title: The impact of developing a comprehensive hernia center on the referral patterns and complexity of hernia care.
abstract: BACKGROUND
  Complex hernia repairs represent a formidable surgical challenge. Several comprehensive hernia centers, including ours, with advanced expertise have recently emerged across the country. However, the effects of tertiary specialization remain largely unclear. We aimed to evaluate the impact of developing a comprehensive hernia center on the referral patterns and costs of patients with complex hernias.
  
  
  METHODS
  A prospectively maintained database was used to identify all patients undergoing open ventral hernia repair (VHR) between 2006 and 2013 at the Case Comprehensive Hernia Center. Patients were separated into two groups by zip code: those traveling either <25 or >100 miles. Demographics, operative characteristics, length of stay and costs data were analyzed.
  
  
  RESULTS
  Of all patients who underwent open VHR during the study period, 287 met the inclusion criteria. Hernia length, width and area were all significantly larger for patients traveling >100 miles (P < 0.01 for all). These patients were also more likely to have active mesh infections (OR 3.57) and non-healing wounds (OR 5.00) when compared with local patients. Length of hospital stay was significantly longer for patients traveling >100 miles compared to those traveling <25 miles (9.7 vs. 6.8; P < 0.0001). Surgical site occurrence, infection and hernia recurrence rates were similar between the two groups during the follow-up period. Patients who traveled >100 miles incurred significantly higher fixed direct and variable direct costs compared to those who traveled <25 miles (P < 0.05 for both).
  
  
  CONCLUSIONS
  The development of a comprehensive hernia center results in centralization of complex hernia care. Patients traveling >100 miles for ventral hernia repair have significantly larger and more complex hernias. The implications for improved patient outcomes and potential reimbursement issues for providing this care should be carefully evaluated.
authors.affiliation: Department of Surgery, Case Comprehensive Hernia Center, Case Western Reserve University, 11100 Euclid Avenue, Cleveland, OH, 44106, USA, sxr433@case.edu.
authors.forename: S
authors.initials: S
authors.lastname: Raigani
authors.forename: G S
authors.initials: GS
authors.lastname: De Silva
authors.forename: C N
authors.initials: CN
authors.lastname: Criss
authors.forename: Y W
authors.initials: YW
authors.lastname: Novitsky
authors.forename: M J
authors.initials: MJ
authors.lastname: Rosen
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D003365:Costs and Cost Analysis; D016208:Databases, Factual; D005260:Female; D006268:Health Facilities / Q000191:economics* / Q000706:statistics & numerical data; D006555:Hernia, Ventral / Q000191:economics* / Q000601:surgery*; D059685:Herniorrhaphy / Q000191:economics*; D006801:Humans; D008297:Male; D008875:Middle Aged; D009820:Ohio / Q000453:epidemiology; D012017:Referral and Consultation / Q000706:statistics & numerical data*; D055815:Young Adult