An economic analysis of safe surgery in low- and middle- income countries: a case study of surgical site infection

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Monahan, Mark ORCID: https://orcid.org/0000-0002-1175-9421 (2024). An economic analysis of safe surgery in low- and middle- income countries: a case study of surgical site infection. University of Birmingham. Ph.D.

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Abstract

Introduction
Surgical Site Infection (SSI) is a common postoperative complication and is associated with substantial financial and quality of life consequences. Numerous logistical challenges make accurate quantification of SSI-related costs and outcomes difficult. SSI has a higher incidence rate in low- and middle- income countries (LMICs) relative to high income countries. This along with efforts to increase the volume of surgeries to address unmet surgical need in LMIC settings gives a more pressing focus on postoperative surgical outcomes. The reduction of postoperative complications is a key outcome measure for safe surgery. For decision makers in resource-constrained environments, it is important to know whether investments in safe surgery represent a worthwhile use of health care resources given the opportunity cost of those healthcare resources.

Thesis aim
The thesis uses primary and secondary research sources to answer the research question: What is the economic rationale for investing in safe surgery interventions to reduce SSI in LMICs?

Methods
Separate systematic reviews on the costs and utility decrement of SSI were undertaken to populate a preliminary economic model to assess the cost-effectiveness of SSI prevention interventions using ‘best guess’ estimates. The model was further refined using cost and quality of life estimates from a re-analysis of an SSI Randomised Control Trial (RCT). Next, the cost and quality of life implications of SSI were ascertained from primary research by i) generating health state valuations associated with SSI, and ii) collecting costs associated with SSI in a sub study of a multinational RCT. The preliminary economic model was then updated with the primary research data to assess the economic rationale of safe surgery interventions to reduce SSI in LMICs.

Results
The base case results of the preliminary decision analytic model indicated that both exemplar interventions were cheaper and more effective than Usual Care and the results were robust to sensitivity analyses across the examined settings. Refining the preliminary model-based economic evaluation with the RCT re-analysis did not change the decision recommendation. For the primary data collection, an SSI was associated with additional postoperative costs in patients undergoing abdominal surgery across Ghana, Mexico, Nigeria, and India. Specially constructed vignettes to describe different severity levels of SSI were successfully valued with the general public remotely using different health state valuation techniques.
For the final updated model with one exception, one or more of the SSI prevention interventions were cost-effective versus Usual Care but these varied by wound contamination. For the patient group in Mexico with Clean-Contaminated wounds, the results varied by outcome measure with Alcoholic Chlorhexidine being the most cost-effective strategy under the Cost per DALY averted approach and Usual Care being the most cost-effective strategy under the Cost per QALY approach.

Conclusion
An economic rationale in investing in safe surgery interventions to reduce SSI in LMICs was uncovered. Despite possible transferability issues with the cost, utility and treatment effectiveness data, the decision recommendations of preliminary economic modelling did not change when the model was iteratively refined with more suitable LMIC data.

Type of Work:

Thesis (Doctorates > Ph.D.)

Award Type:

Doctorates > Ph.D.

Supervisor(s):

Supervisor(s)	Email	ORCID
Roberts, Tracy	UNSPECIFIED	orcid.org/0000-0002-0624-0537
Jowett, Sue	UNSPECIFIED	orcid.org/0000-0001-8936-3745
Pinkney, Thomas	UNSPECIFIED	orcid.org/0000-0001-7320-6673