Rev. bras. ortop. vol.52 número6

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SOCIEDADE BRASILEIRA DE ORTOPEDIA E TRAUMATOLOGIA

w w w . r b o . o r g . b r

Original

Article

Social

profile

and

cost

analysis

of

deep

infection

following

total

hip

replacement

surgery

Vera

Lucia

Frazão

a

_,

_Helder

_de

_Souza

_Miyahara

a

_,

_Ricardo

_Akihiro

_Kirihara

a

_,

Ana

Lucia

Lei

Munhoz

Lima

b

_,

_Alberto

_Tesconi

_Croci

b

_,

_José

_Ricardo

_Negreiros

_Vicente

a,∗ a_Instituto_de_Ortopedia_e_{Traumatologia,}_Faculdade_de_Medicina,_Universidade_de_São_Paulo,_São_Paulo,_SP,_Brazil

b_Departamento_de_Ortopedia_e_{Traumatologia,}_Faculdade_de_Medicina,_Universidade_de_São_Paulo,_São_Paulo,_SP,_Brazil

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Articlehistory:

Received30August2016 Accepted4October2016 Availableonline23October2017

Keywords: Hiparthroplasty Infection Costanalysis

a

b

s

t

r

a

c

t

Objective:Tocharacterizethesocio-economicanddemographicprofileofpatients under-goingsurgeryforrevisiontotalhiparthroplastyregardingthediagnosisofdeepprosthetic infection.

Methods:Twentypatientswereretrospectivelystudied,admittedintheperiodbetween2009 and2010bytheHipSurgeryGroupwiththediagnosisofdeepprostheticinfection,whose proposedtreatmentwassurgical.Thisstudywascarriedoutinthepresenceofthepatient bycompletingtwoformsappliedbythesocialworkeroftheGroup.

Results:Ina20-patientsample,40%weremale,45%wereworkingage,50%ofpatients orig-inatedfromthecapital,85%dependedonbenefits,70%wereretired,60%ofpatientswere fromthishospital,and40%werefromotherservices.Theaveragecostofpatientstothe publicsystemwasR$55,821.62perpatientandthetotalspentontreatmentofpatientsin thestudyexceededonemillionBrazilianreals,totallingR$1,116,432.40.

Conclusion:Infectionfromtotalhiparthroplastygeneratesamajorexpensetothesocial securitysystemandtothepublichealthcaresystem.Physiciansmustalwaysbealerttothe possibleriskfactorsandperioperativecare,strivingtominimizethiscomplication.

Perfil

social

e

análise

de

custo

da

infecc¸ão

pós-operatória

da

artroplastia

total

do

quadril

Palavras-chave: Artroplastiadequadril Infecc¸ão

Análisedecusto

r

e

s

u

m

o

Objetivo:Caracterizaroperfilsocioeconômicoe demográficodepacientessubmetidos à cirurgiade revisãodeartroplastiatotaldoquadrilpordiagnósticodeinfecc¸ãoprotética profunda.

∗ _{Corresponding}_author_.

E-mail:rrnegreiros@gmail.com(J.R.Vicente). http://dx.doi.org/10.1016/j.rboe.2017.10.003

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Métodos: Análisede20pacientesinternadosentre2009e2010peloGrupodeQuadrilcom diagnósticodeinfecc¸ãoprotéticaprofundacujotratamentopropostofoicirúrgico.O tra-balhofoifeitocompreenchimentonapresenc¸adopacientededoisformuláriosaplicados pelaassistentesocialdogrupo.

Resultados:Naamostrade20pacientes,40%pertenciamaosexomasculino,45%estavamem idadeprodutiva,50%eramorigináriosdacapital,85%previdenciários,70%aposentados,60% provenientesdoprópriohospitale40%deoutrosservic¸os.Amédiadecustodospacientes aosistemapúblicofoideR$55.821,62porpaciente,ogastototalnotratamentodospacientes doestudototalizouR$1.116.432,40.

Conclusão: Conclui-sequeaartroplastiatotaldoquadrilinfectadageraumgrandegasto aosistemaprevidenciárioeaosistemadesaúdepúblico,deve-se,portanto,sempreatentar paraospossíveisfatoresderiscoecuidadosperioperatóriosparaqueesseproblemaseja evitado.

Introduction

Amongthepossiblecomplicationsoftotalhiparthroplasties, prostheticinfectionisoneofthemostdevastating,with seri-ousconsequencesforpatients,sincemostofthemwillrequire furthersurgicalinterventions;furthermore,theyare associ-atedwithhigh costs forthe paying sources.They are also associatedwithperiodsofworkleaves,alsooverburdeningthe socialsecuritysystem.

Anumber offactors are relatedtothe increasedriskof prostheticinfection,includingobesity,diabetes, immunosup-pression,previouslargehipsurgeries,smoking,malnutrition, prolonged corticoid therapy, and prolonged surgical time, amongothers.1,2

InBrazil,Law9.431/97hasmadehospitalinfection surveil-lance mandatory, in order to systematically reduce the prevalenceof this complication as a whole in the various medicalspecialties.3_The_Pan_American_Health_Organization coordinated the Study on the efficacy of nosocomial infection control, conducted in Atlanta (United States). That study concludedthat hospital stayincreases the duration ofthe infectionbyameanoffourdays,withanadditionalcostper patientof$1800onadmission.4

Thepresentstudyisaimedatestablishingthe socioeco-nomicanddemographicprofileofpatientswho underwent total hip arthroplasty revision at this medical service due to a diagnosis of deep prosthetic infection, and to identify the costs involved in the treatment of these patients.

Methods

Afterapproval by the Research Ethics Committee,a retro-spectivedescriptivestudywasconductedwithqualitativeand quantitativeanalysis.

Thestudyincludedpatientsadmittedbetween2009and 2010 by The Hip Group of a quaternary university hospi-tal,witha diagnosis ofdeep prosthetic infection inwhom the proposed treatment was surgical. Patients with infec-tionresultingfromtotalhiparthroplastyrevisionsurgeryand

thosewhorequiredintravenousantibiotictherapyas defini-tivetreatmentwithouttheneedforsurgicaltreatmentwere notincluded.Furthermore,patientswhodidnotagreetosign theinformedconsentformtoparticipateintheprojectwere alsoexcluded.

Thestudywascarriedoutbycompleting,inthepatient’s presence,twoformsappliedbythesocialworkerofthegroup, themainauthorofthisstudy.

Questionnaire1(Appendix)addressedthesocialandfamily dataofpatients,aswellasthoseinherenttotreatment.

Questionnaire2(Appendix)addressedthesocioeconomic issuesbasedontheBrazilEconomicClassification,acriterion adopted by the Brazilian Association of Research Compa-nies(Associac¸ãoBrasileiradeEmpresasdePesquisa[Abep]),5 whichassessesthepurchasingpowerofthepopulationand the degreeofeducation ofthehead ofthe family, stratify-ingthepopulationatthefollowinglevels:A1,A2,B1,B2,C1, C2, D, and E. Both forms were pre-tested infive patients, attempting to solve possible execution and reproducibility issues.

Thestudyincluded20patients,fromaninitialpopulation of24 patients, who met theinclusion criteria inthestudy period.Twopatientsdiedduetocausesunrelatedtothe ini-tialdiagnosis,onecontinuedtreatmentintheSupplementary HealthSystem,andonedidnotsigntheInformedConsent Form.

Results

Patient’s sociodemographic and family data are shown in Table1.

Fig.1standsforpatientdistributionaccordingto socioeco-nomiclevel.

Themeannumberofdaysonantibiotictherapy,whether intravenousororal,was266days(30–376).

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Table1–Patientssociodemographicandfamilyaspects. Gender Male 40% Female 60% Age Productive (30–55years) 45% Nonproductive (<30years) 5%

Elderly(over60years) 50%

Maritalstatus Single 20%

Marriedandsimilar 45%

Widowed 20%

Divorced 15% Placeofbirth SP–capital

50%

GreaterSP 20%

SP–countryside 25%

Others 5% SocialSecurity SocialSecurity

Beneficiaries 85%

Non-socialsecuritybeneficiaries 15% Religion Catholics 55% Evangelicals 30% Withoutreligion 10% Buddhists 5% Education CollegeorUniversity

Degree 15% Elementary 55% HighSchool 25% Neverattended school. 5% Socialsecurity situation Retired 70% Sicknessaid 10% Pensioner 10%

Didnotreceive socialsecurity aid

10%

Housing Own70% Rented10% Assigned20%

Qualityofthe housing

Adequate 100%

Inadequate 0% Familysupport Extendedfamily

90%

Caregiver 10% Initialdiagnosis Primaryosteoarthrosis

10%

Secondary 90% Patient’sorigin Thishospital

60%

Othermedicalservices 40%

Dateofdiagnosis Upto4weeks 35%

1–6months 15%

6mto2years 30%

Over2years 20% Numberof surgeries required Single(debridement) 40%

Two(spacerand revision) 30% >2(spacer changeand revision)30% Lengthof hospitalstay

Upto2weeks 50% 2–4weeks 25% >4weeks 25% 0 10 5 20 30 20 15 0 0 5 10 15 20 25 30 35 E D C2 C1 B2 B1 A2 A1

Socioeconomic level – relative distribution (%)

Fig.1–Patientdistributionaccordingtosocioeconomic level.

Discussion

Prostheticinfection isoneofthemostseriousof complica-tions,withsevereconsequencesforpatients,sinceitresults innewsurgicalinterventions,prolongedhospitalstays,and theneedforlong-termantibiotictherapy.6_Moreover,_revisions

ofinfectedarthroplastiesarecostlytohealthcareandsocial securitysystems.

The initial diagnosis of infected patients treated at the medical service, primary osteoarthrosis in 10% and osteoarthrosis secondary to another previous pathology in 90%,isprobablyduetotheprofileofpatientsreferredtothis referenceservice;itmightalsoduetotheagedistributionof theBrazilianpopulation,notablyyoungerthanthatofother countries, which justifiesahigher prevalenceofsecondary osteoarthrosis.

Ofthepatients,40%weremaleand60%female. Accord-ing to Bozig et al.,7 _white _women _aged _between ₇₀ _and 74yearswithcomorbiditiessuchasalcoholism,depression, cardiopulmonary disease, and peripheral vascular insuffi-ciency aremorepronetoperiprosthetic infection.However, accordingtoPoultsidesetal.,8_{comorbidity-associated} infec-tion may also be observed male patients with the same probability.

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Table2–Meancostofhospitalizationaccordingto region.

Presentstudy(BR) US$23,857

Europe US$40,485

UnitedStates US$11,494

UnitedKingdom US$36,728

cases,inwhichasimpledebridementsurgerymightsavethe originalimplantandcauselessharmtothepatient,in addi-tiontoalowersocialcost.Theauthorsthereforeemphasize theimportanceofinitialoutpatientfollow-upconsultations, whichshouldalwaysbeconductedunderthesupervisionofa physicianexperiencedinthematter.

InastudyoftheDepartmentofOrthopedicSurgery, Univer-sityofNorthCarolina(UnitedStates),Clementetal.9_reported meancostsof$11,494inthetreatmentofpatientsreadmitted withadiagnosisofperiprostheticinfection.Vanheganetal.,10 inastudyperformedattheorthopedicdepartmentofthe Uni-versityofLondon,observedamean costof£_21,937_in_the treatmentofthiscomplication.Datafrom theUniversityof Rostock,Germany,inastudybyHaenleetal.,11_showed_a_mean costofD 29,331forthetreatmentofaninfectedarthroplasty vs.D ₆₂₆₅_for_primary_{arthroplasty.}_Other_studies_also_show

thatthiscostisgreatlyincreasedwhentheetiologicalagent responsiblefortheinfectionisamultiresistant microorgan-ism;accordingtoFiliceetal.,thesecostscandoubleinthe caseofaninfectioncausedbyamultisensitivebacterium.12

Table2standsforthemean costofarthroplastiesinthe aforementionedplaces.

Despite the variations observed, due to tax differences (leading to different costs of medication and implants) as well as from the unequal healthcare systems, it is noted that eventhe lowest observedvalue wassignificant, espe-ciallywhen consideringthis data collectivelyin thewhole country.

In addition to expenses with hospital services and materials, it is important to emphasize the deficit in the social security system. In most cases, it is caused by disability retirement due to illness and the prolonged period of hospitalization. In the present study, 90% of the patients were insured by the social security system, of whom 45% were of working-age, which demonstrates the seriousconsequences ofarthroplasty infection forthis system.

Another serious socioeconomic problem found in this study was the origin of the patients: 40% were referred from other medical services, which may be associated with a lack of adequate distribution of hospitals capable of treating high complexity cases, that require adequate equipment for surgical procedures, experienced surgeons, hospital infrastructure, and drug availability. The problem ofthe centralizationofhighcomplexity servicesremains a challenge to be solved in Brazil, a country of continental dimensions.

Inthepresentstudy,thecausesorriskfactorsfor peripros-thetic infection were not studied, but a large part of the population was stratified into socioeconomic classes B2,

C1, and C2, according to the Abep Classification (2007).5 These social classes have lower purchasing power, which may berelatedtosomeofthe mainriskfactorsassociated with periprosthetic infections foundin other studies,such asmalnutrition,preoperativeanemia, andhydroelectrolytic disorders.13

Ofthepatientsincludedinthepresentstudy,15%hada collegeoruniversitydegree,55%elementaryschooldegree, 25%highschooldegree,and5%neverattendedschool,which identifiesthepatientsofthissampleashavinglowpurchasing powerandlowschooling,asindicatedbyOngetal.14_in_their workonthecorrelationbetweenperiprostheticinfectionand thesocioeconomicstatusofpatients.

Conclusion

Infectedtotalhiparthroplastyisapostoperativecomplication thetreatmentofwhichgeneratesgreatexpensetothesocial securityandpublichealthcaresystems,becauseitfrequently involvesrelativelyyoungpatientsofworking-age.Therefore, inordertoavoidtheissue,thepossibleriskfactorsandthe quality of perioperative care should always be taken into account.

Conflicts

of

interest

Theauthorsdeclarenoconflictsofinterest.

Appendix.

Questionnaire1–Patientssocialandfamilydata

•Identification:name,age,gender,religion,schooling,

maritalstatus,andplaceoforigin.

•Socialsecuritysituation:associationandsocial

securitybenefit.

•Housing:area,property,typeofhousing,numberof

rooms,numberofinhabitants,sanitation,selective garbagecollection,drinkingwater,andhealthcare serviceneartheresidence.Asatisfactoryhousing wasdefinedasonewithatleasttworooms,with sanitation,andgarbageandsewagecollection,as wellasaprivatebathroom,allofthesefactors concomitantwiththepresenceofanaccessible healthcareserviceneartheresidence.

•Familysupport:familydynamicsduringtreatment

andhomecare.Theconceptofanextendedfamily denotesaunitbeyondparentsandchildrenformed bycloserelativeswithaffectivetiesandabletogive supporttothepatient.

•Hospitalization:initialdiagnosis,date,numberof

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Questionnaire2–Socioeconomiclevel (questionnaireto obtaintheBrazilianEconomicClassificationdata–newAbep –2008).

Ownershipofcertainitems

Items Does

not own

1 2 3 4

ColorTVs 0 1 2 3 4

VCR/DVD player

0 2 2 2 2

Radios 0 1 2 3 4

Bathrooms 0 4 5 6 7

Vehicles 0 4 7 9 9

Monthly-paid housemaids

0 3 4 4 4

Washing machine

0 2 2 2 2

Refrigerator 0 4 4 4 4

Freezera ₀ ₂ ₂ ₂ ₂

a _Independent_appliance_or_a_2nd_door_on_the_{refrigerator.}

Levelofschoolingofheadofthehousehold

Oldnomenclature Points Current

nomenclature

Illiterate/incomplete elementaryschool

0 Illiterate/upto3rd yearofelementary school

Complete

elementaryschool

01 4thgradeelementary school

Completehigh school

02 Complete

elementaryschool Completehigh

school

04 Completehigh

school CollegeorUniversity

Degree

08 CollegeorUniversity Degree

Classes Score

A1 42to46points

A2 35to41points

B1 29to34points

B2 23to28points

C1 18to22points

C2 14to17points

D 8to13points

E 0to7points

Minimumscore:0 Maximumscore:46

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