title: Cost and quality of life outcome analysis of postoperative infections after subaxial dorsal cervical fusions.
abstract: OBJECTIVE
  Infections following spine surgery negatively affect patient quality of life (QOL) and impose a significant financial burden on the health care system. Postoperative wound infections occur at higher rates following dorsal cervical procedures than ventral procedures. Quantifying the health outcomes and costs associated with infections following dorsal cervical procedures may help to guide treatment strategies to minimize the deleterious consequences of these infections. Therefore, the goals of this study were to determine the cost and QOL outcomes affecting patients who developed deep wound infections following subaxial dorsal cervical spine fusions.
  
  
  METHODS
  The authors identified 22 (4.0%) of 551 patients undergoing dorsal cervical fusions who developed deep wound infections requiring surgical debridement. These patients were individually matched with control patients who did not develop infections. Health outcomes were assessed using the EQ-5D, Pain Disability Questionnaire (PDQ), Patient Health Questionnaire (PHQ-9), and visual analog scale (VAS). QOL outcome measures were collected preoperatively and after 6 and 12 months. Health resource utilization was recorded from patient electronic medical records over an average follow-up of 18 months. Direct costs were estimated using Medicare national payment amounts, and indirect costs were based on patients' missed workdays and income.
  
  
  RESULTS
  No significant differences in preoperative QOL scores were found between the 2 cohorts. At 6 months postsurgery, the noninfection cohort had significant pre- to postoperative improvement in EQ-5D (p = 0.02), whereas the infection cohort did not (p = 0.2). The noninfection cohort also had a significantly higher 6-month postoperative EQ-5D scores than the infection cohort (p = 0.04). At 1 year postsurgery, there was no significant difference in EQ-5D scores between the groups. Health care-associated costs for the infection cohort were significantly higher ($16,970 vs $7658; p < 0.0001). Indirect costs for the infection cohort and the noninfection cohort were $6495 and $2756, respectively (p = 0.03). Adjusted for inflation, the total costs for the infection cohort were $21,778 compared with $9159 for the noninfection cohort, reflecting an average cost of $12,619 associated with developing a postoperative deep wound infection (p < 0.0001).
  
  
  CONCLUSIONS
  Dorsal cervical infections temporarily decrease patient QOL postoperatively, but with no long-term impact; they do, however, dramatically increase the cost of care. Knowledge of the financial burden of wound infections following dorsal cervical fusion may stimulate the development and use of improved prophylactic and therapeutic techniques to manage this serious complication.
authors.affiliation: Cleveland Clinic Center for Spine Health and.
authors.forename: Benjamin D
authors.initials: BD
authors.lastname: Kuhns
authors.forename: Daniel
authors.initials: D
authors.lastname: Lubelski
authors.forename: Matthew D
authors.initials: MD
authors.lastname: Alvin
authors.forename: Jason S
authors.initials: JS
authors.lastname: Taub
authors.forename: Matthew J
authors.initials: MJ
authors.lastname: McGirt
authors.forename: Edward C
authors.initials: EC
authors.lastname: Benzel
authors.forename: Thomas E
authors.initials: TE
authors.lastname: Mroz
mesh_terms: D000328:Adult; D000368:Aged; D002574:Cervical Vertebrae / Q000601:surgery*; D015897:Comorbidity; D004185:Disability Evaluation; D005260:Female; D005500:Follow-Up Studies; D017048:Health Care Costs; D006801:Humans; D008297:Male; D008875:Middle Aged; D010147:Pain Measurement; D011788:Quality of Life; D012086:Reoperation / Q000191:economics; D012189:Retrospective Studies; D013123:Spinal Fusion / Q000191:economics* / Q000379:methods; D013530:Surgical Wound Infection / Q000191:economics* / Q000453:epidemiology / Q000601:surgery
keywords: BMI = body mass index; DCF = dorsal cervical fusion; EMR = electronic medical record; MCID = minimum clinically important difference; PDQ = Patient Disability Questionnaire; PHQ-9 = Patient Health Questionnaire; PRO = patient-reported outcome; QOL = quality of life; SF-36 = 36-Item Short Form Health Survey; VAS = visual analog scale; cervical spine; cost; postoperative infection; quality of life