Infection Control & Hospital Epidemiology (2018), 39, 1183–1188 doi:10.1017/ice.2018.199
Original Article
The cost of managing complex surgical site infections following primary hip and knee arthroplasty: A population-based cohort study in Alberta, Canada
Elissa D. Rennert-May MD1,2, John Conly MD1,3,4,5,6, Stephanie Smith MD, MSc7, Shannon Puloski MD8,
Elizabeth Henderson PhD2, Flora Au MA1 and Braden Manns MD, MSc1,2,5,9 1Department of Medicine, University of Calgary, Calgary, Canada, 2Department of Community Health Sciences, University of Calgary, Calgary, Canada, 3Department of Immunology, Microbiology and Infectious Diseases, University of Calgary, Calgary, Canada, 4Department of Pathology and Laboratory Medicine,
University of Calgary, Calgary, Canada, 5O’Brien Institute for Public Health, University of Calgary, Calgary, Canada, 6Snyder Institute for Chronic Diseases, University of Calgary, Calgary, Canada, 7Department of Medicine, University of Alberta, Edmonton, Canada, 8Department of Surgery, University of Calgary, Calgary, Canada and 9Libin Cardiovascular Institute, University of Calgary, Calgary, Canada
Abstract
Objective: Nearly 800,000 primary hip and knee arthroplasty procedures are performed annually in North America. Approximately 1% of these are complicated by a complex surgical site infection (SSI), leading to very high healthcare costs. However, population-based studies to properly estimate the economic burden are lacking. We aimed to address this knowledge gap. Design: Economic burden study. Methods: Using administrative health and clinical databases, we created a cohort of all patients in Alberta, Canada, who received a primary hip or knee arthroplasty between April 1, 2012, and March 31, 2015. All patients who developed a complex SSI postoperatively were identified through a provincial infection prevention and control database. A combination of corporate microcosting data and gross costing methods were used to determine total mean 12- and 24-month costs, enabling comparison of costs between the infected and noninfected patients. Results: Mean 12-month total costs were significantly greater in patients who developed a complex SSI compared to those who did not (CAD$95,321 [US$68,150] vs CAD$19,893 [US$14,223]; P < .001). The magnitude of the cost difference persisted even after controlling for underlying patient factors. The most commonly identified causative pathogen (38%) was Staphylococcus aureus (95% MSSA). Conclusions: Complex SSIs following hip and knee arthroplasty lead to high healthcare costs, which are expected to rise as the yearly number of surgeries increases. Using our costing estimates, the cost-effectiveness of different strategies to prevent SSIs should be investigated.
(Received 24 May 2018; accepted 21 July 2018)
In Canada, more than 100,000 knee and hip replacements are performed annually,1 including ~10,000 in the province of Alberta.2 In the United States, ~700,000 hip and knee replace- ments are performed annually, and this number is expected to quadruple by the year 2030.3 These procedures can significantly reduce pain and improve mobility and quality of life; however, 1%–2% of patients undergoing joint replacements in North America develop infection after surgery.4,5 The Centers for Disease Control and Prevention (CDC) divides surgical site infections (SSIs) into superficial incisional, deep incisional, and organ-space infections, with the latter 2 considered complex.6 While superficial SSI can usually be managed with oral antibiotics and possibly local debridement, guidelines recommend more
Author for correspondence: Braden Manns; HRIC Building, 2500 University Drive NW, Calgary, AB T2N1N4. E-mail:
braden.manns@
ahs.ca
Cite this article: Rennert-May E. et al. (2018). The cost of managing complex surgical
site infections following primary hip and knee arthroplasty: A population-based cohort study in Alberta, Canada. Infection Control & Hospital Epidemiology 2018, 39, 1183–1188. doi: 10.1017/ice.2018.199
© 2018 by The Society for Healthcare Epidemiology of America. All rights reserved.
intensive management for complex infections.7 A complex SSI generally requires repeat surgery, which can include debridement and retention of the prosthesis, or a complete revision of the joint done in a 1-stage or 2-stage process. All of these surgeries also require treatment with prolonged courses of antibiotics, often delivered intravenously.7 Given the interventions required to manage complex SSIs,
these infections have a major impact on patients and healthcare payers. In the United States, ~US$9.8 billion (2012 dollars) is spent on major healthcare-associated infections annually, with SSIs contributing 33.7% of the total.8 The true cost of managing patients with complex joint infections is uncertain, though a study in Canada using gross costing methods estimated that the average cost for a hospital admission for an infected knee arthroplasty is more than CAD$20,000 (~ US$15,280).4 In the United Kingdom, the cost for just 1 admission related to revision surgery for SSI is ~22,000 pounds (~ US$28,300).9 A study from the United States estimated that the cost of SSIs following hip and knee arthroplasty has increased by US$246 million from 2001 to 2009,
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