J. V. Vu1, V. Gunaseelan1,2, E. Seese2, M. J. Englesbe1,2, G. L. Krapohl1,2, D. A. Campbell1,2, D. Telem1 2Michigan Surgical Quality Collaborative,Ann Arbor, MICHIGAN, USA 1University Of Michigan,Department Of Surgery,Ann Arbor, MI, USA
Background: Despite the benefits of minimally invasive surgery (MIS) for inguinal hernia repair, adoption of this technique has been suboptimal compared to other operations (e.g., colectomy, hysterectomy, cholecystectomy). To better understand the clinical, demographic, and provider factors associated with uptake of MIS for inguinal hernia, we characterized the variation in utilization rate across a statewide population.
Methods: A retrospective cohort study was performed in patients undergoing open and MIS inguinal hernia repair from 2012 to 2016, using data from the Michigan Surgical Quality Collaborative, a statewide surgical collaborative of 73 hospitals. Operations for recurrent hernia, strangulation, or gangrene were excluded. Primary outcome was MIS utilization rate by Dartmouth hospital referral region. Secondary outcomes were provider, patient, and hospital characteristics associated with MIS utilization. Data were evaluated using a weighted hierarchical logistic regression model.
Results: A total of 6,185 inguinal hernia repairs were identified. Utilization of MIS ranged from 13.5% to 42.8% of all repairs across six geographic regions, as demonstrated in Figure 1 (p<0.001). Hospital site accounted for 41% of the variation in utilization; MIS repair was associated with higher hospital volume (p<0.001), but not with teaching status. Out of the 558 total surgeons, 322 (58%) performed no MIS repairs. After controlling for clinical, demographic, and geographic factors, patients aged 18 – 44 (OR 1.68, p<0.001) and patients aged 45 – 64 (OR 1.49, p<0.001) were more likely to receive MIS than patients aged 65 and older. Black patients were less likely to receive MIS than white patients (OR 0.72, p=0.017). Patients with COPD, hypertension, and in American Society of Anesthesiologists Class III or IV were also significantly less likely to undergo MIS repair. There were no differences in MIS utilization with respect to gender, obesity, and tobacco use.
Conclusion: Utilization of MIS for inguinal hernia repair is widely variable by region across a statewide population. Causes of this variation are likely multifactorial and are attributable to hospital, provider, and patient factors. Over half of the surgeons sampled do not perform MIS repair. Additionally, variation in MIS utilization was independently associated with patient age, race, and comorbid conditions. These findings support the presence of a practice gap in the delivery of MIS care. Exploratory, in-depth qualitative work investigating provider and patient-level barriers to MIS inguinal hernia repair is needed to develop evidence-based implementation intervention strategies.
