Safety measures before a surgery aren’t just to save lives – they can also significantly lower the health bill if followed in letter and spirit.
Investing in safe surgeries could significantly reduce the costs associated with surgeries in low-to-middle-income countries like India, according to a study published in the Journal of Hospital Infection.
Mark Monahan, a lecturer of health economics at the Institute of Applied Health, University of Birmingham, led the multinational study. The findings show that surgical site infections extend hospital stays up to a month or more and worsen the financial burden on patients and their families.
What is a surgical site infection?
A surgical site infection is a common complication in surgeries worldwide. It is an infection that occurs at the site of a surgery in the body. It could be a superficial skin infection or a deeper one, involving tissues. About 11% of patients who undergo surgery contract such infections, according to a 2018 WHO report.
Ankit Jain, a consultant of surgical oncology at Jawaharlal Nehru Cancer Hospital and Research Centre, Bhopal, said surgical site infections increase healthcare costs by prolonging hospital stay and by demanding more human and medical resources to treat these infections.
What did the new study do?
In the new study, the researchers investigated resource costs for patients who underwent abdominal surgeries across 13 hospitals in four countries – India, Mexico, Nigeria, and Ghana – between April and October 2020.
The study considered a range of procedures, including caesarean sections, gastric perforation repair, hysterectomy, and umbilical hernia repair. The procedures were classified into two types:
1. Clean-contaminated surgeries – where surgeons cut into the gut, respiratory tract, or urinary tract in controlled sterile conditions
2. Contaminated-dirty surgeries – which includes accidental wounds, spillage from the gut, or a breach in the sterile conditions
About half the surgeries analysed in the study were for benign diseases, 39% were for obstetric issues, and the rest were trauma- or cancer-related surgeries.
The study was a part of a larger randomised controlled trial (RCT) called FALCON, which involved 57 hospitals in seven countries to investigate the effects of interventions on surgical site infections. The trial was led by the National Institute for Health and Care Research, U.K.
Researchers rarely study costs in RCTs and doing so is also complex. Several groups have estimated the costs associated with surgical site infections, but researchers have mostly carried out these studies at the single-hospital level, not across hospitals. Such studies have also estimated costs only up to the patient’s discharge from the hospital, not after.
“This is the first multi-continental surgical cost study of its kind and reveals substantial additional postoperative costs associated with [surgical site infections] across a range of settings,” Dr. Monahan said in a press release.
Did the study have any limitations?
As the COVID-19 pandemic made recruiting patients for the study difficult, researchers included retrospective data for clean-contaminated surgeries, asking patients for the costs they incurred when they had a surgical site infection in the past. This, as the authors write, “may have affected the post-discharge healthcare estimates due to recall bias.”
In addition, the number of samples and surgical site infections in Mexico and Nigeria were too low to draw any general conclusions about costs.
Finally, the cost differences between different countries may have been influenced by several factors, such as the type of hospital in which the study was carried out (private or government, e.g.).
What are the study’s limitations?
In their analysis, the researchers estimated the costs associated with the additional resources that patients with surgical site infections used when they were still at the hospital or returned after discharge, and the costs around patient care after discharge.
They found that surgical site infections occurred in 27% of contaminated-dirty surgeries and 7% of clean-contaminated surgeries. However, the healthcare costs associated with a surgical site infection following a clean-contaminated surgery (higher by 75%) were higher than in the case of a contaminated-dirty surgery (67%).
For clean-contaminated surgeries, patients with surgical site infection incurred healthcare costs of about €959 (Rs 85,300) after surgery. But their counterparts without surgical site infections incurred €517.
On the other hand, patients who suffered surgical site infections after undergoing contaminated-dirty surgeries incurred a total healthcare cost of about €828. But their counterparts without surgical site infections incurred €497.
The bulk of these amounts were for post-surgery patient care in a hospital (96.4% of total cost after clean-contaminated surgery and 92.5% after contaminated-dirty surgery).
The team also added travel costs and income loss to these figures. So people with and without surgical site infections after clean-contaminated surgeries incurred an estimated total expense of €1064 and €605; and those with and without surgical site infections after contaminated-dirty surgeries incurred €997 and €678.
How did the costs change in India?
Notably, India had the highest increase in healthcare costs associated with surgical site infections following clean-contaminated surgeries, at Rs 46,000. It also featured the lowest increase in healthcare costs for surgical site infections after contaminated-dirty surgeries, at Rs 20,000.
The findings echo those from previous studies at a single-hospital level in different countries, including India.
For example, one 2020 study suggested that 5.63% of patients who underwent a caesarean section at S.S.G. Hospital, Baroda, between July 2019 and March 2020 had surgical site infections. The total cost of illness because of the infection was almost thrice as much as the costs to patients without a surgical site infection. The average length of stay in the hospital for the former was 10 days longer than the latter. These patients were also treated with antibiotics for thrice as long as those without such infections.
How can we avoid these costs?
Bengaluru-based transplant surgeon Sonal Asthana said that a substantial number of surgical site infections occur in semi-urgent and emergency surgeries, and the financial burden associated with these infections is significant for patients in India, where insurance coverage is low and out-of-pocket expenses are high.
The number of surgical site infections in India has also been consistently higher than the international average. According to Dr. Asthana, this is because of “late presentation of cases, higher levels of emergency surgery, poor hospital practices, and rampant use of antibiotics.”
“Even a simple checklist of procedures like skin decontamination, adequate site marking before the surgical procedure etc., can reduce errors and morbidity,” he added.
In 2016, the WHO outlined such a checklist for surgical procedures. While they may look simple, Dr. Asthana continued, adhering to them with discipline could considerably lower infection incidence.
Joel P. Joseph is a freelance science journalist and researcher.
