The cost of preventable comorbidities on wound complications in open ventral hernia repair

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The cost of preventable comorbidities on wound complications in open ventral hernia repair Tiffany C. Cox, MD, Laurel J. Blair, MD, Ciara R. Huntington, MD, Paul D. Colavita, MD, Tanushree Prasad, MA, Amy E. Lincourt, PhD, MBA, B. Todd Heniford, MD, FACS, and Vedra A. Augenstein, MD, FACS* Division of Gastrointestinal and Minimally Invasive Surgery, Carolinas Laparoscopic and Advanced Surgery Program, Carolinas Medical Center, Charlotte, North Carolina

article info

abstract

Article history:

Background: Patients with complex ventral hernias may benefit from preoperative optimi-

Received 5 January 2015

zation. This study evaluates the financial impact of preventable comorbidities (PCM) in

Received in revised form

elective open ventral hernia repair.

30 June 2016

Methods: In this single institution prospectively collected data from 2007-2011, hospital

Accepted 2 August 2016

charges (included all hernia-related visits, interventions, or readmissions) and wound-

Available online 9 August 2016

related complications in patients with PCMddiabetes, tobacco use, and obesitydwere compared to patients without such risks using standard statistical methods.

Keywords:

Results: Within the study period, there were 118 patients with no PCM; of those, 33 had

Ventral hernia

complications, and 85 did not. In the 131 patients with two or more PCM, 81 had compli-

Open ventral hernia repair

cations; 89 of 251 patients had complications in the group with only 1 PCM; groups with

Comorbidities

PCM were significantly more likely to have complications compared to the no PCM group

Cost

(62% versus 35.4% versus 28%, P < 0.05). The majority of the patient population was female

Charges

(57.2%) with a mean age of 57.8 y (range, 22-84 ys), and median defect size was 150 cm2

Diabetes mellitus

(interquartile range, 50-283 cm2). Body mass index was higher in PCM group with com-

Smoking

plications than in PCM without complications (40 versus 36 kg/m2, P < 0.05). For patients

Obesity

with complications, the average hospital charges were $80,660 in the PCM group compared

Wound complications

to $55,444 in the no PCM group (P ¼ 0.038). Hospital charges in those with PCM without

Outcomes assessment

complications compared to no PCM with complications were equivalent ($65,453 versus $55,444, P ¼ 0.55). Even when no complications occurred, patients with PCM incurred higher charges than No PCM for inpatient ($61,269 versus $31,236, P < 0.02), outpatient ($4,185 versus $552, P < 0.04), and total hospital charges ($65,453 versus $31,788, P  0.001). Those patients without complications but with a single PCM incurred larger charges than those with no PCM during follow-up ($3578 versus $552, P ¼ 0.04), but there was no difference in hospital or overall total charges (P > 0.05). Interestingly, patients without complications, both hospital ($38,333 versus $61,269, P ¼ 0.02) and total charges ($41,911 versus $65,453, P ¼ 0.01) were increased for patients with 2þ PCM compared to those with only a single PCM. If complications occurred, no difference between the single PCM group compared to the two or more PCM groups existed for hospital, follow-up, or overall charges (P > 0.05).

Accepted for oral presentation at the Academic Surgical Congress, Las Vegas, NV, February 2015. * Corresponding author. Carolinas Medical Center, 1025 Morehead Medical Drive, Suite 300, Charlotte, NC 28204. Tel.: þ1 (704) 355 3168; fax: þ1 (704) 355 4117. E-mail address: [email protected] (V.A. Augenstein). 0022-4804/$ e see front matter Published by Elsevier Inc. http://dx.doi.org/10.1016/j.jss.2016.08.009

cox et al  preventable comorbidities in ovhr

215

Conclusions: Patients with PCM undergoing open ventral hernia repair are more likely to have complications than patients without comorbidities. Patients with PCM generate higher hospital charges than those without PCM even when no complications occur; furthermore, the more PCM, the patient has the more significant the impact. Interestingly, patients with multiple PCM and no complications had equivalent hospital costs compared to patients with no PCM and with complications. Aggressive risk reduction may translate into significant savings. Preoperative preparation of patients before elective surgery is indicated. Published by Elsevier Inc.

Introduction Ventral hernia repairs are common with an annual incidence up to 360,000 repairs performed with an estimated total cost of $3.2 billion and the second most common cause for readmission.1-3 As recurrence rates are becoming more consistent in the literature, other factors, such as quality of life and wound-related complications, have become important quality outcome measures for hernia repair. Focus on outcomes, together with the evaluation of factors affecting outcomes, has brought forward the importance of preoperative patient optimization in attempts to prevent what can be costly specifically for ventral hernia repair which is a leading cause of readmission.3 Comorbidities effect on outcomes is a popular topic in hernia research. Krapta et al.4 showed that patients undergoing open repair for grade II hernias had a 16% increased risk of developing a surgical site occurrence (SSO) when they had comorbidities such as chronic obstructive lung disease, diabetes, a smoking history, or were obese. Any cigarette smoking can negatively impact healing, and even from a single cigarette, cutaneous blood flow recovers more slowly in smokers as it is reduced 38.1% compared to 28.1% reduction in nonsmokers.5,6 Tobacco use alone carries a 2.49 relative risk of wound complications (95% confidence interval [CI], 1.91-3.26, 0.05)7 and has been supported internationally after logistical regression analysis making it a statistically significant risk factor for a wound-related events after ventral hernia repair (P ¼ 0.022).8 Although smokers have an increase adjusted odds ratio (OR) 1.8 times for superficial skin infections (SSI), it is similarly seen that nonsmokers had a reduced risk of SSI with an adjusted OR of 0.4 for that of nonsmokers.9 Smoking has repetitively demonstrated to have significant impact of surgical outcomes, and cessation can be effective in reducing such risk.10 Obesity is becoming a worldwide epidemic. Patients who are obese often have medical comorbidities, are more difficult to operate on, have compromised tissue healing, increased wound complications, and increased intra-abdominal pressure.11 The literature supporting obesity as risk factor for SSO and SSI is extensive. Increased incidence of hernia recurrence with a rising body mass index (BMI) has been well documented as well.12-16 The pooled relative risk of obesity impacting wound healing is a 1.6-time increased risk compared to nonobese patients.16 In laparoscopic repairs, patients with BMI >40 had a four times greater hernia recurrence.17 Furthermore, for BMI over 26, there is an odds ratio of increase risk of wound complication of 1.08 per BMI point.14

This same effect is seen by the American Heart Association to incrementally increase sick days, medical claims, and overall health care costs.18 Diabetes, also considered a preventable comorbidity, whether requiring oral antiglycemic control or insulin dependence, both result in a 20% increase in wound complications (OR, 1.22 and 1.23 respectively, P < 0.025).19 Many other studies validate the effect of diabetes on ventral hernia repairs,13,20,21 and some research has identified diabetes as independently associated with delayed wound healing (OR ¼ 1.62, CI ¼ 1.14-2.35, P  0.05).20 In a recent study evaluating combined results from national outcome registries of Nationwide Inpatient Sample (NIS) and American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP), patients who underwent open ventral hernia repair that had diabetes had a 13.7% risk of major complication compared to 8.8% for nondiabetics (P < 0.0001); the effect was even more profound of a difference for those with uncomplicated controlled diabetes of 12.6% compared to those with complicated uncontrolled diabetes at 23.3% (P < 0.0001) and increasing length of stay as well as overall inpatient charges.22 Minimizing preoperative risks such as severity of patient comorbidities may considerably affect patient outcomes and cost related to hernia repair. Little information exists on evaluating the outcomes of patient optimization in terms of its financial impact. Herein, this study looks at patients with multiple preventable comorbidities (PCM) of diabetes, tobacco use, or obesity versus those patients without such risk factors. Therefore, our aim was to evaluate the economic bearing of PCM during elective, open ventral hernia repair with the intent of proposing preoperative intervention as an area of medicine with significant opportunity to improve patient outcomes and decrease the financial burden of the healthcare system.

Methods Study design Inclusion and exclusion criteria After obtaining institutional review board approval, a prospectively collected surgical outcomes database was reviewed from 2007-2011 in standards of HIPAA compliance. Patients were at least 18 years, had a ventral hernia requiring an open repair, and consented for the study. Patients were required to have the diagnosis of at least two of the three comorbidities

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studied, diabetes mellitus, tobacco use, or obesity, to be included in the two or more PCM group. For patients with only one of these comorbidities they were to be included in the one PCM group. Diabetes mellitus included type I or type II diabetes, tobacco use included all patients smoking up to a month before surgery as it is our standard to request patients undergo smoking cessation 4 wk before surgery, and obesity defined as patients with a BMI >30. Patients in the “No PCM” classification did not have any PCM. Patients undergoing weight loss operations were excluded. All patients provided written informed consent to participate in this study approved by the Carolinas Medical Center’s Institutional Review Board.

Data collection Patient characteristics such as age, sex, race, BMI, comorbidities, and prior abdominal operations were collected. Perioperative characteristics such as fascial defect size, mesh type, mesh size, concomitant procedures (other hernia repairs, hollow viscus, or solid organ excision), operative time, estimated blood loss (EBL), hospital cost, and length of stay (LOS) were collected. Postoperative outcomes such as seroma, cellulitis, wound dehiscence, wounds requiring intervention, hernia recurrence, mesh infections, number of office visits, outpatient costs, and duration of follow-up were included. Patients were divided into groups “without complications” and “with complications”. Complications were defined as any wound or abdominal infection-related complication. All patient, operative, and follow-up data were prospectively collected and stored in the author’s surgical outcomes database. Similar to nationally published databases used for cost comparison such as the Nationwide Inpatient Sample,23 charges collected were used to evaluate all outpatient charges and collected from the billing department. Assessment included all inpatient hospital charges, hernia-related visits, interventions, or readmissions within 1 y.

Statistical analysis Standard statistical analysis was performed using Pearson’s chi-square and Fisher exact test for categorical variables, unpaired t test or KruskaleWallis test for nonparametric continuous data and ordinal variables as appropriate to obtain a two-tailed P value. Values were reported as mean  standard deviation (SD) and data not normally distributed as median with interquartile range (IQR) using Wilcoxon two-sample test. Statistical significance was defined as P < 0.05. All data were analyzed using Statistical Analysis Software, version 9.4 (SAS Institute, Inc., Cary, NC) and Graph-Pad InStat version 3.10 32 bit for Windows (GraphPad Software, San Diego, CA, USA; www.graphpad.com).

Operative approach A total of six surgeons performed 500 VHRs. Although the surgical approach varies slightly for each surgeon and depends on patients, our previously published work24 details our standard operative procedure with recent additional technique of talc applied to the subcutaneous tissues to reduce seroma formation.25

Results Patient characteristics A total of 500 open ventral hernia repair patients met the inclusion criteria and consented to be studied. Patients were classified into six groups: No PCM without complications (n ¼ 85), No PCM with complications (n ¼ 33), 1 PCM without complications (n ¼ 162), 1 PCM with complications (n ¼ 89), 2þ PCM without complications (n ¼ 50), and 2þ PCM with complications (n ¼ 81). In total, there were 118 patients with no PCM, 131 patients with two or more PCM, and 251 with 1 PCM. Any patient with PCM was significantly more likely to have complications compared to the no PCM group (62% versus 35.4% versus 28%, P < 0.05). Seventeen patients had all three comorbidities and were included in the “two or more” PCM groups as appropriate. Overall, majority of the patients were female (57.8%) with a mean age of 57.2  10.1 y (range, 22-84 y). Median defect size was 150 cm2 (IQR: 50-283 cm2), and only 7.2% were primary hernias. Of the incisional hernias, 39.4% were recurrent hernias with an average of 2.1  1.7 prior hernia repairs, 53% of which were performed with mesh. Patient demographics and hernia characteristics are listed in Table 1.

Operative characteristics Average operative time was 216.5  67 min (range, 75506 min). Synthetic mesh was used in 88.5% of repairs with unprotected polypropylene as the majority (75%), Ultrapro (Ethicon) mesh as the most frequent lightweight mesh (18%), Proceed patch (Ethicon) as the most frequent midweight mesh (37%), and 14% of repairs were with a variety of biologic meshes, both porcine and human acellular dermis. Median mesh size was 875 cm2 (IQR, 524-900 cm2). Full operative details are listed in Table 1.

Outcomes and cost: no PCM versus 2þ PCM The average length of stay was 6.9  7.6 d, and average followup was 6.1  9.5 mo. Overall, average number of office visits was 3.7  3.2. Overall, 16.8% of patients were readmitted to the hospital. Outcomes stratified by patient classification groups are outlined in Table 2. The inpatient versus outpatient costs compared across patient classification groups are shown in Tables 3-5. For all patients with complications, the total hospital charges of $80,660 in the 2þ PCM group was significantly greater than the $55,444 in those without PCM (P < 0.038). In those with 2þ PCM, outpatient charges alone were higher for patients with complications compared to those without ($16,312 versus $4,185, P ¼ 0.008); however, there was no statistically significant difference for inpatient charges alone ($64,347 versus $61,269, P ¼ 0.8) or total charges ($80,660 versus $65,453, P ¼ 0.26). There was no difference in charges for those with 2þ PCM without complications compared to the no PCM group with complications for inpatient ($61,269 versus $47,598, P ¼ 0.39), outpatient ($4185 versus 7846, P ¼ 0.32), or total hospital charges ($65,453 versus $55,444, P ¼ 0.55). Even

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cox et al  preventable comorbidities in ovhr

Table 1 e Demographics, hernia, and operative characteristics for the individual groups. No PCM

1 PCM

2þ PCM

Without With Without With Without With complications complications complications complications complications complications (n ¼ 85) (n ¼ 33) (n ¼ 162) (n ¼ 89) (n ¼ 50) (n ¼ 81)

Overall P value

57.8  13

60.5  15.9

55.3  13.4

58.0  11.1

57.2  11.9

53.5  11

0.02

53.0%

36.4%

58.0%

59.6%

54.0%

67.9%

0.06

25.1  3.1

26.2  2.3

33.5  7.0

34.8  7.7

36.3  8.8

40  8.6

<0.001

42.4%

36.4%

43.2%

27.0%

48.0%

63.0%

0.02

Number of prior repairs

2.0  1.2

1.8  1.1

2.3  1.9

1.7  2.0

1.8  1.5

2.1  1.7

0.5

Defect size (cm2)*

62 (6.1-176)

168 (44-225)

120 (30-225)

195 (130-300)

113 (50-299)

220 (110-378)

<0.001

Operative time (min)

175.1  53

240.6  67.9

200.6  48.5

220.0  61.7

208.4  52

245.9  86.4

0.002

EBL (mL)*

50 (25-100)

100 (50-150)

100 (50-150)

150 (100-200)

100 (50-250)

150 (100-250)

<0.001

95.9%

76.7%

97.3%

81.2%

84.8%

79.5%

<0.001

4.1%

23.3%

2.7%

18.8%

15.2%

20.6%

<0.001

625 (320-900)

875 (480-893)

875 (600-900)

875 (600-900)

838 (225-923)

884 (576-1125)

0.08

Concomitant procedures

24.7%

25.0%

21.7%

28.1%

18.0%

21.0%

0.77

Components separation

16.5%

36.4%

22.8%

29.2%

24.0%

33.3%

0.09

4.7%

15.2%

28.4%

42.7%

36.0%

59.3%

<0.001

Age (y) Gender (female) 2

BMI (kg/m ) Prior hernia repair

Synthetic mesh Biologic mesh Mesh size (cm2)*

Panniculectomy

PCM ¼ preventable comorbidities; BMI ¼ body mass index. * Reported as median with interquartile range.

versus $31,788, P  0.001). Subanalysis of charges, specifically patients associated with wound-related complications (Table 6) and mesh infection-related complications (Table 6) are shown.

without complications, patients with 2þ PCM imposed significantly higher charges than those without PCM for inpatient ($61,269 versus $31,236, P < 0.002), outpatient ($4185 versus $552, P < 0.039), and total hospital charges ($65,453

Table 2 e Surgical outcomes for the individual groups. No PCM

1 PCM

2þ PCM

Without With Without With Without With complications complications complications complications complications complications (n ¼ 85) (n ¼ 33) (n ¼ 162) (n ¼ 89) (n ¼ 50) (n ¼ 81) Length of stay (d) Seromas

Overall P value

4.8  3.2

6.8  5.7

6.4  9.7*

7.5  5.3y

7.8  10.3z

9  6.2

<0.001

d

36.4%

d

39.3%

d

39.5%x

0.8

x

0.9

Seromas requiring intervention

d

30.3%

d

31.5%

d

30.9%

Cellulitis

d

45.5%

d

59.6%

d

53.1%x

0.4

Wound dehiscence

d

30.3%

d

d

50.6%x

0.04

30%y

Intraabdominal abscess

d

3.0%

d

3.0%

Mesh infection (n)

d

0

d

6

y

Recurrence

2.4%

6.1%

3.7%

10.1%

Readmission

1.2%

21.2%

4.9%*

38.2%y

LOS ¼ length of stay. * Compared to No PCM without complications, P > 0.05. y Compared to No PCM with complications, P > 0.05. z Compared to 1 PCM without complications, P > 0.05. x Compared to 1 PCM with complications, P > 0.05.

x

d

4.9%

d

4

2.0%

9.9%

0.46

37.0%y,x

<0.001

8%*,z

0.6 0.3

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Table 3 e Total charges for no PCM without complications versus 1 PCM and 2D PCM without complications.

Total charges Inpt Total charges Outpt Total charges

No PCM

1 PCM

P value

2þ PCM

P value

Without complications (n ¼ 85)

Without complications (n ¼ 162)

$31,235.52

$38,333.13

0.06

$61,268.62*

0.002

$552.36

$3577.77

0.04

$4184.86y

0.039

$31,787.89

$41,910.90

0.06

$65,453.48*

0.001

Without complications (n ¼ 50)

Inpt ¼ inpatient; Outpt ¼ outpatient. * Compared to 1 PCM, P < 0.05. y Compared to 1 PCM, P > 0.05.

Outcomes and cost: no PCM versus 1 PCM There were 162 patients without complications and 89 patients with complications (35.4% overall complication rate) in the 1 PCM group. When comparing outcomes, there was a significant difference (P < 0.05) for measured outcomes in patients with even a single PCM compared to those without such risk. Although there were very few mesh infections, there were no mesh infections in patients with no PCM compared to patients with even 1 PCM. In respect to charges, those patients without complications but with a single PCM had increased charges than those with no PCM during followup ($3578 versus $552, P ¼ 0.04), but there was no difference in hospital or overall total charges (P > 0.05).

Outcomes and cost: 1 PCM versus 2þ PCM When comparing patients with 1 PCM to those with two or more, there was no difference in surgical outcomes (P > 0.05). Interestingly, for patients without complications yet with PCM, both hospital ($38,333 versus $61,269, P ¼ 0.02) and total charges ($41,911 versus $65,453, P ¼ 0.01) were increased with two or more PCM compared to those with a single PCM. However, if complications occurred, the number of PCM did not affect hospital, follow-up, or overall charges (P > 0.05).

obesity, or diabetes) were more likely to have wound-related complications, and their care was more expensive than that of patients without such comorbidities. In those patients who developed wound-related complications, patients with multiple PCM incurred higher outpatient, inpatient, and total charges compared to patients without PCM. Indeed, even when comparing patients with multiple PCM without complications to patients with no PCM who had complications, the care for patients with no PCM was less expensive. Our study is consistent with recent publications emphasizing that multiple comorbidities can increase rates of wound-related complications and quantifies the intuitive assumption that this increases costs. This study further highlights the financial impact preventable comorbidities have on ventral hernia repair even when no complications occur, indicating that additional care necessary for those with high-risk comorbidities during elective repair can negatively impact the cost for the patient. For patients that developed complications, the more preventable comorbidities the patient had, there was an increase of total charges incurred compared to those without such comorbidities. Interestingly, even when patients with multiple preventable comorbidities do not develop a complication, their hospital costs are significantly increased compared to their healthier counterparts who suffer worse outcomes.

Current literature

Discussion In this prospectively collected study of open ventral hernia repairs, patients with preventable comorbidities (smoking,

Efforts to analyze cost-effectiveness have been applied to several arenas of ventral hernia repair technique. Stey et al.26 recently published a cost comparison of ventral hernias

Table 4 e Total charges for no PCM with complications versus 1 PCM and 2D PCM without complications.

Total charges Inpt Total charges Outpt Total charges

No PCM

1 PCM

With complications (n ¼ 33)

Without complications (n ¼ 162)

$47,597.91

$38,333.13

$7845.63 $55,443.54

Inpt ¼ inpatient; Outpt ¼ outpatient. * Compared to 1 PCM with complications, P < 0.05. y Compared to 1 PCM with complications, P > 0.05.

P value

1 PCM

2þ PCM

P value

With complications (n ¼ 89)

Without complications (n ¼ 50)

0.05

$54,589.84

$61,268.62y

0.39

$3577.77

<0.001

$12,644.75

$4184.86*

0.32

$41,910.90

0.003

$67,234.59

$65,453.48y

0.55

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Table 5 e Total charges for no PCM with complications versus 1 PCM and 2D PCM with complications.

Total charges Inpt Total charges Outpt Total charges

No PCM

1 PCM

P value

2þ PCM

P value

With complications (n ¼ 33)

With complications (n ¼ 89)

$47,597.91

$54,589.84

0.48

$64,347.40*

0.09

$7845.63

$12,644.75

0.08

$16,312.23*

0.12

$55,443.54

$67,234.59

0.29

$80,659.62*

0.04

With complications (n ¼ 81)

Inpt ¼ inpatient, Outpt ¼ outpatient. * Compared to 1 PCM, P > 0.05.

demonstrating that elective repair of nonincarcerated ventral hernias was cost effective when quality-adjusted life expectancy was applied. In larger scale studies of ventral hernia repair evaluating the national patient populous, cost comparison contrasting differing volume centers with trends over time27 and comparison of open versus laparoscopic approach with a focus on sociodemographic factors28 have been evaluated. Imaging,29 nontechnical perioperative aspects,30 comparison of suture versus mesh,31-33 comparison of approach, namely open versus laparoscopic,28,34-39 adjunct procedures such as components separation,40 utility of synthetic or biologic mesh,40-44 or even location of mesh placement45 have been factors considered for cost analysis of ventral hernia repairs. An emphasis on comorbidities has recently become more emphasized and so has identification of its influence on outcomes.4,19,43,46-48 Obesity alone was evaluated for its effect on cost in the NIS, demonstrating statistically significant difference in total hospital charges when comparing techniques of open versus laparoscopic ventral hernia repair ($48,5123 versus $40,387, P < 0.001).49 Recently, Fischer et al.43 related patients with diabetes with increased cost when they had three or more comorbidities specifically linking diabetes with

increased cost of repair ($61,302 versus $28,906, P ¼ 0.005); however, it did not assess if the comorbidity alone, whether coupled or uncoupled with complications, increased the cost of a ventral hernia repair compared to those without such preventable comorbidities. In respect to outpatient follow-up, when wound complications occur, the difference in charges has been shown in previous research to be $6200  13,800 compared to $1400  7900 with an average of 6.7 office visits for those with wound complications to that of 2.4 office visits for those without complications (P < 0.0001).14 Reduction of this financial burden may accomplished by preoperative optimization of patient comorbidities.

Limitations This is a prospectively collected database, and the focus of this article was to compare patient outcomes and charges for wound-related complications. Quality of life data were not available for all patients; however, complications were evaluated in respect to presence of preoperative preventable comorbidities.

Future directions

Table 6 e Charges of complications for no PCM versus 1 PCM and 2D PCM. No PCM

1 PCM

2þ PCM

P value

Wound complications Charges Inpt

$47,597.91

$54,065.94

$61,481.47*

0.08

Charges Outpt

$7845.63

$8324.97

$13,926.56*

0.38

Charges total

$55,443.54

$62,390.92

$75,408.03*

0.07

Charges Inpt

d

$61,837.14

$107,909.42*

0.78

Charges Outpt

d

$72,401.69

$52,574.38*

0.93

Charges total

d

$134,238.82

$160,483.80*

0.52

Mesh infections

Inpt ¼ inpatient, Outpt ¼ outpatient. * Compared to 1 PCM, P > 0.05.

In this study, we have shown the consequence of preventable comorbidities on cost of ventral hernia repairs. For patients with preventable comorbidities, the increase in the complexity of care accounts for the charges in taking care of comorbid patients even if they have excellent surgical outcomes without complications. Optimizing patients preoperatively has demonstrated to have a huge impact on preventing complications and also decreasing charges associated with patient care. To offer our patients the best possible outcomes, our benchmark for patient’s preoperative readiness must be set by data driven analysis. Surgeons are increasingly recognizing this concern as a recently published survey in 2012 stated that 43% of cases of elective ventral hernia repair that did not undergo an operation listed the contraindication to operate secondary to concomitant morbid obesity.50 Although this may seem extreme, the concept that better outcomes are seen with lower BMI patients for example has been further supported here and by financial considerations as well. Overall, requiring patients to lose weight reduces the mass of intrabdominal contents may increase compliance of the abdominal wall potentially minimizing the chance of component separation required and allow for myofascial

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reapproximation. Computed tomography (CT) scans can be used to predict when component separation will be necessary in an obese patient but can increase wound complications when this technique is used, whereas weight loss before surgery can increase abdominal wall compliance minimizing the risk to need components release.51 Current methods of surgeons requesting patients to lose weight have not proven sufficient for preoperative weight reduction compared to internal medicine providers counseling patients to lose weight for medical reasons.52 This study intentionally excluded bariatric procedures for the purpose of eliminating centers focused on such problems. However, as preoperative weight loss for bariatric centers has shown success,53 the concept of a multidisciplinary center focused on supporting patients in these preoperative efforts have promise for the future in elective hernia repair. A multidisciplinary approach designed to advocate for the patient and establish accountability to the preoperative optimization goals has been shown to be very effective; Rosen et al. reported on a group of patients who on average lost 24 kg and 9 points in BMI over 17 mo period to the operating room. When committed to lifestyle changes, 88% of patients maintained weight loss for 18 mo.54 Surgical weight loss such as gastric bypass before an elective definitive ventral hernia repair is also an option for patients and can be considered in cases of extreme weight loss and can result in excellent ventral hernia repair outcomes.55 Evidence regarding adverse effects of nicotine is significant.5,6,9 However, optimizing patients before elective ventral hernia surgery by smoking cessation for at least 4 wk before surgery, weight loss, and diabetes management may decrease the risk of postoperative wound complications.14 Several studies, including randomized controlled trials, have proven that between 3-6 weeks of smoking cessation can reduce postoperative complications.56-59 It is becoming much more apparent that controlling preventable comorbidities reduces complications and charges associated with postoperative care.

Conclusion Elective ventral hernia operations in patients with multiple preventable comorbidities are costly in multiple ways. When patients develop complications after OVHR, those with two or more preventable comorbidities have higher hospital costs than those with no preventable comorbidities. Patients with two or more preventable comorbidities and no complications have equivalent hospital costs to those patients with no preventable comorbidities who suffered complications. Although inpatient charges were no different, patients with no complications yet with a single preventable comorbidity resulted in increased follow-up costs compared to those patients with no preventable comorbidities. Preoperative optimization of patients before elective surgery is substantial, and aggressive risk reduction may translate into better outcomes and significant savings for the health care system. The future involves the concept of value in preparation for the patient and a construct of accountability to rigorously improve or eliminate these comorbidities before elective hernia repair.

Acknowledgment Author contributions: B.T.H. and V.A.A. contributed to the study design; T.C.C., L.J.B., P.D.C., T.P., A.E.L., B.T.H., and V.A.A. performed data acquisition/analysis; T.C.C., L.J.B., C.R.H., B.T.H., and V.A.A. drafted the manuscript; All authors performed the critical review of the article.

Disclosures V.A.A., B.T.H., and A.E.L. have previously been awarded surgical research and education grants from W.L. Gore and Associates, Ethicon, Novadaq, Bard/Davol, and LifeCell Inc. All other authors have no potential conflicts or disclosures relevant to this work.

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