Skip to main content Accessibility help

The impact of surgical site infections on hospital contribution margin—a European prospective observational cohort study

  • Marco von Strauss (a1) (a2), Walter R. Marti (a3), Edin Mujagic (a1), Michael Coslovsky (a4), Katharina Diernberger (a5), Peter Hall (a6), Jasmin Zeindler (a1), Lilian A. Salm (a3), Savas D. Soysal (a1) (a2), Robert Mechera (a1) (a2), Urs von Holzen (a1) (a7) and Walter P. Weber (a1)...



Surgical site infections (SSIs) are common surgical complications that lead to increased costs. Depending on payer type, however, they do not necessarily translate into deficits for every hospital.


We investigated how surgical site infections (SSIs) influence the contribution margin in 2 reimbursement systems based on diagnosis-related groups (DRGs).


This preplanned observational health cost analysis was nested within a Swiss multicenter randomized controlled trial on the timing of preoperative antibiotic prophylaxis in general surgery between February 2013 and August 2015. A simulation of cost and income in the National Health Service (NHS) England reimbursement system was conducted.


Of 5,175 patients initially enrolled, 4,556 had complete cost and income data as well as SSI status available for analysis. SSI occurred in 228 of 4,556 of patients (5%). Patients with SSIs were older, more often male, had higher BMIs, compulsory insurance, longer operations, and more frequent ICU admissions. SSIs led to higher hospital cost and income. The median contribution margin was negative in cases of SSI. In SSI cases, median contribution margin was Swiss francs (CHF) −2045 (IQR, −12,800 to 4,848) versus CHF 895 (IQR, −2,190 to 4,158) in non-SSI cases. Higher ASA class and private insurance were associated with higher contribution margins in SSI cases, and ICU admission led to greater deficits. Private insurance had a strong increasing effect on contribution margin at the 10th, 50th (median), and 90th percentiles of its distribution, leading to overall positive contribution margins for SSIs in Switzerland. The NHS England simulation with 3,893 patients revealed similar but less pronounced effects of SSI on contribution margin.


Depending on payer type, reimbursement systems with DRGs offer only minor financial incentives to the prevention of SSI.


Corresponding author

Author for correspondence: Marco von Strauss, Email:


Hide All

Authors of equal contribution.



Hide All
1. Badia, JM, Casey, AL, Petrosillo, N, Hudson, PM, Mitchell, SA, Crosby, C. Impact of surgical site infection on healthcare costs and patient outcomes: a systematic review in six European countries. J Hosp Infect 2017;96:115.
2. Coello, R, Charlett, A, Wilson, J, Ward, V, Pearson, A, Borriello, P. Adverse impact of surgical site infections in English hospitals. J Hosp Infect 2005;60:93103.
3. Kirkland, KB, Briggs, JP, Trivette, SL, Wilkinson, WE, Sexton, DJ. The impact of surgical-site infections in the 1990s: attributable mortality, excess length of hospitalization, and extra costs. Infect Control Hosp Epidemiol 1999;20:725730.
4. Rosenthal, MB. Nonpayment for performance? Medicare’s new reimbursement rule. N Engl J Med 2007;357:15731575.
5. Eappen, S, Lane, BH, Rosenberg, B, et al. Relationship between occurrence of surgical complications and hospital finances. JAMA 2013;309:15991606.
6. Barie, PS. No pay for no performance. Surg Infect 2007;8:421433.
7. Figueroa, JF, Wang, DE, Jha, AK. Characteristics of hospitals receiving the largest penalties by US pay-for-performance programmes. BMJ Qual Saf 2016;25:898900.
8. Lewis, SS, Moehring, RW, Chen, LF, Sexton, DJ, Anderson, DJ. Assessing the relative burden of hospital-acquired infections in a network of community hospitals. Infect Control Hosp Epidemiol 2013;34:12291230.
9. Mangram, AJ, Horan, TC, Pearson, ML, Silver, LC, Jarvis, WR. Guideline for prevention of surgical site infection, 1999. Hospital Infection Control Practices Advisory Committee. Infect Control Hosp Epidemiol 1999;20:250278; quiz 279–280.
10. Vegas, AA, Jodra, VM, Garcia, ML. Nosocomial infection in surgery wards: a controlled study of increased duration of hospital stays and direct cost of hospitalization. Eur J Epidemiol 1993;9:504510.
11. Poulsen, KB, Bremmelgaard, A, Sorensen, AI, Raahave, D, Petersen, JV. Estimated costs of postoperative wound infections. A case-control study of marginal hospital and social security costs. Epidemiol Infect 1994;113:283295.
12. Weber, WP, Zwahlen, M, Reck, S, et al. Economic burden of surgical site infections at a European university hospital. Infect Control Hosp Epidemiol 2008;29:623629.
13. Broex, EC, van Asselt, AD, Bruggeman, CA, van Tiel, FH. Surgical site infections: how high are the costs? J Hosp Infect 2009;72:193201.
14. Dimick, JB, Pronovost, PJ, Cowan, JA, Lipsett, PA. Complications and costs after high-risk surgery: where should we focus quality improvement initiatives? J Am Coll Surg 2003;196:671678.
15. Weber, WP, Mujagic, E, Zwahlen, M, et al. Timing of surgical antimicrobial prophylaxis: a phase 3 randomised controlled trial. Lancet Infect Dis 2017;17:605614.
16. Mujagic, E, Zwimpfer, T, Marti, WR, et al. Evaluating the optimal timing of surgical antimicrobial prophylaxis: study protocol for a randomized controlled trial. Trials 2014;15:188.
18. Eurostat. Purchasing power parities in the European Union. Published 2015. Accessed October 26, 2018.
19. Team, RC. A Language and Environment for Statistical Computing. Vienna: R Foundation for Statistical Computing; 2018.
20. Koenker, R. quantreg: Quantile Regression. R package version 5.35. Vienna: R Foundation for Statistical Computing; 2018.
21. Haider, AH, Gupta, S, Zogg, CK, et al. Beyond incidence: costs of complications in trauma and what it means for those who pay. Surgery 2015;158:96103.
22. Leaper, DJ, van Goor, H, Reilly, J, et al. Surgical site infection—a European perspective of incidence and economic burden. Int Wound J 2004;1:247273.
23. Wick, EC, Hirose, K, Shore, AD, et al. Surgical site infections and cost in obese patients undergoing colorectal surgery. Arch Surg 2011;146:10681072.
24. Alfonso, JL, Pereperez, SB, Canoves, JM, Martinez, MM, Martinez, IM, Martin-Moreno, JM. Are we really seeing the total costs of surgical site infections? A Spanish study. Wound Repair Regen 2007;15:474481.
25. Eappen, S, Rosenberg, B, Gawande, AA. Complications from surgery and hospital finances—reply. JAMA 2013;310:747748.
26. Jenks, PJ, Laurent, M, McQuarry, S, Watkins, R. Clinical and economic burden of surgical site infection (SSI) and predicted financial consequences of elimination of SSI from an English hospital. J Hosp Infect 2014;86:2433.
27. Scally, CP, Thumma, JR, Birkmeyer, JD, Dimick, JB. Impact of surgical quality improvement on payments in medicare patients. Ann Surg 2015;262:249252.
28. Papanicolas, I, McGuire, A. Do financial incentives trump clinical guidance? Hip Replacement in England and Scotland. J Health Econ 2015;44:2536.
29. von Strauss Und Torney, M, Thommen, S, Dell-Kuster, S, et al. Surgical treatment of uncomplicated diverticulitis in Switzerland: comparison of population-based data over two time periods. Colorect Dis 2017;19:840850.
30. Mehra, T, Koljonen, V, Seifert, B, et al. Total inpatient treatment costs in patients with severe burns: towards a more accurate reimbursement model. Swiss Med Wkly 2015;145:w14217.
31. Boyce, JM, Potter-Bynoe, G, Dziobek, L. Hospital reimbursement patterns among patients with surgical wound infections following open heart surgery. Infect Control Hosp Epidemiol 1990;11:8993.

Related content

Powered by UNSILO
Type Description Title
Supplementary materials

von Strauss et al. supplementary material
von Strauss et al. supplementary material

 Word (1.7 MB)
1.7 MB

The impact of surgical site infections on hospital contribution margin—a European prospective observational cohort study

  • Marco von Strauss (a1) (a2), Walter R. Marti (a3), Edin Mujagic (a1), Michael Coslovsky (a4), Katharina Diernberger (a5), Peter Hall (a6), Jasmin Zeindler (a1), Lilian A. Salm (a3), Savas D. Soysal (a1) (a2), Robert Mechera (a1) (a2), Urs von Holzen (a1) (a7) and Walter P. Weber (a1)...


Altmetric attention score

Full text views

Total number of HTML views: 0
Total number of PDF views: 0 *
Loading metrics...

Abstract views

Total abstract views: 0 *
Loading metrics...

* Views captured on Cambridge Core between <date>. This data will be updated every 24 hours.

Usage data cannot currently be displayed.