Abstract: The Impact of Hospital Volume on Clinical and Economic Outcomes in Ventral Hernia Repair: An Analysis with National Policy Implications

Abstract

INTRODUCTION: There is a growing interest in identifying provider and hospital characteristics associated with improved patient outcomes for surgical procedures. Increased operative volume has been associated with benefits in patient centric and economic outcomes for a variety of surgical procedures. In ventral hernia repair, however, there has been a paucity of studies assessing the association between procedure volume and patient outcomes. The objectives of this study are to evaluate the associations between elective hospital ventral hernia repair procedure volume and patient outcomes, including both clinical and economic outcomes. METHODS: The 2014 National Inpatient Sample was queried for patients who underwent elective, open ventral (incisional) hernia repair with or without mesh. Outcomes included occurrence of major or wound-based in-hospital complications, extended length of stay (>4 days), and increased costs (>$12,816). High-volume hospitals were defined as the 90th percentile of case volume or higher (>60 cases/year). Multivariate regression was performed to access the outcomes associated with high-volume hospitals. RESULTS: 54075 patients at 2049 hospitals were retrieved. 41.4 percent of patients were treated at high-volume hospitals. There were significant differences in mesh use (67.2 percent vs 63.8 percent; p<0.001), smokers (30.4 percent vs 27.9 percent; p<0.001), unadjusted major complications (9.5 percent vs 8.6 percent; p<0.001), and unadjusted wound-based complications (6.2 percent vs 5.0 percent; p<0.001) between HV and non-HV. After adjustments for clinical and hospital characteristics, patients treated at high-volume hospitals were less likely to experience a major complication (OR, 0.882; 95 percent CI, 0.815 to 0.955; p=0.002) or wound-based complication (OR, 0.838; 95 percent CI, 0.763 to 0.920; p<0.001). However, in terms of resource utilization, patients treated at high-volume hospitals were more likely to experience an extended length of stay (OR, 1.143; 95 percent CI, 1.090 to 1.199; p<0.001) and an increase in costs (OR, 1.225; 95 percent CI, 1.166 to 1.287; p<0.001). CONCLUSION: Hospitals that perform a larger number of ventral hernia repairs may provide better patient outcomes than lower-volume hospitals. However, these same high volume centers demonstrate an extended length of stay and increased costs thus conflicting with the idea that concentration of resources in high volume centers generates cost-savings. Further research is needed to understand the reason for this gap in proper resource utilization in high volume ventral hernia repair centers.