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National Collaborating Centre for Women's and Children's Health (UK). Surgical Site Infection: Prevention and Treatment of Surgical Site Infection. London: RCOG Press; 2008 Oct. (NICE Clinical Guidelines, No. 74.)

Appendix DCost-effectiveness of hair removal

D.1. Literature survey

Five studies were identified in the cost-effectiveness review.39–43

A series of case studies in a descriptive pilot study41 undertaken in Belgium compared the cost-effectiveness of three preoperative skin preparation protocols – razor, clipper and depilatory cream – in conjunction with whole-body disinfection with chlorhexidine in patients undergoing coronary artery bypass graft (CABG) surgery.

What appeared to be a prospective cohort study42 undertaken in the USA compared preoperative hair removal with disposable razors, clipper and depilatory cream, as well as no hair removal.

D.1.1. Methodological quality of published health economic studies

It was difficult to assess from these studies which methods of hair removal (i.e. shaving using razors, depilatory cream or clipping) were most cost-effective. Furthermore, nearly all of these studies were undertaken more than 20 years ago. Three studies39,40,42 had very limited cost analyses. Two studies40,42 did not include the staff costs associated with hair removal, which is important as the time spent by the healthcare professional removing hair from the patient will vary among the different preoperative hair removal interventions. One study39 only included the costs of treating SSI in the analysis and did not include the costs of preoperative hair removal.

D.1.2. Results of published studies

Two studies40,42 compared shaving using razors with no preoperative hair removal. As these two studies only included the costs of preoperative hair removal, they found that shaving was more costly than no hair removal.

Four studies40–43 compared shaving using razors with the use of depilatory cream. One study40 found that the costs of consumables per 100 patients were approximately £14 for shaving and £22 for the depilatory cream. One study41 found no statistically significant difference in depilation costs for the two groups, with median costs per patient for the razor and cream depilation groups being $6.13 and $8.16, respectively (P = 0.10). One study42 found that the use of depilatory cream was more expensive than shaving using razors ($56.70 and $11.40/m2/1000 patients/year, respectively). The authors reported that, despite the depilatory cream being the most expensive intervention, the additional costs could be offset by the time and labour saved. However, the authors did not provide any estimates of these savings. One study43 found that the mean cost to prepare an area of 250 cm2 (average hernia repair) cost £0.25 when using the depilatory cream compared with £0.80 when shaving, after taking into account staff time and the disposable equipment used.

Two studies40,42 examined depilatory cream with no preoperative hair removal. As these two studies only included the costs of preoperative hair removal, they found that depilatory cream was more costly than no hair removal.

It is difficult to assess from these studies, three of which were undertaken more than 20 years ago, which method of hair removal (i.e. depilatory cream or clipping) is most cost-effective. Additional economic analysis was thus conducted to inform the GDG on the cost-effectiveness of the various hair removal practices, including no hair removal, as an intervention to prevent SSIs.

D.2. Economic modelling

D.2.1. Method

A decision-analytic economic model was developed to assess the cost-effectiveness of the various methods of preoperative removal of patients’ hair. The analysis was undertaken from the perspective of the National Health Service (NHS), and all costs were updated to 2004 prices using the Hospital and Community Health Services (HCHS) pay and price inflation index. The model structure is illustrated in Figure D.1 and the comparisons in this analysis were:

Figure D.1. Decision-analytic hair removal model.

Figure D.1

Decision-analytic hair removal model.

  1. no hair removal
  2. hair removal by shaving using razors
  3. hair removal using depilatory cream
  4. hair removal using an electric clipper.

In a hypothetical cohort of 1000 patients undergoing surgery, the probability of acquiring an SSI after surgery and the associated mortality risk for patients with or without SSI for each group was modelled. Some patients have adverse reactions to depilatory cream and this was incorporated into model with the assumption that such patients undergo hair removal with an electric clipper instead. Outcomes were measured both in terms of the number of SSIs prevented and the number of quality-adjusted life-years (QALYs) gained, As quality of life information was only available for 1 year after surgery, the time horizon of the model was 1 year after surgery.

D.2.2. Data

Effectiveness data

Data from the clinical literature review was used to derive the proportion of SSIs in each of the preoperative hair removal groups. The literature reported that depilatory cream could cause adverse skin reactions in some cases and, as such, patients should be tested before full hair removal by applying some cream on an inconspicuous part of the skin. From the literature, the rate of adverse skin reactions to depilatory cream was found to be 7.8%.41

Mortality rates after surgery were derived from the Nosocomial Infection National Surveillance System (NINNS) study.4 This study found that in those patients who did not acquire an SSI following their operation the risk of death was 2.6% (95% CI 2.5% to 2.7%), compared with a significantly higher risk of death in those patients acquiring an SSI, who faced a 6.6% (95% CI 5.7% to 7.6%) risk of dying following surgery (Table D.1).

Table D.1. Effectiveness data for hair removal methods in the literature.

Table D.1

Effectiveness data for hair removal methods in the literature.

Quality of life data in patients undergoing surgery were derived from a case control study that compared the impact of SSIs following orthopaedic surgery on quality of life.223 In this study, case-patients (i.e. those with an SSI) and matched controls were interviewed 1 year after detection of SSI or after initial surgery, respectively. Quality of life was measured using the short form of a questionnaire containing 36 items (SF-36). Results of the SF-36 were then converted to utility values using a published algorithm.224

Resource use and cost data

The costs included in the analysis were the direct costs of the various hair removal methods (i.e. staff time associated with removing patients’ hair and the hospital costs associated with treating a wound infection). The costs of the actual surgical procedure were not included as it was assumed they would be similar between the four different patient groups.

The time required to remove patients’ hair prior to surgery was derived from a 1996 study41 that found that the median time required for hair removal (after standardisation of hair growth between groups) was:

  • 8 minutes and 32 seconds for a shaving area of 1.78 m2 using razors
  • 16 minutes and 13 seconds for an area of 1.83 m2 using clippers
  • 6 minutes and 20 seconds for an area of 1.80 m2 using depilatory cream.

Using these data, the time required to remove hair in an area of 0.25 m2 was estimated for each of the three removal methods. The time taken was then multiplied by the average wage for a band E nurse.229

Table D.2Resource use and costs for hair removal methods

ParameterBaselineMinimum/lowerMaximum/upperReferences
Depilation time (seconds per 1.0 m2):
 Clipper41720662841
 Razor31911052741
 Depilatory cream23815032541
Average wage for a band E nurse (per minute)£0.31£0.29£0.41229
Cost of clipper:
 Annual cost£55.75£30.50£96.03230
 Price of disposable clipper blade£1.92£1.73£2.11231
 Number of operations per year10008001200Assumption
Cost of depilatory cream:
 Price of 100 ml of depilatory cream£4.69£3.75£5.63Personal communication
 Number of operations per 100 ml213Personal communication
Price of disposable razor£0.12£0.11£0.13231
Costs of treating SSI:
 Additional days in hospital if SSI11.379.4313.664
 Cost per bed day due to SSI£306.58£229.94£383.234

The price of an electric clipper (£94.91) and its charger (£73.88) were derived from a healthcare provider’s catalogue,230 with the price of the disposable blades (£1.92 per blade) used in the electric clipper being derived from the NHS Purchasing and Supply Agency catalogue.231 It was assumed that one clipper could be used during a 3 year period. Based on a 3.5% interest rate, the yearly cost of the clipper and charger was £55.75, using the equivalent annual cost method.8 Assuming an average of 1000 operations per year,41 the cost per patient for using the clipper was estimated at £1.98 per patient.

The price of a single disposable razor blade (£0.12) was derived from the NHS Purchasing and Supply Agency catalogue.231

It was assumed that Veet® depilatory cream would be used for patients’ hair removal. Using price data from Veet’s preferred supplier in the UK, the price of a 100 ml package was £4.69, and it was assumed that 100 ml of depilatory cream was enough for two patients (personal communication with Veet’s customer care).

The hospital costs associated with treating SSIs were derived from the NNINS.4 The survey found that patients who acquired an SSI had an additional length of stay in hospital of 11.4 days more than patients with no SSI. The study also found that the cost per extra day spent in hospital due to SSI, in 2004 prices, was £307. This translates to an additional £3,500 per patient for treating an SSI.

D.2.3. Results

The decision tree model predicted the number of SSIs prevented, the number of deaths prevented and the number of QALYs gained with each hair removal strategy. Each of the methods was then ranked by costs (i.e. from the least to the most costly) and an incremental cost-effectiveness ratio (ICER; i.e. additional cost per QALY gained) was then estimated by comparing each hair removal method with its next best alternative.

Cost–utility analysis

Despite shaving using razors being one of the less costly options for hair removal, once the costs of treating SSI were included in the analysis, this option became the most expensive. After including the costs of treating SSIs in the analysis, the use of clippers for preoperative hair removal was found to be the cheapest option and was also found to generate the highest number of QALYs (Table D.3). As a result, when hair removal using electric clippers was compared with no preparation, with depilatory cream, or with shaving using razors, it was found to be dominant (i.e. it was both more effective and less costly).

Table D.3. QALYs gained and total costs for each hair removal method for 1000 patients undergoing surgery.

Table D.3

QALYs gained and total costs for each hair removal method for 1000 patients undergoing surgery.

D.2.4. Sensitivity analysis

A probabilistic sensitivity analysis showed that the use of electric clipper for preoperative hair removal was the intervention most likely to be cost-effective at both a £20,000 and a £30,000 threshold for willingness to pay for a QALY. Furthermore, the results of the analysis also showed that, irrespective of the cost-effectiveness threshold, the use of electric clippers was always the option most likely to be cost-effective. Hair removal with depilatory cream was the next most likely option to be cost-effective. Hair removal using razors and no preparation were found to be the interventions with the lowest probabilities of cost-effectiveness.

D.3. Discussion

The results of both the cost-effectiveness and the cost–utility analysis showed that hair removal with electric clippers was the most cost-effective method for preoperative hair removal. It was shown to be both more effective (in terms of SSIs prevented and QALYs gained) and less costly than its alternatives. These results were further strengthened in the sensitivity analysis, which showed that hair removal with electric clippers was the hair removal option most likely to be cost-effective, irrespective of the cost-effectiveness threshold (i.e. the amount the decision maker is willing to pay per unit of effect, in this case an extra QALY).

The results of this model are in line with the results from other studies evaluating the costs of different hair removal methods, which also did not recommend the use of razors for preoperative hair removal.39–43 As with other studies, the model showed that, although the use of razors was one of the cheapest interventions in terms of material costs,39,41 once the costs of treating SSIs were included in the analysis this intervention generated higher costs than the other methods of hair removal, and was also associated with the highest rates of SSIs.

However, the model had several limitations. Firstly, the price of the electric clipper and charger were not identified in the NHS Purchasing and Supply Agency catalogue and thus had to be derived from the catalogue of a healthcare provider, which might not be the actual price paid by the NHS as it is likely that the NHS would pay substantially less. Secondly, only the costs of treating SSI in hospital, and not in the community, were included. As SSI may also be treated in the community, the costs in the model of SSI treatment are likely to be an underestimate. Thirdly, the time horizon of the model was limited to just 1 year, owing to limited data on the quality of life of patients who acquired an SSI.

Copyright © 2008, National Collaborating Centre for Women’s and Children’s Health.

No part of this publication may be reproduced, stored or transmitted in any form or by any means, without the prior written permission of the publisher or, in the case of reprographic reproduction, in accordance with the terms of licences issued by the Copyright Licensing Agency in the UK [www.cla.co.uk]. Enquiries concerning reproduction outside the terms stated here should be sent to the publisher at the UK address printed on this page.

The use of registered names, trademarks, etc. in this publication does not imply, even in the absence of a specific statement, that such names are exempt from the relevant laws and regulations and therefore for general use.

Cover of Surgical Site Infection
Surgical Site Infection: Prevention and Treatment of Surgical Site Infection.
NICE Clinical Guidelines, No. 74.
National Collaborating Centre for Women's and Children's Health (UK).
London: RCOG Press; 2008 Oct.

NICE (National Institute for Health and Care Excellence)

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