Economic impact of cardiac implantable electronic device infections: cost analysis at one year in a large U.S. health insurer

Aims: Cardiac device infections (CDIs) are serious adverse events associated with morbidity and mortality, significant costs and increased healthcare utilization. The objective of the current study was to characterize the CDI rate by device type, risk factors for infection and healthcare costs from a large U.S. health insurer perspective.Materials and Methods: A retrospective analysis of a large U.S. health insurer database identified commercial and Medicare Advantage with Part D (MAPD) members ≥18 years with ≥1 claim for a cardiac implantable electronic device (CIED) procedure between 01 October 2011 and 31 October 2015. CIEDs included pacemakers (IPG), implantable cardioverter defibrillators (ICDs), and cardiac resynchronization therapy - pacemakers without (CRT-P) and with defibrillation (CRT-D). Probabilities of CDI through one-year post implant were estimated using the Kaplan-Meier method. A regression model with stepwise variable selection was used to select risk factors associated with CDIs.Results: A total of 63,406 patients were included with an overall CDI rate of 1.28% (1.0% de novo and 1.74% replacement devices), varying by device type: IPG = 0.91%; ICD = 1.63%; CRT-p = 1.50%; CRT-D = 2.22%. The average adjusted annual medical costs were 2.4 times greater [95% confidence interval (CI) = 2.1-2.7] for those with an infection compared to those without, and the incremental cost difference was estimated to be $57,322 [95% CI $46,572-$70,484]. Observed risk factors of CDIs included prior device infection [Odds ratio (OR) = 11.356; 95% CI = 7.923-16.276], undergoing a CIED replacement procedure (OR = 1.644; 95% CI = 1.361-1.987), implantation of a high-power device (OR = 1.354; 95% CI = 1.115-1.643), and younger age (age < 65) (OR = 1.607; 95% CI = 1.307-1.976).Conclusions: The CDI rate at one year ranged from 0.91%-2.22% depending on device type. Management of CDIs among commercial and MAPD members is associated with high healthcare expenditures.

Prevalence and burden of orthopaedic implantable-device infections in Italy: a hospital-based national study

BACKGROUND

Healthcare-associated infections (HAIs) represent a serious burden to individual safety and healthcare sustainability. Identifying which patients, procedures and settings are most at risk would offer a significant contribution to HAI management and prevention. The purpose of this study is to estimate 1) orthopaedic implantable device-related infection (OIDRI) prevalence in Italian hospitals and 2) the gap between the remuneration paid by the Italian healthcare system and the real costs sustained by Italian hospitals to treat these episodes.

METHODS

This is a cross-sectional study based on hospital discharge forms registered in 2012 and 2014. To address the first goal of this study, the national database was investigated to identify 1) surgical procedures associated with orthopaedic device implantation and 2) among them, which patient characteristics (age, sex), type of admission, and type of discharge were associated with a primary diagnosis of infection. To address the second goal, 1) each episode of infection was multiplied by the remuneration paid by the Italian healthcare system to the hospitals, based on the diagnosis-related group (DRG) system, and 2) the total days of hospitalization required to treat the same episodes were multiplied by the average daily cost of hospitalization, according to estimates from the Ministry of the Economy and Finance (MEF).

RESULTS

In 2014, 1.55% of the total hospitalizations for orthopaedic device implantation procedures were associated with a main diagnosis of infection, with a negligible increase of 0.04% compared with 2012. Hip and knee replacement revisions, male patients and patients older than 65 years were more exposed to infection. A total of 51.63% of patients were planned admissions to the hospital, 68.75% had an ordinary discharge to home, and 0.9% died. The remuneration paid by the healthcare system to the hospitals was € 37,519,084 in 2014, with 3 DRGs covering 70.6% of the total. The cost of the actual days of hospitalization to treat these episodes was 17.5 million more than the remuneration received.

CONCLUSIONS

The OIDRI prevalence was lower than that described in recent surveys in acute care settings, although the numbers were likely underestimated. The cost of treatment varied significantly depending on the remuneration system adopted.

Economic impact of introducing TYRX amongst patients with heart failure and reduced ejection fraction undergoing implanted cardiac device procedures: a retrospective model based cost analysis

BACKGROUND AND AIMS

Infection is a serious and expensive complication of Cardiac Implantable Electronic Device (CIED) procedures. A retrospective based cost analysis was performed to estimate Trust level savings of using the TYRX antibacterial envelope as a primary prevention measure against infection in a tertiary referral centre in South London, UK.

METHODS

A retrospective cohort of heart failure patients with reduced ejection fraction undergoing Implantable Cardioverter Defibrillator (ICD) or Cardiac Resynchronization Therapy (CRT) procedures were evaluated. Decision-analytic modelling was performed to determine economic savings of using the envelope during CIED procedure vs CIED procedure alone.

RESULTS

Over a 12 month follow-up period following CIED procedure, the observed infection rate was 3.14% (n = 5/159). The average cost of a CIED infection inpatient admission was £41,820 and, further to economic analysis, the additional costs attributable to infection was calculated at £62,213.94. A cost saving of £624 per patient by using TYRX during CIED procedure as a primary preventative measure against infection was estimated.

CONCLUSIONS

TYRX would be a cost-saving treatment option amongst heart failure patients undergoing ICD and CRT device procedures based on analysis in the local geographical area of South London. If upscaled to the UK population, we estimate potential cost savings for the National Health Service (NHS).

2018 International Consensus Meeting on Musculoskeletal Infection: Research Priorities from the General Assembly Questions

Musculoskeletal infections (MSKI) remain the bane of orthopedic surgery, and result in grievous illness and inordinate costs that threaten healthcare systems. As prevention, diagnosis, and treatment has remained largely unchanged over the last 50 years, a 2nd International Consensus Meeting on Musculoskeletal Infection (ICM 2018, https://icmphilly.com) was completed. Questions pertaining to all areas of MSKI were extensively researched to prepare recommendations, which were discussed and voted on by the delegates using the Delphi methodology. The questions, including the General Assembly (GA) results, have been published (GA questions). However, as critical outcomes include: (i) incidence and cost data that substantiate the problems, and (ii) establishment of research priorities; an ICM 2018 research workgroup (RW) was assembled to accomplish these tasks. Here, we present the result of the RW consensus on the current and projected incidence of infection, and the costs per patient, for all orthopedic subspecialties, which range from 0.1% to 30%, and $17,000 to $150,000. The RW also identified the most important research questions. The Delphi methodology was utilized to initially derive four objective criteria to define a subset of the 164 GA questions that are high priority for future research. Thirty-eight questions (23% of all GA questions) achieved the requisite > 70% agreement vote, and are highlighted in this Consensus article within six thematic categories: acute versus chronic infection, host immunity, antibiotics, diagnosis, research caveats, and modifiable factors. Finally, the RW emphasizes that without appropriate funding to address these high priority research questions, a 3rd ICM on MSKI to address similar issues at greater cost is inevitable.

Does pin tract infection after external fixator limits its advantage as a cost-effective solution for open fractures in low-middle income countries, a prospective cohort study

OBJECTIVE

To determine the frequency of pin tract infection in external fixator tibia and its effects on the definite fracture fixation and bone healing.

Methods

The prospective study was conducted at Lady Reading Hospital, Peshawar, Pakistan, from August 2017 to July 2018, and comprised patients regardless of age and gender with open fracture tibia Gustillo-Anderson type II and type IIIA. Pin tract infection was assessed following the application of locally made external fixation of tibia open fractures. Follow-up was done fortnightly till soft tissue healing, removal of external fixator and definite fracture healing. Pin tract infection was classifiedand treated according to the Checketts-Otterburn classification system. SPSS 20 was used for data analysis.

Results

Of the 117 patients, 95(81%) were males and 22(19%) were females with an overall mean age of 24.7±9.35 years. Pin tract infection was documented in 28(23.9%) patients. Minor and major pin tract infections were reported in 27(96.4%) and 1(3.5%) patient respectively. Soft tissues healed in 27(96.4%) cases.

Conclusion

External fixator for initial stabilisation of open tibial fractures in all patients is recommended..

Cardiac implantable electronic device (CIED) infections are expensive and associated with prolonged hospitalisation: UK Retrospective Observational Study

Background

There are limited reports outlining the financial cost of treating cardiac implantable electronic device (CIED) infection outside the United States. This study aimed to determine the average treatment cost of CIED infection in a large UK tertiary referral centre and compared costs of different treatment pathways that are recognised in the management of CIED infection (early versus delayed re-implantation).

Methods

We retrospectively analysed cost and length of stay (LOS) data for consecutive patients undergoing infected CIED extraction with cardiac resynchronization therapy (CRT-D [with defibrillator], CRT-P [with pacemaker]), implantable cardioverter-defibrillators (ICDs) and permanent pacemakers (PPMs).

Results

Between January 2013 and March 2015, complete data was available for 84 patients (18 [21.4%] CRT-D, 24 [28.6%] ICDs and 42 [50.0%] PPMs). When all cases were considered the cost of infection ranged from £5,139 (PPM) to £24,318 (CRT-D). Considering different treatment strategies; 41 (48.8%) underwent CIED extraction and re-implantation during the same admission (early re-implant strategy (ER). 43 (51.2%) underwent extraction, but were then discharged home to be re-admitted for day-case re-implantation (delayed re-implant strategy (DR)). Median LOS was significantly shorter in DR compared to ER (5.0 vs. 18.0 days, p<0.001). The total cost of CIED infection episode was similar for both treatment strategies (median £14,241.48 vs. £14,741.70 including wearable defibrillator (Lifevest) and outpatient antibiotics costs, ER vs. DR; p = 0.491).

Conclusion

CIED infections are expensive and associated with significant health-economic burden. When all device types were considered, a DR strategy is associated with reduced LOS without an increased cost penalty.

[Economic Analysis of the Costs of Hospital Stay of Patients with Infection as a Complication of Total Replacements - Part 1: Total Knee Arthroplasty]

PURPOSE OF THE STUDY The study aims to quantify the costs of a hospital stay of patients with total knee periprosthetic joint infection throughout the period of treatment. MATERIAL AND METHODS The group included patients who have been treated at our department for infection as a complication of total knee replacement since 1 January 2011, who have been provided with treatment (including complications) exclusively at the departments of Nemocnice České Budějovice, a.s. and whose treatment can be considered completed in 2018. The patients were included in the study regardless of the type of infection and method of treatment. The group consisted of 24 patients (11 men and 13 women). There were 2 cases of early postoperative infection, 6 cases of late postoperative infection and 16 cases of hematogenous infection. The group includes 17 patients treated by a two-stage reimplantation, 6 patients treated by a revision surgery with implant retention, and 1 patient treated by a one-stage replacement. In selected patients, all the reported points for all the hospital stays and costs incurred on a separately charged material were ascertained and the final sum was compared with the reimbursement obtained by the hospital in the DRG system valid for the respective year of treatment. The total costs were analysed and moreover, an analysis by type of infection and method of treatment was carried out. RESULTS The average costs of managing infection as a complication of TKA in our department amounted to CZK 405 864 (CZK 66 768-CZK 181 17). The average cost of a two-stage revision was CZK 497 487, the cost of a revision surgery with original implant retention was CZK 175 312. The reimbursement in respect of the monitored cases in the DRG system equalled CZK 276 230 (CZK 40 943-CZK 848 401). The aforementioned suggests that the average loss per a treated patient is CZK 129 635 (CZK + 26 066Kč-CZK -332 774). DISCUSION Our study is in agreement with recent literature, when confirming that the care associated with infections as a complication of TKA is very costly (especially in case of a two-stage reimplantation) and also that this care is not fully covered by the health insurance company. The reimbursement made by the health insurance companies does not cover on average 1/3 of the costs of care for an infectious patient. Theoretically, the reasons behind the reduced reimbursement may be sanctions which, however, cannot be accepted in case of late hematogenous infections which constituted more than 50% in our group. CONCLUSIONS Our study presented the actual costs associated with the care of TKA infection. It makes sense that the most expensive is the two-stage reimplantation, which is nevertheless still considered to be the gold standard procedure in chronic TKA infection. High costs of therapy together with the requirement of expert care would justify the introduction of care provided by specialised centres. In this case, centralisation could result in a more efficient use of funds and improvement of the quality of provided care. Key words:total knee arthroplasty, PJI - periprostetic joint infection, economic analysis. ÚVOD.

[Economic Analysis of the Costs of Hospital Stay of Patients with Infection as a Complication of Total Replacements - Part 2: Total Hip Arthroplasty]

PURPOSE OF THE STUDY The study aims to quantify the costs of a hospital stay of patients with periprosthetic joint infection after total hip arthroplasty throughout the period of treatment. MATERIAL AND METHODS The group included patients who have been treated at our department for infection as a complication of total hip replacement since 1 January 2011, who have been provided with treatment (including complications) exclusively at the departments of Nemocnice České Budějovice, a.s. and whose treatment can be considered completed in 2019. The patients were included in the study regardless of the type of infection and method of treatment. The group consisted of 36 patients (16 men and 20 women). There were 3 cases of early postoperative infection, 14 cases of late postoperative infection and 19 cases of hematogenous infection. The group includes 8 patients treated by a one-stage reimplantation, 19 patients managed by a two-stage reimplantation, 6 patients treated by a revision surgery with implant retention, and 3 patients in whom only the implant removal was possible. In selected patients, all the reported points for all the hospital stays and costs incurred on a separately charged material were ascertained and the final sum was compared with the reimbursement obtained by the hospital in the DRG system valid for the respective year of treatment. The total costs were analysed and also an analysis by type of infection and method of treatment was carried out. RESULTS The average costs of managing infection as a complication of total hip arthroplasty at our department amounted to CZK 320 065 (CZK 56 995 - CZK 953 614), the reimbursement in respect of the monitored cases in the DRG system equalled CZK 220 503 (CZK 89 149 - CZK 589 974). The aforementioned suggests that the average loss per treated patient is CZK 99 562 (CZK + 63 372 - CZK -428 499). DISCUSION Care associated with infections as a complication of total hip arthroplasty is very costly and these costs are not fully covered by the reimbursement from the health insurance companies. In the Czech Republic, these costs have not been quantified as yet, therefore it is only possible to compare the costs with international publications arriving at similar conclusions and with own monitoring of the costs of periprosthetic joint infections after total hip arthroplasty. The most economically efficient is the one-stage replacement which, however, is not suitable for all the patients, and the two-stage reimplantation continues to be the gold standard. In our study, the most expensive was found to be the treatment of periprosthetic joint infection after total hip arthroplasty, in which also the highest financial loss is reported. CONCLUSIONS Due to the very high costs of treatment for periprosthetic joint infections after total hip arthroplasty, it is necessary to exert maximum efforts to prevent periprosthetic joint infections and to consider a change in the method of financing, particularly in centres to which patients are referred from other centres in order to make this treatment economically viable. Key words:total hip arthroplasty, PJI - periprosthetic joint infection, economic analysis.

Dalbavancin in the treatment of different gram-positive infections: a real-life experience

Dalbavancin is a lipoglycopeptide with a very prolonged half-life enabling treatment with a single intravenous administration that has been approved to treat complicated skin and soft-tissue infections. Information on the efficacy and safety of dalbavancin in other situations is very scarce. This retrospective study included adult patients who received at least one dose of dalbavancin between 2016 and 2017 in 29 institutions in Spain. The primary objective was to report the use of dalbavancin in clinical practice, including its efficacy and tolerability. The potential impact of dalbavancin on reducing the length of hospital stay and hospital costs was also evaluated. A total of 69 patients received dalbavancin during the study period (58.0% male; median age 63.5 years). Dalbavancin was used to treat prosthetic joint infection (29.0%), acute bacterial skin and skin-structure infection (21.7%), osteomyelitis (17.4%) and catheter-related bacteraemia (11.6%). These infections were mainly caused by Staphylococcus aureus (27 isolates), coagulase-negative staphylococci (24 isolates) and Enterococcus spp. (11 isolates). All but two patients received previous antibiotics for a median of 18 days. Dalbavancin was administered for a median of 21 days (range 7-168 days), and concomitant antimicrobial therapy was prescribed to 25 patients (36.2%). The overall clinical success rate of dalbavancin was 84.1%. Adverse events, mainly mild in intensity, were reported in nine patients. Overall, dalbavancin was estimated to reduce hospitalisation by 1160 days, with an estimated overall cost reduction of €211 481 (€3064 per patient). Dalbavancin appears to be an effective therapy for many serious Gram-positive infections.

Cost-Effectiveness of Staphylococcus aureus Decolonization Strategies in High-Risk Total Joint Arthroplasty Patients

BACKGROUND

The risk of prosthetic joint infection increases with Staphylococcus aureus colonization. The cost-effectiveness of decolonization is controversial. We evaluated cost-effectiveness decolonization protocols in high-risk arthroplasty patients.

METHODS

An analytical model evaluated risk under 3 protocols: 4 swabs, 2 swabs, and nasal swab alone. These were compared to no-screening and universal decolonization strategies. Cost-effectiveness was evaluated from the hospital, patient, and societal perspective.

RESULTS

Under base case conditions, universal decolonization and 4-swab strategies were most effective. The 2-swab and universal decolonization strategy were most cost-effective from patient and societal perspectives. From the hospital perspective, universal decolonization was the dominant strategy (much less costly and more effective).

CONCLUSION

S aureus decolonization may be cost-effective for reducing prosthetic joint infections in high-risk patients. These results may have important implications for treatment of patients and for cost containment in a bundled payment system.

Global health resource utilization associated with pacemaker complications

AIM

To estimate health resource utilization (HRU) associated with the management of pacemaker complications in various healthcare systems.

METHODS

Electrophysiologists (EPs) from four geographical regions (Western Europe, Australia, Japan, and North America) were invited to participate. Survey questions focused on HRU in the management of three chronic pacemaker complications (i.e. pacemaker infections requiring extraction, lead fractures/insulation breaches requiring replacement, and upper extremity deep venous thrombosis [DVT]). Panelists completed a maximum of two web-based surveys (iterative rounds). Mean, median values, and interquartile ranges were calculated and used to establish consensus.

RESULTS

Overall, 32 and 29 panelists participated in the first and second rounds of the Delphi panel, respectively. Consensus was reached on treatment and HRU associated with a typical pacemaker implantation and complications. HRU was similar across regions, except for Japan, where panelists reported the longest duration of hospital stay in all scenarios. Infections were the most resource-intensive complications and were characterized by intravenous antibiotics days of 9.6?13.5 days and 21.3?29.2 days for pocket and lead infections respectively; laboratory and diagnostic tests, and system extraction and replacement procedures. DVT, on the other hand, was the least resource intensive complication.

LIMITATIONS

The results of the panel represent the views of the respondents who participated and may not be generalizable outside of this panel. The surveys were limited in scope and, therefore, did not include questions on management of acute complications (e.g. hematoma, pneumothorax).

CONCLUSIONS

The Delphi technique provided a reliable and efficient approach to estimating resource utilization associated with chronic pacemaker complications. Estimates from the Delphi panel can be used to generate costs of pacemaker complications in various regions.

Periprosthetic joint infection

Periprosthetic joint infections are a devastating complication after arthroplasty and are associated with substantial patient morbidity. More than 25% of revisions are attributed to these infections, which are expected to increase. The increased prevalence of obesity, diabetes, and other comorbidities are some of the reasons for this increase. Recognition of the challenge of surgical site infections in general, and periprosthetic joint infections particularly, has prompted implementation of enhanced prevention measures preoperatively (glycaemic control, skin decontamination, decolonisation, etc), intraoperatively (ultraclean operative environment, blood conservation, etc), and postoperatively (refined anticoagulation, improved wound dressings, etc). Additionally, indications for surgical management have been refined. In this Review, we assess risk factors, preventive measures, diagnoses, clinical features, and treatment options for prosthetic joint infection. An international consensus meeting about such infections identified the best practices and further research needs. Orthopaedics could benefit from enhanced preventive, diagnostic, and treatment methods.

Saline-coupled bipolar sealing in revision total knee arthroplasty for infection

Blood conservation with saline-coupled bipolar sealing devices in primary total knee arthroplasty (TKA) has had mixed results. Moreover, investigators have not studied these devices in infected TKA cases in which conventional methods of blood management cannot be used. We conducted a single-surgeon, case-control study to evaluate how the choice of an electrocautery device affects total blood loss, transfusion requirements, and total cost in revision TKA for infection. Each of the 80 patients in the study had an infected TKA and underwent surgery that involved the use of a saline-coupled bipolar sealing device at our institution. Results were compared with those of a control group of 40 patients immediately predating use of this device. Groups were matched for age, body mass index, American Society of Anesthesiologists (ASA) classification, and surgery type. We then compared the groups on multiple variables, including total blood loss, transfusion requirements, operative time, and hemoglobin decrease. The groups did not differ with respect to blood loss or transfusion requirements. However, operative time was significantly lower in the bipolar sealer group. This difference translated to an average net additional cost of about $70 per case. Given the results of this study, use of a saline-coupled bipolar sealing device in patients with infected TKAs is not clinically or economically justified.

Where do knee revisions for infection, fracture, and other revisions get treated?

Complicated knee revision procedures require specific expertise that may not be available across the healthcare network. Teaching hospitals appear to perform more knee revisions overall than urban or rural hospitals. We examined the location of care and payer status for all knee revisions including complex revisions (infection, periprosthetic fracture). Although only 39.7% of all primary total knee cases were performed in teaching hospitals, over half of all knee revisions were performed in teaching hospitals. Knee revision procedures, including treatment of periprosthetic infections and fractures are performed more often in teaching hospitals than in urban and rural settings combined. Reimbursement that does not match the cost of care for complex revision and infection cases may have a disproportionate impact on teaching hospitals.

Cost analysis of peri-operative antibiotic administration in total knee arthroplasty

BACKGROUND

Rationale perioperative antibiotic for prevent infection in total knee arthroplasty is well established. The recommendation are preoperative antibiotic should be administered within 1 h before skin incision and prophylactic antibiotics should be administered within 1 h before skin incision, if prolong surgery more than 4-6 hours need addition doses and duration of prophylactic antibiotic administration should not exceed the 24-hour postoperative period then not need for additional antibiotic. If there is evidences of infection, intravenous antibiotic and follow by oral antibiotic is mandatory in acute infection in conjuction with scrub and debridement. Because the burden of infection in joint replacement is disaster, it seemed to increase the antibiotic uses and impact about the cost concerned after total knee arthroplasty. No data available about the pharmaco-economical study of perioperative antibiotic in total knee arthroplasty have been established.

OBJECTIVE

Primary outcomes is cost anaylsis of perioperative antibiotic uses in real clinical practice for total knee arthroplasty. Secondary outcome is infectioned total knee that need to reoperative for scrub and debridement.

MATERIAL AND METHOD

Prospective opened lable study from joint registry in Police General Hospital from June, 2010 till March, 2011. With minimum 12 months follow-up. Total Knee Arthroplasty was enrolled in the present study about 218 cases. 3 patients lossed follow-up in each groups, so the total number in the present study are 209 patients. Perioperative antibiotic consumption initial doses and followed for 48 hour is divided in 3 group: group 1 Fosmycin 4 g (2 g initially plus 2 g intraoperatively) for 70 patients group 2: Fosmycin 2 g for 68 patients. Group 3: Cefalosporin group for 71 patients. The cost of subsequence uses of intravenous and oral antibiotic were record. And also the cases that need to scrub debridement with the indication of infected total knee arthroplasty were recorded. The minimum follow-up about 12 months (range 12-18 months).

RESULTS

The extend of intravenous antibiotic administration postop more than 48 hours in group 1 is 38 patients (54.28%) and oral antibiotic 42 patients (60%), in group 2 is 45 patients (66.18%) and oral antibiotic 40 patients (58.2%), in group 3 58 patients (81.7%) and oral antibiotic 60 patients (84.51%). The percentage of expenses preoperative intravenous and postoperative 48 hour: intravenous antibiotic during hospitalization: post operative antibiotic in group 1 is 19.82%: 59.69%: 20.49%; group 2 is 10.41%: 68.40%: 21.19% and group 3 is 1.39% 80.85%: 17.76%. The average total perioperative cost antibiotic (baht) in group 1: group 2: group 3 are 4,068: 4,776: 5,468. The infected case need operated for scrub and debridement in group 1 is 1 cases, group 2 is one cases and group 3 is 1 cases.

CONCLUSION

Overall expense increased in both intravenous and oral antibiotic prophylaxis in total knee arthtroplasty for prevention of infection. The major cost of perioperative antibiotic is intravenous antibiotic more than 48 hours during hospitalization, the least number of patients and percentages of cost is in group 1 than group 2 and 3. The percentage of patients oral antibiotics are least in group 2 than group 1, 3 but the average cost is likely to be quite substantially lower in group 1 then group 2, 3.

Current concepts for clean air and total joint arthroplasty: laminar airflow and ultraviolet radiation: a systematic review

BACKGROUND

With the trend toward pay-for-performance standards plus the increasing incidence and prevalence of periprosthetic joint infection (PJI), orthopaedic surgeons must reconsider all potential infection control measures. Both airborne and nonairborne bacterial contamination must be reduced in the operating room.

QUESTIONS/PURPOSES

Analysis of airborne bacterial reduction technologies includes evaluation of (1) the effectiveness of laminar air flow (LAF) and ultraviolet light (UVL); (2) the financial and potential health costs of each; and (3) an examination of current national and international standards, and guidelines.

METHODS

We systematically reviewed the literature from Ovid, PubMed (Medline), Cochrane DSR, ACP Journal Club, DARE, CCTR, CMR, HTA, NHSEED, CINAHLPLUS, and Google Scholar published until June 2010 focusing on ultraclean air, ultraviolet light, and laminar air.

RESULTS

High-level data demonstrating substantial PJI reduction of any infection control method may not be feasible as a result of the relatively low rates of occurrence and the expense and difficulty of conducting a large enough study with adequate power. UVL has potentially unacceptable health costs and the Centers for Disease Control and Prevention (CDC) recommends against its use. European countries have standardized LAF and it is used by the majority of American joint surgeons.

CONCLUSIONS

Both LAF and UVL reduce PJI. The absence of a high level of evidence from randomized trials is not proof of ineffectiveness. The historically high cost of LAF has decreased substantially. Only LAF has been standardized by several European countries. The CDC recommends further study of LAF but recommends UVL not be used secondary to documented potential health risks to personnel.

Eliminating hospital acquired infections: is it possible? Is it sustainable? Is it worth it?

An estimated 2 million hospital-acquired infections (HAI) are now reported annually in the US, and are associated with an estimated $5 billion in additional health care costs. With this, the growing incidence of HAI has become "ground zero" in the campaign to improve patient safety and eliminate waste in health care.We studied the characteristics of high-performing organizations and their leaders outside of health care to determine how such organizations become "best in class." We then sought to apply the principles that led to this status to eliminating HAI associated with central venous catheters.Observations of the current condition of health care revealed multiple defects in various processes, that were breeding grounds for error. Redesign of these processes by the people involved in them under the guidance of a leader resulted in an 86% reduction in infections in the blood. Overall, financial performance improved by $5.1 million over a 2-year period. Mortality in intensive care units declined by 29%.Using methods borrowed from highly reliable industries and engaging workers at the point of care can have profound and sustainable effects in nearly eliminating HAI, with significant clinical and financial benefits.

Effects of provider patient volume and comorbidity on clinical and economic outcomes for total knee arthroplasty: a population-based study

Our study examined how provider patient volume, postoperative infection rate, and perioperative complication affect length of stay, hospitalization charges, and adverse outcomes for patients undergoing total knee arthroplasty (TKA). The study sample included patients who had undergone total knee arthroplasty at all acute care hospitals in Taiwan between 2000 and 2003. Two economic indicators revealed linear associations with surgeon's patient volume, hospital's patient volume, and comorbidity score. Patients who developed postoperative infections remained hospitalized an average of 8.49 days longer than did patients with no infection. Postoperative infection was associated with surgeon experience. Our findings indicate that a surgeon's patient volume has a more significant effect than a hospital's patient volume on clinical outcomes. However, patient volumes for both surgeon and hospital are equally important in economic outcomes.

Economic impact of treatment for surgical site infections in cases of total knee arthroplasty in a tertiary public hospital in Brazil

The aim of this study was to estimate the additional cost of treatment of a group of nosocomial infections in a tertiary public hospital. A retrospective observational cohort study was conducted by means of analyzing the medical records of 34 patients with infection after total knee arthroplasty, diagnosed in 2006 and 2007, who met the criteria for nosocomial infection according to the Centers for Disease Control and Prevention. To estimate the direct costs of treatment for these patients, the following data were gathered: length of hospital stay, laboratory tests, imaging examinations, and surgical procedures performed. Their costs were estimated from the minimum values according to the Brazilian Medical Association. The estimated cost of the antibiotics used was also obtained. The total length of stay in the ward was 976 days, at a cost of US$ 18,994.63, and, in the intensive care unit, it was 34 days at a cost of US$ 5,031.37. Forty-two debridement procedures were performed, at a cost of US$ 5,798.06, and 1965 tests (laboratory and imaging) were also performed, at a cost of US$ 15,359.25. US$ 20,845.01 was spent on antibiotics and US$ 1,735.16 on vacuum assisted closure therapy, microsurgical flaps, implant removal, spacer use, and surgical revision. The total additional cost of these cases of hospital infection in 2006 and 2007 was of US$ 91,843.75. Based on that, we demonstrate that the high cost of treatment for hospital infections emphasizes the importance of taking measures to prevent and control hospital infection.

Increasing financial burden of revision total knee arthroplasty

We reviewed the peri-operative and financial data of patients who underwent revision total knee arthroplasty in our institution between 1997 and 2006. The aims were to compare difference in cost between aseptic and septic cases and to identify the sources of preventable cost increase in revision knee procedure. The study group comprised 117 women (65%) and 62 men (35%). The median age of patients decreased from 73 years (37-83 years) in 1997-2001 to 70 years (15-91 years) in 2002-2006, a decline of 4% (P < 0.05). The mean ASA scores also dropped from 3 to 2 between the two periods. Despite this, the mean total cost of revision knee procedure continued to increase. Patients undergoing revision arthroplasty because of infection had much higher (P = 0.0001) cost compared to their aseptic counterpart. Increase in the costs of investigations (P < 0.05) and implant (P < 0.05) was the major contributing factors. The cost of implants increased by 32-35% (P < 0.05) depending on implant selection. Changing demographics will increase the requirement for this surgery and thus increase its overall cost to society. Cost increases associated with unnecessary investigations, prolonged hospital stay and use of expensive implants should be avoided.

Linezolid versus Vancomycin for Prosthetic Joint Infections: a Cost Analysis

BACKGROUND

Prosthetic joint infections (PJIs) caused by methicillin-resistant gram-positive bacteria are primarily treated by intravenous vancomycin. Linezolid, active against methicillin-resistant strains and available in oral and intravenous dosage forms, is a potential alternative to vancomycin for the treatment of PJIs.

OBJECTIVE

To analyze the cost of linezolid therapy (outpatient setting) and vancomycin therapy (inpatient and outpatient settings) for PJIs caused by methicillin-resistant gram-positive bacteria.

METHODS

A decision tree was designed to simulate the clinical outcome and healthcare resource utilization of linezolid, vancomycin by outpatient and home parenteral antimicrobial therapies (OHPAT) and vancomycin administered in inpatient setting (rehabilitation facility) for patients with PJIs caused by methicillin-resistant strains. Clinical inputs were estimated from literature and the cost analysis was conducted from the perspective of the public healthcare provider in Hong Kong.

RESULTS

The base-case analysis showed that the vancomycin (OHPAT) group (USD14,470 per patient) was the least costly alternative, followed by the linezolid group (USD17,877 per patient) and the vancomycin (rehabilitation) group (USD19,980 per patient) (1USD = 7.8HKD). The clinical treatment success rates of vancomycin and linezolid were influential factors. Monte Carlo 10,000 simulations showed that the vancomycin (OHPAT) group was less costly than the arms of linezolid and vancomycin (rehabilitation) 64% and 100% of the time, respectively. The linezolid group was less costly than the vancomycin (rehabilitation) group in 65%of the times.

CONCLUSION

Home-infusion of vancomycin therapy appears to be the least costly treatment approach for PJIs caused by methicillin-resistant gram-positive bacteria from the perspective of a Hong Kong public health organization.

[Cost and outcome of hip's arthroplasty nosocomial infection. Case and control study]

Case-control study for evaluation of cost and outcome of nosocomial surgical site infection in primary hip arthroplasty during a period of 5 years. Mean hospitalization time in the orthopedic service was 54 days for cases, and 13 days for control (p<0.05). Mean hospitalization time in Intensive Care Unit (ICU) was 1.1 days for cases. There were 0.83 post primary surgery interventions in cases, and a mean of 2.08 bacteriological cultures in each case. Controls didn't have hospitalizations in the ICU surgical reinterventions nor cultures necessary. The mean cost of infected patients was US $: 6,174.8. Mean cost in controls was US $: 2,354.7. The excess of cost due to infections was US $: 2,354.7 on the average. Outcomes in cases were: normal function 30.8%; moderate or serious sequelae 46.2%; death rate 15, 4%. The measured parameters contributed to raise case costs, and they caused an unsatisfactory outcome for two third of the patients.

The impact of infection after total hip arthroplasty on hospital and surgeon resource utilization

BACKGROUND

Deep infection following total hip arthroplasty is a devastating complication for the patient and a costly one for patients, surgeons, hospitals, and payers. The purpose of this study was to compare revision total hip arthroplasty for infection, revision total hip arthroplasty for aseptic loosening, and primary total hip arthroplasty with respect to their impact on hospital and surgeon resource utilization and referral patterns to a tertiary-care hospital.

METHODS

Clinical, demographic, and economic data were obtained for twenty-five consecutive patients with an infection after a total hip replacement who underwent a two-stage revision arthroplasty (Group 1) performed by one of two surgeons, between March 2001 and December 2002, at a single institution. Similar data were collected during the same time-period for a cohort of twenty-five consecutive patients who underwent revision of both components because of aseptic loosening (Group 2) and twenty-five consecutive patients who underwent a primary hip arthroplasty (Group 3). Quantitative and categorical variables were compared among the groups. Referral patterns were examined by reviewing the primary diagnosis for all patients referred to our institution for a revision total hip arthroplasty during a five-year period.

RESULTS

Revision procedures for infection were associated with longer operative time, more blood loss, and a higher number of complications compared with revisions for aseptic loosening or primary total hip arthroplasty (p < 0.02 for all). Revisions for infection were also associated with a higher total number of hospitalizations, total number of days in the hospital, total number of operations, total hospital costs, total outpatient visits, and total outpatient charges during the twelve-month period following the index procedure (p < 0.001 for all). The incidence of referrals to our institution for a diagnosis of infection following total hip arthroplasty increased significantly over a five-year period (Spearman rank correlation, 1.0; p = 0.0083), while referral rates for revision for causes other than infection remained relatively constant (Spearman rank correlation, 0.500; p = 0.3910).

CONCLUSIONS

The treatment of patients with an infection after a total hip arthroplasty is associated with significantly greater hospital and physician resource utilization compared with the treatment of patients who have a revision because of aseptic loosening or who have a primary total hip arthroplasty. We believe that the lack of incremental reimbursement associated with these procedures results in strong financial disincentives for physicians and hospitals to provide treatment for patients with an infection after a total hip arthroplasty.

Good news and bad news: the cost of mending a broken heart

The approval of a new treatment protocol known as "destination therapy" highlights the realities of today's health economics. This article discusses the technology, the economics and the philosophy of the newly approved left-ventricular-assist systems.

The Jarvik 2000 is associated with less infections than the HeartMate left ventricular assist device

OBJECTIVES

Device-related infections remain a considerable problem of left-ventricular support. We compared the device-related-infections between the HeartMate left ventricular assist device (LVAD) and the Jarvik 2000 permanent LVAD, a device with a novel retroauricular power-supply.

METHODS

Between December 2000 and September 2002 we implanted the HeartMate-vented, electrical-system in 11 patients and the permanent Jarvik 2000 in six patients. Total support time was 1626 patient-days (HeartMate, 26-271 days) versus 1246 patient-days (Jarvik 2000, 8-411 days). As potential risk factors for infection we analyzed age, preoperative hospital-days, total protein, cardiac index, maximal oxygen uptake, use of inotropes, LVAD risk-score-index and Aaronson-Mancini-score, intubation time, and intensive care unit stay. We used the Center of Disease Control definitions for surgical site infections.

RESULTS

HeartMate-patients were younger than Jarvik 2000 patients (46+/-13 versus 58+/-6 years, P=0.056), there were no other differences in the risk factors. Four HeartMate-patients needed late (>or=48 h) surgical revisions for bleeding/hematomas versus no revisions in the Jarvik 2000 patients. In the HeartMate-patients, there were seven (64%) driveline-infections, five (45%) device-pocket infections, and three (27%) bloodstream-infections, or 0.43 device-related infections/100 patient-days. Infections occurred early (34+/-31 days). Three patients required urgent transplantation due to bloodstream infection. There were no adverse outcomes in the HeartMate-group due to infection. In the Jarvik 2000 patients, there was one driveline-infection (16%) after 270 days of support (0.08 device-related infections/100 patient-days), significantly less than in the HeartMate-group (P=0.044). Driveline infections resolved with antibiotics and local wound care in the Jarvik 2000 patient, but only in one of seven HeartMate-patients.

CONCLUSIONS

Implantation of the Jarvik 2000 is associated with less device-related infections than the HeartMate-LVAD. The power-supply of the permanent Jarvik 2000 is suitable for long-term mechanical support.

Ventriculitis complicating use of intraventricular catheters in adult neurosurgical patients

Ventriculitis is a serious complication of intraventricular catheter (IVC) use, with rates of IVC-related infections ranging from 0% to 45% and gram-positive organisms predominating. We prospectively analyzed ventriculostomy-related infections occurring among 157 adult neurosurgical patients (mean age, 54.9 years; 90 [57%] were women) from 1995 through 1998, to determine the incidence of, risk factors for, and organisms that cause ventriculitis. A total of 196 IVC events resulted in 11 infections (5.6%; 9 were caused by gram-negative organisms and 2 by coagulase-negative staphylococci). Independent risk factors for IVC-related infection include length of IVC placement (8.5 days [infected] vs. 5.1 days [uninfected]; P=.007) and cerebrospinal fluid leakage about the IVC (P=.003). The length of hospital stay (30.8 days vs. 22.6 days; P=.03) and mean total hospital charges ($85,674.27 vs. $55,339.21; P=.009) were greater for infected patients than for uninfected patients. In addition, a microbiologic shift from gram-positive organisms toward gram-negative organisms was noted. This study suggests that IVC-related infections remain serious infections that increase the length of hospitalization.

[The comparative costs of vancomycin treatment versus teicoplanin in osteoarticular infection caused by methicillin-resistant staphylococci]

This clinical and economical study compared two glycopeptides regimen i.e., vancomycin and teicoplanin in the treatment of osteoarticular infection involving methicillin-resistant staphylococcus. After randomization, 15 patients (group 1) received vancomycin (23 F per gram) in continuous infusion through a central venous catheter and 15 others (group 2) intramuscular teicoplanin (311-357 F a 400 mg vial). The clinical study focused on treatment tolerance in an in-patient setting as well as in a non in-patient one. The cost analysis focused on total expenses including those of antibiotics, those of medical devices for antibiotic administration and those of the complications caused by the antibiotics use. Total expenses per patient averaged 8744 F with vancomycin and 8555 F with teicoplanin (NS). The apparent money saving by using a cheap antibiotic (i.e. vancomycin) was illusionary as one took in account the expenses for medical devices e.g., central venous catheters required to administer vancomycin and the complications due to the use of these devices.

The cost and implications of reoperation after surgery for fracture of the hip

Revision operations after fracture of the hip are costly, in both monetary and personal terms. We have assessed whether these costs applied equally to all complications after the primary procedure. We studied 3,154 consecutive patients with fracture of the hip and analysed the complications and financial implications related to reoperation within one year of injury. The results showed that revision surgery is not always associated with a significant increase in morbidity, financial cost or mortality, but is directly related to the underlying complication.

Financial impact of tertiary care in an academic medical center

OBJECTIVE

To analyze the financial impact of three complex vascular surgical procedures to both an academic hospital and a department of surgery and to examine the potential impact of decreased reimbursements.

SUMMARY BACKGROUND DATA

The cost of providing tertiary care has been implicated as one potential cause of the financial difficulties affecting academic medical centers.

METHODS

Patients undergoing revascularization for chronic mesenteric ischemia, elective thoracoabdominal aortic aneurysm repair, and treatment of infected aortic grafts at the University of Florida were compared with those undergoing elective infrarenal aortic reconstruction and carotid endarterectomy. Hospital costs and profit summaries were obtained from the Clinical Resource Management Office. Departmental costs and profit summary were estimated based on the procedural relative value units (RVUs), the average clinical cost per RVU ($33.12), surgeon charges, and the collection rate for the vascular surgery division (30.2%) obtained from the Faculty Group Practice. Surgeon work effort was analyzed using the procedural work RVUs and the estimated total care time. The analyses were performed for all payors and the subset of Medicare patients, and the potential impact of a 15% reduction in hospital and physician reimbursement was analyzed.

RESULTS

Net hospital income was positive for all but one of the tertiary care procedures, but net losses were sustained by the hospital for the mesenteric ischemia and infected aortic graft groups among the Medicare patients. In contrast, the estimated reimbursement to the department of surgery for all payors was insufficient to offset the clinical cost of providing the RVUs for all procedures, and the estimated losses were greater for the Medicare patients alone. The surgeon work effort was dramatically higher for the tertiary care procedures, whereas the reimbursement per work effort was lower. A 15% reduction in reimbursement would result in an estimated net loss to the hospital for each of the tertiary care procedures and would exacerbate the estimated losses to the department.

CONCLUSIONS

Caring for complex surgical problems is currently profitable to an academic hospital but is associated with marginal losses for a department of surgery. Economic forces resulting from further decreases in hospital and physician reimbursement may limit access to academic medical centers and surgeons for patients with complex surgical problems and may compromise the overall academic mission.

Cost of treating an infected total knee replacement

Twenty consecutive cases of infected total knee replacements surgically treated between 1990 and 1993 in which complete clinical and financial data were available were reviewed to determine the resources required of the hospital and the surgeon. These results were compared with a similar analysis of a stratified, unselected sample 30 cases each of primary total knee arthroplasty and nonseptic revision total knee arthroplasty during the same period. Parameters compared between the infected total knee replacement, noninfected revision total knee replacement, and primary total knee replacement included number of surgical procedures performed, number of hospitalizations, number of hospital days, total operative time, and total intraoperative blood loss. Financial data included the amount charged and reimbursed by the hospital and by the surgeon. The actual hospital cost was estimated as well. Based on all parameters measured, surgical treatment of the infected total knee implant required 3 to 4 times the resources of the hospital and the surgeon compared with a primary total knee implant and approximately twice the resources of a nonseptic revision total knee implant. The reimbursement received resulted in an estimated net loss of approximately $15,000 per case to the hospital for the group as a whole, but approximately $30,000 per case per Medicare patient.

Comparison of muscle flaps and delayed secondary intention wound healing for infected lower extremity arterial grafts

Selective preservation of infected arterial grafts is an alternative to graft excision. The purpose of this study was to compare the outcome and cost of treating infected lower extremity arterial grafts with either muscle flaps (MFs) or delayed secondary intention (DSI) wound healing. Between 1985 and 1991 we treated 28 graft infections by graft preservation. All grafts (19 polytetrafluoroethylene, 8 autologous vein, and 1 Dacron) were patent with intact anastomoses and showed no signs of sepsis. Wounds in 18 patients were treated by repeated, aggressive operative debridement and allowed to heal by DSI. Wounds in 10 patients were treated with MFs (4 sartorius, 3 gracilis, 1 rectus abdominis, 1 semimembranous, and 1 gastrocnemius). Costs included anesthesiologists' and surgeons' fees, operating room charges, and daily semiprivate and ICU bed charges. Four (14%) patients died from cardiac complications (1 DSI and 1 MF), sepsis (1 MF), and anastomotic hemorrhage (1 DSI). Of the 24 survivors, 4 patients treated by DSI required graft excision for nonhealing wounds (2), graft thrombosis (1), and recurrent infection (1). However, 3 of these 4 patients were not candidates for MFs because the wounds were not considered acceptable for a flap. Twenty (83%) grafts in survivors were successfully preserved after long-term follow-up (mean 26 mo). No survivors required an amputation. Twenty patients who did not require graft removal were compared for treatment by MF (n = 8) or DSI (n = 12). Two MFs (both sartorius) in survivors necrosed and a new flap was required to successfully preserve the graft.(ABSTRACT TRUNCATED AT 250 WORDS)

Prosthetic osteomyelitis with special reference to the knee: risks, treatment and costs

The overall incidence of osteomyelitis following primary knee arthroplasty is 1-2%. Major risk factors are large prostheses, rheumatoid arthritis, postoperative wound-healing complications, skin infections, and prior deep infections. The major infecting organism is Staphylococcus aureus. Healing of the infection is to be expected in 20% when systemic antibiotics alone are used, in 24% when soft tissue surgery is used, in 50% when resection arthroplasty is used, in 76% when revision arthroplasty is used, in 90% when arthrodesis is used, and in 100% when amputation is used. The direct medical costs average US$ 62,100 for an infected patient and US$ 8600 for a non-infected patient. Attention should focus on prophylactic measures directed towards the soft tissue problems: by avoiding conflicting skin incisions, by gentle handling of the periarticular soft tissues, by avoiding the use of constrained prostheses and oversized compartmental prostheses, by letting wound healing take priority over motion in knees with compromised soft tissues, and by using prophylactic antibiotic treatment for skin ulcers until these have healed.

Chemoprophylaxis of prosthetic joint patients during dental treatment: a decision-utility analysis

A decision-analytic model and a cost effectiveness analysis was performed on 1 million hypothetic prosthetic joint patients undergoing dental treatment, to determine the most cost-effective strategy to prevent late prosthetic joint infections. The cost per quality-adjusted life-year saved (QALY) was determined for three preventive strategies: no prophylaxis, oral penicillin, and oral cephalexin. The UCLA Pain-Walking-Function-Activity Scale was used to obtain quality-of-life adjustments (utility assessment) for the study population. Costs were derived from 70 patients hospitalized between July 1, 1982, and June 30, 1986, at the UCLA Center for Health Sciences. The most cost-effective preventive strategy was the no prophylaxis alternative ($196,500/QALY). However, by recommending a 1-day strategy of oral cephalexin only to those dental patients at high risk for late prosthetic joint infections rather than a 3-day regimen to all patients, the cost effectiveness improved from $1.1 million/QALY to $446,100/QALY while maintaining a low risk of death (0.38 deaths per 10(6) dental visits).