RESUMO
The role of wound protectors in laparoscopic surgeries is highly controversial in the literature. Some studies demonstrate their benefit in reducing the rate of surgical site infections; however, these results are not reproducible across all procedures. In addition to protecting the operative wound, these devices can be used at sites of surgical specimen extraction in laparoscopic procedures. Several commercially available devices serve this purpose but are scarcely available in resource-limited settings. One of the reasons for this limitation is the cost of the device. In this technical note, we aim to provide a cost-effective option utilizing materials readily available in the operating room and with a simple fabrication process.
Assuntos
Laparoscopia , Laparoscopia/instrumentação , Laparoscopia/economia , Laparoscopia/métodos , Humanos , Desenho de Equipamento , Infecção da Ferida Cirúrgica/prevenção & controle , Infecção da Ferida Cirúrgica/economiaRESUMO
OBJECTIVE: Vascular groin incision complications contribute significantly to patients' morbidity and rising health care costs. Negative pressure therapy over the closed incision decreases the infection rate in cardiac and orthopedic procedures. This study prospectively evaluated negative pressure therapy as a means to decrease wound complications and associated health care costs. METHODS: This was a randomized, prospective, single-institution study of 119 femoral incisions closed primarily after elective vascular surgery including both inflow (eg, aortofemoral) and outflow (eg, femoral-popliteal bypass) procedures. Incisions were categorized as high risk for wound complications on the basis of body mass index >30 kg/m2, pannus, reoperation, prosthetic graft, poor nutrition, immunosuppression, or hemoglobin A1c >8% and randomized 1:1 to standard gauze (n = 60) dressing vs negative pressure therapy (Prevena [Acelity, San Antonio, Tex], n = 59). Wound complication rate, length of stay (LOS), reoperation, readmission, and variable hospital costs were determined during 30 days. Statistical analysis was performed using χ2 test along with a two-sample unpaired t-test for continuous variables. RESULTS: There were no significant demographic differences (age, sex, risk factors for wound complication) between the two high-risk groups. In low-risk controls, the major wound complication rate was 4.8% (involving one infection in 21 incisions), resulting in a 3.8-day LOS, 4.8% reoperation, 4.8% readmission rate, and $17,599 in average variable cost. For high-risk controls, there was a significant increase in major wound complications to 25% (including all 12 infections in 60 incisions), LOS (10.6 days), reoperation (18.3%), readmission (16.7%), and costs ($36,537). Finally, negative pressure therapy significantly reduced major wound complications to 8.5% (including five of six infections in 59 incisions; P < .001), reoperation (8.5%; P < .05), and readmission (6.8%; P < .04) but not LOS (10.6 days). The average variable cost was reduced ($30,492), yielding an average savings of $6045 per patient (P = .11). CONCLUSIONS: This study suggests that negative pressure therapy significantly reduces the major wound complication, reoperation, and readmission rates for patients at high risk for groin wound complications. Furthermore, this therapy may lead to a reduction in hospital costs. Negative pressure therapy for all groin incisions considered at high risk for wound complications is recommended.
Assuntos
Artéria Femoral/cirurgia , Virilha/irrigação sanguínea , Tratamento de Ferimentos com Pressão Negativa , Infecção da Ferida Cirúrgica/prevenção & controle , Procedimentos Cirúrgicos Vasculares/efeitos adversos , Cicatrização , Adulto , Idoso , Idoso de 80 Anos ou mais , Redução de Custos , Análise Custo-Benefício , Feminino , Custos Hospitalares , Humanos , Tempo de Internação , Masculino , Pessoa de Meia-Idade , Tratamento de Ferimentos com Pressão Negativa/efeitos adversos , Tratamento de Ferimentos com Pressão Negativa/economia , Readmissão do Paciente , Philadelphia , Estudos Prospectivos , Reoperação , Fatores de Risco , Infecção da Ferida Cirúrgica/economia , Infecção da Ferida Cirúrgica/microbiologia , Infecção da Ferida Cirúrgica/cirurgia , Fatores de Tempo , Resultado do Tratamento , Procedimentos Cirúrgicos Vasculares/economiaRESUMO
BACKGROUND: Cosmetic tourism has become increasingly popular despite many associated risks. The economic impact of atypical mycobacterial infections in cosmetic tourism is poorly defined in the literature. We sought to investigate the costs and clinical course of patients with these infections. METHODS: A retrospective review of all patients managed by the Plastic Surgery Division at Columbia University Medical Center from 2013 to 2014 with atypical mycobacterial surgical site infections after cosmetic surgery outside the United States was performed. Data including patient demographics, procedure costs, clinical course, impact on daily life, and costs associated with complications were collected using hospital billing information, patient questionnaires, telephone interviews, and clinical charts. Cost analysis was done to identify the personal and societal costs of these complications. RESULTS: Data from 10 patients were collected and analyzed. Management of mycobacterial infections cost an average of $98,835.09 in medical charges. The indirect cost of these infections was $24,401 with a mean return to work time of 6.7 months. Total patient savings from cosmetic tourism was $3419. The total cost of a mycobacterial infection was greater than $123,236.47. Although the incidence of mycobacterial infection abroad is unknown, the potential cost of an infection alone outweighs the financial benefits of cosmetic tourism if the risk exceeds 2.77%. CONCLUSIONS: Atypical mycobacterial infections as a result of cosmetic tourism come at considerable cost to patients and the health care system. When our results are taken into consideration with other risks of cosmetic tourism, the financial risks likely far outweigh the benefits.
Assuntos
Técnicas Cosméticas/economia , Custos de Cuidados de Saúde/estatística & dados numéricos , Turismo Médico/economia , Infecções por Mycobacterium não Tuberculosas/economia , Infecção da Ferida Cirúrgica/economia , Adulto , Colômbia , Técnicas Cosméticas/efeitos adversos , Redução de Custos/estatística & dados numéricos , Análise Custo-Benefício , República Dominicana , Feminino , Humanos , Pessoa de Meia-Idade , Infecções por Mycobacterium não Tuberculosas/diagnóstico , Infecções por Mycobacterium não Tuberculosas/etiologia , Infecções por Mycobacterium não Tuberculosas/terapia , Cidade de Nova Iorque , Estudos Retrospectivos , Risco , Infecção da Ferida Cirúrgica/diagnóstico , Infecção da Ferida Cirúrgica/terapiaRESUMO
BACKGROUND: This article presents a break-even analysis for preoperative Staphylococcus aureus colonization screening and decolonization protocols in total hip arthroplasty (THA) and total knee arthroplasty (TKA). METHODS: Protocol costs, baseline infection rates after arthroplasty, and average revision costs were obtained from institutional records and the literature. The break-even analysis determined the absolute risk reduction (ARR) in infection rate required for cost-effectiveness. RESULTS: S aureus nasal screening ($144.07) was cost effective when initial infection rates of TKA (1.10%) and THA (1.63%) had an ARR of 0.56% and 0.45%, respectively. The most inexpensive decolonization treatment ($5.09) was cost effective with an ARR of 0.02% for both TKA and THA. The most expensive decolonization option ($37.67) was cost effective with ARRs of 0.15% (TKA) and 0.12% (THA). CONCLUSION: Preoperative S aureus decolonization can be highly cost effective, whereas colonization screening requires excessively high reductions in infection rate.
Assuntos
Artroplastia de Quadril/efeitos adversos , Artroplastia do Joelho/efeitos adversos , Infecções Estafilocócicas/diagnóstico por imagem , Infecções Estafilocócicas/economia , Staphylococcus aureus , Infecção da Ferida Cirúrgica/economia , Artroplastia de Quadril/economia , Artroplastia do Joelho/economia , Análise Custo-Benefício , Humanos , Programas de Rastreamento/economia , Modelos Econômicos , Mupirocina/administração & dosagem , Mupirocina/economia , Infecções Estafilocócicas/prevenção & controle , Infecção da Ferida Cirúrgica/prevenção & controleRESUMO
The financial burden of antibiotic resistance is a serious concern worldwide. The aim of this study was to describe the excess costs associated with pneumonia, bacteraemia, surgical site infections and intra-abdominal infections (IAIs) caused by carbapenem-resistant Gram-negative bacilli in Medellín, Colombia, an endemic region for carbapenem resistance. A cohort study was conducted in a third-level hospital from 2014-2015. All patients with carbapenem-resistant and carbapenem-susceptible Gram-negative bacterial infections were included. Pharmaceutical, medical and surgical direct costs were described from the health system perspective. Excess costs were estimated from generalised linear models with gamma distribution and adjusted for variables that could affect the cost difference. A total of 218 patients were enrolled, 48 (22.0%) of whom were infected with carbapenem-resistant bacteria. IAIs were the most frequent. The adjusted total excess cost was US$3966 [95% confidence interval (CI) US$1684-6249], with a significantly higher cost for antibiotics, followed by hospital stay, laboratory tests and interconsultation. The highest excess cost was attributed mainly to the use of broad-spectrum antibiotics (US$1827, 95% CI US$1005-2648), followed by length of hospital stay (US$1015, 95% CI US$163-1867). The results of this study highlight the importance of designing antimicrobial stewardship programmes and infection control strategies in endemic regions to reduce the financial threat of antimicrobial resistance to health systems.
Assuntos
Bacteriemia/economia , Infecções por Bactérias Gram-Negativas/tratamento farmacológico , Infecções por Bactérias Gram-Negativas/economia , Custos de Cuidados de Saúde , Infecções Intra-Abdominais/economia , Pneumonia Bacteriana/economia , Infecção da Ferida Cirúrgica/economia , Idoso , Antibacterianos/uso terapêutico , Bacteriemia/tratamento farmacológico , Bacteriemia/microbiologia , Carbapenêmicos/uso terapêutico , Colômbia , Farmacorresistência Bacteriana Múltipla , Enterobacter cloacae/efeitos dos fármacos , Feminino , Infecções por Bactérias Gram-Negativas/microbiologia , Humanos , Infecções Intra-Abdominais/tratamento farmacológico , Infecções Intra-Abdominais/microbiologia , Klebsiella pneumoniae/efeitos dos fármacos , Tempo de Internação/economia , Masculino , Pessoa de Meia-Idade , Pneumonia Bacteriana/tratamento farmacológico , Pneumonia Bacteriana/microbiologia , Pseudomonas aeruginosa/efeitos dos fármacos , Infecção da Ferida Cirúrgica/tratamento farmacológico , Infecção da Ferida Cirúrgica/microbiologiaRESUMO
BACKGROUND: The use of a prophylactic antibiotic in an amputation surgery is a key element for the successful recovery of the patient. We aim to determine, from the perspective of the Colombian health system, the cost-effectiveness of administering a prophylactic antibiotic among patients undergoing lower limb amputation due to diabetes or vascular illness in Colombia. METHODS: A decision tree was constructed to compare the use and nonuse of a prophylactic antibiotic. The probabilities of transition were obtained from studies identified from a systematic review of the clinical literature. The chosen health outcome was reduction in mortality due to prevention of infection. The costs were measured by expert consensus using the standard case methodology, and the resource valuation was carried out using national-level pricing manuals. Deterministic sensitivity, scenarios, and probabilistic analyses were conducted. RESULTS: In the base case, the use of a prophylactic antibiotic compared with nonuse was a dominant strategy. This result was consistent when considering different types of medications and when modifying most of the variables in the model. The use of a prophylactic antibiotic ceases to be dominant when the probability of infection is greater than 48%. CONCLUSIONS: The administration of a prophylactic antibiotic was a dominant strategy, which is a conclusion that holds in most cases examined; therefore, it is unlikely that the uncertainty around the estimation of costs and benefits change the results. We recommend creating policies oriented toward promoting the use of a prophylactic antibiotic during amputation surgery in Colombia.
Assuntos
Amputação Cirúrgica/economia , Antibacterianos/administração & dosagem , Antibacterianos/economia , Antibioticoprofilaxia/economia , Angiopatias Diabéticas/economia , Angiopatias Diabéticas/cirurgia , Custos de Medicamentos , Extremidade Inferior/irrigação sanguínea , Doenças Vasculares Periféricas/economia , Doenças Vasculares Periféricas/cirurgia , Infecção da Ferida Cirúrgica/economia , Infecção da Ferida Cirúrgica/prevenção & controle , Amputação Cirúrgica/efeitos adversos , Amputação Cirúrgica/mortalidade , Colômbia , Análise Custo-Benefício , Técnicas de Apoio para a Decisão , Árvores de Decisões , Angiopatias Diabéticas/diagnóstico , Angiopatias Diabéticas/mortalidade , Esquema de Medicação , Humanos , Modelos Econômicos , Doenças Vasculares Periféricas/diagnóstico , Doenças Vasculares Periféricas/mortalidade , Infecção da Ferida Cirúrgica/microbiologia , Resultado do TratamentoRESUMO
Hereditary spastic paraplegia (HSP) is characterized by weakness and spasticity of the lower extremities. Kjellin’s syndrome is a rare syndrome associated with HSP. The syndrome is characterized by the presence of bilateral retinal flecks, similar to the findings in Stargardt disease and fundus flavimaculatus. We report the case of a 34-year-old male who presented with complete features of Kjellin’s syndrome, with typical retinal findings observed on multimodal imaging (spectral domain optical coherence tomography [SD-OCT], near-infrared reflectance and autofluorescence imaging). The ophthalmological changes at early stages of the disease may not impair visual acuity. Therefore, the detection of central retinal degeneration requires thorough fundus examination.
A paralisia espástica hereditária (HSP) é caracterizada por fraqueza e espasticidade das extremidades inferiores. A síndrome de Kjellin é uma rara associação de HSP com a presença de flecks retinianos similares aos encontrados em pacientes com doença de Stargardt ou fundus flavimaculatus. Descrevemos os achados em imagens multimodais da retina (tomografia de coerência óptica de domínio espectral [SD-OCT], reflectância próxima ao infravermelho e autofluorescência) em um paciente de 34 anos que apresenta conjunto completo de sinais e sintomas da síndrome de Kjellin. As alterações retinianas em estágios iniciais da doença podem aparecer, mesmo sem redução da acuidade visual, e por isso, para detecção da degeneração central da retina, é necessário exame minucioso do fundo de olho.
Assuntos
Idoso , Humanos , Antibacterianos/uso terapêutico , Artroplastia de Quadril/economia , Artroplastia do Joelho/economia , Mupirocina/uso terapêutico , Infecções Estafilocócicas/prevenção & controle , Infecção da Ferida Cirúrgica/prevenção & controle , Administração Intranasal , Antibacterianos/economia , Análise Custo-Benefício , Técnicas de Apoio para a Decisão , Árvores de Decisões , Custos de Cuidados de Saúde , Controle de Infecções/economia , Controle de Infecções/métodos , Mupirocina/economia , Cuidados Pré-Operatórios , Anos de Vida Ajustados por Qualidade de Vida , Staphylococcus aureus , Infecções Estafilocócicas/diagnóstico , Infecções Estafilocócicas/economia , Infecção da Ferida Cirúrgica/economia , Estados UnidosRESUMO
OBJECTIVE: Describe implementation of a successful program to reduce doses (cefazolin 2 to 1 g) used for antimicrobial prophylaxis. METHODS: Evaluation of an intervention program to reduce prophylactic antimicrobial doses. The intervention included weekly staff discussions, automatic dispensation of 1g-vial of cefazolin by the pharmacy unless expressly requested by surgeon and increase in post-discharge surveillance as a strategy to reassure surgeons of the safety of the reduction. In the pre and post intervention periods, a prospective study of antimicrobial consumption and surgical site infections were measured. RESULTS: There were 5,164 and 5,204 deliveries in 2001-2002 and 2003-2004, respectively; 1,524 (29.5%) and 1,363 (26%) were cesarean sections. There was a 45% decrease in cefazolin vials used on average per cesarean section (2.29 to 1.25). Patients evaluated increased from 16% to 67% and the SSI rates in both periods were 3.34% to 2.42%, respectively. CONCLUSION: An ample intervention, including administrative and educational measures, led to high compliance with dose reduction and saved more than US$4,000 in cefazolin, considered important because government reimbursement in Brazil for cesarean section is $80.
Assuntos
Antibacterianos/administração & dosagem , Antibioticoprofilaxia/métodos , Cefazolina/administração & dosagem , Cesárea , Infecção da Ferida Cirúrgica/prevenção & controle , Antibacterianos/economia , Antibioticoprofilaxia/economia , Cefazolina/economia , Cesárea/economia , Feminino , Humanos , Gravidez , Avaliação de Programas e Projetos de Saúde , Estudos Prospectivos , Infecção da Ferida Cirúrgica/economiaRESUMO
OBJECTIVE: Describe implementation of a successful program to reduce doses (cefazolin 2 to 1 g) used for antimicrobial prophylaxis. METHODS: Evaluation of an intervention program to reduce prophylactic antimicrobial doses. The intervention included weekly staff discussions, automatic dispensation of 1g-vial of cefazolin by the pharmacy unless expressly requested by surgeon and increase in post-discharge surveillance as a strategy to reassure surgeons of the safety of the reduction. In the pre and post intervention periods, a prospective study of antimicrobial consumption and surgical site infections were measured. RESULTS: There were 5,164 and 5,204 deliveries in 2001-2002 and 2003-2004, respectively; 1,524 (29.5 percent) and 1,363 (26 percent) were cesarean sections. There was a 45 percent decrease in cefazolin vials used on average per cesarean section (2.29 to 1.25). Patients evaluated increased from 16 percent to 67 percent and the SSI rates in both periods were 3.34 percent to 2.42 percent, respectively. CONCLUSION: An ample intervention, including administrative and educational measures, led to high compliance with dose reduction and saved more than US$4,000 in cefazolin, considered important because government reimbursement in Brazil for cesarean section is $80.
OBJETIVO: descrever a implantação de um programa de redução de doses usadas para profilaxia antimicrobiana em cesárea. MÉTODOS: Descrição a implantação de um programa de redução de profilaxia com cefazolina de 2 g para 1 g através de discussões semanais com profissionais, dispensação automática de frascos de 1 g de cefazolina pela farmácia exceto quando feito pedido expresso pelo cirurgião. Houve um trabalho para aumentar a vigilância pós alta, com o objetivo de tranquilizar os cirurgiões quanto à segurança da nova dose. Foi realizada uma avaliação prospectiva, antes e depois da implantação do programa, do consumo de cefazolina e das taxas de infecção obtidas por vigilância durante a hospitalização e após a alta. RESULTADOS: Houve 5.164 e 5.204 partos em 2001-2 e 2003-4, respectivamente, sendo que 1.524 (29,5 por cento) e 1.363 (26 por cento) foram cesáreas. Houve uma queda de consumo de frascos de cefazolina de 45 por cento (2,29 para 1,25 por cesárea). O número de pacientes avaliados para infecção hospitalar aumentou de 16 por cento para 67 por cento, e as taxas de infecção foram 3,34 por cento e 2,42 por cento, respectivamente. CONCLUSÃO: Uma intervenção ampla, que incluiu medidas administrativas e educacionais, levou a uma alta adesão ao programa de redução de dose profilática em cesárea e permitiu uma economia acima de US$ 4.000 apenas considerando custos com cefazolina. Esta pode ser considerada importante especialmente porque o reembolso do SUS para parto cesárea é aproximadamente US$ 80.