Systematic Reviews
Copyright ©The Author(s) 2019. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Clin Cases. Jul 26, 2019; 7(14): 1825-1836
Published online Jul 26, 2019. doi: 10.12998/wjcc.v7.i14.1825
Cost-analysis of inpatient and outpatient parenteral antimicrobial therapy in orthopaedics: A systematic literature review
Christoph Kolja Boese, Philipp Lechler, Michael Frink, Michael Hackl, Peer Eysel, Christian Ries
Christoph Kolja Boese, Michael Hackl, Peer Eysel, Christian Ries, Department of Orthopaedic and Trauma Surgery, University Hospital of Cologne, Cologne 50931, Germany
Philipp Lechler, Clinic for Trauma and Hand Surgery, Kreiskliniken, Altötting 84503, Germany
Philipp Lechler, Michael Frink, Center for Orthopaedics and Trauma Surgery, University Hospital Giessen and Marburg, Marburg 35043, Germany
Author contributions: Boese CK designed the study and performed the literature analysis; Boese CK analysed the data and Ries C reviewed the data analysis critically; Boese CK and Ries C wrote substantial parts of the manuscript; Lechler P and Frink M provided input to the study concept; Lechler P, Frink M, Hackl M and Eysel P critically reviewed the manuscript and provided expert opinion.
Conflict-of-interest statement: Boese CK is employee of Smith and Nephew GmbH, Germany. The other authors report no conflict of interest. All authors have no financial disclosures with respect to this manuscript.
PRISMA 2009 Checklist statement: The authors have read the PRISMA 2009 Checklist, and the manuscript was prepared and revised according to the PRISMA 2009 Checklist.
Open-Access: This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
Corresponding author: Christoph Kolja Boese, MD, Senior Lecturer, Department of Orthopaedic and Trauma Surgery, University Hospital of Cologne, Joseph-Stelzmann Street 9, Cologne 50931, Germany. christoph.boese@uk-koeln.de
Telephone: +49-221-4784682 Fax: +49-221-47886731
Received: March 8, 2019
Peer-review started: March 11, 2019
First decision: May 10, 2019
Revised: May 28, 2019
Accepted: June 27, 2019
Article in press: June 27, 2019
Published online: July 26, 2019
Processing time: 141 Days and 0.8 Hours
ARTICLE HIGHLIGHTS
Research background

Increasing numbers of total joint arthroplasties worldwide are noted. This is associated with rising risk for revision surgery. Periprosthetic joint infections (PPJI) play a significant role in revisions. Treatment of PPJI often requires long-term antimicrobial therapy. In PPJI, a bone-infection must be assumed and therefore antiinfective therapy lasts for 6-12 wk or longer. Parenteral antiinfective therapy is often required. Usually, parenteral therapy requires an inpatient setting [Inpatient parenteral antibiotic therapy (IPAT)] and goes along with high direct as well as indirect costs. An alternative is outpatient parenteral treatment [Outpatient parenteral antibiotic therapy (OPAT)]. So far, there is a lack of knowledge regarding health economic effects of IPAT and OPAT in general and for PPJI specifically.

Research motivation

To identify the proposed economical benefits of OPAT in comparison to IPAT health economic cost-benefit analysis are needed. While various publications dealt with OPAT, generalization of assumptions requires input from multiple studies. We aimed to perform a systematic literature review of published literature on cost comparisons of OPAT and IPAT to better delineate the effects. The motivation was generating evidence to support OPAT for PPJI and create awareness for this alternative treatment option.

Research objectives

The aim of this study was an economic comparison of IPAT and OPAT. A systematic literature review was performed for this purpose.

Research methods

For this purpose, a search strategy was developed and we performed a systematic review of published literature by searching the Medline database via PubMed. All abstracts meeting the inclusion criteria were identified, and relevant articles were analyzed in detail. Relevant data was extracted and homogenized.

Research results

The literature search identified 619 potential studies of interest. 328 were excluded during screening. 215 full texts were available for in-depth analysis. For quantitative analysis of OPAT and IPAT cost, 21 studies were included. Costs for IPAT were between 1.10 to 17.34 times higher than those for OPAT. Only one study showed marginally lesser costs for IPAT. Only one study focused specifically on PPJI.

Research conclusions

To the best of our knowledge, this is the first comprehensive systematic literature review outside the CIVAS report on cost effectiveness of OPAT. The review provides a wide overview over the exiting literature with minimal exclusion criteria. The presentation of extracted data allows for detailed understanding of included studies. Limitations of the study were the heterogeneity of studies from different health care systems and a wide time interval. Still, this open inclusion allows for better understanding of the available data worldwide.

Research perspectives

While the beneficial cost effect of OPAT has been shown, there is need to provide more specific studies. In particular, there is need to analyze cost structures for PPJI treatment in different health care systems. With such studies, guidelines to implement OPAT into the standard of care might be created.