M. J. Nisiewicz1, M. Plymale2,3, D. Davenport2, S. Saleh1, T. Buckley1, Z. Hassan1, J. S. Roth2,3 1University of Kentucky,College Of Medicine,Lexington, KY, USA 2University of Kentucky,Department Of Surgery,Lexington, KY, USA 3University Of Kentucky,Division Of General Surgery,Lexington, KY, USA
Introduction:
Repair of ventral and incisional hernias (VHR) remains a costly challenge for healthcare systems. In a prior study of a single surgeon’s elective inpatient open VHR practice, a cost model was developed which predicted over 70% of hospital cost variation, and included CDC wound class, hernia defect size, age, ASA class, number of mesh pieces, and use of biologic mesh. The purpose of the current study was to evaluate the ventral hernia cost model with multiple surgeons’ elective inpatient open VHR cases and to extend to include non-elective/urgent/emergent, outpatient and laparoscopic VHR.
Methods:
With IRB approval, elective and emergent cases of open and laparoscopic VHR (CPT codes 49560, 49561, 49565, 49566, 49654, 49655, 49656, 49657) performed at a single facility by multiple surgeons from October 1, 2014 to December 31, 2017 were identified. Cases in which VHR was done as a secondary procedure were excluded. Demographics, comorbidity status, ASA class, CDC wound class, length of stay, and 30 day outcomes were obtained from the local NSQIP database. Medical record review determined hernia defect size. Hospital cost data was obtained from the hospital cost accounting system. Forward multivariable regression of log transformed costs identified independent drivers of cost (p for entry < .05, for exit > .10).
Results:
Of the 387 VHRs, 74% were open repairs, 35.4% included separation of components, and 14.7% were non-elective. Mean age was 55 years, and 52% of patients were female. The base cost for an outpatient primary small VHR without mesh implantation was $4114. Including only the open, elective VHR cases, the previously reported six-factor cost model predicted 50% of the total cost variation. With all VHRs included, ten variables were found to independently drive costs, predicting 60% of the total cost variation from the base cost. Biggest cost drivers (≥ 15% increase) were preoperative open wound (+$1207), preoperative SIRS/sepsis (+$740), hernia defect size (+$616), inpatient status (+$875), use of absorbable mesh vs. synthetic or no mesh (+$752), use of biologic mesh (+$1000), and utilization of multiple mesh pieces (+$795). Other cost drivers included age, obesity, morbid obesity, and recurrent hernia.
Conclusion:
Elective hernia repair cost variability may be predicted utilizing a six-factor model. In the broader context of all VHR repair at our institution, recurrent hernia, inpatient and non-elective surgery are greater cost drivers than wound class. Obesity, the presence of an open wound and systemic inflammation, relatively rare in the elective group due to optimization but more common in urgent/emergent cases, replaced ASA class as cost drivers. Age, defect size, mesh type and number of meshes utilized were common to both models. A hernia cost model utilizing readily identifiable preoperative factors can be utilized to predict resource utilization.