PMC9413182_01
Overview of datasets for the estimation of antimicrobial resistance impact on surgery patients in England. Boxes represent the setting and/or type of the data, bullet points represent the name of the dataset, followed by a high-level description the use of the dataset in square brackets, for the purposes of Surgical Site Infection and Antimicrobial Resistance research. For more information on data sources (see Supplementary Table A1). NHS, national health service; SSI, surgical site infection.
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In terms of data access, although all the patient-based data sources outlined in Figure 1 are not fully open-access due to patient identifiable data and subsequent data safeguarding, summary statistics are published openly. This allows for more robust patient outcome inclusion, such as cost-of-SSI and mortality impacts (see Supplementary Figure A1 for more detail). There is also the challenge of the increased cost of requiring long-term assisted living for individuals with non-operative management of end-stage osteoarthritis in the elderly population, these costs could be incorporated into Figure 2 by separating out non-surgical management of hip pain and non-surgical treatment of SSIs by settings of care, potentially parameterised by the social care and society demographic data highlighted by Figure 1.
A conceptual model for estimating the impact of antimicrobial resistance on surgery patients. The progress of patients through a surgical management pathway with the potential for infection is depicted following from left to right. Patients initially start (far left) in one of three health states (blue circles) and progress through treatment decisions (rectangles). Circles represent health states, rectangles represent pathway treatment decisions, (c) represents a collapsed branch that mirrors that of another branch within that level (for example the pathway following "No Prophylaxis" includes the same transitions and states as "Prophylaxis." Yi represents microbes where i = 1,...,m different microbes of clinical importance; Xp,t represents antibiotics given for prophylaxis (p = 1,...,n) at time t, Tx represents antibiotics given for treatment of SSI (t = 1,....,q). It may be that p = t. The length of time patients spends in each state (indicated by a curved returning arrow) is variable.
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Additionally, other social care data sources listed in Figure 2 (and described further in Supplementary Table A1) provide information on long and short-term forms of social care that could be useful for costing purposes, if/when applicable to the patient groups of interest. Figure 2, we highlight that there are the potentially numerous patient pathways with different drug regimens and potential for infection with different organisms. Figure 2 highlights the complexity of this issue, with transition rates and outcomes potentially heterogenous for different drug and bacteria combinations (Supplementary Figure A2 gives a simple example of one drug-bacterial combinations for a portion of this pathway). AMR effects were not incorporated into the equations, a weighted average of the cost of different prophylaxis guidelines between Trusts was used to account for this. At an individual level, the specific microbe that caused the infection and type of antimicrobial used to treat it could be important in terms of pathways (and subsequently outcomes and costs), thus the scope of different combinations of prophylactic and therapeutic drug-pathogen exposure definitions (of Yi and Xp,t in Figure 2 representing different microbes, prophylaxis and treatment antibiotics, respectively) warrant consideration by experts in SSIs depending on the scale of the research question (e.g., local, regional or national). Average adjusted-wage losses per excess death and days unable-to-work could be estimated through ONS data on employment and wages, and combined with excess deaths and days (e.g., in hospital) counted through (Figure 2). SSIs, under which 60% undertook continuous surveillance for 2019/20, SSIS reports the incidence of SSI from surveilled hip surgery patients, and the distribution of causative microbes across these SSIs. Such reports can therefore be used to estimate transition probabilities across Figure 2 for contracting microbe-specific SSIs following hip replacement surgery in England, alongside assumptions of prophylaxis impact, in the absence of more granular data (see Supplementary Figure A2 for a worked example). There is also the challenge of the increased cost of requiring long-term assisted living for individuals with non-operative management of end-stage osteoarthritis in the elderly population, these costs could be incorporated into Figure 2 by separating out non-surgical management of hip pain and non-surgical treatment of SSIs by settings of care, potentially parameterised by the social care and society demographic data highlighted by Figure 1.