Major article
Surgical site infection prevention following total hip arthroplasty in Australia: A cost-effectiveness analysis

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Background

Surgical site infection (SSI) is associated with substantial costs for health services, reduced quality of life, and functional outcomes. The aim of this study was to evaluate the cost-effectiveness of strategies claiming to reduce the risk of SSI in hip arthroplasty in Australia.

Methods

Baseline use of antibiotic prophylaxis (AP) was compared with no antibiotic prophylaxis (no AP), antibiotic-impregnated cement (AP + ABC), and laminar air operating rooms (AP + LOR). A Markov model was used to simulate long-term health and cost outcomes of a hypothetical cohort of 30,000 total hip arthroplasty patients from a health services perspective. Model parameters were informed by the best available evidence. Uncertainty was explored in probabilistic sensitivity and scenario analyses.

Results

Stopping the routine use of AP resulted in over Australian dollars (AUD) $1.5 million extra costs and a loss of 163 quality-adjusted life years (QALYs). Using antibiotic cement in addition to AP (AP + ABC) generated an extra 32 QALYs while saving over AUD $123,000. The use of laminar air operating rooms combined with routine AP (AP + LOR) resulted in an AUD $4.59 million cost increase and 127 QALYs lost compared with the baseline comparator.

Conclusion

Preventing deep SSI with antibiotic prophylaxis and antibiotic-impregnated cement has shown to improve health outcomes among hospitalized patients, save lives, and enhance resource allocation. Based on this evidence, the use of laminar air operating rooms is not recommended.

Section snippets

Methods

There are several steps preceding the actual cost-effectiveness analysis: choosing infection prevention strategies for evaluation (comparators), designing the decision model, and identifying parameters to inform model health states. The cost-effectiveness analysis consists of a baseline analysis using point estimates of parameter values, followed by analysis considering uncertainty surrounding model parameters, as well as scenario analyses.

Baseline analysis

Table 2 illustrates outcomes for the baseline comparator and alternative strategies. Compared with baseline AP, the use of additional ABC in all cemented primary THAs would prevent 46 deep SSI and save $3,909 for each QALY gained and hence be cost saving. Not using AP would increase costs by approximately $1.5 million for losing over 163 QALYs. If LOR were used in all primary THAs, costs would increase by approximately $4.6 million, and 127 QALYs are lost. Using AP + ABC clearly dominates the

Interpretation of findings

In the baseline and uncertainty analysis, AP + ABC clearly dominated the other 2 strategies (No AP, AP + LOR), which both showed a substantial increase in deep SSI cases, resulting in higher mortality and higher costs. If these strategies were implemented, health care providers would absurdly incur costs to harm patients. These results also verified the cost-effectiveness of routinely administering preoperative AP in primary THAs as an infection prevention measure in the absence of using

Conclusion

This project contributes to a framework for decision making in infection control in Australia and possibly other countries with comparable structures. The routine use of preoperative AP is cost-effective and should be continued. Resource allocation can be further improved by additionally using antibiotic-impregnated cement in all cemented primary THAs. Laminar air operating theaters proved harmful to patients as well as being costly. Based on this evidence, their use is not recommended.

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  • Cited by (0)

    Supported by the Orthopaedic Research Unit at the Prince Charles Hospital and the Centre for Healthcare Related Infection Surveillance and Prevention (CHRISP) in Brisbane, Australia.

    Conflicts of interest: None to report.

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