Elsevier

Surgery

Volume 144, Issue 2, August 2008, Pages 317-321
Surgery

Outcome
Cost-effectiveness of routine radiographs after emergent open cavity operations

https://doi.org/10.1016/j.surg.2008.03.012Get rights and content

Background

Emergency surgery increases the risk of a retained surgical sponge (RSS) by 9-fold. In most cases, surgical counts are falsely reported as correct. We hypothesized that the institutional costs resulting from a RSS would make routine intraoperative radiography (IOR) more cost-effective than surgical counts in preventing RSS after emergent open cavity cases.

Methods

A cost-effectiveness analysis was performed to compare routine IOR with surgical counts after emergent open cavity operations. Parameter estimates were obtained from the literature, expert opinion via a standardized survey, and existing institutional data.

Results

Routine IOR was the preferred strategy ($705 vs $1155 per patient) under the assumptions of the base case. The surgical count strategy was dominated by the institutional costs incurred after a RSS. Routine IOR was preferential as long as the sensitivity of surgical counts was less than 98% and the legal fees were more than $44,000 per case of RSS.

Conclusions

Routine IOR is a simple, cost-effective option to reduce the occurrence of this preventable medical error. Institutional costs and legal fees associated with RSS dominate the cost of the surgical count strategy, making routine IOR a more cost-effective strategy than surgical counts given the best available parameter estimates.

Section snippets

The model

This study was conducted using a decision-analysis simulation design. Decision analysis is a quantitative technique for synthesizing data form numerous sources to evaluate diagnostic or therapeutic alternatives. All decision analyses involve the following steps: (1) the competing strategies and outcomes associated with each strategy are specified in a decision model; (2) the probabilities for each of these outcomes are estimated from the most appropriate available data and assigned to each

Results

Baseline analysis was performed using the base case assumptions described, and it incorporated the probabilities and costs of the reference case listed in Table I. According to the underlying assumptions of the model, the expected value (effectiveness) of IOR is 1.000, meaning that the model-derived incidence of RSS after the IOR strategy is less than 1 in 1000. Because sponge counts have false-negative results, the expected value for sponge counting is 0.999, or 1 RSS for every 1000 patients.

Discussion

Retained surgical instrument and sponges are among the most dreaded of surgical complications. The concern is particularly high after emergent cases when the hurried nature of pre- and intraoperative procedures can lead to medical errors. Although surgical counts are an accurate way to prevent RSS when they can be performed correctly (as for most elective cases), most cases of RSS occur after the count has been reported as correct. The most common reasons for falsely correct counts often apply

Conclusion

Currently, there is a tremendous amount of variability in the way that institutions address the issue of RSS and a paucity of evidence to support (or refute) an aggressive strategy of mandatory IOR in all open-cavity cases. The current study demonstrates routine IOR to be a simple, cost-effective option to reduce the occurrence of this preventable medical error. Institutional costs and legal fees associated with RSS dominate the cost of the surgical count strategy, making routine IOR a more

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Presented at the 3rd Annual Academic Surgical Congress, Huntington Beach, California, February 2008.

Supported in part by an Agency for Healthcare Research and Quality grant (T32 HS 013833 to L.A.D.).

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