S. R. Kaslow1, M. Stem2, J. K. Canner1, G. L. Adrales2 1Johns Hopkins Surgery Center For Outcomes Research,Department Of Surgery,Baltimore, MD, USA 2Johns Hopkins School Of Medicine,Baltimore, MD, USA
Introduction
In January 2014 Maryland enacted a Global Budget Revenue (GBR) system in which all payers and hospitals are connected in a fixed payment capitated system to improve access to preventive care and care coordination. Many determinants of health addressed by GBR are also predictors of emergent ventral hernia repair (VHR). We aimed 1) to investigate associations between GBR implementation and the proportion of VHRs performed emergently, and 2) to study how implementation impacted risk factors of emergent VHR.
Methods
Patients with a diagnosis of ventral hernia who underwent surgical repair were identified in the Maryland Health Services Cost Review Commission patient-level case mix data from 2011 through Q3 2015, excluding trauma diagnoses. Patients were stratified into two groups: pre- and post-GBR implementation. Multivariable logistic regression was used to identify risk factors for emergent VHR performed pre- and post-implementation and to assess the impact of GBR on emergent cases.
Results
A total of 8,938 patients were identified. 3,770 (42.2%) patients underwent an emergent procedure: 2,517 (68.0%) pre- and 1,253 (33.9%) post-implementation. The proportion of emergent VHRs remained the same after implementation (33.2% in 2011-2013 vs. 33.6% in 2014-2015, p=0.71). Adjusted analysis showed that implementation had no significant impact on requiring an emergent procedure (OR 1.01, 95% CI 0.92-1.11, p=0.81). The patient risk factors for emergent VHR (age ≥75, Black race, Charlson Comorbidity Index, insurance) did not change dramatically after GBR implementation. However, a Charlson score of 2 or higher was associated with emergent VHR before implementation (Score 0: Ref; Score 2: OR 1.27, 95% CI 1.07-1.52, p=0.01; score ≥3: OR 1.30, 95% CI 1.10-1.53, p<0.001), while a score of 1 or higher was associated with emergent VHR after implementation (score 1: OR 1.32, 95% CI 1.09-1.60, p=0.01; score 2: OR 1.35, 95% CI 1.06-1.72, p=0.02; score ≥3: OR 1.75, 95% CI 1.38-2.20, p<0.001). Additionally, median income in the highest two quartiles had a lower risk of emergent VHR before implementation (1st quartile: Ref; 3rd quartile: OR 0.68, 95% CI 0.58-0.79, p<0.001; 4th quartile: OR 0.74, 95% CI 0.63-0.87, p<0.001); this association was not statistically significant in the post-implementation period.
Conclusion
GBR implementation had no significant impact on emergent VHR or the factors associated with emergent VHR. However, lower risk patients (i.e. lower Charlson Comorbidity score) were more likely to undergo emergent VHR after GBR implementation which may be due to surgical trends other than GBR such as watchful waiting. While higher income was protective against emergent VHR before implementation, the association between income and emergent VHR was not present after GBR implementation. Additional study is needed to determine if GBR improved access to care and lessened the impact of income or if there were other contributing factors.