title: Delineation of factors associated with prolonged length of stay after laparoscopic ventral hernia repair leads to a clinical pathway and improves quality of care.
abstract: BACKGROUND
  Centers for Medicare and Medicaid Services define laparoscopic ventral hernia repair (LVHR) as outpatient procedure. We identified our institutional length of stay (LOS) to be above the National Surgical Quality Improvement Program (NSQIP) benchmark of 1 day [interquartile range (IQR) 2 days]. This study was undertaken to investigate risk factors associated with prolonged hospital stay and design an intervention to decrease median LOS.
  
  
  METHODS
  This study analyzed institutional NSQIP data on patients who underwent elective LVHR from 2006 to 2011 to define factors associated with prolonged LOS, defined as LOS > 2 days. Modifiable factors identified in the initial analysis were included in a clinical care pathway to impact LOS. We repeated the NSQIP data analysis after implementation (4/2011-9/2012) to assess the effect of our intervention. Analysis was by univariate, ANOVA and logistic regression models.
  
  
  RESULTS
  During the pre-implementation period, 80 patients with a median age of 54 years (31-84) stayed a median of 2 days (IQR 3). On univariate analysis, factors associated with prolonged LOS included operative time, mesh size, amount of narcotics used and female gender. In multivariate analysis, operative time and narcotics used were associated with a prolonged LOS, C statistic = 0.88. Introduction of a clinical pathway focusing on non-narcotic pain relief resulted in a decrease in mean narcotic usage from 223 to 63 mg morphine equivalents/patient (p < 0.0001), decrease in median LOS to 1 day (IQR 2) (p = 0.027), in line with NSQIP benchmarks, a slight decrease in complications and a 10% decrease in hospital cost.
  
  
  CONCLUSIONS
  High narcotic use and long operative times are independent predictors of prolonged LOS in our patient population. Introduction of a standardized clinical care pathway designed to reduce perioperative narcotic use resulted in shorter LOS, improved quality and cost savings for patients undergoing LVHR.
authors.affiliation: Department of Surgery, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA.
authors.forename: Jennifer
authors.initials: J
authors.lastname: Leonard
authors.affiliation: Department of Surgery, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA.
authors.forename: Tina J
authors.initials: TJ
authors.lastname: Hieken
authors.affiliation: Department of Surgery, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA.
authors.forename: Malek
authors.initials: M
authors.lastname: Hussein
authors.affiliation: Department of Health Sciences Research, Mayo Clinic, Rochester, MN, USA.
authors.forename: W Scott
authors.initials: WS
authors.lastname: Harmsen
authors.affiliation: Department of Surgery, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA.
authors.forename: Mark
authors.initials: M
authors.lastname: Sawyer
authors.affiliation: Affiliated Practice Network, Mayo Clinic, Rochester, MN, USA.
authors.forename: John
authors.initials: J
authors.lastname: Osborn
authors.affiliation: Department of Surgery, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA. bingenercasey.juliane@mayo.edu.
authors.forename: Juliane
authors.initials: J
authors.lastname: Bingener
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D000700:Analgesics / Q000627:therapeutic use; D019091:Critical Pathways; D004363:Drug Utilization; D005260:Female; D006555:Hernia, Ventral / Q000601:surgery*; D006801:Humans; D010535:Laparoscopy; D007902:Length of Stay; D008297:Male; D008875:Middle Aged; D008910:Minnesota; D061646:Operative Time; D010149:Postoperative Pain / Q000188:drug therapy; D058996:Quality Improvement
chemical_list: D000700:Analgesics
keywords: Abdominal; Costs; Hernia; Pain; Quality control; Technical