Margaret A Plymale, MSN, RN1, Ranjan Ragulojan, BSc2, Daniel L Davenport, PhD, MBA3, J. Scott Roth, MD1. 1University of Kentucky Division of General Surgery, 2University of Kentucky College of Medicine, 3University of Kentucky Department of Surgery
Introduction: Ventral and incisional hernia repair (VHR) is a common general surgical procedure with a significant incidence of postoperative complications and readmissions. Federal and private insurers are targeting increased “value” through both improved outcomes and reduced costs. However, cost data in clinically relevant terms is still rare. This study aims to identify VHR costs associated with clinically relevant factors in order to facilitate strategies by surgeons to enhance the value of VHR.
Methods: This retrospective study of 385 consecutive VHRs matched the pre-, peri- and postoperative data from a single site’s ACS NSQIP database with hospital costs from the cost accounting system. Operating room (ORC), total admission (AdmitC), and 90-day post discharge (90PDC) costs were analyzed relative to the NSQIP clinical variables using non-parametric tests.
Results: Median ORC were $6,900 (interquartile range $5,600-$10,000); AdmitC, $10,700 ($7,500-$18,600); and 90PDC, $0 ($0-$800). Female gender, age, ASA class, hypertension and preoperative open wound were associated with both increased ORC and AdmitC; COPD with increased AdmitC. ASA class and chronic steroid use were predictive of 90PDC. Operative variables associated with both increased ORC and AdmitC included inpatient surgery, open approach, recurrent hernia, wound class, operative duration, concomitant procedure, mesh size, biologic mesh, number of mesh pieces, and transfusion within 72 h of operation. Of these, wound class only was associated with 90PDC. Obesity, diabetes, smoking, emergent status, incarcerated hernia and transfer status were not associated with any costs. Inpatient occurrence of any of the NSQIP complications was associated with increased AdmitC, with organ space infections, sepsis, and prolonged mechanical ventilation conferring the largest increases. Post-discharge occurrence of wound infection/dehiscence, UTI or sepsis all increased 90PDC. Patients with post-discharge ED visits had a median increase of $2,600 in 90PDC; readmissions $7,700; outpatient surgery, $4,200; and imaging/lab visits, $600.
Conclusions: Value assessment of hospitals performing VHR will need to adequately adjust for numerous pre- and perioperative cost drivers. Reducing complications will likely reduce costs, particularly reducing wound, urinary tract and systemic infections. Elevated ASA class, steroid use and wound class predict 90PDC and could be used to target patients needing additional post-discharge care. An appreciation of these factors associated with hernia repair costs may be useful in guiding surgeon practice to provide the greatest value in hernia procedures.