C. A. Vitous1, S. M. Jafri1, C. Seven1, M. Novitsky1, J. B. Dimick1,2, D. A. Telem1,2 1University Of Michigan,Center For Healthcare Outcomes And Policy, Institute For Healthcare Policy And Innovation,Ann Arbor, MI, USA 2University Of Michigan,Department Of Surgery,Ann Arbor, MI, USA
Introduction: While variation in the technique of abdominal wall hernia repair is widely accepted, it is poorly characterized. Although it is known that a great deal of this variation is based on surgeon and patient factors, how these factors influence the decision-making process remains unclear. In this context, we sought to gain an in-depth understanding of the factors that motivate decision making for surgeons. In order to do this, we explored areas of agreement and disagreement, or concordance and discordance, in decision-making patterns using common clinical case scenarios.
Methods: The data in this abstract is based on 6 qualitative clinical vignettes that were conducted with 21diverse, practicing surgeons who practice abdominal wall hernia repairs in a variety of institutional and geographic settings across the state of Michigan. Clinical vignettes were designed to capture the approach to controversial areas in abdominal wall hernia repair involving patient (e.g., obesity, smoking status, diabetes, age) and hernia (e.g., size, location, symptoms) factors. Through thematic analysis, using NVivo (version 11.4.3), we located, analyzed, and reported patterns within the data.
Results: Thematic analysis demonstrated a wide variety of decision-making patterns in the following 3 main domains: 1) surgeon willingness to perform elective repair, 2) surgeon preference for open, laparoscopic, or robotic repair, and 3) thresholds for contingent factors. Areas of little variation, or great concordance, were found in approaches to active tobacco users, with all surgeons utilizing a minimally invasive approach for repairs and avoiding an open approach. Additionally, concordance was found in the practice of discouraging patients from pursuing surgical interventions for small hernias (.5cm), instead placing patients on watchful criteria. Areas of discordance were far more prevalent in the clinical case scenarios presented to participants. To begin, significant variation was found in surgeon willingness to perform elective repairs on patients with confounding health risks, including uncontrolled diabetes, active tobacco use, and obesity. Further, in instances where surgeons were willing to perform elective repairs, significant differences emerged in the acceptable parameters for contingent factors, such as obesity, smoking cessation requirements, and glycemic levels. Finally, variation was found in approaches for large defects, with significant difference found in the upper size limits for utilizing a minimally invasive approach. Factors that influenced variation were wide-ranging, but included a preference for approach based on surgeon experience/training (both formal and informal), patient preference, and environmental considerations, such as the size of the hospital, geographic location, and whether the institution was private or public.
Conclusion: All of the clinical scenarios revealed at least some level of discordance in practice patterns motivated by individual surgeon preference and environmental considerations, rather than evidence based guidelines. These novel findings understanding the motivations and behaviors driving patient and technique selection will be invaluable to the design of evidence based interventions to decrease variability and promote evidence-based practice in abdominal wall hernia repair.