A. Mehta1, S. Hutfless2, A. B. Blair3, A. Dwarakanath4, H. T. Nguyen5 1Johns Hopkins University,School Of Medicine,Baltimore, MD, USA 2Johns Hopkins Hospital,Department Of Gastroenterology And Hepatology,Baltimore, MD, USA 3Johns Hopkins Hospital,Department Of Surgery,Baltimore, MD, USA 4Johns Hopkins Bayview Medical Center,Department Of Surgery,Baltimore, MD, USA 5Johns Hopkins Bayview Medical Center,Comprehensive Hernia Center,Baltimore, MD, USA
Introduction: While inguinal hernias are common surgical diagnoses, minimally symptomatic patients are often not scheduled for repairs and are asked to seek medical attention if they develop symptoms. When this happens, patients commonly undergo a scheduled operation or go to an emergency department (ED) for expedited care. While emergent repairs of inguinal hernias are associated with higher mortality, little is known regarding how simply presenting through the ED impacts postoperative mortality and the patient characteristics associated with ED admission.
Methods: We performed a retrospective analysis of the 2009–2013 Nationwide Inpatient Sample for unilateral inguinal hernia repairs. We examined inpatient care to understand the potential severity of outcomes for an otherwise elective condition. Multivariable logistic regressions adjusted for patient and hospital characteristics were used to determine how ED admission affected mortality and the predictors of ED admission. Patient and hospital characteristics included gender, race, age, payer status, comorbidities, obstruction, gangrene, recurrent hernia, hospital type, teaching institution, bed size, region, and discharge quarter.
Results: There were 116,357 inpatient hospitalizations; the majority (57%) resulted from ED admissions and 80% of ED-admitted patients had obstruction or gangrene. Overall mortality decreased from 2.03% in 2009 to 1.36% in 2013. Independent predictors of mortality included patient age (18-44: OR 0.04 [95%-CI 0.01-0.34]; 45-64: 0.27 [0.17-0.44]; ref: 65+), number of comorbidities (1: 2.79 [1.27-6.10]; 2-3: 3.94 [1.87-8.32]; 4+: 16.92 [8.16-35.12]; ref: 0) and admission through the ED (1.67 [1.21-2.29]), even after adjusting for obstruction and gangrene (Figure). Notable predictors of ED admission included black race (1.47 [1.29-1.69]), Hispanic ethnicity (1.35 [1.18-1.54]), self-pay (2.29 [1.97-2.66]) and Medicaid insurance (1.76 [1.50-2.06]), obstruction (9.77 [9.05-10.55]) and gangrene (18.24 [13.00-25.59]).
Conclusion: Inpatient inguinal hernia repairs resulting from ED admissions were predominately associated with complications necessitating urgent care and likely not from ED overutilization. However, we found that simply presenting through the ED was independently associated with a 67% higher postoperative mortality rate compared to that of a scheduled operation, even after adjusting for obstruction and gangrene. Black, Hispanic and self-pay patients were most likely to present through the ED. Our findings suggest a difference in ED utilization and in subsequent outcomes by patient race and insurance for this common surgical condition. Furthermore, additional consideration may be given for elective repairs in older patients with multiple comorbidities.
