A Cost-Utility Analysis of the Use of Closed-Incision Negative Pressure System in Vascular Surgery Groin Incisions

A Cost-Utility Analysis of the Use of -125 mm Hg Closed-incision Negative Pressure Therapy in Oncoplastic Breast Surgery

Background

Closed-incision negative pressure therapy (ciNPT) decreases the rate of wound complications in oncoplastic breast surgery (OBS) but at a fiscal cost. Our aim was to examine the cost-utility of ciNPT in OBS.

Methods

A literature review was performed to obtain the probabilities and outcomes for the treatment of unilateral breast cancer with OBS with ciNPT versus without. Reported utility scores in the literature were used to calculate quality-adjusted life years (QALYs) for each health state. A decision analysis tree was constructed with rollback analysis to determine the more cost-effective strategy. An incremental cost-utility ratio was calculated. Sensitivity analyses were performed.

Results

OBS with ciNPT is associated with a higher clinical effectiveness (QALY) of 33.43 compared to without (33.42), and relative cost increase of $667.89. The resulting incremental cost-utility ratio of $57432.93/QALY favored ciNPT. In one-way sensitivity analysis, ciNPT was the more cost-effective strategy if the cost of ciNPT was less than $1347.02 or if the probability of wound dehiscence without was greater than 8.2%. Monte Carlo analysis showed a confidence of 75.39% that surgery with ciNPT is more cost effective.

Conclusion

Despite the added cost, surgery with ciNPT is cost-effective. This finding is a direct result of decreased overall wound complications with ciNPT.

PICO™ (Closed-Incision Negative-Pressure Wound Therapy) Dressing Use as Postoperative Prophylaxis for Preventing Surgical Site Infections in Spinal Surgery: A Retrospective Single-Centre Study

Introduction Surgical site infections (SSIs) are one of the dreaded complications of spinal surgery. These typically develop within the first 30 days following surgery. The overall pooled incidence of SSIs is reported at 3.1%. Negative pressure wound therapy (NPWT) has been employed for the management of open wounds and soft tissue injury. There has been a recent trend towards the use of closed incision NPWT (ciNPT), such as PICO. There are only a few studies evaluating the prophylactic use of ciNPT in spinal surgery. The aim of this study was to evaluate whether prophylactic use of PICO dressings can reduce SSI incidence and complications in spinal surgery. Methods Data were collected retrospectively for patients undergoing spinal surgery, with a PICO dressing used for closed surgical incisions, from February 2021 to October 2022. Each patient was followed up for 30 days. The results were compared with local hospital infection control statistics for previous years. Results A total of 50 patients underwent spinal surgery and had PICO dressings post-operatively. None of the patients developed a seroma. Two out of 50 (4.0%) patients developed wound dehiscence and then subsequent SSI (1 superficial, 1 deep). These were managed conservatively with the use of antibiotics and prolonged ciNPT. None of these patients returned to the theatre. The average SSI incidence from previous years was 9.27 ± 4.14 per annum (1.15%), but with an average of 77.3% of these requiring a return to theatres. Conclusion Our study reflects that there is no difference in the incidence rates for SSIs for patients who have PICO dressings versus those having standard occlusive dressings as post-operative closed surgical incision site wound closure following spinal surgery. For those who do develop SSIs, there was no difference in the rates of return to theatres among the two patient populations.

Optimizing Surgical Outcomes and the Role of Preventive Surgery: A Scoping Review

BACKGROUND

 Plastic and reconstructive surgeons are often presented with reconstructive challenges as a sequela of complications in high-risk surgical patients, ranging from exposure of hardware, lymphedema, and chronic pain after amputation. These complications can result in significant morbidity, recovery time, resource utilization, and cost. Given the prevalence of surgical complications managed by plastic and reconstructive surgeons, developing novel preventative techniques to mitigate surgical risk is paramount.

METHODS

 Herein, we aim to understand efforts supporting the nascent field of Preventive Surgery, including (1) enhanced risk stratification, (2) advancements in postoperative care. Through an emphasis on four surgical cohorts who may benefit from preventive surgery, two of which are at high risk of morbidity from wound-related complications (patients undergoing sternotomy and spine procedures) and two at high risk of other morbidities, including lymphedema and neuropathic pain, we aim to provide a comprehensive and improved understanding of preventive surgery. Additionally, the role of risk analysis for these procedures and the relationship between microsurgery and prophylaxis is emphasized.

RESULTS

 (1) medical optimization and prehabilitation, (2) surgical mitigation techniques.

CONCLUSION

 Reconstructive surgeons are ideally placed to lead efforts in the creation and validation of accurate risk assessment tools and to support algorithmic approaches to surgical risk mitigation. Through a paradigm shift, including universal promotion of the concept of "Preventive Surgery," major improvements in surgical outcomes may be achieved.

A Cost-Effectiveness Analysis of Wittmann Patch-Assisted Abdominal Closure Compared to Planned Ventral Hernia in Management of the Open Abdomen

BACKGROUND

Inability to achieve primary fascial closure after damage control laparotomy is a frequently encountered problem by acute care and trauma surgeons. This study aims to compare the cost-effectiveness of Wittmann patch-assisted closure to the planned ventral hernia closure.

METHODS

A literature review was performed to determine the probabilities and outcomes for Wittmann patch-assisted primary closure and planned ventral hernia closure techniques. Average utility scores were obtained by a patient-administered survey for the following: rate of successful surgeries (uncomplicated abdominal wall closure), surgical site infection, wound dehiscence, abdominal hernia and enterocutaneous fistula. A visual analogue scale (VAS) was utilized to assess the survey responses and then converted to quality-adjusted life years (QALYs). Total cost for each strategy was calculated using Medicare billing codes. A decision tree was generated with rollback and incremental cost-utility ratio (ICUR) analyses. Sensitivity analyses were performed to account for uncertainty.

RESULTS

Wittmann patch-assisted closure was associated with higher clinical effectiveness of 19.43 QALYs compared to planned ventral hernia repair (19.38), with a relative cost reduction of US$7777. Rollback analysis supported Wittmann patch-assisted closure as the more cost-effective strategy. The resulting negative ICUR of -156,679.77 favored Wittmann patch-assisted closure. Monte Carlo analysis demonstrated a confidence of 96.8% that Wittmann patch-assisted closure was cost-effective.

CONCLUSIONS

This study demonstrates using the Wittmann patch-assisted closure strategy as a more cost-efficient management of the open abdomen compared to the planned ventral hernia approach.

Cost Utility of Transcatheter Aortic Valve Replacement: Sapien 3 Versus CoreValve Evolut R

Transcatheter aortic valve replacement (TAVR) has become the preferred treatment for severe aortic stenosis. Previous studies compare clinical outcomes of leading TAVR valves, but there is no evidence of cost-utility comparison, leaving a clinical information gap when selecting valves. Here we share a cost-utility analysis comparing the Sapien 3 (S3) (Edwards Lifesciences, Irvine, CA) and CoreValve Evolut R (ER) (Medtronic, Dublin, IR) across five clinical endpoints. Utility scores from patient surveys and clinical outcomes from the literature were used to estimate quality-adjusted life years (QALYs) associated with successful procedure and postoperative complications for S3 and ER. A decision tree was constructed with rollback analysis to highlight the more cost-effective strategy. An incremental cost-utility ratio (ICUR) analysis was performed with a willingness to pay at $50,000. Deterministic and probabilistic sensitivity analyses were performed to validate robustness of results and account for uncertainty. S3 was found to be more costly ($68,377 vs. $66,072), but more effective (1.87 vs . 1.66) compared with ER. An ICUR of 11,288.12 favored S3, making it the more cost-effective option with a moderate confidence of 73.68% in Monte Carlo analysis. Cost-utility analysis can be used to aid in healthcare economics decision-making when selecting between comparable technologies used for TAVR procedures.