Hospital effect on infections after four major surgical procedures: outlier and volume-outcome analysis using all-inclusive state data

The burden of surgical site infections in Australia: A cost-of-illness study

OBJECTIVE

To estimate the cost of surgical site infections in Australian public hospitals in 2018-19, to demonstrate the economic burden of hospital-associated infection in a well-resourced health system.

METHODS

A cost-of-illness analysis was conducted over a 1-year time horizon based on data from published literature extrapolated using simulation techniques. The direct and indirect costs of SSI were estimated for Australia and each of its states and territories.

RESULTS

An estimated 16,541 cases of SSI occurred in Australian public hospitals in 2018-19, resulting in a total direct cost of A$323.5 million. The average cost per case was A$18,814, which was 2.5 times the average per capita spending on health. The indirect costs of absenteeism and premature death were valued at A$23.0 million and A$2 948.1 million per annum, respectively.

CONCLUSION

SSI is a significant but preventable cost with most of the financial burden coming from premature deaths but underreporting means our costs are likely underestimated.

Beyond the operating room: do hospital characteristics have an impact on surgical site infections after colorectal surgery? A systematic review

Background

Hospital characteristics have been recognized as potential risk factors for surgical site infection for over 20 years. However, most research has focused on patient and procedural risk factors. Understanding how structural and process variables influence infection is vital to identify targets for effective interventions and to optimize healthcare services. The aim of this study was to systematically review the association between hospital characteristics and surgical site infection in colorectal surgery.

Main body

A systematic literature search was conducted using PubMed, Scopus and Web of Science databases until the 31st of May, 2021. The search strategy followed the Participants, Exposure/Intervention, Comparison, Outcomes and Study design. The primary outcome of interest was surgical site infection rate after colorectal surgery. Studies were grouped into nine risk factor typologies: hospital size, ownership affiliation, being an oncological hospital, safety-net burden, hospital volume, surgeon caseload, discharge destination and time since implementation of surveillance. The STROBE statement was used for evaluating the methodological quality.

A total of 4703 records were identified, of which 172 were reviewed and 16 were included. Studies were published between 2008 and 2021, and referred to data collected between 1996 and 2016. Surgical site infection incidence ranged from 3.2 to 27.6%. Two out of five studies evaluating hospital size adjusted the analysis to patient and procedure-related risk factors, and showed that larger hospitals were either positively associated or had no association with SSI. Public hospitals did not present significantly different infection rates than private or non-profit ones. Medical school affiliation and higher safety-net burden were associated with higher surgical site infection (crude estimates), while oncological hospitals were associated with higher incidence independently of other variables. Hospital caseload showed mixed results, while surgeon caseload and surveillance time since implementation appear to be associated with fewer infections.

Conclusions

Although there are few studies addressing hospital-level factors on surgical site infection, surgeon experience and the implementation of a surveillance system appear to be associated with better outcomes. For hospitals and services to be efficiently optimized, more studies addressing these variables are needed that take into account the confounding effect of patient case mix.

Association between the frequency of surgeries for video-assisted thoracic surgery and the incidence of consequent surgical site infections: a retrospective observational study based on national surveillance data

Background

The association between the frequency of surgeries and the incidence of surgical site infections (SSIs) has been reported for various surgeries. However, no previous study has explored this association among video-assisted thoracic surgeries (VATS). Hence, we aimed to investigate the association between the frequency of surgeries and SSI in video-assisted thoracic surgeries.

Methods

We analyzed the data of 26,878 thoracic surgeries, including 21,154 VATS, which were collected during a national surveillance in Japan between 2014 and 2018. The frequency of surgeries per hospital department was categorized into low (< 50/year), moderate (50–100/ year), and high (> 100/year). Chi-squared test or Fisher’s exact test was used for discrete explanatory variables, whereas Wilcoxon’s rank-sum test or Kruskal-Wallis test was used for continuous explanatory variables. Univariate analysis of the department groups was conducted to explore confounding factors associated with both SSIs and the department groups. We used a multiple logistic regression model focusing on VATS and stratified by the National Nosocomial Infections Surveillance System (NNIS) risk index.

Results

The rates of SSIs in the hospital groups with low, moderate, and high frequency of surgeries were 1.39, 1.05, and 1.28%, respectively. In the NNIS risk index 1 stratum, the incidence of SSIs was significantly lower in the moderate-frequency of surgeries group than that in the other groups (odds ratio [OR]: vs. low-frequency of surgeries: 2.48 [95% confidence interval [CI]: 1.20–5.13], P = 0.0143; vs. high-frequency of surgeries: 2.43 [95% CI: 1.44–4.11], P = 0.0009). In the stratum of NNIS risk indices 2 and 3, the incidence of SSI was significantly higher in the low-frequency of surgeries group (OR: 4.83, 95% CI: 1.47–15.93; P = 0.0095).

Conclusion

The result suggests that for departments with low-frequency of surgeries, an increase in the frequency of surgeries to > 50 per department annually potentially leads to a decrease in the incidence of SSIs. This occurs through an increase in the experience of the departmental surgeons and contributes to the improvement of VATS outcomes in thoracic surgeries.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12879-021-06050-6.

Postoperative Delirium Following Joint Replacement in Patients With Dementia in New South Wales, Australia: A State-Wide Retrospective Cohort Study

The objective of the current study was to investigate the variation in postoperative delirium in patients with dementia undergoing joint replacement in New South Wales (NSW) Australia public hospitals, identify factors related to its occurrence, and explore the volume-outcome relationship. The NSW Admitted Patient Data (July 2001 to June 2014) were used in this study and included patients with dementia undergoing joint replacement who were 65 or older with minor to severe comorbidities. Mixed-effect logistic models were applied to investigate hospital-level variation and factors associated with postoperative delirium. The between-hospital variability of postoperative delirium was 0.19% prior to 2008-2009 and 8.32% after 2008-2009. Hospital volume was not inversely associated with postoperative delirium rate. During 2001-2014, the incidence of postoperative delirium increased by 13% per annum (95% confidence interval [CI] 10% to 16%), while it increased by 15% per annum (95% CI 8% to 22%) after 2008-2009. An integrated approach addressing complex needs of patients with dementia may reduce the observed unwarranted variation and improve surgical outcomes. [Research in Gerontological Nursing, 13(5), 243-253.].

Novel approaches to surgical site infections: what recommendations can be made?

INTRODUCTION

Surgical site infections (SSI) are one of the most frequent healthcare-associated infections worldwide, representing a substantial burden on the healthcare system and the individual patient. Various risk factors for SSI have been identified, which can be separated into patient-related, procedure-related and other risk factors. Areas covered: Other risk factors relevant for SSI are the season in which surgery is performed, the volume of surgeries in a department, the working atmosphere in the operating room and the indications for surgery. Overall, the risk of SSI is higher during summertime. Higher-volume departments appear to be protective against SSI as does a calm working atmosphere. The frequency of certain types of surgery differs greatly among European countries. The decision to perform surgery appears to be dependent on the patient's condition as well as the healthcare system and financial incentives. Expert commentary: When possible, elective surgery should not be executed during summertime but during cooler times of year. Departments with a high volume of surgical procedures should be given preference. The establishment of a calm working atmosphere is beneficial to a surgeon's performance and can reduce SSI rates. The indications for performing surgery should be carefully reevaluated whenever possible.