Cost-effectiveness analysis of hernioplasties before and after the implementation of the ACERTO project

NASCIMENTO, JOSÉ EDUARDO DE AGUILAR; SALOMÃO, ALBERTO BICUDO; RIBEIRO, MARA REGINA ROSA; SILVA, ROBERTA FERREIRA DA; ARRUDA, WESLEY SANTANA CORREA

doi:10.1590/0100-6991e-20202438

ABSTRACT

Objective:

to compare hospital costs and clinical outcomes in inguinal and incisional hernioplasty before and after implementation of the ACERTO project in a university hospital.

Methods:

retrospective study of 492 patients undergoing either inguinal hernioplasty (n=315) or incisional hernioplasty (n=177). The investigation involved two phases: between January 2002 and December 2005, encompassing cases admitted before the implementation of the ACERTO protocol (PRE-ACERTO period), and the other phase, with cases operated between January 2006 and December 2011, after the implementation of the protocol (ACERTO period). The main outcome variable was the comparison of the mean hospital costs between the two periods. As secondary endpoints, we analyzed the length of stay, the surgical site infection rate and mortality. We used the cost method suggested by Public Sector Cost Information System.

Results:

surgical site infection was higher (p = 0.039) in the first phase of the study for both inguinal hernia operations (2 (1.6%) versus 0 (0%) cases) and incisional hernioplasty (5 (7.6%) versus 3 (2.7%) cases). The length of stay decreased one day after the implementation of the ACERTO protocol (p=0.005). There was a reduction in costs per patient from R$ 4,328.58 per patient in the first phase to R$ 2,885.72 in the second phase (66.7% reduction).

Conclusion:

there was a reduction in infectious morbidity, length of stay and hospital costs in hernioplasty after the implementation of the ACERTO protocol.

Keywords:
Hospital Costs; Herniorrhaphy; Surgical Wound Infection; Preoperative Care; Postoperative Care

[1] Mailing address: José Eduardo de Aguilar Nascimento E-mail: je.nascimentocba@gmail.com

Conventional conducts	Conducts recommended by the ACERTO protocol
• Minimum preoperative fasting of eight hours (from the night before the operation).	• No prolonged preoperative fasting. Use of a liquid diet enriched with carbohydrate (12% maltodextrin) until the day before the operation, with the possibility of ingestion up to 2 hours before the operation (3h in case of morbid obesity). Exception: important gastroesophageal reflux and pyloric stenosis syndrome.
• Diet reestablished in the afternoon for operations carried out in the morning or on the next day for thee ones performed in the afternoon.	• Diet after the operation as soon as cleared by the anesthesiologist (if possible, in the anesthetic recovery room).
• Postoperative venous hydration at a volume of 40mL/kg.	• Intravenous hydration should not be prescribed in hernioplasties, in the immediate postoperative period, unless justified.
• Signature of informed consent form for the operation by the patient.	• Consent form and detailed preoperative information to the patient. Encourage the patient to walk and feed early in the postoperative period.
• Use of drains, catheters and antibiotics as preferred by the surgeon.	• No use of prophylactic drains.
• Early postoperative mobilization.	• Justified and standardized use of antibiotics.
• No preoperative nutritional therapy.	• Ultra-early mobilization: sitting and walking on the same day of the operation for at least two hours, and for six hours on the following days.
	• Oral supplement when at nutritional risk.

Variable	R$
Average costs for hospitalization - Patient/day (R$)	11.904,50
Average hospitalization costs - Number of admissions	7.035,29
Average costs for hospitalization - Surgical clinics daily rates	1.442,86

	Pre-ACERTO		ACERTO		p
Operations	190 (38.6)		302(61.4)
Type of hernia (n; %)
Inguinal	124 (65.3)		191 (63.3)
Incisional	66 (34.7)		111 (36.7)		0,65
Gender (n,%)	Masc.	Fem.	Masc.	Fem.
	139	51	235	67	0.24
Median age (interquartile range)	50 (23)		48.5 (24)		0.31
Malnutrition (n,%)	55 (28.9)		77 (25.5)		0,40
Preoperative oral supplement (n,%)	0		22 (7.28)		<0,001
ASA score I / II	101(53.2)		164 (54.3)

Variable	Period pre-ACERTO	ACERTO	p
SSI * (n;%)	7 /190 (3.68)	3/302 (0.99)	0.039
Length of hospital stay (median and interquartile range) in days	3(2)	2 (1)	0.001
Deaths	2/190 (1.05)	0 (0)	0.14