New tool may help stratify risk for surgical site infection

Last Updated: 2017-04-18

By Marilynn Larkin

NEW YORK (Reuters Health) - A new tool that assesses the risk of surgical site infections (SSIs) in colon cancer patients could identify those in need of aggressive preventive efforts, researchers in Massachusetts suggest.

Dr. David Berger of Massachusetts General Hospital (MGH) in Boston told Reuters Health by email, “The idea behind this study was to create an easy-to-use risk score such that effort and dollars could be matched to patients with higher propensity for infection. The hope is that this simple stratification will allow efforts to be more targeted (to) reduce overall healthcare costs while at the same time augmenting efforts to reduce SSIs.”

Dr. Berger and colleagues analyzed data from 1,481 patients (50% men, median age 67) who underwent colon cancer surgery at MGH from 2004 through 2014. Among those, 6.1% had an SSI, they report in JAMA Surgery, online April 12.

Certain patient-related factors were associated with a higher incidence of SSIs. For example, rates were significantly higher among those who were obese (11.7% versus 4.0% for those not obese; P<0.001); abused alcohol (10.6% versus 5.7%; P=0.04); had type 2 diabetes (8.8% versus 5.5%; P=0.046); or smoked (7.4% versus 4.8%; P=0.04).

Rates also were higher among patients whose surgery lasted longer than 140 minutes (7.5% versus 5.0%; P=0.05) or who underwent nonlaparoscopic interventions (laparoscopic, 4.1% versus nonlaparoscopic, 6.7%; P=0.07). These risk factors also were associated with an increase in SSI rates as a compounded score (mutual correlations, such as lifetime smoking and alcohol abuse, P<0.001).

The number of risk factors was significantly associated with an increase in the SSI rate (P<0.001). The SSI rate was 2.3% (equivalent to a relative risk of 0.4) for those with no more than one risk factor; 5.2% (RR, 0.78) for those with two risks; 7.8% (RR, 1.38) for those with three; and 13.6% (RR, 2.71) for those with four or more risk factors.

Dr. Berger said, “The risk score can be applied in other areas; however, we chose to begin with colon surgery because of the relatively higher baseline infection rates.”

Editorialist Dr. Daniel Albo of the Georgia Cancer Center at Augusta University told Reuters Health, “Developing a more targeted approach to (perioperative SSI-reducing) bundle utilization based on identifiable risk factors could lead to a reduction of overtreatment in low-risk patients, and (a reduction in) potential undertreatment in high-risk colon cancer surgery patients.”

“An interesting concept is the potential utilization of this type of program in the new realities of the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) reimbursement,” he said by email. “As MACRA shifts hospital and physician payments from a fee-for-service structure to a value-based one, this type of initiative could be submitted as part of an Alternative Payment Model (APM). APMs may qualify for higher levels of reimbursement for services tied to increases in performance and reductions in the cost of care.”

“Value can be defined as where increases in quality intersect with a reduction in the cost of care,” Dr. Albo continued. “Understanding patient and perioperative risk factors that increase complication rates after surgery could lead to the deployment of targeted quality improving bundles.”

“This more targeted approach could be a powerful tool in our quest to achieve the value-based proposition in the management of our surgical patients," he concluded.

Dr. Daniel Labow, Chief of the Surgical Oncology Division at Mount Sinai Hospital in New York City, told Reuters Health by email, “Though the factors and description of increased risk of infection are not new, the organization into (an) SSI risk score may be helpful in indentifying which patients are at increased risk and then perhaps applying more intense monitoring or other (strategies) to help decrease the infection rate in those patients.”

SOURCE: http://bit.ly/2opqpYc

JAMA Surg 2017.