N. Liu1, T. M. Prout3, Y. Xu1, S. Marowski4, L. M. Funk2,5, J. A. Greenberg2, A. L. Shada2, A. O. Lidor2 2University Of Wisconsin,Department Of Surgery / Division Of Minimally Invasive, Foregut, And Bariatric Surgery,Madison, WI, USA 3University Of Wisconsin,Department Of Radiology,Madison, WI, USA 4University Of Wisconsin,Madison, WI, USA 5William S. Middleton VA Hospital,Madison, WI, USA 1University Of Wisconsin,Department Of Surgery,Madison, WI, USA
Introduction: Inguinal hernia repair is one of the most frequently performed general surgery procedures; over 700,000 inguinal hernia repairs are done per year in the United States alone. In current clinical practice, the diagnosis of inguinal hernia is based on physical exam. Smaller hernias not detectable on exam may require imaging for further evaluation. Imaging modalities include MRI, CT, and ultrasound. While ultrasound is considered low risk, other imaging studies have risks of radiation and contrast. However, every study places an economic burden on both individuals and the healthcare system. Recently, the American Board of Internal Medicine initiated the Choosing Wisely campaign, directed towards limiting unnecessary care. The objective of our study was to determine the prevalence of unnecessary imaging in the diagnosis of inguinal hernias.
Methods: We included 2125 patients who underwent elective inguinal hernia surgery at a single institution academic center from 1/6/2010 to 12/29/2017. Within this cohort, we identified the patients that received CT, MRI or Ultrasound Imaging that included the inguinal region within 6 months prior to surgery. Through chart review of primary care, emergency department, and surgery provider notes for physical exam findings and imaging indications, we categorized patients into 4 imaging categories: unrelated (imaging ordered for other indications), necessary (clinically suspected occult hernia by referring provider), unnecessary (detectable hernia by referring provider), and borderline (undetectable hernia by referring provider but detectable by surgeon).
Results: Of 2125 patients who underwent inguinal hernia surgery, 417 patients had imaging studies 6 months prior to surgery. 167 radiology studies were excluded for having unrelated imaging and excluded, leaving us with a total of 250 patients. 5.7% (n=121) of all patients undergoing inguinal hernia surgery, received unnecessary imaging. Of these, 66.9% were ultrasounds and 33.1% were CTs. 2.8% of all patients had necessary studies, while 3.3% had borderline studies. The majority of the studies identified were ultrasounds ordered by primary care providers (Table 1).
Conclusion: 5.7% of all patients who undergo inguinal hernia surgery have potentially unnecessary diagnostic radiology studies. We can extrapolate that of 700,000 inguinal hernia surgeries done in the US per year, approximately 40,000 patients may be undergoing unnecessary studies. This could not only expose patients to avoidable risks, but also places a significant economic burden on patients and our already strained health system. We aim to utilize these results to develop an algorithm to guide the efficient diagnosis of inguinal hernias.
