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Surgical Endoscopy

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01-01-2017

Ventral and incisional hernia: the cost of comorbidities and complications

Authors: Margaret A. Plymale, Ranjan Ragulojan, Daniel L. Davenport, J. Scott Roth

Published in: Surgical Endoscopy | Issue 1/2017

Abstract

Introduction

Ventral and incisional hernia repair (VIHR) is among the most frequently performed abdominal operations with significant incidence of postoperative complications and readmissions. Payers are targeting increased “value” of care through improved outcomes and reduced costs. Cost data in clinically relevant terms is still rare. This study aims to identify hospital costs associated with clinically relevant factors in order to facilitate strategies by surgeons to enhance the value of VIHR.

Methods

An IRB-approved retrospective review of VIHRs performed at the University of Kentucky from April 2009 through September 2013 was conducted. NSQIP clinical data and hospital cost data were matched. Operating room (ORC), total encounter (TEC), and 90-day postdischarge (90PDC) hospital costs were analyzed relative to clinical variables using non-parametric tests.

Results

In total 385 patients that underwent VIHR during the time period were included in the analyses. Considering all VIHRs, median [interquartile range (IQR)] ORC was $6900 ($5600–$10,000); TEC was $10,700 ($7500–$18,600); and 90PDC was $0 ($0–$800). Compared to all VIHRs, ASA Class ≥ 3 was associated with increased ORC and TEC (p < .001), and 90PDC (p < .01). Preoperative open wound was associated with increased ORC and TEC (p < .001). Numerous operative variables were associated with both increased ORC and TEC. Wound Class > 1 was associated with increased ORC and TEC (p < .001) and 90PDC (p < .01). Inpatient occurrence of any complication was associated with increased TEC and 90PDC (p < .001).

Conclusions

ASA Class ≥ 3, Wound Class > 1, open abdominal wound, and postoperative complications significantly increase costs. Although the hospital encounter represents the majority of the cost associated with VIHR, additional costs are incurred during the 90-day postoperative period. An appreciation of global costs is essential in developing alternative payment models for hernia in order to provide the greatest value in hernia care.

Merkow RP, Ju MH, Chung JW, Hall BL, Cohen ME, Williams MV, Tsai TC, Ko CY, Bilimoria KY (2015) Underlying reasons associated with hospital readmission following surgery in the United States. JAMA 313:483–495. doi:10.1001/jama.2014.18614 CrossRefPubMed

Lovecchio F, Farmer R, Souza J, Khavanin N, Dumanian GA, Kim JY (2014) Risk factors for 30-day readmission in patients undergoing ventral hernia repair. Surgery 155(4):702–710. doi:10.1016/j.surg.2013.12.021 CrossRefPubMed

Kassin MT, Owen RM, Perez SD, Leeds I, Cox JC, Schnier K, Sadiraj V, Sweeney JF (2012) Risk factors for 30-day hospital readmission among general surgery patients. J Am Coll Surg 215(3):322–330. doi:10.1016/j.jamcollsurg.2012.05.024 CrossRefPubMedPubMedCentral

Baltodano PA, Webb-Vargas Y, Soares KC, Hicks CW, Cooney CM, Cornell P, Burce KK, Pawlik TM, Eckhauser FE (2016) A validated, risk assessment tool for predicting readmission after open ventral hernia repair. Hernia 20:119–129. doi:10.1007/s10029-015-1413-2 CrossRefPubMed

Brooke BS, Stone DH, Cronenwett JL, Nolan B, DeMartino RR, MacKenzie TA, Goodman DC, Goodney PP (2014) Early primary care provider follow-up and readmission after high-risk surgery. JAMA Surg 149:821–828. doi:10.1001/jamasurg.2014157 CrossRefPubMedPubMedCentral

Nguyen MT, Li LT, Hicks SC, Davila JA, Suliburk JW, Leong M, Kao LS, Berger DH, Liang MK (2013) Readmission following open ventral hernia repair: incidence, indications, and predictors. Am J Surg 206:942–949. doi:10.1016/j.amjsurg.2013.08.022 CrossRefPubMed

Holihan JL, Alawadi Z, Martindale RG, Roth JS, Wray CJ, Ko TC, Kao L, Liang MK (2015) Adverse events after ventral hernia repair: the vicious cycle of complications. J Am Coll Surg 221:478–485. doi:10.1016/j.jamcollsurg.2015.04.026 CrossRefPubMed

Liang MK, Goodenough CJ, Martindale RG, Roth JS, Kao LS (2015) External validation of the ventral hernia risk score for prediction of surgical site infections. Surg Infect 16:36–40. doi:10.1089/sur.2014.115 CrossRef

Poulose BK, Shelton J, Phillips S, Moore D, Nealon W, Penson D, Holzman MD (2012) Epidemiology and cost of ventral hernia repair: making the case for hernia research. Hernia 16:179–183. doi:10.1007/s10029-011-0879-9 CrossRefPubMed

10.

Hackbarth G, Reischauer R, Mutt A (2008) Collective accountability for medical care—toward bundled medicare payments. N Engl J Med 359:3–5. doi:10.1056/NEJMp0803749 CrossRefPubMed

11.

Centers for Medicare and Medicaid Services (2016) The merit-based incentive payment system (MIPS) & alternative payment models (APMs). https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Value-Based-Programs/MACRA-MIPS-and-APMs/MACRA-MIPS-and-APMs.html. Accessed 8 Feb 2016

12.

Reynolds D, Davenport D, Korosec R, Roth JS (2013) Financial implications of ventral hernia repair: a hospital cost analysis. J Gastrointest Surg 17:159–167. doi:10.1007/s11605-012-1999-y CrossRefPubMed

13.

Davenport DL, Henderson WG, Khuri SF, Mentzer RM (2005) Preoperative risk factors and surgical complexity are more predictive of costs than postoperative complications: a case study using the National Surgical Quality Improvement Program (NSQIP) database. Ann Surg 242:463–471PubMedPubMedCentral

14.

Petro CC, O’Rourke CP, Posielski NM, Criss CN, Raigani S, Prabhu AS, Rosen MJ (2016) Designing a ventral hernia staging system. Hernia 20:111–117. doi:10.1007/s10029-015-1418-x CrossRefPubMed

15.

Fischer JP, Wes AM, Wink JD, Nelson JA, Rohrbach JI, Braslow BM, Kovach SJ (2014) Analysis of perioperative factors associated with increased cost following abdominal wall reconstruction (AWR). Hernia 18:617–624. doi:10.1007/s10029-014-1276-y CrossRefPubMed

16.

Berger RL, Li LT, Hicks SC, Davila JA, Kao LS, Liang MK (2013) Development and validation of a risk-stratification score for surgical site occurrence and surgical site infection after open ventral hernia repair. J Am Coll Surg 217:974–982. doi:10.1016/j.jamcollsurg.2013.08.003 CrossRefPubMed

17.

Sorensen LT (2012) The clinical impact of smoking and smoking cessation: a systematic review and meta-analysis. Arch Surg 147:373–383CrossRefPubMed

18.

Goodenough CJ, Liang MK, Nguyen MT, Nguyen DH, Holihan JL, Awawadi ZM, Roth JS, Wray CJ, Ko TC, Kao LS (2015) Preoperative glycosylated hemoglobin and postoperative glucose together predict major complications after abdominal surgery. J Am Coll Surg 221:854–861CrossRefPubMed

19.

Stone AB, Grant MC, Pio Roda C, Hobson D, Pawlik T, Wu CL, Wick EC (2016) Implementation costs of an enhanced recovery after surgery program in the United States: a financial model and sensitivity analysis based on experiences at a quaternary academic medical center. J Am Coll Surg 222:113. doi:10.1016/j.jamcollsurg.2015.11.021 CrossRef

20.

Thiele RH, Rea KM, Turrentine FE, Friel CM, Hassinger TE, Goudreau BJ, Umapathi BA, Kron IL, Sawyer RG, Hedrick TL, McMurry TL (2015) Standardization of care: impact of an enhanced recovery protocol on length of stay, complications and direct costs after colorectal surgery. J Am Coll Surg 220:430–443. doi:10.1016/j.jamcollsurg.2014.12.042 CrossRefPubMed

21.

Fayezizadeh M, Petro CC, Rosen MJ, Novitsky YW (2014) Enhanced recovery after surgery pathway for abdominal wall reconstruction: pilot study and preliminary outcomes. Plast Reconstr Surg 134:151S–159S. doi:10.1097/prs.0000000000000674 CrossRefPubMed

22.

Haynes AB, Weiser TG, Berry WR, Lipsitz SR, Breizat AH, Dellinger EP, Herbosa T, Joseph S, Kibatala PL, Lapitan MC, Merry AF, Moorthy K, Reznick RK, Taylor B, Gawande AA, Safe Surgery Saves Lives Study Group (2009) A surgical safety checklist to reduce morbidity and mortality in a global population. New Engl J Med 360:491–499CrossRefPubMed

23.

Scally CP, Thumma JR, Birkmeyer JD, Dimick JB (2015) Impact of surgical quality improvement on payments in medicare patients. Ann Surg 262:249–252CrossRefPubMedPubMedCentral

24.

Hammermeister K (2009) The National Surgical Quality Improvement Program: learning from the past and moving to the future. Am J Surg 198:S69–S73CrossRefPubMed

25.

Hakko E, Guvenc S, Karaman I, Cakmak A, Erdem T, Cakmakci M (2015) Long-term sustainability of zero central-line associated bloodstream infections is possible with high compliance with care bundle elements. East Mediterr Health J 21:293–298PubMed

26.

Pavia M, Mazza M (2016) Adding innovative practices and technology to central line bundle reduces bloodstream infection rate in challenging pediatric population. Am J Infect Control 44:112–114. doi:10.1016/j.ajic.2015.08.026 CrossRefPubMed

27.

Eappen S, Lane BH, Rosenberg B, Lipsitz SA, Sadoff D, Matheson D, Berry WR, Lester M, Gawande AA (2013) Relationship between occurrence of surgical complications and hospital finances. JAMA 309:1599–1606. doi:10.1001/jama.2013.2773 CrossRefPubMed

28.

Gani F, Hundt J, Makary MA, Haider AH, Zogg CK, Pawlik TM (2016) Financial impact of postoperative complication following hepato-pancreatico-biliary surgery for cancer. Ann Surg Oncol 23:1064–1070. doi:10.1245/s10434-015-5042-x CrossRefPubMed

29.

Colavita PD, Tsirline VB, Walters AL, Lincourt AE, Belyansky I, Heniford BT (2013) Laparoscopic versus open hernia repair: outcomes and sociodemographic utilization results from the nationwide inpatient sample. Surg Endosc 27:109–117. doi:10.1007/s00464-012-2432-z CrossRefPubMed

30.

Colavita PD, Tsirline VB, Belyansky I, Walters AL, Lincourt AE, Sing RF, Heniford T (2012) Prospective, long-term comparison of quality of life in laparoscopic versus open ventral hernia repair. Ann Surg 256:714–723CrossRefPubMed

31.

Liu Y, Pleasants RA, Croft JB, Wheaton AG, Khosrow H, Malarcher AM, Ohar JA, Kraft M, Mannino DM, Strange C (2015) Smoking duration, respiratory symptoms, and COPD in adults aged ≥ 45 years with a smoking history. Int J COPD 10:1409–1416. doi:10.2147/COPD.S82259 CrossRef

Title: Ventral and incisional hernia: the cost of comorbidities and complications
Authors: Margaret A. Plymale
Ranjan Ragulojan
Daniel L. Davenport
J. Scott Roth
Publication date: 01-01-2017
Publisher: Springer US
Published in: Surgical Endoscopy / Issue 1/2017
Print ISSN: 0930-2794
Electronic ISSN: 1432-2218
DOI: https://doi.org/10.1007/s00464-016-4977-8

At a glance: The STEP trials

Springer Medicine

Ventral and incisional hernia: the cost of comorbidities and complications

Abstract

Introduction

Methods

Results

Conclusions

At a glance: The STEP trials

Springer Medicine

Abstract

Introduction

Methods

Results

Conclusions

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