Report Card on Surgical Care Improvement Project (SCIP): Nationwide Inpatient Sample Infection Data 2001–2006

The Cost of Surgical Site Infections after Colorectal Surgery in the United States from 2001 to 2012: A Longitudinal Analysis

Surgical site infections (SSIs) are among the most common types of postoperative complications in the United States and are associated with significant prevalence of morbidity and mortality in patients undergoing surgical interventions, especially in colorectal surgery (CRS) where SSI rates are significantly higher than those of similar operative sites. SSIs were identified from the National Inpatient Sample-Healthcare Cost and Utilization Project database from 2001 to 2012 based on the specification of an ICD-9 code. Propensity score matching was used to compare costs associated with SSI cases with those of non-SSI controls among elective and nonelective admissions. Results were projected nationally using Healthcare Cost and Utilization Project sampling methodology to evaluate the incidence of SSIs and ascertain the national cost burden retrospectively. Among 4,851,359 sample-weighted hospitalizations, 4.2 per cent (203,597) experienced SSI. Elective admissions associated with SSI-stayed hospitalized for an average of 7.8 days longer and cost $18,410 more than their counterparts who did not experience an SSI. Nonelective admissions that experienced an SSI had an 8.5-day longer hospital stay and cost $20,890 more than counterparts without perioperative infections. This represents a 3 per cent annual growth in costs for SSIs and seems to be largely driven by cost increases in treatment of SSIs for elective surgeries. Current efforts of SSI management after CRS focused on compliance with guidelines and tracking of infection rates would benefit from some improvements. Considering the growing costs and increase in resource utilization associated with SSIs from 2001 to 2012, further research on costs associated with management of SSIs specific to CRS is necessary.

Current status of quality measurement in colon and rectal surgery

There is increasing pressure from the public and insurance payors for transparency and accountability in ensuring the quality of health care. In response to this, hospitals are now mandated to participate in quality improvement initiatives, and to report on their performance. This article describes three programs related to the measurement of quality that impact colon and rectal surgery: the Surgical Care Improvement Project, the National Surgical Quality Improvement Program, and the Surgical Care and Outcomes Assessment Program.

Appropriateness of surgical antimicrobial prophylaxis in the Latium region of Italy, 2008: a multicenter study

BACKGROUND

There is still wide variability in surgical antimicrobial prophylaxis (SAP) practice by different surgical teams and specialties, with potential impact on adverse events and the emergence of antibiotic resistance.

METHODS

We assessed SAP appropriateness in a regional prospective multicenter study on the basis of the agreement of the Surgical Care Improvement Project indicators (SCIP-Inf) with Italian guidelines (GL).

RESULTS

Prophylaxis was administered in 2,664 of 2,835 procedures (94%): In 2,346 of 2,468 (95%) as indicated and in 318 of 367 (86.6%) in which they were not indicated. The SCIP-Inf1 (timing), SCIP-Inf2 (antibiotic choice), and SCIP-Inf3 (duration) were in agreement with GL in 1,172 (50%), 1,983 (84.5%), and 1,121 (48%) of 2,346 procedures, respectively.

CONCLUSIONS

These results suggest the need for implementation of an antimicrobial stewardship program in this surgical setting.

Peritoneal closure versus no peritoneal closure for patients undergoing non-obstetric abdominal operations

BACKGROUND

There is no consensus regarding whether the peritoneum should be closed or left open during non-obstetric operations involving laparotomy. Neither is there consensus about the method of closure of the peritoneum (continuous suture versus interrupted suture). If closing the peritoneum could be omitted without complications, or even with benefit for patients, this could result in reductions in the cost of abdominal operations by reducing both the number of sutures used and the operating time.

OBJECTIVES

To compare the benefits and harms of parietal peritoneal closure compared with no parietal peritoneal closure in patients undergoing non-obstetric abdominal operations.

SEARCH METHODS

In Februrary 2013 we searched the The Cochrane Wounds Group Specialised Register (searched 14 February 2013); The Cochrane Central Register of Controlled Trials (CENTRAL) (2013, Issue 1); The Database of Abstracts of Reviews of Effects (2013, Issue 1); Ovid MEDLINE (1946 to February Week 1, 2013); Ovid EMBASE (1974 to 2013 Week 06); and EBSCO CINAHL 1982 to 8 February 2013).

SELECTION CRITERIA

We included only randomised controlled trials (RCTs) comparing peritoneal closure with no peritoneal closure in patients (adults and children) undergoing non-obstetric abdominal operations. All relevant RCTs irrespective of language, publication status, publication year, or sample size were included in the analysis.

DATA COLLECTION AND ANALYSIS

Two review authors independently identified trials and extracted data. We calculated the risk ratio (RR) with 95% confidence intervals (CI) for comparing the binary outcomes between the groups, and mean difference (MD) with 95% CI for comparing the continuous outcomes. We performed the meta-analysis using both a fixed-effect model and a random-effects model. Intention-to-treat analysis was performed whenever possible.

MAIN RESULTS

Five trials involving 836 participants randomised to peritoneal closure (410 participants) and no peritoneal closure (426 participants) were included in this review. All the trials were at high risk of bias. All the trials included participants undergoing laparotomy (open surgery). Four of the five trials used catgut or chromic catgut for peritoneal closure. Three trials involved vertical incisions and two trials involved transverse incisions. None of the trials reported 30-day mortality. There was no significant difference in the one-year mortality between the two groups (RR 1.11; 95% CI 0.56 to 2.19) in the only trial that reported this outcome. The only serious peri-operative adverse event reported was burst abdomen, which was reported by three trials. Overall, 10/663 (1.5%) of participants developed burst abdomen. There was no significant difference in the proportion of participants who developed burst abdomen between the two groups (RR 0.71; 95% CI 0.22 to 2.35). The same three trials reported the proportion of participants who developed incisional hernia. Details of the follow-up period were only available for one trial, and so we were unable to calculate the incidence rate. Overall, 17/663 (2.5%) of participants developed incisional hernia. There was no significant difference in the proportion of participants who developed incisional hernia between the two groups (RR 0.92; 95% CI 0.37 to 2.28). None of the trials reported quality of life; the incidence rate of, or proportion of participants who developed, intestinal obstruction due to adhesions; or re-operation due to incisional hernia or adhesions. Only one trial reported the length of hospital stay, and this trial did not include readmissions in its calculations. There was no significant difference in the length of hospital stay between the two groups (MD 0.40 days; 95% CI -0.51 to 1.31).

AUTHORS' CONCLUSIONS

There is no evidence for any short-term or long-term advantage in peritoneal closure for non-obstetric operations. If further trials are performed on this topic, they should have an adequate period of follow-up and adequate measures should be taken to ensure that the results are not subject to bias.

Adherence to surgical care improvement project measures and post-operative surgical site infections

BACKGROUND

Surgical site infection (SSI) is unequivocally morbid and costly. The estimated 300,000 SSIs annually in the United States represent the second most common infection among surgical patients, prolong hospitalization by 7-10 days, and have an estimated annual incremental cost of $1 billion. The mortality rate associated with SSI is 3%, with about three quarters of deaths being attributable directly to the infection. Prevention is possible for the most part, and concerted effort has been made to limit these infections, arguably to little effect.

METHODS

Review of pertinent English-language literature.

RESULTS

Numerous risk factors for SSI and tactics for prevention have been described, but efforts to bundle these tactics into an effective, comprehensive prevention program have been disappointing. Numerous studies now demonstrate that the Surgical Care Improvement Program (SCIP), which focused on process improvement rather than outcomes, has been ineffective despite governmental support, financial penalties for non-compliance, and consequent widespread implementation.

CONCLUSION

Required reporting has increased awareness of the problem of SSI, but just as the complexity of SSI risk, pathogenesis, and preventions reflects the complexity of the disease, many other factors must be taken into account, including the skill and knowledge of the surgical team and promulgation of a culture of quality and safety in surgical patient care.