducir la carga posoperatoria del cuidado de la herida sin riesgo intraoperatorio o posoperatorio significativo. Además, la reconstrucción con colgajo puede resultar un dolor posoperatorio menor. Consulte Video Resumen en http://links.lww.com/DCR/B416.

Timing and Cost of Wound Complications After Colorectal Resection.

BACKGROUND: More than 50% of postoperative wound complications occur after discharge. They are the most common postoperative complication and the most common reason for readmission after a surgical procedure. Little is known about the long-term costs of postdischarge wound complications after surgery. OBJECTIVE: We sought to understand the differences in costs and characteristics of wound complications identified after hospital discharge for patients undergoing colorectal surgery in comparison with in-hospital complications. DESIGN: This is an observational cohort study using Veterans Health Administration Surgical Quality Improvement Program data. SETTING: This study was conducted at a Veterans Affairs medical center. SETTING: Patients undergoing colorectal resection between October 1, 2007 and September 30, 2014. MAIN OUTCOME MEASURES: The primary outcomes measured were adjusted costs of care at discharge, 30 days, and 90 days after surgery. RESULTS: Of 20,146 procedures, 11.9% had a wound complication within 30 days of surgery (49.2% index-hospital, 50.8% postdischarge). In comparison with patients with index-hospital complications, patients with postdischarge complications had fewer superficial infections (65.0% vs 72.2%, p < 0.01), more organ/space surgical site infections (14.3% vs 10.1%, p < 0.01), and higher rates of diabetes (29.1% vs 25.0%, p = 0.02), and they were to have had a laparoscopic approach for their surgery (24.7% vs 18.2%, p < 0.01). The average cost including surgery at 30 days was $37,315 (SD = $29,319). Compared with index-hospital wound complications, postdischarge wound complications were $9500 (22%, p < 0.001) less expensive at 30 days and $9736 (15%, p < 0.001) less expensive at 90 days. Patients with an index-hospital wound complication were 40% less likely to require readmission at 30 days, but their readmissions were $12,518 more expensive than readmissions among patients with a newly identified postdischarge wound complication (p < 0.001). LIMITATIONS: This study was limited to patient characteristics and costs accrued only within the Veterans Affairs system. CONCLUSIONS: Patients with postdischarge wound complications have lower 30- and 90-day postoperative costs than those with wound complications identified during their index hospitalization and almost half were managed as an outpatient. TIEMPO Y COSTO DE LAS COMPLICACIONES LA HERIDA DESPUS DE LA RESECCIN COLORRECTAL: ANTECEDENTES:Más del 50% de complicaciones postoperatorias de la herida ocurren después del alta. Es la complicación postoperatoria más común y el motivo más frecuente de reingreso después del procedimiento quirúrgico. Poco se sabe sobre los costos a largo plazo de las complicaciones de la herida después del alta quirúrgica.OBJETIVO:Intentar en comprender las diferencias en los costos y las características de las complicaciones de la herida, identificadas después del alta hospitalaria, en pacientes sometidos a cirugía colorrectal, en comparación con las complicaciones intrahospitalarias.DISEÑO:Estudio de cohorte observacional utilizando datos del Programa de Mejora de la Calidad Quirúrgica de la Administración de Salud de Veteranos.ENTORNO CLÍNICO:Administración de Veteranos.PACIENTES:Pacientes sometidos a resección colorrectal entre el 1/10/2007 y el 30/9/2014.PRINCIPALES MEDIDAS DE VALORACIÓN:Costos de atención ajustados al alta, 30 días y 90 días después de la cirugía.RESULTADOS:De 20146 procedimientos, el 11,9% tuvo una complicación de la herida dentro de los 30 días de la cirugía. (49,2% índice hospitalario, 50,8% después del alta). En comparación con los pacientes, del índice de complicaciones hospitalarias, los pacientes con complicaciones posteriores al alta, tuvieron menos infecciones superficiales (65,0% frente a 72,2%, p <0,01), más infecciones de órganos/espacios quirúrgicos (14,3% frente a 10,1%, p <0,01), tasas más altas de diabetes (29,1% versus 25,0%, p = 0,02), y deberían de haber tenido un abordaje laparoscópico para su cirugía (24,7% versus 18,2%, p <0,01). El costo promedio, incluida la cirugía a los 30 días, fue de $ 37,315 (desviación estándar = $ 29,319). En comparación con el índice de complicaciones de las herida hospitalaria, las complicaciones de la herida después del alta fueron $ 9,500 (22%, p <0,001) menor costo a los 30 días y $ 9,736 (15%, p<0,001) y menor costo a los 90 días. Los pacientes con índice de complicación de la herida hospitalaria, tenían un 40% menos de probabilidades de requerir reingreso a los 30 días, pero sus reingresos eran $ 12,518 más costosos que los reingresos entre los pacientes presentando complicación de la herida recién identificada después del alta (p <0,001).LIMITACIONES:Limitado a las características del paciente y los costos acumulados solo dentro del sistema VA.CONCLUSIONES:Pacientes con complicaciones de la herida post alta, tienen menores costos postoperatorios a los 30 y 90 días, que aquellos con complicaciones de la herida identificadas durante su índice de hospitalización y aproximadamente la mitad fueron tratados de forma ambulatoria.

Initial Outcomes of a Novel Irrigating Wound Protector for Reducing the Risk of Surgical Site Infection in Elective Colectomies.

BACKGROUND: Surgical site infection (SSI) rates in elective colorectal surgery remain high due to intraoperative exposure of colonic bacteria at the surgical site. We aimed to evaluate 30-day SSI outcomes of a novel wound retractor that combines barrier protection with continuous wound irrigation in elective colorectal resection. MATERIALS AND METHODS: A retrospective single-center cohort-matched analysis included all patients undergoing elective colorectal resection utilizing the novel irrigating wound protector (IWP) from April 2015 to July 2019. A control cohort of patients who underwent the same procedures with a standard wound protector over the same time period were also identified. Patients from both groups were matched for procedure type, procedure approach, pathology requiring operation, age, sex, race, body mass index, diabetes, smoker status, hypertension, presence of disseminated cancer, current steroid or immunosuppressant use, wound classification, and American Society of Anesthesiologist classification. SSI frequency, SSI subtype (superficial, deep, or organ space), hospital length of stay (LOS) and associated procedure were tabulated through 30 postoperative days. Fisher's exact test and number needed to treat (NNT) were used to compare SSI rates and estimate cost between both groups. RESULTS: The IWP group had 41 patients. The control group had 82 patients. Control-matched variables were similar for both groups. 30-day SSI rates were significantly lower in the IWP group (P=0.0298). length of stay was significantly shorter in the IWP group (P=0.0150). The NNT for the IWP to prevent one episode of SSI was 8.2 patients. CONCLUSIONS: The novel IWP device shows promise to reducing the risk of SSI in elective colorectal surgery.

Wound infection following implant removal of foot, ankle, lower leg or patella; a protocol for a multicenter randomized controlled trial investigating the (cost-)effectiveness of 2 g of prophylactic cefazolin compared to placebo (WIFI-2 trial).

BACKGROUND: Elective implant removal (IR) after fracture fixation is one of the most common procedures within (orthopedic) trauma surgery. The rate of surgical site infections (SSIs) in this procedure is quite high, especially below the level of the knee. Antibiotic prophylaxis is not routinely prescribed, even though it has proved to lower SSI rates in other (orthopedic) trauma surgical procedures. The primary objective is to study the effectiveness of a single intravenous dose of 2 g of cefazolin on SSIs after IR following fixation of foot, ankle and/or lower leg fractures. METHODS: This is a multicenter, double-blind placebo controlled trial with a superiority design, including adult patients undergoing elective implant removal after fixation of a fracture of foot, ankle, lower leg or patella. Exclusion criteria are: an active infection, current antibiotic treatment, or a medical condition contraindicating prophylaxis with cefazolin including allergy. Patients are randomized to receive a single preoperative intravenous dose of either 2 g of cefazolin or a placebo (NaCl). The primary analysis will be an intention-to-treat comparison of the proportion of patients with a SSI at 90 days after IR in both groups. DISCUSSION: If 2 g of prophylactic cefazolin proves to be both effective and cost-effective in preventing SSI, this would have implications for current guidelines. Combined with the high infection rate of IR which previous studies have shown, it would be sufficiently substantiated for guidelines to suggest protocolled use of prophylactic antibiotics in IR of foot, ankle, lower leg or patella. Trial registration Nederlands Trial Register (NTR): NL8284, registered on 9th of January 2020, https://www.trialregister.nl/trial/8284.

The impact of surgical site infection on hospitalisation, treatment costs, and health-related quality of life after vascular surgery.

Surgical site infections (SSI) substantially increase costs for healthcare providers because of additional treatments and extended patient recovery. The objective of this study was to assess the cost and health-related quality of life impact of SSI, from the perspective of a large teaching hospital in England. Data were available for 144 participants undergoing clean or clean-contaminated vascular surgery. SSI development, length of hospital stay, readmission, and antibiotic use were recorded over a 30-day period. Patient-reported EQ-5D scores were obtained at baseline, day 7 and day 30. Linear regressions were used to control for confounding variables. A mean SSI-associated length of stay of 9.72 days resulted in an additional cost of £3776 per patient (including a mean antibiotic cost of £532). Adjusting for age, smoking status, and procedure type, SSI was associated with a 92% increase in length of stay (P < 0.001). The adjusted episode cost was £3040. SSI reduced patient utility between baseline and day 30 by 0.156 (P = 0.236). Readmission rates were higher with SSI (P = 0.017), and the rate to return to work within 90 days was lower. Therefore, strategies to reduce the risk of surgical site infection for high-risk vascular patients should be investigated.

Surgical Site Infections and their economic significance in hepatopancreatobiliary surgery: A retrospective incidence, cost, and reimbursement analysis in a German centre of the highest level of care.

Surgical site infections (SSI) in open Hepatopancreatobiliary (HPB) surgery are common complications. They worsen patients' outcomes and prolong hospital stays. Their economic significance in the German diagnosis related groups (DRG) system is mostly unknown. To investigate their economic importance, we evaluated all cases for SSIs as well as clinical and financial parameters undergoing surgery in our centre from 2015 and 2016. Subsequently, we carried out a cost-revenue calculation by assessing our billing data and the cost matrix of the InEK (German Institute for the Payment System in Hospitals). A total of 13.5% of the patients developed a superficial, 9% a deep incisional, and 2.4% of the patients an organ space SSI. Compared with Patients without SSI, Patients with SSI had more comorbidities, were older, and their average length of stay was extended by 19 days (P < .001). The financial loss per SSI-case was €-7035.65 despite increased reimbursement, which resulted in a calculated total loss for the hospital of €-802 064.62 in 2015 and 2016. Surgical site infections are common complications of open HPB surgery, which lead to a significant increase in the cost per case. Further prevention strategies need to be developed. Besides, an adjustment of revenues must be demanded.

Postoperative Surgical Site Infections: Understanding the Discordance Between Surveillance Systems.

OBJECTIVE: To characterize agreement in the ascertainment of surgical site infections (SSIs) between the National Surgical Quality Improvement Program (NSQIP), National Healthcare Safety Network (NHSN), and administrative data. BACKGROUND: The NSQIP, NHSN, and administrative data are the primary systems used to monitor and report SSIs for the purpose of quality control and benchmarking of hospitals and surgeons. These systems have different methods for identifying SSIs. METHODS: We queried the NHSN, NSQIP, and administrative data systems for patients who had an operation at 1 of 4 hospitals within a single health system between January 2013 and September 2015. The detection of an SSI during a postoperative hospitalization was the outcome of analysis. Any SSI detected by one (or more) of these systems was analyzed by 2 reviewers to determine the presence of discrete elements of documentation constituting evidence of SSI. Concordance between the 3 systems (NHSN, NSQIP, and administrative data) was analyzed using Cohen's kappa. RESULTS: After application of appropriate exclusion criteria, a cohort of 9447 inpatient operations was analyzed. In total, 130 SSIs were detected by 1 or more of the 3 systems, with reported SSI rates of 0.5% (NHSN), 0.7% (administrative data), and 1.0% (NSQIP). Of these 130 SSIs, only 17 SSIs were reported by all 3 systems. The concordance between these 3 systems was moderate (kappa values NSQIP-NHSN = 0.50 [0.40-0.60], administrative-NHSN = 0.36 [0.24-0.47], and administrative-NSQIP = 0.47 [0.38-0.57]). Chart review found that reasons for discordance were related to issues of different criteria as well as inaccuracies. CONCLUSION: There is significant discordance in the determination of SSIs reported by the NHSN, NSQIP, and administrative data. The differences and limitations of each of these systems have to be recognized, especially when using these data for quality reports and pay for performance.

Assessment of the Risk and Economic Burden of Surgical Site Infection Following Colorectal Surgery Using a US Longitudinal Database: Is There a Role for Innovative Antimicrobial Wound Closure Technology to Reduce the Risk of Infection?

BACKGROUND: Colorectal surgical procedures place substantial burden on health care systems because of the high complication risk, of surgical site infections in particular. The risk of surgical site infection after colorectal surgery is one of the highest of any surgical specialty. OBJECTIVE: The purpose of this study was to determine the incidence, cost of infections after colorectal surgery, and potential economic benefit of using antimicrobial wound closure to improve patient outcomes. DESIGN: Retrospective observational cohort analysis and probabilistic cost analysis were performed. SETTINGS: The analysis utilized a database for colorectal patients in the United States between 2014 and 2018. PATIENTS: A total of 107,665 patients who underwent colorectal surgery were included in the analysis. MAIN OUTCOME MEASURES: Rate of infection was together with identified between 3 and 180 days postoperatively, infection risk factors, infection costs over 24 months postoperatively by payer type (commercial payers and Medicare), and potential costs avoided per patient by using an evidence-based innovative wound closure technology. RESULTS: Surgical site infections were diagnosed postoperatively in 23.9% of patients (4.0% superficial incisional and 19.9% deep incisional/organ space). Risk factors significantly increased risk of deep incisional/organ-space infection and included several patient comorbidities, age, payer type, and admission type. After 12 months, adjusted increased costs associated with infections ranged from $36,429 to $144,809 for commercial payers and $17,551 to $102,280 for Medicare, depending on surgical site infection type. Adjusted incremental costs continued to increase over a 24-month study period for both payers. Use of antimicrobial wound closure for colorectal surgery is projected to significantly reduce median payer costs by $809 to $1170 per patient compared with traditional wound closure. LIMITATIONS: The inherent biases associated with retrospective databases limited this study. CONCLUSIONS: Surgical site infection cost burden was found to be higher than previously reported, with payer costs escalating over a 24-month postoperative period. Cost analysis results for adopting antimicrobial wound closure aligns with previous evidence-based studies, suggesting a fiscal benefit for its use as a component of a comprehensive evidence-based surgical care bundle for reducing the risk of infection. See Video Abstract at http://links.lww.com/DCR/B358. EVALUACIÓN DEL RIESGO Y LA CARGA ECONÓMICA DE LA INFECCIÓN DEL SITIO QUIRÚRGICO DESPUÉS DE UNA CIRUGÍA COLORRECTAL UTILIZANDO UNA BASE DE DATOS LONGITUDINAL DE EE.UU.: ¿EXISTE UN PAPEL PARA LA TECNOLOGÍA INNOVADORA DE CIERRE DE HERIDAS ANTIMICROBIANAS PARA REDUCIR EL RIESGO DE INFECCIÓN?: Los procedimientos quirúrgicos colorrectales suponen una carga considerable para los sistemas de salud debido al alto riesgo de complicaciones, particularmente las infecciones del sitio quirúrgico. El riesgo de infección posoperatoria del sitio quirúrgico colorrectal es uno de los más altos de cualquier especialidad quirúrgica.El propósito de este estudio fue determinar la incidencia, el costo de las infecciones después de la cirugía colorrectal y el beneficio económico potencial del uso del cierre de la herida con antimicrobianos para mejorar los resultados de los pacientes.Análisis retrospectivo de cohorte observacional y análisis de costo probabilístico.El análisis utilizó la base de datos para pacientes colorrectales en los Estados Unidos entre 2014 y 2018.Un total de 107,665 pacientes sometidos a cirugía colorrectal.Se identificó una tasa de infección entre 3 y 180 días después de la operación, los factores de riesgo de infección, los costos de infección durante 24 meses posteriores a la operación por tipo de pagador (pagadores comerciales y Medicare), y los costos potenciales evitados por paciente utilizando una tecnología innovadora de cierre de heridas basada en evidencias.Infecciones del sitio quirúrgico, diagnosticadas postoperatoriamente en el 23,9% de los pacientes (4,0% incisional superficial y 19,9% incisional profunda / espacio orgánico). Los factores de riesgo aumentaron significativamente el riesgo de infección profunda por incisión / espacio orgánico e incluyeron comorbilidades selectivas del paciente, edad, tipo de pagador y tipo de admisión. Después de 12 meses, el aumento de los costos asociados con las infecciones varió de $ 36,429 a $ 144,809 para los pagadores comerciales y de $ 17,551 a $ 102,280 para Medicare, según el tipo de infección del sitio quirúrgico. Los costos incrementales ajustados continuaron aumentando durante un período de estudio de 24 meses para ambos pagadores. Se prevé que el uso del cierre antimicrobiano de la herida para la cirugía colorrectal reducirá significativamente los costos medios del pagador en $ 809- $ 1,170 por paciente en comparación con el cierre tradicional de la herida.Los sesgos inherentes asociados a las bases de datos retrospectivas limitaron este estudio.Se encontró que la carga del costo de la infección del sitio quirúrgico es mayor que la reportada previamente, y los costos del pagador aumentaron durante un período postoperatorio de 24 meses. Los resultados del análisis de costos para la adopción del cierre de heridas antimicrobianas se alinean con estudios previos basados en evidencia, lo que sugiere un beneficio fiscal para su uso como componente de un paquete integral de atención quirúrgica basada en evidencia para reducir el riesgo de infección. Consulte Video Resumen en http://links.lww.com/DCR/B358.

An Evidence-Based Care Protocol Improves Outcomes and Decreases Cost in Pediatric Appendicitis.

BACKGROUND: Appendicitis is a common indication for urgent abdominal surgery in the pediatric population. The postoperative management varies significantly in time to discharge and cost of care. The objective of this study was to investigate whether implementation of an evidence-based protocol after an appendectomy would lead to decreased length of stay and cost of care. METHODS: In 2014 at the Children's Hospital of Pittsburgh, an initiative to develop an evidenced-based protocol to treat appendicitis was undertaken. A work group was formed of pediatric surgeons and other important personnel to determine best practices. Treatment pathways were created. Pathways differed with recommendation on postoperative antibiotic choice and duration, diet initiation, and discharge criteria. Data were prospectively gathered from all patients (ages 0-18 y) with acute appendicitis from January 2015 to December 2016. Primary outcomes were length of stay and cost of care. Secondary outcomes were surgical site infection, readmission rate, and duration of postoperative antibiotics. RESULTS: Among the 1289 patients, 481 patients were in the preprotocol cohort and 808 patients were in the postprotocol cohort. 27% of patients had an intraoperative diagnosis of complicated appendicitis. There was a significantly shorter length of stay in the postprotocol cohort (P < 0.001). Median costs for the whole cohort decreased 0.6% and 24.6% for patients with complicated appendicitis after protocol initiation (P < 0.01). CONCLUSIONS: This study has demonstrated that introduction of an evidence-based clinical care protocol for pediatric patients with appendicitis leads to shorter hospital stay and decreased hospital costs.

Closed incision negative pressure therapy: Results of recent trials and recommendations for clinical practice.

BACKGROUND: Open abdominal surgery is associated with high rates of wound complications . Surgical site infection (SSI) is associated with prolonged length of stay, delayed treatment and high rates of readmission (1, 3, 4). Negative pressure wound therapy over closed incisions (ciNPWT) is a novel approach to prevention of SSI. We reviewed the outcomes of studies comparing ciNPWT and standard therapy in open abdominal wounds to assess the efficacy of the current evidence base. AIM: To assess the effect of negative pressure wound therapy used over closed incisions in open abdominal surgery. METHODS: Search of relevant terms was conducted on PubMed, Scopus and Cochrane to identify studies published between Jan 2006-Feb 2019. Studies were chosen based on specific inclusion criteria. Articles were screened to assess demographics, study design and outcomes. RESULTS: Seven retrospective and six prospective randomised controlled trials were identified for inclusion, totalling 3048 participants. 967 received ciNPWT and 2081 received standard treatment. Studies assessed a mix of surgeries (colorectal n = 6, pancreaticoduodenectomy n = 1, gynaecologic n = 1, acute care surgery n = 1, mixed open n = 2). ciNPWT was statistically significant in reducing SSI in 9 of 13 studies. CONCLUSION: ciNPWT in open abdominal surgery has demonstrated promising results for reducing SSI rate in some trials however, patient selection remains unclear. Recent randomized controlled trials have failed to demonstrate benefit overall with use of ciNPWT in open abdominal surgery. Further multicentre prospective trials are needed for cost-benefit analysis and appropriate patient-selection.

A break-even analysis of benzoyl peroxide and hydrogen peroxide for infection prevention in shoulder arthroplasty.

BACKGROUND: Newer strategies to decolonize the shoulder of Cutibacterium acnes may hold promise in minimizing the occurrence of infections after shoulder arthroplasty, but little is known about their cost-effectiveness. Break-even models can determine the economic viability of interventions in settings with low outcome event rates that would realistically preclude a randomized clinical trial. We used such modeling to determine the economic viability of benzoyl peroxide and hydrogen peroxide for infection prevention in shoulder arthroplasty. METHODS: Skin decolonization protocol costs ($11.76 for benzoyl peroxide; $0.96 for hydrogen peroxide), baseline infection rates for shoulder arthroplasty (0.70%), and infection-related care costs ($50,230) were derived from institutional records and the literature. A break-even equation incorporating these variables was developed to determine the absolute risk reduction (ARR) in the infection rate to make prophylactic use economically justified. The number needed to treat was calculated from the ARR. RESULTS: Topical benzoyl peroxide is considered economically justified if it prevents at least 1 infection out of 4348 shoulder arthroplasties (ARR = 0.023%). Hydrogen peroxide is economically justified if it prevents at least 1 infection out of 50,000 cases (ARR = 0.002%). These protocols remained economically viable at varying unit costs, initial infection rates, and infection-related care costs. CONCLUSIONS: The use of topical benzoyl peroxide and skin preparations with hydrogen peroxide are highly economically justified practices for infection prevention in shoulder arthroplasty. Efforts to determine drawbacks of routine skin decolonization strategies are warranted as they may change the value analysis.

Clinical and economic burden of wound care in the tropics: a 5-year institutional population health review.

The aim of this study is to evaluate the clinical and economic burden of wound care in the Tropics via a 5-year institutional population health review. Within our data analysis, wounds are broadly classified into neuro-ischaemic ulcers (NIUs), venous leg ulcers (VLUs), pressure injuries (PIs), and surgical site infections (SSIs). Between 2013 and 2017, there were a total of 56 583 wound-related inpatient admissions for 41 461 patients, with a 95.1% increase in wound episodes per 1000 inpatient admissions over this period (142 and 277 wound episodes per 1000 inpatient admissions in 2013 and 2017, respectively). In 2017, the average length of stay for each wound episode was 17.7 days, which was 2.4 times that of an average acute admission at our institution. The average gross charge per wound episode was USD $12 967. Among the 12 218 patients with 16 674 wound episodes in 2017, 71.5% were more than 65 years of age with an average Charlson Comorbidity Index (CCI) of 7.2. Half (51.9%) were moderately or severely frail, while 41.3% had two or more wound-related admission episodes. In 2017, within our healthcare cluster, the gross healthcare costs for all inpatient wound episodes stand at USD $216 million within hospital care and USD $596 000 within primary care. Most NIU patients (97.2%) had diabetes and they had the most comorbidities (average CCI 8.4) and were the frailest group of patients (44.9% severely frail). The majority of the VLU disease burden was at the specialist outpatient setting, with the average 1-year VLU recurrence rate at 52.5% and median time between healing and recurrence at 9.5 months. PI patients were the oldest (86.5% more than 65 years-old), constituted the largest cohort of patients with 3874 patients at an incidence of 64.6 per 1000 admissions in 2017, and have a 1-year all-cause mortality rate of 14.3%. For SSI patients, there was a 125% increase of 14.2 SSI wound episodes per 1000 inpatient admissions in 2013 to 32.0 in 2017, and a 413% increase in wound-related 30-day re-admissions, from 40 in 2013 (4.1% of all surgeries) to 205 (8.3% of all surgeries) in 2017. The estimated gross healthcare cost per patient ranges from USD $15789-17 761 across the wound categories. Similar to global data, there is a significant and rising trend in the clinical and economic burden of wound care in Tropics.

Interventions and Innovation to Prevent Surgical Site Infection in Colorectal Surgery: A Cost-Effectiveness Analysis.

BACKGROUND: Surgical site infection (SSI), particularly in colorectal surgery, continues to cause substantial morbidity and cost. Both process- and product-based interventions have been proposed and implemented. No cost-effectiveness analysis of such interventions has been published. MATERIALS AND METHODS: This study used a decision-analytic model to evaluate the cost-effectiveness of strategies for the prevention of SSI. Costs, utilities, and transition probabilities were obtained from literature review. We used a lifetime time horizon, captured with explicit event modeling for a year plus quantification of enduring health outcomes. We represented costs in 2017 US dollars and health effects in Quality-Adjusted Life Years (QALYs). Deterministic and probabilistic sensitivity analyses were performed. RESULTS: Both process- and device-based strategies were dominant-clinically superior and also less expensive-compared with no intervention. Two types of double-ring wound protection barrier devices with greater anticontamination functionality were found to be both clinically superior and cost-saving compared with bundled process measures and simpler single-ring devices. Gains in QALYs were 230 per 1000 patients, and cost savings were 2.2 million dollars per 1000 patients, driven primarily by the high cost of SSI. CONCLUSIONS: We found process-based interventions and wound protection devices to be superior to no intervention in the prevention of SSI. Double ring devices offered a distinct advantage over simpler devices, with small reductions in SSI risk leading to substantial cost savings. Further innovation in device-based wound protection devices may offer increased prevention of SSI at acceptable cost-effectiveness levels.

Cost-Effectiveness of Negative Pressure Incision Management System in Cardiac Surgery.

BACKGROUND: Sternal wound infections (SWIs) can be a devastating long-term complication with significant morbidity and health care cost. The purpose of this analysis was to evaluate the cost-effectiveness of negative pressure incision management systems (NPIMS) in cardiac surgery. MATERIALS AND METHODS: All cardiac surgery cases at an academic hospital with risk scores available (2009-2017) were extracted from an institutional database (n = 4455). Patients were stratified by utilization of NPIMS, and high risk was defined as above the median. Costs included infection-related readmissions and were adjusted for inflation. Multivariable regression models assessed the risk-adjusted cost of SWI and efficacy of NPIMS use. Cost-effectiveness was modeled using TreeAge Pro using institutional results. RESULTS: The rate of deep SWI was 0.9% with an estimated cost of $111,175 (P < 0.0001). The rate of superficial SWI was 0.8% at a cost of $7981 (P = 0.08). Risk-adjusted NPIMS use was not significantly associated with reduced SWI (OR 1.2, P = 0.62) and thus not cost-effective. However, in the high-risk cohort with an OR 0.84 (P = 0.72) and SWI rate of 2.3%, NPIMS use cost $205 per patient with an incremental cost-effectiveness ratio of $179,092. Therefore, NPIMS is estimated to be cost-effective with a deep SWI rate over 1.3% or improved efficacy (OR < 0.83). CONCLUSIONS: SWIs are extremely expensive complications with estimates of $111,175 for deep yet only $7981 for superficial. Although NPIMS was not cost-effective for SWI prevention as currently utilized, a protocol for use on patients with a higher risk of sternal infection could be cost-effective.

Cost-effectiveness of incisional negative pressure wound therapy compared with standard care after caesarean section in obese women: a trial-based economic evaluation.

OBJECTIVE: To evaluate the cost-effectiveness of incisional negative pressure wound therapy (iNPWT) in preventing surgical site infection in obese women after caesarean section. DESIGN: A cost-effectiveness analysis conducted alongside a clinical trial. SETTING: Five obstetric departments in Denmark. POPULATION: Women with a pregestational body mass index (BMI) ≥30 kg/m2 . METHOD: We used data from a randomised controlled trial of 876 obese women who underwent elective or emergency caesarean section and were subsequently treated with iNPWT (n = 432) or a standard dressing (n = 444). Costs were estimated using data from four Danish National Databases and analysed from a healthcare perspective with a time horizon of 3 months after birth. MAIN OUTCOME MEASURES: Cost-effectiveness based on incremental cost per surgical site infection avoided and per quality-adjusted life-year (QALY) gained. RESULTS: The total healthcare costs per woman were €5793.60 for iNPWT and €5840.89 for standard dressings. Incisional NPWT was the dominant strategy because it was both less expensive and more effective; however, no statistically significant difference was found for costs or QALYs. At a willingness-to-pay threshold of €30,000, the probability of the intervention being cost-effective was 92.8%. A subgroup analysis stratifying by BMI shows that the cost saving of the intervention was mainly driven by the benefit to women with a pre-pregnancy BMI ≥35 kg/m2 . CONCLUSION: Incisional NPWT appears to be cost saving compared with standard dressings but this finding is not statistically significant. The cost savings were primarily found in women with a pre-pregnancy BMI ≥35 kg/m2 . TWEETABLE ABSTRACT: Prophylactic incisional NPWT reduces the risk of SSI after caesarean section and is probably dominant compared with standard dressings #healtheconomics.

Spinal Cord Stimulation Infection Rate and Incremental Annual Expenditures: Results From a United States Payer Database.

OBJECTIVES: Surgical site infections (SSIs) result in significant negative clinical and economic outcomes. The objective of this study is to estimate annual health expenditures associated with spinal cord stimulation (SCS)-related infections. MATERIALS AND METHODS: Data from the Truven MarketScan® databases were used to identify patients with an SCS implant (2009-2014) and a continuous health plan enrollment for at least 12-months before and after implant (index date). Annual expenditures were estimated for patients with a device-related infection vs. those without infection since index date. A generalized linear model estimated annual expenditures attributable to device-related infection. Multivariable expenditure models were conducted separately for patients in initial and replacement groups, controlling for demographics, comorbidities, and clinical characteristics. RESULTS: The study included 6615 patients. Multivariable expenditure models revealed that patients with infection have higher annual expenditures than patients without infection. Estimated incremental annual healthcare expenditures for patients with an infection were $59,716 (95% CI: $48,965-$69,480) for initial implanted patients and $64,833 (95% CI: $37,377-$86,519) for replacement patients. Only 26% of patients who were explanted for infection underwent a reimplant. CONCLUSIONS: These results show the substantial expenditure burden associated with an SCS-related infection. Management of SCS-related infection is important from both clinical and economic standpoints. The economic and clinical data presented here reinforce the need for additional research and strategies for healthcare providers to minimize SCS infections. Future economic research is needed to further define the specific economic cost drivers associated with the extensive expenditure burden.

Cost effectiveness of Glove Endobag in Laparoscopic Cholecystectomy: Review of the available literature.

Laparoscopic cholecystectomy is the most common procedure performed worldwide and remains the gold standard for symptomatic gallstones. The most common complication obser ved during this procedure is gallbladder perforation resulting in spillage of stones and bile into peritoneal cavity. In order to avoid such complications, gallbladder is commonly extracted in an endobag. The current literature review was conducted to assess the efficacy and cost-effectiveness of glove endobags. PubMed and Google Scholar databses were searched to find relevant studies from January 1990 to December 2017. Search terms used were 'glove endobag' and 'laparoscopic cholecystectomy'. Literature suggests glove endobag is an effective and comparatively inexpensive compared to commercially prepared endobags.