Background: 

Postoperative surgical site infections (SSIs) and the associated complications impact morbidity and mortality and result in substantial burden to the health-care system. These complications are typically reported during the 90-day surveillance period, with implications for reimbursement and quality measurement; however, the long-term effects of SSI are not routinely assessed. We evaluated the long-term effects of SSI on health-care utilization and cost following orthopaedic surgery in an observational cohort study.

Methods: 

Patients in the Veterans Affairs health-care system who underwent an orthopaedic surgical procedure were included. The exposure of interest was an SSI within 90 days after the index procedure. The primary outcome was health-care utilization in the 2 years after discharge. Data for inpatient admission, inpatient days, outpatient visits, emergency room visits, total costs, and subsequent surgeries were also obtained. After adjusting for factors affecting SSI, we examined differences in each health-care utilization outcome by postoperative SSI occurrence and across time with use of differences-in-differences analysis. Cost differences were modeled with use of a gamma distribution with a log link.

Results: 

A total of 96,983 patients were included, of whom 4,056 (4.2%) had an SSI within 90 days of surgery. After adjusting for factors known to impact SSI and preoperative health-care utilization, SSI was associated with a greater risk of outpatient visits (relative risk [RR], 1.29; 95% confidence interval [CI], 1.26 to 1.32), emergency room visits (RR, 1.18; 95% CI, 1.15 to 1.21), and inpatient admission (RR, 1.35; 95% CI, 1.32 to 1.38) at 2 years postoperatively. The average cost among patients with an SSI was $148,824 ± $268,358 compared with $42,125 ± $124,914 among those without an SSI (p < 0.001). In the adjusted analysis, costs for patients with an SSI were 64% greater at 2 years compared with those without an SSI (RR, 1.64; 95% CI, 1.57 to 1.70). Overall, of all subsequent surgeries conducted within the 2-year postoperative period, 37% occurred within the first 90 days.

Conclusions: 

The reported effects of a postoperative SSI on health-care utilization and cost are sustained at 2 years post-surgery—a long-term impact that is not recognized in quality-measurement models. Efforts, including preoperative care pathways and optimization, and policies, including reimbursement models and risk-adjustment, should be made to reduce SSI and to account for these long-term effects.

Level of Evidence: 

Economic Level IV. See Instructions for Authors for a complete description of levels of evidence.

中文翻译：

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质量报告窗口可能无法捕捉骨科手术后手术部位感染的影响

背景： 

术后手术部位感染 (SSI) 和相关并发症会影响发病率和死亡率，并给医疗保健系统带来巨大负担。这些并发症通常在 90 天的监测期内报告，对报销和质量测量有影响；然而，SSI 的长期影响并未进行常规评估。我们在一项观察性队列研究中评估了 SSI 对骨科手术后医疗保健利用率和成本的长期影响。

方法： 

退伍军人事务医疗保健系统中接受骨科手术的患者也被纳入研究。感兴趣的风险敞口是指数程序后 90 天内的 SSI。主要结果是出院后 2 年内的医疗保健利用率。还获得了入院、住院天数、门诊就诊、急诊室就诊、总费用和后续手术的数据。在调整了影响 SSI 的因素后，我们使用差异中的差异分析检查了术后 SSI 发生和跨时间的每个医疗保健利用结果的差异。使用带有对数链接的伽马分布对成本差异进行建模。

结果： 

共纳入 96,983 名患者，其中 4,056 名（4.2%）在手术后 90 天内发生 SSI。在调整了影响 SSI 和术前医疗保健利用率的已知因素后，SSI 与门诊就诊（相对风险 [RR]，1.29；95% 置信区间 [CI]，1.26 至 1.32）、急诊室就诊的风险增加相关（RR，1.18；95% CI，1.15 至 1.21）和术后 2 年住院（RR，1.35；95% CI，1.32 至 1.38）。SSI 患者的平均费用为 148,824 ± 268,358 美元，而没有 SSI 的患者的平均费用为 42,125 ± 124,914 美元（p < 0.001）。在调整后的分析中，与没有 SSI 的患者相比，有 SSI 的患者 2 年的费用高出 64%（RR，1.64；95% CI，1.57 至 1.70）。总体而言，在术后 2 年内进行的所有后续手术中，

结论： 

报告的术后 SSI 对医疗保健利用率和成本的影响在术后 2 年持续存在——这种长期影响在质量测量模型中没有得到认可。应努力减少 SSI 并考虑这些长期影响，包括术前护理途径和优化，以及包括报销模式和风险调整在内的政策。

证据等级： 

经济四级。有关证据级别的完整描述，请参见作者说明。