Costs Associated With Modifiable Risk Factors in Ventral and Incisional Hernia Repair
Authors: Ryan Howard, Michael Thompson, Zhaohui Fan, Michael Englesbe, Justin B. Dimick, Dana A. Telem
Journal: JAMA Network Open (2019)

<h3>Importance</h3> Ventral and incisional hernia repair (VIHR) is an extremely common operation, after which complications are also fairly common. A number of preoperative risk factors are known to contribute to increased complications after surgical repair; however, the individual relative association of these risk factors with adverse outcomes and increased spending is unclear. Quantifying the association of individual risk factors may help surgeons implement targeted surgical optimization, improve outcomes, and reduce spending. <h3>Objective</h3> To identify the attributable association of modifiable risk factors for adverse outcomes after VIHR on outcomes and episode-of-care payments. <h3>Design, Setting, and Participants</h3> This cross-sectional study was performed using a population-based sample of adult patients and episode spending data from January 1, 2012, to December 31, 2018, from a statewide multipayer registry. A multilevel mixed-effects logistic regression model was used to examine the contribution of patient-specific risk factors to adverse outcomes. Attributable risk and population attributable risk fraction were calculated to estimate the additional spending attributable to individual risk factors. Data were analyzed from April 2018 to September 2018. <h3>Main Outcomes and Measures</h3> Any complications, serious complication, discharge not to home, 30-day emergency department utilization, and 30-day readmission. Episode-of-care spending was calculated for these outcomes. <h3>Results</h3> This study included 22 664 patients (median [interquartile range] age, 55 [44-64] years; 10 496 [46.3%] women) undergoing VIHR with identified significant preoperative risk factors. Fourth-quartile body mass index (BMI), calculated as weight in kilograms divided by height in meters squared and defined as a mean (SD) BMI of 43 (6), was associated with increased risk of any complication (odds ratio [OR], 1.64; 95% CI, 1.30-2.06;<i>P</i> &lt; .001) and serious complication (OR, 1.67; 95% CI, 1.22-2.31;<i>P</i> = .002). Insulin-dependent diabetes was associated with increased risk of any complication (OR, 1.34; 95% CI, 1.03-1.73;<i>P</i> = .03), serious complication (OR, 1.51; 95% CI, 1.08-2.12;<i>P</i> = .02), discharge not to home (OR, 1.49; 95% CI, 1.12-1.98;<i>P</i> = .005), and 30-day readmission (OR, 1.68; 95% CI, 1.32-2.14;<i>P</i> &lt; .001). Median (interquartile range) additional episode spending for any complication was $9934 ($9224-$11 851), of which $1304 ($1208-$1552) was attributable to fourth-quartile BMI. Median (interquartile range) additional episode spending for a serious complication was $26 648 ($20 632-$33 166), of which $3638 ($2827-$4544) was attributable to fourth-quartile BMI, $650 ($495-$796) was attributable to insulin-dependent diabetes, and $567 ($433-$696) was attributable to unhealthy alcohol use. <h3>Conclusions and Relevance</h3> In this cross-sectional study, modifiable risk factors, such as obesity, insulin-dependent diabetes, and unhealthy alcohol use, were associated with adverse outcomes after VIHR. These factors were significantly associated with increased health care spending; therefore, preoperative optimization may improve outcomes and decrease episode-of-care costs.