The $1,000 Infection Tax

In this new era of cost containment in medicine, adding over $1,000 to the cost of a procedure sounds fiscally irresponsible, yet it is a part of every total knee replacement (TKR), in California.

In a recent retrospective review of the California State Inpatient Database by Daniels, et al., of hospital charges associated with adverse outcomes, 344 of over 56,000 total knee arthroplasties (TKAs) (0.6%) had a postoperative infection. Median total charges for each infection averaged $168,964 per case for a total cost to insurers and patients of $58,123,616. That averaged out to an additional $1,029 for each and every TKA performed in California during the study period of 2008 through 2009.

Total hips fared even worse, although by a slim margin, at $1,057 per case. The study, which also included lumbar laminectomies (LL), posterior lumbar inter body fusions (PLIF), and anterior cervical discectomies and foramenotomies, revealed that anterior procedures had the lowest infection rate (just 0.03%) and the lowest infection cost per case (a mere $66 – such a bargain!)

Bean Counters Who Are Penny Wise but Pound Foolish

As surgeons, we filter our results through rose-colored glasses, often placing “non-optimal” results on a distant shelf. And, as a surgeon performing 200 TKAs per year, I expected to see, and did see, one infection out of that group. Yet, according to Daniels, et al., the added cost of that one infected patient most likely cost the system $170,000.

There is a blatant disconnect between this very real $1,000 infection tax per case and the day to day financials of running a busy operating room. The added expense of “new technology” such as a vitamin E impregnated polyethylene liner for a TKA can increase the cost of the case by $500 as well as a generate a call from the orthopaedic administrator counting the beans. Yet that same administrator has absolutely no idea of what that surgeon’s overall results were for the previous year.

Spine Surgery Infections

Postoperative infections are rife within orthopaedics and not simply confined to total joint replacement. One paper by Adogwa, et al., out of Duke University Medical Center in 2016 reported an overall surgical site infection rate of 3.2% among 1,400 consecutive patients undergoing elective spine surgery at Duke University Hospital between 2008 and 2010. And while the authors did not assign a monetary value to these cases, the implications of these numbers are significant.

Surgeons and industry are responding in a variety of ways, ranging from simple common sense techniques to changes in surgical technique or high tech solutions.

Bible, et al., were able to significantly reduce the level spinal implant contamination from 16.7% down to 2.0% simply by covering up the implant trays with sterile towels at the beginning of each case. McGirt, et al., demonstrated a significant reduction in surgical site infection (SSI) for two level posterior lumbar trans-foramina inter body fusion (P/TLIF) from 7.0% for an open technique down to 4.6% for a minimally invasive technique. And Litrico, et al., reported a reduction from 6% to 2% for P/TLIFs by employing single use instrumentation. Finally, Mont, et al., lowered costs by $140 to $220 per case with single use instrumentation for total knee replacement.

Emerging Strategies to Cut Infections

The significant cost of SSIs in joint and spine surgery should serve to justify the cost of any effort to reduce post-operative infections. Efforts as simple as covering implants from the beginning of each case, to minimally invasive techniques, to single use instruments can have a substantial impact upon the long-term cost of these procedures.

Author: Jay D. Mabrey, M.D., whose 35 year career in orthopedics included residency at Duke University Medical Center, service in the United States Army Medical Corps, Fellowship at the Hospital for Special Surgery and a long, distinguished career at Baylor University Medical Center where, in addition to his overall leadership at that institution, developed the Joint Wellness Program that helped patients get up after surgery more quickly, developed the first virtual reality surgical simulator for knee arthroscopy and chaired the FDA Orthopaedic Device Panel, is Orthopedics This Week’s newest contributing writer and editor.  

(Adogwa et al., 2016; Bible et al., 2013; Daniels et al., 2016; Litrico et al., 2016; McGirt et al., 2011; Mont. M.A.;Johnson, 2013)

Adogwa, O., Elsamadicy, A. A., Han, J. L., Karikari, I. O., Cheng, J., & Bagley, C. A. (2016). 30-Day Re-admission after Spine Surgery: An Analysis of 1400 Consecutive Spine Surgery Patients. Spine (Phila Pa 1976). doi:10.1097/BRS.0000000000001779

Bible, J. E., O’Neill, K. R., Crosby, C. G., Schoenecker, J. G., McGirt, M. J., & Devin, C. J. (2013). Implant contamination during spine surgery. Spine J, 13(6), 637-640. doi:10.1016/j.spinee.2012.11.053

Daniels, A. H., Kawaguchi, S., Contag, A. G., Rastegar, F., Waagmeester, G., Anderson, P. A., Hart, R. A. (2016). Hospital charges associated with “never events”: comparison of anterior cervical discectomy and fusion, posterior lumbar interbody fusion, and lumbar laminectomy to total joint arthroplasty. J Neurosurg Spine, 25(2), 165-169. doi:10.3171/2015.11.SPINE15776

Litrico, S., Recanati, G., Gennari, A., Maillot, C., Saffarini, M., & Le Huec, J. C. (2016). Single-use instrumentation in posterior lumbar fusion could decrease incidence of surgical site infection: a prospective bi-centric study. Eur J Orthop Surg Traumatol, 26(1), 21-26. doi:10.1007/s00590-015-1692-4

McGirt, M. J., Parker, S. L., Lerner, J., Engelhart, L., Knight, T., & Wang, M. Y. (2011). Comparative analysis of perioperative surgical site infection after minimally invasive versus open posterior/transforaminal lumbar interbody fusion: analysis of hospital billing and discharge data from 5170 patients. J Neurosurg Spine, 14(6), 771-778. doi:10.3171/2011.1.SPINE10571

Mont. M.A.;Johnson, A. J. I., K.; Pivec, R,; Blasser, K.E.; McQueen, D.; Puri, L.; Dethmers, D.A.; Miller, D. W.; Ireland, P.H.; Shurman, J.R.; Bonutti, P. (2013). Single-use instrumentation, cutting blocks, and trials decrease contamination during total knee arthroplasty: a prospective comparison of navigated and nonnavigated cases. J Knee Surg, 26(4), 285-290.