Determining the Association Between Insurance Type and Myofascial Release in Large Ventral Hernias.

INTRODUCTION: Abdominal wall reconstruction (AWR) utilizes advanced myofascial releases to perform complex ventral hernia repair (VHR). The relationship between the performance of AWR and disparities in insurance type is unknown. METHODS: The Abdominal Core Health Quality Collaborative was queried for adults who had undergone an elective VHR between 2013 and 2020 with a hernia size ≥10 cm. Patients with missing insurance data were excluded. Comparison groups were divided by insurance type: favorable (private, Medicare, Veteran's Administration, Tricare) or unfavorable (Medicaid and self-pay). Propensity score matching compared the cumulative incidence of AWR between the favorable and unfavorable insurance comparison groups. RESULTS: In total, 26,447 subjects met inclusion criteria. The majority (89%, n = 23,617) had favorable insurance, while (11%, n = 2830) had unfavorable insurance. After propensity score matching, 2821 patients with unfavorable insurance were matched to 7875 patients with favorable insurance. The rate of AWR with external oblique release or transversus abdominis release was significantly higher (23%, n = 655) among the unfavorable insurance group compared to those with favorable insurance (21%, n = 1651; P = 0.013). CONCLUSIONS: This study provides evidence that patients with unfavorable insurance may undergo AWR with external oblique or transversus abdominis release at a greater rate than similar patients with favorable insurance. Understanding the mechanisms contributing to this difference and evaluating the financial implications of these trends represent important directions for future research in elective VHR.

Virtual Interviews for Surgical Fellowship are an Acceptable Alternative to In-Person Interviews for Applicants and Faculty Alike.

Background: In-person interviews have traditionally been an integral part of the fellowship application process to allow faculty and applicants to interact and evaluate the intangible aspects of the matching process. COVID-19 has forced a transition away from in-person interviews to a virtual platform. This study sought to track faculty and applicant perspectives on this transition. Study Design: Prospectively collected survey data was obtained from all participants after each of 3 consecutive virtual interview days for minimally invasive surgery fellowship at a single academic institution. Results: One hundred percent (27/27 applicants and 9/9 faculty) of interview participants completed the survey. Cost (100% applicants, 77.8% faculty) was perceived as the greatest barrier to in-person interviews, and "inability to get a feel for the program/applicant" was the largest concern for virtual interviews (66.7% applicants, 88.9% faculty). After interviews, most participants strongly agreed that they were able to assess education (66.7% applicants, 77.8% faculty), clinical experience (70.4% applicants, 77.8% faculty), and research potential (70.4% applicants, 88.9% faculty) through the virtual platform. Only 44.4% of each group strongly agreed that they could assess "overall fit" equally as well. Most faculty (6/9, 66.7%), but fewer applicants (10/27, 37.0%), were willing to completely eliminate in-person interviews. Conclusion: Virtual interviews may be an acceptable alternative to in-person interviews in times of COVID-19 and beyond. Offering a virtual format may help to eliminate costs associated with in-person visits while adequately assessing the fit of a program for both applicants and faculty, though applicants still desire an in-person option.

Greatest Quality of Life Improvement in Patients With Large Ventral Hernias: An Individual Assessment of Items in the HerQLes Survey.

BACKGROUND: Ventral hernia repair (VHR) has been shown to improve overall quality of life (QOL) by the validated 12-question Hernia-Related Quality-of-Life survey (HerQLes). However, which specific aspects of quality of life are most affected by VHR have not been formally investigated. METHODS: Through retrospective analysis of the Abdominal Core Health Quality Collaborative national database, we measured the change in each individual component of the HerQLes questionnaire from a pre-operative baseline assessment to one-year postoperatively in VHR patients. RESULTS: In total, 1,875 VHR patients had completed both pre- and post-operative questionnaires from 2014-2018. They were predominately Caucasian (92.3%), 57.9 ± 12.4 Y old, and evenly gender split (50.5% male, 49.5% female, P = 0.31). Most operations were performed open (80.5%) with fewer laparoscopic (7.5%) or robotic cases (12.1%). For each of the 12 individual categories, improvement in QOL from baseline to 1-Y was found to be statistically significant (P < 0.0001). This held true with subgroup analysis of small (<2 cm), medium (2-6 cm), and large (>6 cm) hernias (P < 0.0001), though a larger improvement was seen in 8 of 12 components in hernias >6 cm (P < 0.001). Operative approach did not carry a significant effect except in medium hernias (2-6 cm), where an open approach saw a greater improvement in the "accomplish less at work" item (P = 0.02). CONCLUSIONS: VHR is associated with improvement in each of the 12 components of QOL measured in the HerQLes questionnaire, regardless of the size of their hernia. The amount of improvement, however, may be dependent on hernia size and approach.

Evaluation of Wound Photography for Remote Postoperative Assessment of Surgical Site Infections.

Importance: Surgeons are increasingly interested in using mobile and online applications with wound photography to monitor patients after surgery. Early work using remote care to diagnose surgical site infections (SSIs) demonstrated improved diagnostic accuracy using wound photographs to augment patients' electronic reports of symptoms, but it is unclear whether these findings are reproducible in real-world practice. Objective: To determine how wound photography affects surgeons' abilities to diagnose SSIs in a pragmatic setting. Design, Setting, and Participants: This prospective study compared surgeons' paired assessments of postabdominal surgery case vignettes with vs without wound photography for detection of SSIs. Data for case vignettes were collected prospectively from May 1, 2007, to January 31, 2009, at Erasmus University Medical Center, Rotterdam, the Netherlands, and from July 1, 2015, to February 29, 2016, at Vanderbilt University Medical Center, Nashville, Tennessee. The surgeons were members of the American Medical Association whose self-designated specialty is general, abdominal, colorectal, oncologic, or vascular surgery and who completed internet-based assessments from May 21 to June 10, 2016. Intervention: Surgeons reviewed online clinical vignettes with or without wound photography. Main Outcomes and Measures: Surgeons' diagnostic accuracy, sensitivity, specificity, confidence, and proposed management with respect to SSIs. Results: A total of 523 surgeons (113 women and 410 men; mean [SD] age, 53 [10] years) completed a mean of 2.9 clinical vignettes. For the diagnosis of SSIs, the addition of wound photography did not change accuracy (863 of 1512 [57.1%] without and 878 of 1512 [58.1%] with photographs). Photographs decreased sensitivity (from 0.58 to 0.50) but increased specificity (from 0.56 to 0.63). In 415 of 1512 cases (27.4%), the addition of wound photography changed the surgeons' assessment (215 of 1512 [14.2%] changed from incorrect to correct and 200 of 1512 [13.2%] changed from correct to incorrect). Surgeons reported greater confidence when vignettes included a wound photograph compared with vignettes without a wound photograph, regardless of whether they correctly identified an SSI (median, 8 [interquartile range, 6-9] vs median, 8 [interquartile range, 7-9]; P < .001) but they were more likely to undertriage patients when vignettes included a wound photograph, regardless of whether they correctly identified an SSI. Conclusions and Relevance: In a practical simulation, wound photography increased specificity and surgeon confidence, but worsened sensitivity for detection of SSIs. Remote evaluation of patient-generated wound photographs may not accurately reflect the clinical state of surgical incisions. Effective widespread implementation of remote postoperative assessment with photography may require additional development of tools, participant training, and mechanisms to verify image quality.

Cost-Utility Analysis of Biologic and Biosynthetic Mesh in Ventral Hernia Repair: When Are They Worth It?

BACKGROUND: Biologic and biosynthetic meshes typically cost more than synthetic meshes for use in ventral hernia repair (VHR), with unknown comparative effectiveness. STUDY DESIGN: Cost-utility analysis was performed from a limited societal perspective assessing direct medical costs and outcomes for open, elective, retromuscular VHR. Short-term and 5-year major complications and costs were modeled using best available evidence from published studies, Healthcare Cost and Utilization Project data, and Americas Hernia Society Quality Collaborative data. Costs were analyzed in 2017 US dollars, and utilities were assessed using quality adjusted life years (QALYs). Sensitivity analyses were performed to determine threshold probabilities of long-term complications favoring particular mesh types. RESULTS: Synthetic mesh was the preferred strategy, with a cost of $15,620 and QALYs of 18.85, assuming a baseline 5.6% rate of long-term complications for all meshes. One-way sensitivity analysis demonstrated that biosynthetic and biologic mesh became the better choice as long-term complication rates for synthetic mesh increased to 15.5% and 26.2%, respectively. Two-way sensitivity analysis demonstrated that biologic and biosynthetic meshes became favorable as the cost of biologic mesh decreased and long-term synthetic mesh complication rates increased. Biologic and biosynthetic meshes also became more cost-effective when their relative long-term complication rates decreased and long-term synthetic mesh complication rates increased. CONCLUSIONS: Using modeling techniques, synthetic mesh is the best option for retromuscular VHR given currently available evidence. We established long-term complication thresholds, possibly justifying the higher up-front costs for biologic or biosynthetic meshes. This emphasizes the critical need to obtain long-term complication surveillance data to help individualize mesh choice in VHR.

Hidden Morbidity of Ventral Hernia Repair with Mesh: As Concerning as Common Bile Duct Injury?

BACKGROUND: Ventral hernia repair with mesh is increasingly common, but the incidence of long-term complications that necessitate mesh explantation is unknown. We aimed to determine the epidemiology of mesh explantation after ventral hernia repair and to compare this with common bile duct injury, a dreaded complication of laparoscopic cholecystectomy. STUDY DESIGN: We evaluated a retrospective cohort of patients undergoing ventral hernia repair by linking the all-payers State Inpatient Databases and State Ambulatory Surgery Databases for New York, California, and Florida. We followed patients longitudinally from 2005 to 2011 for the primary end point of mesh explantation, designated by concurrent procedure codes for ventral hernia repair and foreign body removal. We determined time to mesh explantation and calculated cumulative costs for surgical care, comparing these with historical data for common bile duct injury. RESULTS: During the study period, 619,751 patients underwent at least one ventral hernia repair (91% open, 9% laparoscopic). In a mean follow-up of 3 years, 438 patients (0.07%) had mesh removed at a median of 346 days after repair. Median cumulative cost for patients requiring mesh explantation was $21,889 vs $6,983 without (p < 0.01). Rates of mesh explantation and costs were on par with laparoscopic common bile duct injury, based on published data, but occurred later in the postoperative course. CONCLUSIONS: By this conservative estimate, complications of ventral hernia repair with implantable mesh are comparably as frequent as for common bile duct injury, but occur later in a patient's experience. Long-term follow-up is critically necessary to fully understand the ramifications of implanted devices.

Insurance status influences emergent designation in surgical transfers.

BACKGROUND: There is a perception among surgeons that hospitals disproportionately transfer unfavorably insured patients for emergency surgical care. Emergency medical condition (EMC) designation mandates referral center acceptance of patients for whom transfer is requested. We sought to understand whether unfavorably insured patients are more likely to be designated as EMCs. MATERIALS AND METHODS: A retrospective cohort study was performed on patient transfers from a large network of acute care facilities to emergency surgery services at a tertiary referral center from 2009-2013. Insurance was categorized as favorable (commercial or Medicare) or unfavorable (Medicaid or uninsured). The primary outcome, transfer designation as EMC or non-EMC, was evaluated using multivariable logistic regression. A secondary analysis evaluated uninsured patients only. RESULTS: There were 1295 patient transfers in the study period. Twenty percent had unfavorable insurance. Favorably insured patients were older with fewer nonwhite, more comorbidities, greater illness severity, and more likely transferred for care continuity. More unfavorably insured patients were designated as EMCs (90% versus 84%, P < 0.01). In adjusted models, there was no association between unfavorable insurance and EMC transfer (odds ratio [OR], 1.61; 95% confidence interval [CI], 0.98-2.69). Uninsured patients were more likely to be designated as EMCs (OR, 2.27; CI, 1.08-4.77). CONCLUSIONS: The finding that uninsured patients were more likely to be designated as EMCs suggests nonclinical variation that may be mitigated by clearer definitions and increased interfacility coordination to identify patients requiring transfer for EMCs.

Disease-based mortality after percutaneous endoscopic gastrostomy: utility of the enterprise data warehouse.

BACKGROUND: Percutaneous endoscopic gastrostomy (PEG) remains a mainstay of enteral access. Thirty-day mortality for PEG has ranged from 16 to 43 %. This study aims to discern patient groups that demonstrate limited survival after PEG placement. The Enterprise Data Warehouse (EDW) concept allows an efficient means of integrating administrative, clinical, and quality-of-life data. On the basis of this concept, we developed the Vanderbilt Procedural Outcomes Database (VPOD) and analyzed these data for evaluation of post-PEG mortality over time. METHODS: Patients were identified using the VPOD from 2008 to 2010 and followed for 1 year after the procedure. Patients were categorized according to common clinical groups for PEG placement: stroke/CNS tumors, neuromuscular disorders, head and neck cancers, other malignancies, trauma, cerebral palsy, gastroparesis, or other indications for PEG. All-cause mortality at 30, 60, 90, 180, and 360 days was determined by linking VPOD information with the Social Security Death Index. Chi-square analysis was used to determine significance across groups. RESULTS: Nine hundred fifty-three patients underwent PEG placement during the study period. Mortality over time (30-, 60-, 90-, 180-, and 360-day mortality) was greatest for patients with malignancies other than head and neck cancer (29, 45, 57, 66, and 72 %) and least for cerebral palsy or patients with gastroparesis (7 % at all time points). Patients with neuromuscular disorders had a similar mortality curve as head and neck cancer patients. Stroke/CNS tumor patients and patients with other indications had the second highest mortality, while trauma patients had low mortality. CONCLUSIONS: PEG mortality was much higher in patients with malignancies other than head and neck cancer compared to previously published rates. PEG should be used with great caution in this and other high-risk patient groups. This study demonstrates the power of an EDW-based database to evaluate large numbers of patients with clinically meaningful results.

The chosen few: disproportionate resource use in ventral hernia repair.

The objectives of this study were to determine if disproportionately small numbers of patients use more resources for ventral hernia repair (VHR) and to identify factors associated with this group. Patients undergoing VHR were identified using national 2009 Healthcare Cost and Utilization Project data. Mean total hospital charges (THCs) were calculated and patients were divided into high charges (HC, greater than 50% mean THC) and low charges (LC, 50% or less mean THC) groups. Multivariate analysis was used to identify factors associated with the HC group. We estimated 181,000 hospitalizations for VHR in 2009 with mean THC of $54,000. Fifteen per cent of patients comprised the HC group with 85 per cent in the LC group. The HC group had higher THC ($173,000 vs $32,000; P < 0.05), increased mean length of stay (16.0 vs 4.1 days, P < 0.05), and higher mortality (6.3 vs 0.6%, P < 0.05). Risk factors for HC included congestive heart failure (odds ratio [OR], 2.2; 95% confidence interval [CI], 2.0 to 2.5), chronic lung disease (OR, 1.3; 95% CI, 1.2 to 1.4), Asian race (OR, 2.5; 95% CI, 1.7 to 3.7), nonelective operation (OR, 1.9; 95% CI, 1.6 to 2.3), and male gender (OR, 1.2; 95% CI, 1.1 to 1.3). For inpatient VHR, a remarkably small proportion of patients use disproportionately high hospital resources. The identified risk factors can help surgeons predict patients who are likely to consume large amounts of resources.

Global Assessment of Gastrointestinal Endoscopic Skills (GAGES): a valid measurement tool for technical skills in flexible endoscopy.

BACKGROUND: Simulators may improve the efficiency, safety, and quality of endoscopic training. However, no objective, reliable, and valid tool exists to assess clinical endoscopic skills. Such a tool to measure the outcomes of educational strategies is a necessity. This multicenter, multidisciplinary trial aimed to develop instruments for evaluating basic flexible endoscopic skills and to demonstrate their reliability and validity. METHODS: The Global Assessment of Gastrointestinal Endoscopic Skills (GAGES) Upper Endoscopy (GAGES-UE) and Colonoscopy (GAGES-C) are rating scales developed by expert endoscopists. The GAGES scale was completed by the attending endoscopist (A) and an observer (O) in self-assessment (S) during procedures to establish interrater reliability (IRR, using the intraclass correlation coefficient [ICC]) and internal consistency (IC, using Cronbach's alpha). Instrumentation was evaluated when possible and correlated with total scores. Construct and external validity were examined by comparing novice (NOV) and experienced (EXP) endoscopists (Student's t-test). Correlations were calculated for GAGES-UE and GAGES-C with participants who had performed both. RESULTS: For the 139 completed evaluations (60 NOV, 79 EXP), IRR (A vs. O) was 0.96 for GAGES-UE and 0.97 for GAGES-C. The IRR between S and A was 0.78 for GAGES-UE and 0.89 for GAGES-C. The IC was 0.89 for GAGES-UE, and 0.95 for GAGES-C. There were mean differences between the NOV and the EXP endoscopists for GAGE-UE (14.4 +/- 3.7 vs. 18.5 +/- 1.6; p < 0.001) and GAGE-C (11.8 +/- 3.8 vs. 18.8 +/- 1.3; p < 0.001). Good correlation was found between the scores for the GAGE-UE and the GAGE-C (r = 0.75; n = 37). Instrumentation, when performed, demonstrated correlations with total scores of 0.84 (GAGE-UE; n = 73) and 0.86 (GAGE-C; n = 45). CONCLUSIONS: The GAGES-UE and GAGES-C are easy to administer and consistent and meet high standards of reliability and validity. They can be used to measure the effectiveness of simulator training and to provide specific feedback. The GAGES results can be generalized to North American and European endoscopists and may contribute to the definition of technical proficiency in endoscopy.

Model for end-stage liver disease: did the new liver allocation policy affect waiting list mortality?

OBJECTIVE: To examine the impact of the Model for End-stage Liver Disease (MELD) on waiting list mortality. DESIGN: Interrupted time series with a nominal inception point of the intervention on February 27, 2002. SETTING: United Network for Organ Sharing Standard Transplant Analysis and Research file data from March 1, 1999, to July 30, 2004. PARTICIPANTS: All adult candidates on the waiting list for liver transplantation in the United States during the study period. INTERVENTION: Implementation of the MELD policy. MAIN OUTCOME MEASURES: Waiting list mortality, waiting time to transplantation, number of new registrants, and posttransplantation survival. RESULTS: Although no preintervention trend was identified, the policy change was associated with an immediate effect of increasing waiting list mortality by 2.2 deaths per 1000 registrants per month (from approximately 11 to 13 deaths per 1000 registrants per month; 95% confidence interval [CI], 1.1 to 3.4; P = .001) followed by a postintervention decline in waiting list mortality over time (-0.09 death per 1000 registrants per month; 95% CI, -0.16 to -0.03; P <.001). An immediate effect of decreased waiting time was also noted (from approximately 294 to 250 days; -44.4 days; 95% CI, -77.1 to -11.7 days; P <.001), which reached a new, lower postintervention steady state. The intervention had no effect on the number of new registrants listed per month or on 3- and 6-month posttransplantation survival. CONCLUSION: After an initial increase in waiting list mortality, the implementation of the MELD-based allocation policy was associated with an overall decline in waiting list mortality and time to transplantation.

Optimizing choledocholithiasis management: a cost-effectiveness analysis.

HYPOTHESIS: Endoscopic retrograde cholangiopancreatography (ERCP) is more cost-effective for managing incidental choledocholithiasis (CDL) after laparoscopic cholecystectomy and intraoperative cholangiogram (LC/IOC) than laparoscopic common bile duct exploration (LCBDE). DESIGN: A cost-effectiveness analysis was performed to compare ERCP with LCBDE. Sensitivity analyses were performed to determine the key contributors to cost-effectiveness between the 2 treatment options. SETTING: Costs were approached from the institutional perspective considering a typical patient undergoing LC/IOC at a large referral center. PATIENTS: The base case patient evaluated was a woman 18 years of age or older with symptomatic cholelithiasis and incidental CDL discovered at the time of LC/IOC. INTERVENTIONS: Endoscopic retrograde cholangiopancreatography with drainage procedure performed after LC/IOC or LCBDE during LC/IOC. MAIN OUTCOME MEASURES: Costs, quality-adjusted life years gained, mean cost-effectiveness ratios, and incremental cost-effectiveness ratios. RESULTS: In the base case analysis, ERCP was the optimal treatment choice with a cost of $24 300 for 0.9 quality-adjusted life years gained compared with $28 400 and 0.88 quality-adjusted life years for LCBDE. Endoscopic retrograde cholangiopancreatography remained the optimal strategy for CDL in multiway probabilistic sensitivity analysis. If LCBDE were performed and the cost of a potential operative case lost was $3100 or less and the cost of ERCP hospitalization was $18 000 or more, then LCBDE became the preferred treatment for CDL. CONCLUSIONS: Endoscopic retrograde cholangiopancreatography was both less costly and more effective than LCBDE. Factors important to choosing the best strategy for CDL management included the cost of a potential case lost due to LCBDE performance and the cost of ERCP hospitalization.

Cervical spine evaluation in urban trauma centers: lowering institutional costs and complications through helical CT scan.

BACKGROUND: In the evaluation of the cervical spine (c-spine), helical CT scan has higher sensitivity and specificity than plain radiographs in the moderate- and high-risk trauma population, but is more costly. We hypothesize that institutional costs associated with missed injuries make helical CT scan the least costly approach. STUDY DESIGN: A cost-minimization study was performed using decision analysis examining helical CT scan versus radiographic evaluation of the c-spine. Parameter estimates were obtained from the literature for probability of c-spine injury, probability of paralysis after missed injury, plain film sensitivity and specificity, CT scan sensitivity and specificity, and settlement cost of missed injuries resulting in paralysis. Institutional costs of CT scan and plain radiography were used. Sensitivity analyses tested robustness of strategy preference, accounted for parameter variability, and determined threshold values for individual parameters on strategy preference. RESULTS: C-spine evaluation with helical CT scan has an expected cost of US 554 dollars per patient compared with US 2,142 dollars for plain films. CT scan is the least costly alternative if threshold values exceed US 58,180 dollars for institutional settlement costs, 0.9% for probability of c-spine fracture, and 1.7% for probability of paralysis. Plain films are least costly if CT scan costs surpass US 1,918 dollars or plain film sensitivity exceeds 90%. CONCLUSIONS: Helical CT scan is the preferred initial screening test for detection of cervical spine fractures among moderate- to high-risk patients seen in urban trauma centers, reducing the incidence of paralysis resulting from false-negative imaging studies and institutional costs, when settlement costs are taken into account.