C. W. Reynolds1, A. K. Hallway3, J. Sinamo3, S. S. Bidwell1, D. A. Telem2,3, M. Rubyan4 1University of Michigan Medical School, Ann Arbor, MI, USA 2Michigan Medicine, Department Of Surgery, Ann Arbor, MI, USA 3University of Michigan, Center For Healthcare Outcomes And Policy, Ann Arbor, MI, USA 4University of Michigan, School Of Public Health, Ann Arbor, MI, USA
Introduction: Surgical decision making for older adult patients undergoing elective operations is not well understood. Ventral hernia repair (VHR) is one of the most common elective operations, yet there is limited understanding of provider decision making among older adults in the context of clinically nuanced data. We aimed to determine if there was provider bias related to perceived risk of VHR for older adults compared with the general population.
Methods: All adult patients in the Michigan Surgical Quality Collaborative Core Optimization Hernia Registry (MSQC COHR) were included in this study. The registry is a representative, random sample of adult patients from 70 Hospitals across the state of Michigan, encompassing surgeries performed between Jan 1, 2020 to March 31, 2023. The primary outcome was 30-day complications across three age groups: 18-64, 65-84, and ≥85. Secondary outcomes included surgical approach, mesh use, and component separation technique utilization. Mixed effects logistic regression was used to evaluate the independent association of minimally invasive surgery (MIS) repair and 30-day composite postoperative complications, controlling for patient, hernia, and intraoperative variables and clustering at the surgeon and hospital level.
Results: Among 8,659 patients, 74.9% were <65 years old, 24.0% were 65-84, and 1% was ≥85. Comorbidities increased with age, including hypertension, OSA, COPD, DVT, and cancer (all P<.001). MIS rates varied across hospitals (Median=31.4%, IQR: [14.8-51.6%]). Multivariate logistic regression demonstrated that older patients were less likely to receive MIS, which persisted across all sized hernias (Graphic 1). Patients most likely to undergo MIS were female (aOR=1.21, 95% CI: 1.09-1.34), black (aOR=1.30, 95% CI: 1.12-1.52), with larger hernias: 2-5.9cm (aOR=1.76, 95% CI: 1.57-1.97); ≥6cm (aOR=1.30, 95% CI: 1.09-1.56), with a history of previous hernia repair (aOR=1.17, 95% CI: 1.02-1.34), and intraoperative use of mesh (aOR=14.4, 95% CI: 11.68-17.79). Variation existed in likelihood of MIS approach across hospital site (aOR=1.42, 95% CI: 1.19-1.71) and surgeon (aOR=3.18, 95% CI: 2.86-3.54). Additional analysis demonstrated no difference in complication rate among age groups (P=0.483).
Conclusion: Our findings demonstrate that despite equivocal complication rates between younger and older adults, the oldest adults (≥85) undergoing VHR are significantly less likely to receive MIS approaches across all sized hernias, with variabilities across sites and hospitals. These results suggest care delivery variation in caring for older adults, who may be less likely to receive MIS despite its benefits. MIS could be an equally safe option even in older adults and should be considered with respect to improvements in patient satisfaction and recovery.
