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Cassidy DE, Shao Z, Howard R, Englesbe MJ, Dimick JB, Telem DA, Ehlers AP. Variability in surgical approaches to hernias in patients with ascites. Surg Endosc 2024; 38:735-741. [PMID: 38049668 DOI: 10.1007/s00464-023-10598-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2023] [Accepted: 11/14/2023] [Indexed: 12/06/2023]
Abstract
BACKGROUND Hernias in patients with ascites are common, however we know very little about the surgical repair of hernias within this population. The study of these repairs has largely remained limited to single center and case studies, lacking a population-based study on the topic. STUDY DESIGN The Michigan Surgical Quality Collaborative and its corresponding Core Optimization Hernia Registry (MSQC-COHR) which captures specific patient, hernia, and operative characteristics at a population level within the state was used to conduct a retrospective review of patients with ascites undergoing ventral or inguinal hernia repair between January 1, 2020 and May 3, 2022. The primary outcome observed was incidence and surgical approach for both ventral and inguinal hernia cohorts. Secondary outcomes included 30-day adverse clinical outcomes as listed here: (ED visits, readmission, reoperation and complications) and surgical priority (urgent/emergent vs elective). RESULTS In a cohort of 176 patients with ascites, surgical repair of hernias in patients with ascites is a rare event (1.4% in ventral hernia cohort, 0.2% in inguinal hernia cohort). The post-operative 30-day adverse clinical outcomes in both cohorts were greatly increased compared to those without ascites (ventral: 32% inguinal: 30%). Readmission was the most common complication in both inguinal (n = 14, 15.9%) and ventral hernia (n = 17, 19.3%) groups. Although open repair was most common for both cohorts (ventral: 86%, open: 77%), minimally invasive (MIS) approaches were utilized. Ventral hernias presented most commonly urgently/emergently (60%), and in contrast many inguinal hernias presented electively (72%). CONCLUSION A population-level, ventral and incisional hernia database capturing operative details for 176 patients with ascites. There was variation in the surgical approaches performed for this rare event and opportunities for optimization in patient selection and timing of repair.
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Affiliation(s)
- Devon E Cassidy
- University of Michigan Medical School, 1500 E Medical Center Dr., Ann Arbor, MI, USA.
| | - Zhihong Shao
- Department of Surgery, University of Michigan, Ann Arbor, MI, USA
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, MI, USA
| | - Ryan Howard
- Department of Surgery, University of Michigan, Ann Arbor, MI, USA
| | | | - Justin B Dimick
- Department of Surgery, University of Michigan, Ann Arbor, MI, USA
| | - Dana A Telem
- Department of Surgery, University of Michigan, Ann Arbor, MI, USA
| | - Anne P Ehlers
- Department of Surgery, University of Michigan, Ann Arbor, MI, USA
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Ehlers AP, Nham W, Vitous CA, Hosea F, Palazzolo KP, Howard R, Delaney L, Shao JM, Rubyan M, Telem DA. Life after "no": barriers to behavior change for persons declined hernia repair due to high-risk features. Surg Endosc 2023; 37:8663-8669. [PMID: 37500919 DOI: 10.1007/s00464-023-10283-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2023] [Accepted: 07/05/2023] [Indexed: 07/29/2023]
Abstract
INTRODUCTION Delaying an elective operation to mitigate risk factors improves patient outcomes. Elective ventral hernia repair is one such example. To address this issue, we developed a pre-operative optimization clinic to support high-risk patients seeking elective ventral hernia repair. Unfortunately, few patients progressed to surgery. Within this context, we sought to understand the barriers to behavior change among these patients with the goal of improving care for patients undergoing elective surgery. METHODS We performed semi-structured, qualitative interviews with 20 patients who were declined ventral hernia repair due to either active tobacco use or obesity. Patients were recruited from a pre-operative optimization clinic at an academic hospital. Interviews sought to characterize patients' perceived barriers to behavior change. Interviews were concluded once thematic saturation was reached. We used an inductive thematic analysis to analyze the data. All data analysis was performed using MAXQDA software. RESULTS Among 20 patients (mean age 50, 65% female, 65% White), none had yet undergone ventral hernia repair. While most patients had a positive experience in the clinic, among those who did not, we found three dominant themes around behavior change: (1) Patient's role in behavior change: how the patient perceived their role in making behavior changes optimize their health for surgery; (2) Obtainability of offered resources: the need for more support for patients to access the recommended healthcare; and (3) Patient-provider concordance: the extent to which patients and providers agree on the relative importance of different attributes of their care. CONCLUSION Behavior change prior to elective surgery is complex and multifaceted. While improving access to tobacco cessation resources and obesity management may improve outcomes for some, patients may benefit from increased on-site facilitation to promote access to resources as well as the use of patient-facing decision support tools to promote patient-provider concordance.
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Affiliation(s)
- Anne P Ehlers
- Department of Surgery, University of Michigan, 1500 E Medical Center Drive, SPC 5343, 2210 Taubman Center, Ann Arbor, MI, 48109, USA.
- Michigan Surgical Quality Collaborative-Core Optimization Health Registry (MSQC-COHR), Ann Arbor, MI, USA.
- Henry Ford Health, Detroit, MI, USA.
| | - Wilson Nham
- Michigan Medicine Emergency Medicine Research, Ann Arbor, MI, USA
- Henry Ford Health, Detroit, MI, USA
| | - C Ann Vitous
- Center for Healthcare Outcomes and Policy, Ann Arbor, MI, USA
- Henry Ford Health, Detroit, MI, USA
| | - Forrest Hosea
- Michigan Surgical Quality Collaborative-Core Optimization Health Registry (MSQC-COHR), Ann Arbor, MI, USA
- Henry Ford Health, Detroit, MI, USA
| | - Krisinda P Palazzolo
- Center for Healthcare Outcomes and Policy, Ann Arbor, MI, USA
- Henry Ford Health, Detroit, MI, USA
| | - Ryan Howard
- Department of Surgery, University of Michigan, 1500 E Medical Center Drive, SPC 5343, 2210 Taubman Center, Ann Arbor, MI, 48109, USA
- Michigan Surgical Quality Collaborative-Core Optimization Health Registry (MSQC-COHR), Ann Arbor, MI, USA
- Henry Ford Health, Detroit, MI, USA
| | - Lia Delaney
- Henry Ford Health, Detroit, MI, USA
- Department of Surgery, Stanford University, Palo Alto, CA, USA
| | - Jenny M Shao
- Department of Surgery, University of Michigan, 1500 E Medical Center Drive, SPC 5343, 2210 Taubman Center, Ann Arbor, MI, 48109, USA
- Michigan Surgical Quality Collaborative-Core Optimization Health Registry (MSQC-COHR), Ann Arbor, MI, USA
- Henry Ford Health, Detroit, MI, USA
| | - Michael Rubyan
- Henry Ford Health, Detroit, MI, USA
- Department of Health Management and Policy, School of Public Health, University of Michigan, Ann Arbor, MI, USA
| | - Dana A Telem
- Department of Surgery, University of Michigan, 1500 E Medical Center Drive, SPC 5343, 2210 Taubman Center, Ann Arbor, MI, 48109, USA
- Michigan Surgical Quality Collaborative-Core Optimization Health Registry (MSQC-COHR), Ann Arbor, MI, USA
- Henry Ford Health, Detroit, MI, USA
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Solano QP, Howard R, Mullens CL, Ehlers AP, Delaney LD, Fry B, Shen M, Englesbe M, Dimick J, Telem D. The impact of frailty on ventral hernia repair outcomes in a statewide database. Surg Endosc 2023; 37:5603-5611. [PMID: 36344897 PMCID: PMC9640794 DOI: 10.1007/s00464-022-09626-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2022] [Accepted: 09/11/2022] [Indexed: 11/09/2022]
Abstract
INTRODUCTION Preoperative frailty is a strong predictor of postoperative morbidity in the general surgery population. Despite this, there are a paucity of research examining the effect of frailty on outcomes after ventral hernia repair (VHR), one of the most common abdominal operations in the USA. We examined the association of frailty with short-term postoperative outcomes while accounting for differences in preoperative, operative, and hernia characteristics. METHODS We retrospectively reviewed the Michigan Surgery Quality Collaborative Hernia Registry (MSQC-HR) for adult patients who underwent VHR between January 2020 and January 2022. Patient frailty was assessed using the validated 5-factor modified frailty index (mFI5) and categorized as follows: no (mFI5 = 0), moderate (mFI5 = 1), and severe frailty (mFI5 ≥ 2). Our primary outcome was any 30-day complication. Multivariable logistic regression was used to evaluate the association of frailty with outcomes while controlling for patient, operative, and hernia variables. RESULTS A total of 4406 patients underwent VHR with a mean age (SD) of 55 (15) years, 2015 (46%) females, and 3591 (82%) white patients. The mean (SD) BMI of the cohort was 33 (8) kg/m2. A total of 2077 (47%) patients had no frailty, 1604 (36%) were moderately frail, and 725 (17%) were severely frail. The median hernia size (interquartile range) was 2.5 cm (1.5-4.0 cm). Severe frailty was associated with increased odds of any complication (adjusted Odds Ratio (aOR) 3.12, 95% CI 1.78-5.47), serious complication (aOR 5.25, 95% CI 2.17-13.19), SSI (aOR 3.41, 95% CI 1.58-7.34), and post-discharge adverse events (aOR 1.70, 95% CI 1.24-2.33). CONCLUSION After controlling for patient, operative, and hernia characteristics, frailty was independently associated with increased odds of postoperative complications. These findings highlight the importance of preoperative frailty assessment for risk stratification and to inform patient counseling.
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Affiliation(s)
- Quintin P Solano
- University of Michigan Medical School, Ann Arbor, MI, USA
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, MI, USA
| | - Ryan Howard
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, MI, USA
- Department of Surgery, University of Michigan, Ann Arbor, MI, USA
| | - Cody L Mullens
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, MI, USA
- Department of Surgery, University of Michigan, Ann Arbor, MI, USA
| | - Anne P Ehlers
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, MI, USA
- Department of Surgery, University of Michigan, Ann Arbor, MI, USA
| | - Lia D Delaney
- University of Michigan Medical School, Ann Arbor, MI, USA
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, MI, USA
| | - Brian Fry
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, MI, USA
- Department of Surgery, University of Michigan, Ann Arbor, MI, USA
| | - Mary Shen
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, MI, USA
- Department of Surgery, University of Michigan, Ann Arbor, MI, USA
| | - Michael Englesbe
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, MI, USA
- Department of Surgery, University of Michigan, Ann Arbor, MI, USA
- Michigan Surgical Quality Collaborative, Ann Arbor, MI, USA
| | - Justin Dimick
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, MI, USA
- Department of Surgery, University of Michigan, Ann Arbor, MI, USA
- Michigan Surgical Quality Collaborative, Ann Arbor, MI, USA
- Division of Minimally Invasive Surgery, Department of Surgery, Michigan Medicine, 2926 Taubman Center, 1500 E Medical Center Dr, SPC 5331, Ann Arbor, MI, USA
| | - Dana Telem
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, MI, USA.
- Department of Surgery, University of Michigan, Ann Arbor, MI, USA.
- Michigan Surgical Quality Collaborative, Ann Arbor, MI, USA.
- Division of Minimally Invasive Surgery, Department of Surgery, Michigan Medicine, 2926 Taubman Center, 1500 E Medical Center Dr, SPC 5331, Ann Arbor, MI, USA.
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Solano QP, Thumma JR, Mullens C, Howard R, Ehlers A, Delaney L, Fry B, Shen M, Englesbe M, Dimick J, Telem D. Variation of ventral and incisional hernia repairs in kidney transplant recipients. Surg Endosc 2022; 37:3173-3179. [PMID: 35962230 DOI: 10.1007/s00464-022-09505-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2022] [Accepted: 07/23/2022] [Indexed: 10/15/2022]
Abstract
INTRODUCTION As survivorship following kidney transplant continues to improve, so does the probability of intervening on common surgical conditions, such as ventral or incisional hernia, in this population. Ventral hernia management is known to vary across institutions and this variation has an impact on patient outcomes. We sought to evaluate hospital level variation of ventral or incisional hernia repair (VIHR) in the kidney transplant population. METHODS We performed a retrospective review of 100% inpatient Medicare claims to identify patients who underwent kidney transplant between 2007 and 2018. The primary outcome was 1- and 3-year ventral or incisional risk- and reliability-adjusted VIHR rates. Patient and hospital characteristics were evaluated across risk- and reliability-adjusted VIHR rate tertiles. Models were adjusted for age, sex, race, and Elixhauser comorbidities. RESULTS Overall, 139,741 patients underwent kidney transplant during the study period with a mean age (SD) of 51.6 (13.7) years. 84,717 (60.6%) were male, and 72,657 (52.0%) were white. Median follow up time was 5.4 years. 2098 (1.50%) patients underwent VIHR. the 1 year risk- and reliability-adjusted hernia repair rates were 0.49% (95% Conf idence Interval (CI) 0.48-0.51, range 0.31-0.59) in tertile 1, 0.63% (95% CI 0.62-0.63, range 0.59-0.68) in tertile 2, and 0.98 (95% CI 0.91-1.05, range 0.68-2.94) in tertile 3. Accordingly, compared to hospitals in tertile 1, the odds of post-transplant hernia repair tertile 2 hospitals were 1.78 (95% CI 1.37-2.31) and at tertile 3 hospitals 3.53 (95% CI 2.87-4.33). CONCLUSIONS In a large cohort of Medicare patients undergoing kidney transplant, the overall cumulative incidence of hernia repair varied substantially across hospital tertiles. Patient and hospital characteristics varied across tertile, most notably in diabetes and obesity. Future research is needed to understand if program and surgeon level factors are contributing to the observed variation in treatment of this common disease.
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Affiliation(s)
- Quintin P Solano
- University of Michigan Medical School, Ann Arbor, MI, USA.,Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, MI, USA
| | - Jyothi R Thumma
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, MI, USA
| | - Cody Mullens
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, MI, USA.,Department of Surgery, University of Michigan, Ann Arbor, MI, USA
| | - Ryan Howard
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, MI, USA.,Department of Surgery, University of Michigan, Ann Arbor, MI, USA
| | - Anne Ehlers
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, MI, USA.,Department of Surgery, University of Michigan, Ann Arbor, MI, USA
| | - Lia Delaney
- University of Michigan Medical School, Ann Arbor, MI, USA
| | - Brian Fry
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, MI, USA.,Department of Surgery, University of Michigan, Ann Arbor, MI, USA
| | - Mary Shen
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, MI, USA.,Department of Surgery, University of Michigan, Ann Arbor, MI, USA
| | - Michael Englesbe
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, MI, USA.,Department of Surgery, University of Michigan, Ann Arbor, MI, USA.,Michigan Surgical Quality Collaborative, Ann Arbor, MI, USA
| | - Justin Dimick
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, MI, USA.,Department of Surgery, University of Michigan, Ann Arbor, MI, USA.,Division of Minimally Invasive Surgery, Department of Surgery, Michigan Medicine, 2926 Taubman Center, 1500 E Medical Center Dr, SPC 5331, Ann Arbor, MI, 48109-5331, USA
| | - Dana Telem
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, MI, USA. .,Department of Surgery, University of Michigan, Ann Arbor, MI, USA. .,Division of Minimally Invasive Surgery, Department of Surgery, Michigan Medicine, 2926 Taubman Center, 1500 E Medical Center Dr, SPC 5331, Ann Arbor, MI, 48109-5331, USA.
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