J. K. Sinamo1,2, A. L. Kappelman1,3,4, A. Hallway1,2, M. Rubyan1,3, A. P. Ehlers1,2,4,5, D. A. Telem1,2,4 2University Of Michigan, Department Of Surgery, Ann Arbor, MI, USA 3University Of Michigan, School Of Public Health, Ann Arbor, MI, USA 4University Of Michigan, Medical School, Ann Arbor, MI, USA 5Veteran’s Affairs Ann Arbor Health Care, Ann Arbor, MI, USA 1University Of Michigan, Center For Healthcare Outcomes And Policy, Ann Arbor, MI, USA
Introduction: While previous literature identifies a clear opportunity to improve adherence to preoperative optimization prior to hernia repair, it fails to account for patient similarities within and variability across hospitals and surgeons. In this context, we leverage a mixed effects model to identify those factors that most associated with nonadherence to smoking cessation and obesity management prior to hernia repair.
Methods: Using the Michigan Surgical Quality Collaborative-Core Optimization Hernia Registry (MSQC-COHR), we identified 11,086 adult (18+) patients who underwent hernia surgery between January 2020 and April 2023. The registry is a representative, random sample of adult patients from 70 hospitals across the state of Michigan and it encompasses surgeries performed between Jan 1, 2020 to March 31, 2023. A logistic mixed-effects model was used to evaluate the association between hernia repair in individuals with obesity (BMI > 35) or active tobacco use, and factors such as patient demographics, comorbid conditions, hernia characteristics (e.g., size, location), and socioeconomic factors (e.g., insurance). Treatment site and surgeon were incorporated as random intercepts.
Results: Nearly half (45.9%) of the individuals who underwent hernia repair were classified as either obese or actively smoking at the time of the repair. The likelihood of undergoing hernia repair under such conditions increased for individuals of a younger age (2.7% less likely with each year increase, p<0.001), of female sex (11.3% more likely than males, p<0.001), those identifying as single-race White (9.8% more likely than single-race non-White/multi-racial; p<0.01), and those with comorbid conditions such as diabetes (12.4% more likely; p<0.001) and hypertension (14.2% more likely; p<0.001). Socioeconomic factors that increased this likelihood included having self-pay or non-commercial insurance (9% more likely than commercial insurance; p<0.001). Regarding hernia-related factors, a larger hernia size increased the likelihood by 1.0% for each cm increase (p<0.001). Individuals with active tobacco use and obesity were more likely to undergo a laparoscopic (11.4% more likely; p<0.05) or robotic (18.1% more likely; p<0.001) approach compared to an open one.
Conclusion: Accounting for patient similarities within hospitals and the variability across different hospitals and surgeons, factors related to patients, hernias, and insurance continue to be associated with poor adherence to optimization. This highlights an opportunity for improvement in optimization prior to hernia repair. The use of laparoscopic and robotic methods requires further study and may suggest a belief that minimally invasive therapies mitigate risk.