Kyle L. Barner, OMS-III1; Cameron G. Hanson, OMS-II1; Kevin A. Witte, D.O.2
1Kansas City University of Medicine and Biosciences
2St. Luke’s Health System
In 2015, The Center for Disease Control and Prevention reported 30.3 million patients in America were estimated to have diabetes mellitus (DM) with 1.5 million new cases diagnosed every year. The financial burden for diagnosed DM is high, costing $327 billion in 2017 alone. Beyond the fiscal repercussions, DM has been found to significantly increase post-operative complications as a systemic and chronic comorbidity. It is thus imperative to better understand how efficient and optimal DM management pre- and post-operatively may potentially attenuate such complications. Prior studies found decreased surgical site infection (SSI) rates in DM patients who underwent preoperative glycemic control. In this study, we set out to determine if a difference in SSI rates exists in uncontrolled DM patients undergoing open reduction internal fixation (ORIF) procedures and determine the impact of the post-ORIF infection on the length of hospital stay (LOS) and total charges for the admission.
This retrospective cohort study utilized data from the Healthcare Cost and Utilization Project-National Inpatient Sample database to identify adult patients (18+ years) who developed a SSI after ORIF of the femur, tibia, fibula, humerus, ulna or radius between 2012-2014. Comparative analyses were based on three cohorts using ICD-9 diagnosis codes for: controlled DM, uncontrolled DM or no DM. Patients missing information on age, total charges and LOS were excluded from the study. SSI rates, total charges, and LOS were examined and compared between ORIF patients with uncontrolled DM and ORIF patients without comorbid DM or SSI.
851,870 patients underwent ORIF between the years of 2012-2014. Patients with uncontrolled DM had an SSI rate of 0.44% (90/20,405) while those with controlled DM had an SSI rate of 0.29% (420/142,530). In patients without comorbid DM, the SSI rate was 0.23% (1,465/636,320). Patients with uncontrolled or controlled DM had SSI rates significantly higher (p<0.01 and p<0.05, respectively) than patients without DM who underwent an ORIF procedure.
The LOS and total charges of uncontrolled DM patients with SSI were compared against the non-DM/non-SSI patient sample to observe the overall financial burden. For non-DM/non-SSI patients undergoing ORIF, average LOS was 4.75 days and total charges were $60,847. Uncontrolled DM patients who developed SSI had a significantly increased LOS (16.5 days, p<0.0001) and total charges ($188,358, p<0.001).
Patients with uncontrolled DM have a significantly increased rate of SSI associated with a 3.5x increased LOS and 3x increased total charges for ORIF procedures. From a national perspective, uncontrolled DM patients with SSI post-ORIF were associated with an additional 1,057 hospital days and hospital costs exceeding 11.5 million for the studied time period. Optimization of pre/post-operative care for patients with uncontrolled DM undergoing ORIF may help decrease the risk of SSI and financial sequalae.