Corrigendum to "Incidence and impact of surgical site infections on length of stay and cost of care for patients undergoing open procedures" [Surg Open Sci (2023) 1-18/ISSN 2589-8450].

[This corrects the article DOI: 10.1016/j.sopen.2022.10.004.].

Incidence and impact of surgical site complications on length of stay and cost of care for patients undergoing open procedures.

Background: Surgical site complications (SSCs) can have serious and life-threatening consequences for patients; however, their frequency and impact on healthcare utilization across surgical procedures, particularly for non-infectious SSCs, are unknown. This study examined incidence of overall SSCs and non-infectious SSCs in patients undergoing open surgical procedures in the United States and their effect on length of stay (LOS) and costs. Methods: This retrospective study utilizing 2019-2020 data from Medicare and Premier Health Database identified patients with SSCs during hospitalization or within 90 days of discharge. Propensity score matching was used to calculate incremental LOS and costs attributable to SSCs. Mean LOS and costs attributable to SSCs for the index admission, readmissions, and outpatient visits were summed by procedure and Charlson Comorbidity Index score to estimate the overall impact of an SSC on LOS and costs across healthcare settings. Results: Overall and non-infectious SSC rates were 7.3 % and 5.3 % respectively for 2,696,986 Medicare and 6.7 % and 5.0 % for 1,846,254 Premier open surgeries. Total incremental LOS and cost per SSC were 7.8 days and $15,339 for Medicare patients and 6.2 days and $17,196 for Premier patients. Incremental LOS and cost attributable to non-infectious SSCs were 6.5 days and $12,703 and 5.2 days and $14,477 for Medicare and Premier patients respectively. Conclusions: This study utilizing two large national databases provides strong evidence that SSCs, particularly non-infectious SSCs, are not uncommon in open surgeries and result in increased healthcare utilization and costs. These findings demonstrate the need for increased adoption of evidence-based interventions that can reduce SSC rates.

Incidence and impact of surgical site infections on length of stay and cost of care for patients undergoing open procedures.

Background: Surgical site infections (SSIs) are associated with increased morbidity and mortality; however, current SSI rates across open procedures and their effect on healthcare delivery are unknown. The objective of this study was to examine incidence of SSIs for open surgical procedures in the United States and impact on length of stay (LOS) and costs. Methods: This retrospective study utilizing 2019-2020 data from Medicare and Premier identified patients with SSIs occurring during hospitalization or within 90 days of discharge. Propensity score matching was used to calculate incremental LOS and costs attributable to SSIs. Mean LOS and costs attributable to SSIs for the index admission, readmissions, and outpatient visits were summed by procedure and Charlson Comorbidity Index score to estimate the overall impact of an SSI on LOS and costs across healthcare settings. Results: SSI rates were 2.0% for 2,696,986 Medicare and 1.8% for 1,846,254 Premier open surgeries. Total incremental LOS and cost per SSI, including index admission, readmissions, and outpatient visits were 9.3 days and $18,626 for Medicare patients and 7.8 days and $20,979 for Premier patients. SSI rates were higher for urgent/emergency surgeries compared to overall SSI rates. Although less common that superficial SSIs, deep SSIs resulted in higher incremental LOS and index costs for the index admission and for SSI-related readmissions. Conclusions: This study of SSIs utilizing two large national databases provides robust data and analytics reinforcing and bolstering current evidence that SSIs occur infrequently but are detrimental to patients in terms of increased LOS and care costs.

The effect of timing of instillation therapy on outcomes and costs for patients receiving negative pressure wound therapy.

INTRODUCTION: Although NPWTi-d has been associated with improved patient outcomes compared with NPWT alone, questions remain regarding the timing of NPWTi-d initiation. OBJECTIVE: This study examined the effect of the timing of NPWTi-d initiation on patient outcomes and costs. METHODS: A retrospective analysis was conducted utilizing a national, all-payer hospital database and included patients who received NPWTi-d in 2019. A matched cohort of 514 patients who received either early (within 1 day of NPWT application) or late (within 2-7 days of NPWT application) NPWTi-d initiation was created using propensity scoring. Differences in clinical outcomes and costs were compared using Wilcoxon rank sum, chi-square, and t tests. RESULTS: Early NPWTi-d initiation was associated with significantly shorter NPWT duration (7.0 vs. 11.4 days; P <.0001) and inpatient stay (13.4 vs. 16.3 days; P <.0001) compared with late NPWTi-d initiation. Early NPWTi-d initiation was also associated with fewer debridements, OR visits during hospitalization, days until final OR procedure, and wound-related readmissions. Patients with early NPWTi-d initiation had a $10 877 lower mean cost of index admission (P <.0001), which included lower NPWT costs. CONCLUSION: Study data suggest that in these patients with wounds, early NPWTi-d initiation helped improve patient outcomes and reduced care costs.

Embedded Health Systems Science as a driver of care improvement within an integrated delivery organization.

BACKGROUND: Embedded Health Systems Science (HSS) has the potential to reduce gaps between research and delivery of evidence-based medicine. Models are needed to guide the development of embedded HSS in health care delivery organizations particularly with the rise of value-based care. METHODS: The development of HSS infrastructure at a large nonprofit health care delivery organization is described, along with an embedded HSS diabetes study to illustrate the integration of program specific data, electronic health records, and health care system data infrastructure. To compare diabetes outcomes across four evidenced-based programs, a control group was developed from EHR data using propensity score matching. Mixed effect adjusted models were used to estimate reductions in hemoglobin A1c (HbA1c) and body weight. RESULTS: Adjusted analyses using an EHR derived comparison group demonstrated significantly different findings than unadjusted pre to post analyses. The embedded HSS study indicates that appropriate statistical methods, staff with required expertise, and integration with health system data infrastructure are needed to develop timely and rigorous HSS outcomes that effectively improve patient care. CONCLUSIONS: Embedded HSS has the potential to inform value-based care models and contribute to evidence-based medicine approaches that improve patient care. Although developing system wide integrated data structures and staff with the appropriate skills requires substantial effort, the outcome is more reliable evaluations that lead to higher quality and higher value care. IMPLICATIONS: Health care delivery organizations can improve patient care by dedicating resources to embed HSS into its routine operations.

Evaluating the Cost-Effectiveness of the ABCDE Bundle: Impact of Bundle Adherence on Inpatient and 1-Year Mortality and Costs of Care.

OBJECTIVES: Growing evidence supports the Awakening and Breathing Coordination, Delirium monitoring/management, and Early exercise/mobility (ABCDE) bundle processes as improving a number of short- and long-term clinical outcomes for patients requiring ICU care. To assess the cost-effectiveness of this intervention, we determined the impact of ABCDE bundle adherence on inpatient and 1-year mortality, quality-adjusted life-years, length of stay, and costs of care. DESIGN: We conducted a 2-year, prospective, cost-effectiveness study in 12 adult ICUs in six hospitals belonging to a large, integrated healthcare delivery system. SETTING: Hospitals included a large, urban tertiary referral center and five community hospitals. ICUs included medical/surgical, trauma, neurologic, and cardiac care units. PATIENTS: The study included 2,953 patients, 18 years old or older, with an ICU stay greater than 24 hours, who were on a ventilator for more than 24 hours and less than 14 days. INTERVENTION: ABCDE bundle. MEASUREMENTS AND MAIN RESULTS: We used propensity score-adjusted regression models to determine the impact of high bundle adherence on inpatient mortality, discharge status, length of stay, and costs. A Markov model was used to estimate the potential effect of improved bundle adherence on healthcare costs and quality-adjusted life-years in the year following ICU admission. We found that patients with high ABCDE bundle adherence (≥ 60%) had significantly decreased odds of inpatient mortality (odds ratio 0.28) and significantly higher costs ($3,920) of inpatient care. The incremental cost-effectiveness ratio of high bundle adherence was $15,077 (95% CI, $13,675-$16,479) per life saved and $1,057 per life-year saved. High bundle adherence was associated with a 0.12 increase in quality-adjusted life-years, a $4,949 increase in 1-year care costs, and an incremental cost-effectiveness ratio of $42,120 per quality-adjusted life-year. CONCLUSIONS: The ABCDE bundle appears to be a cost-effective means to reduce in-hospital and 1-year mortality for patients with an ICU stay.

Association of Opioid-Related Adverse Drug Events With Clinical and Cost Outcomes Among Surgical Patients in a Large Integrated Health Care Delivery System.

Importance: Opioids are commonly used for pain control during and after invasive procedures. However, opioid-related adverse drug events (ORADEs) are common and have been associated with worse patient outcomes. Objectives: To examine the incidence of ORADEs in patients undergoing hospital-based surgical and endoscopic procedures and to evaluate the association of ORADEs with clinical and cost outcomes. Design, Setting, and Participants: In this retrospective study of clinical and administrative data, ORADEs were identified using International Classification of Diseases, Ninth Revision diagnosis codes for known adverse effects of opioids or by opioid antagonist use. Multivariable regression analysis was used to measure the association of ORADEs with outcomes after adjusting for potential confounding factors. The setting was 21 acute care hospitals in a large integrated health care delivery system. Participants were 135 379 patients (aged ≥18 years, admitted from January 1, 2013, to September 30, 2015) who underwent surgical and endoscopic procedures and were given opioids. Exposure: Opioid use, reported as morphine milligram equivalent doses. Main Outcomes and Measures: Opioid-related adverse drug events and their association with inpatient mortality, discharge to another care facility, length of stay, cost of hospitalization, and 30-day readmission. Results: Among 135 379 adult patients in this study (67.5% female), 14 386 (10.6%) experienced at least one ORADE. Patients with ORADEs were more likely to be older, of white race/ethnicity, and male and have more comorbidities. Patients with ORADEs received a higher total dose of opioids (median morphine milligram equivalent dose, 46.8 vs 30.0 mg; P < .001) and for a longer duration (median, 3.0 vs 2.0 days; P < .001). In adjusted analyses, ORADEs were associated with increased inpatient mortality (odds ratio [OR], 28.8; 95% CI, 24.0-34.5), greater likelihood of discharge to another care facility (OR, 2.9; 95% CI, 2.7-3.0), prolonged length of stay (OR, 3.1; 95% CI, 2.8-3.4), high cost of hospitalization (OR, 2.7; 95% CI, 2.4-3.0), and higher rate of 30-day readmission (OR, 1.3; 95% CI, 1.2-1.4). ORADEs were associated with a 2.9% increase in absolute mortality, an $8225 increase in cost for the index hospitalization, and a 1.6-day increase in length of stay for the index hospitalization. Conclusions and Relevance: Opioid-related adverse drug events were common among patients undergoing hospital-based invasive procedures and were associated with significantly worse clinical and cost outcomes. Hospital-acquired harm from ORADEs in the surgical patient population is an important opportunity for health systems to improve patient safety and reduce cost.

A Review of Multifaceted Care Approaches for the Prevention and Mitigation of Delirium in Intensive Care Units.

OBJECTIVE: The objective of this review is to examine the effectiveness, implementation, and costs of multifaceted care approaches, including care bundles, for the prevention and mitigation of delirium in patients hospitalized in intensive care units (ICUs). DATA SOURCES: A systematic search using Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines was conducted utilizing PubMed, EMBASE, and CINAHL. Searches were limited to studies published in English from January 1, 1988, to March 31, 2014. Randomized controlled trials and comparative studies of multifaceted care approaches with the reduction of delirium in ICU patients as an outcome and evaluations of the implementation or cost-effectiveness of these interventions were included. DATA EXTRACTION: Data on study methods including design, cohort size, interventions, and outcomes were abstracted, reviewed, and summarized. Given the variability in study design, populations, and interventions, a qualitative review of findings was conducted. DATA SYNTHESIS: In all, 14 studies met our inclusion criteria: 6 examined outcomes, 5 examined implementation, 2 examined outcomes and implementation, and 1 examined cost-effectiveness. The majority of studies indicated that multifaceted care approaches were associated with improved patient outcomes including reduced incidence and duration of delirium. Additionally, improvements in functional status and reductions in coma and ventilator days, hospital length of stay, and/or mortality rates were observed. Implementation strategies included structured quality improvement approaches with ongoing audit and feedback, multidisciplinary care teams, intensive training, electronic reporting systems, and local support teams. The cost-effectiveness analysis indicated an average reduction of $1000 in hospital costs for patients treated with a multifaceted care approach. CONCLUSION: Although multifaceted care approaches may reduce delirium and improve patient outcomes, greater improvements may be achieved by deploying a comprehensive bundle of care practices including awakening and breathing trials, delirium monitoring and treatment, and early mobility. Further research to address this knowledge gap is essential to providing best care for ICU patients.

Effectiveness of a community health worker-led diabetes self-management education program and implications for CHW involvement in care coordination strategies.

PURPOSE: The purpose of this study was to evaluate the effectiveness of a Community Health Worker (CHW)-led diabetes self-management education (DSME) program and to understand how CHWs and primary care providers (PCPs) work together to provide comprehensive diabetes care. METHODS: A quantitative pre- and postassessment of change in patients' blood glucose levels (A1C), blood pressure, and body mass index was performed to determine the clinical effectiveness of the program. Qualitative, semi-structured interviews with 5 CHWs and 7 PCPs were conducted to assess how CHWs were incorporated into clinical teams and their impact on care delivery and diabetes-related outcomes. RESULTS: Patients who participated in the program experienced a statistically significant decrease in mean A1C levels and systolic blood pressure readings 1 year post baseline. CHWs provided high-quality care and bridged the gap between patients and care providers through diabetes management support and education, medication assistance, access to community resources, and social support. CONCLUSIONS: CHWs play a variety of roles in helping patients overcome barriers to diabetes control and can be successfully integrated into a health care system's care coordination strategy.

Effective strategies to improve the management of diabetes: case illustration from the diabetes health and wellness institute.

Many patients with diabetes do not have access to clinical care or medications, resulting in cases of undiagnosed diabetes or uncontrolled diabetes, especially in patients of low socioeconomic status. Given these considerations, new strategies are needed to control the rampant growth of diabetes and prevent new cases. This article discusses effective strategies for improving the management of diabetes in underserved populations, with special reference to the Juanita J. Craft Diabetes Health and Wellness Institute, a unique partnership between a large, urban integrated health care system, the City of Dallas, and a South Dallas community.