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    Original Investigation
    November 27, 2019

    Costs Associated With Modifiable Risk Factors in Ventral and Incisional Hernia Repair

    Author Affiliations
    • 1Department of Surgery, University of Michigan Health System, Ann Arbor
    • 2Department of Cardiac Surgery, University of Michigan Medical School, Ann Arbor
    • 3Michigan Value Collaborative, Ann Arbor
    • 4Center for Healthcare Outcomes and Policy, Ann Arbor, Michigan
    JAMA Netw Open. 2019;2(11):e1916330. doi:10.1001/jamanetworkopen.2019.16330
    Key Points español 中文 (chinese)

    Question  What is the attributable association of modifiable preoperative risk factors with clinical outcomes and health care spending after ventral and incisional hernia repair (VIHR)?

    Findings  In this cross-sectional analysis of 22 664 adult patients undergoing VIHR, morbid obesity, insulin-dependent diabetes, and unhealthy alcohol use were significantly associated with adverse outcomes. Additional spending for a serious complication after surgery was $26 648, of which $3638 was associated with morbid obesity, $650 was associated with insulin-dependent diabetes, and $567 was associated with unhealthy alcohol use.

    Meaning  Quantifying the association of individual risk factors with adverse outcomes after VIHR may help surgeons develop targeted interventions to reduce complications and surgical spending.


    Importance  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.

    Objective  To identify the attributable association of modifiable risk factors for adverse outcomes after VIHR on outcomes and episode-of-care payments.

    Design, Setting, and Participants  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.

    Main Outcomes and Measures  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.

    Results  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; P < .001) and serious complication (OR, 1.67; 95% CI, 1.22-2.31; P = .002). Insulin-dependent diabetes was associated with increased risk of any complication (OR, 1.34; 95% CI, 1.03-1.73; P = .03), serious complication (OR, 1.51; 95% CI, 1.08-2.12; P = .02), discharge not to home (OR, 1.49; 95% CI, 1.12-1.98; P = .005), and 30-day readmission (OR, 1.68; 95% CI, 1.32-2.14; P < .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.

    Conclusions and Relevance  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.