What is the likely impact on surgical site infections in Australian hospitals if smoking rates are reduced? A cost analysis

INTRODUCTION

Assisting smokers to quit before surgery reduces surgical site infection (SSI) risk. The short-term economic benefits of reducing SSIs by embedding tobacco dependence treatment in Australian hospitals are unknown. Estimated annual number of SSIs prevented, and hospital bed-days (HBD) and costs saved from reducing smoking before surgery are calculated.

METHODS

The most recent number of surgical procedures and SSI rates for Australia were sourced. The number of smokers and non-smokers having a SSI were calculated using the UK Royal College of Physicians reported adjusted odds ratio (1.79), and the proportion of SSIs attributable to smoking calculated. The potential impact fraction was used to estimate reductions in SSIs and associated HBDs and costs from reducing the smoking rates among surgical patients from 23.9% to 10% or 5% targets. Uncertainty around the final estimates was calculated using probabilistic sensitivity analysis.

RESULTS

In 2016-17, approximately 40,593 (95% UI 32,543, 50,239) people having a surgical procedure in Australia experienced a SSI leading to 101,888 extra days (95% UI 49,988, 200,822) in hospital. If the smoking rate among surgical patients was reduced to 10%, 3,580 (95% UI 2,312, 5,178) SSIs would be prevented, and 8,985 (95% UI 4,094, 19,153) HBDs and $19.1M (95% UI $7.7M, $42.5M) saved in one year. If the smoking rate was reduced to 5%, 4,867 (95% UI 3,268, 6,867) SSIs would be prevented, and 12,217 (95% UI 5,614, 25,642) HBDs and $26.0M (95% UI $10.8M, $57.0M) would be saved.

CONCLUSIONS

The findings suggest achieving smoking rate targets of 10% or 5% would provide substantial short-term health and economic benefits through reductions in SSIs. Embedding tobacco dependence treatment in Australian hospitals would provide value for money by reducing costs and improving clinical quality and safety. A more comprehensive, modelled economic evaluation synthesising the best available evidence is needed to confirm findings.

Health-related quality of life in patients with inoperable malignant bowel obstruction: secondary outcome from a double-blind, parallel, placebo-controlled randomised trial of octreotide

Background

This analysis aims to evaluate health-related quality of life (HrQoL) (primary outcome for this analysis), nausea and vomiting, and pain in patients with inoperable malignant bowel obstruction (IMBO) due to cancer or its treatments randomised to standardised therapies plus octreotide or placebo over a maximum of 72 h in a double-blind clinical trial.

Methods

Adults with IMBO and vomiting recruited through 12 services spanning inpatient, consultative and community settings in Australia were randomised to subcutaneous octreotide infusion or saline. HrQoL was measured at baseline and treatment cessation (EORTC QLQ-C15-PAL). Mean within-group paired differences between baseline and post-treatment scores were analysed using Wilcoxon Signed Rank test and between group differences estimated using linear mixed models, adjusted for baseline score, sex, age, time, and study arm.

Results

One hundred six of the 112 randomised participants were included in the analysis (n = 52 octreotide, n = 54 placebo); 6 participants were excluded due to major protocol violations. Mean baseline HrQoL scores were low (octreotide 22.1, 95% CI 14.3, 29.9; placebo 31.5, 95% CI 22.3, 40.7). There was no statistically significant within-group improvement in the mean HrQoL scores in the octreotide (p = 0.21) or placebo groups (p = 0.78), although both groups reported reductions in mean nausea and vomiting (octreotide p < 0.01; placebo p = 0.02) and pain scores (octreotide p < 0.01; placebo p = 0.03). Although no statistically significant difference in changes in HrQoL scores between octreotide and placebo were seen, an adequately powered study is required to fully assess any differences in HrQoL scores.

Conclusion

The HrQoL of patients with IMBO and vomiting is poor. Further research to formally evaluate the effects of standard therapies for IMBO is therefore warranted.

Trial registration

Australian New Zealand Clinical Trials Registry ACTRN12608000211369 (date registered 18/04/2008)

Supplementary Information

The online version contains supplementary material available at 10.1186/s12885-020-07549-y.

Economic evaluation of the randomised, double-blind, placebo-controlled study of subcutaneous ketamine in the management of chronic cancer pain

Background:

Treating chronic, uncontrolled, cancer pain with subcutaneous ketamine in patients unresponsive to opioids and co-analgesics remains controversial, especially in light of recent evidence demonstrating ketamine does not have net clinical benefit in this setting.

Aim:

To evaluate the cost-effectiveness of subcutaneous ketamine versus placebo in this patient population.

Design and setting:

A within-trial cost-effectiveness analysis of the Australian Palliative Care Clinical Studies Collaborative’s randomised, double-blind, placebo-controlled trial of ketamine was conducted from a healthcare provider perspective. Mean costs and outcomes were estimated from participant-level data over 5 days including positive response, health-related quality of life (HrQOL) measured with the Functional Assessment of Chronic Illness Therapy–Palliative Care (FACIT-Pal), ketamine costs, medication usage and in-patient stays.

Results:

There was no statistically significant difference in responder rates, but higher toxicity and worse HrQOL for ketamine participants (mean change −3.10 (standard error (SE) 1.76), ketamine n = 93; 4.53 (SE 1.38), placebo n = 92). Estimated total mean costs were AU$706 higher per ketamine participant (AU$6608) compared with placebo (AU$5902), attributable to the cost of higher in-patient costs as well as costs of ketamine administration. The results were robust to sensitivity analyses accounting for different medication use costing methods and removal of cost outliers.

Conclusion:

The findings suggest subcutaneous ketamine in conjunction with opioids and standard adjuvant therapy is neither an effective nor cost-effective treatment for refractory pain in advanced cancer patients.

Clinician-reported changes in octreotide prescribing for malignant bowel obstruction as a result of an adequately powered phase III study: A transnational, online survey

BACKGROUND

Translating research evidence into clinical practice often has a long lag time.

AIM

To determine the impact of a phase III randomised controlled trial on palliative care clinicians' self-reported practice change.

DESIGN

Online survey about use of octreotide in managing inoperable malignant bowel obstruction due to cancer or its treatments distributed in November 2016, 2 years after the first publication of the study in a peer-reviewed journal. Demographic, self-reported practice and the reasons underpinning this were collected. Responses were aggregated to 'practice modified' or 'practice not modified'. A multinomial regression model explored predictors of practice change.

SETTING

Members of the Australian New Zealand Society of Palliative Medicine.

RESULTS

Response rate was 20.8% (106/509): 55.6% were aged >50 years, 56.5% were female and 77% had previously prescribed octreotide for this clinical indication. Out of 106 respondents, 52 (49.1%) indicated modified practice (60.9% of those who had previously prescribed octreotide in this setting). In those who reported practice change, most frequently octreotide was now used when other therapies failed; for not changing practice, 'more confirmatory evidence was needed' was most often cited. In the regression model, older age (clinician age = 50-59 years; relative risk = 0.147; 95% confidence interval = 0.024-0.918; p = 0.04) and having practices with lower proportions of people treated with octreotide (0%-20%; relative risk = 0.039; 95% confidence interval = 0.002-0.768; p = 0.033) predicted greater self-reported practice change.

CONCLUSION

Clinician-reported change in practice in the survey is seen in the majority of respondents. This suggests that there is a cohort of 'early adopters' within palliative care practice as new evidence becomes available.

Seizure-related hospital admissions, readmissions and costs: Comparisons with asthma and diabetes in South Australia

PURPOSE

Seizures are listed as an Ambulatory Care Sensitive Condition (ACSC), where, in some cases, hospitalisation may be avoided with appropriate preventative and early management in primary care. We examined the frequencies, trends and financial costs of first and subsequent seizure-related hospital admissions in the adult and paediatric populations, with comparisons to bronchitis/asthma and diabetes admissions in South Australia between 2012 and 2014.

METHODS

De-identified hospital separation data from five major public hospitals in metropolitan South Australia were analysed to determine the number of children and adults admitted for the following Australian Refined Diagnosis Related Groups: seizure related conditions; bronchitis/asthma; and diabetes. Additional data included length of hospital stay and type of admission. Demographic data were analysed to identify whether social determinants influence admission, and a macro costing approach was then applied to calculate the financial costs to the Health Care System.

RESULTS

The rate of total seizure hospitalizations was 649 per 100,000; lower than bronchitis/asthma (751/100,000), yet higher than diabetes (500/100,000). The highest proportions of subsequent separations were recorded by children with seizures regardless of complexity (47% +CSCC; 17% -CSCC) compared with asthma (11% +CSCC; 14% -CSCC) or diabetes (14% +CSCC; 13% -CSCC), and by adults with seizures with catastrophic or severe complications/comorbidity (25%), compared with diabetes (22%) or asthma (14%). The mean cost per separation in both children and adults was highest for diabetes (AU$4438/$7656), followed by seizures (AU$2408/$5691) and asthma (AU$2084/$3295).

CONCLUSIONS

Following the lead of well-developed and resourced health promotion initiatives in asthma and diabetes, appropriate primary care, community education and seizure management services (including seizure clinics) should be targeted in an effort to reduce seizure related hospitalisations which may be avoidable, minimise costs to the health budget, and maximise health care quality.