title: The impact of healthcare rationing on elective and emergency hernia repair.
abstract: In 2011 the local clinical commissioning group introduced a policy restricting funding for elective hernia repairs. Anecdotally, it was felt that this resulted in an increased number of emergency hernia repairs in our trust. Our primary objective was to assess whether this was actually the case. Our secondary objective was to quantify the risks of non-elective hernia repair.
  
  
  
  We performed a retrospective cohort study, analysing all hernia surgeries performed between 2010 and 2013. The data were obtained from the trust Patient Information System. A total of 2556 patients underwent repair of inguinal, umbilical, incisional, femoral or ventral hernias over this time.
  
  
  
  As the policy intended, the number of elective hernia repairs reduced from 857 over 12 months before the funding restrictions to 606 in the same period afterwards (p < 0.001). Over the same time period, however, a significant rise in total emergency hernia repairs was demonstrated, increasing from 98 to 150 (p < 0.001). 30-day readmission rates also increased from 5.1 % before the policy introduction to 8.5 % afterwards (p = 0.006). In our data, the rate of bowel resection rises from 0.97 to 12.9 % for emergency operation compared to elective hernia repair (p < 0.001), while the median length of stay rises from less than 24 h to 3 days.
  
  
  
  Our data suggest that the funding restrictions introduced in 2011 were followed by a statistically significant and unintended increase in emergency hernia repairs in our trust, with associated increased risks to patient safety.
authors.affiliation: Department of General Surgery, Gloucester Royal Hospital, Great Western Road, Gloucester, GL13NN, UK. morchard@doctors.org.uk.
authors.forename: M R
authors.initials: MR
authors.lastname: Orchard
authors.affiliation: Department of Statistics, The Chinese University of Hong Kong, Shatin, Hong Kong.
authors.forename: J A
authors.initials: JA
authors.lastname: Wright
authors.affiliation: Information Management and Technology Directorate, North Bristol NHS Trust, Bristol, UK.
authors.forename: A
authors.initials: A
authors.lastname: Kelly
authors.affiliation: , Bristol, UK.
authors.forename: D J
authors.initials: DJ
authors.lastname: McCabe
authors.affiliation: Department of General Surgery, North Bristol NHS Trust, Bristol, UK.
authors.forename: J
authors.initials: J
authors.lastname: Hewes
mesh_terms: D000328:Adult; D017558:Elective Surgical Procedures / Q000191:economics / Q000706:statistics & numerical data; D004630:Emergencies / Q000191:economics / Q000453:epidemiology; D005260:Female; D015276:Health Care Rationing / Q000191:economics* / Q000706:statistics & numerical data; D046449:Hernia, Abdominal / Q000191:economics / Q000453:epidemiology* / Q000601:surgery*; D059685:Herniorrhaphy / Q000191:economics* / Q000379:methods; D006801:Humans; D008297:Male; D008875:Middle Aged; D061214:Patient Safety / Q000191:economics / Q000706:statistics & numerical data; D012189:Retrospective Studies; D018570:Risk Assessment
keywords: Funding restrictions; Hernia; Patient safety