C. T. Aquina1, K. N. Kelly1, C. P. Probst1, J. C. Iannuzzi1, K. Noyes1, F. J. Fleming1, J. R. Monson1 1University Of Rochester,Surgical Health Outcomes & Research Enterprise (S.H.O.R.E.),Rochester, NY, USA
Introduction: Notwithstanding that inguinal hernia repair is the most common general surgical procedure with an estimated 750,000 repairs performed each year in the United States, there is currently little information regarding the impact of surgeon volume on outcomes following inguinal hernia repair, specifically whether increasing surgeon volume is associated with reoperation rates or resource utilization.
Methods: The New York Statewide Planning and Research Cooperative System database was queried for elective outpatient open inguinal hernia repairs performed in New York States from 2001-2006 using ICD-9 and CPT codes. Low (<25 cases per year) and high (≥25 cases per year) surgeon volume was defined using the bottom tertile and upper two tertiles for number of open inguinal hernia repairs performed per year, respectively. Bivariate, mixed-effect Cox proportional-hazards, and negative binomial regression analyses were performed assessing for factors associated with reoperation for recurrence, procedure time, and downstream total cost calculated as the sum of total facility charges for initial and recurrent repair.
Results: Among 129,269 inguinal hernia repairs, the overall rate of reoperation for recurrence within 5 years was 1.7%. The median time to reoperation was 1.8 years where 4.8% of the reoperations were emergent. Recurrent hernia repair was performed by the same surgeon in only 57% of patients. A significant inverse relationship was seen between surgeon volume and reoperation rate, procedure time, and healthcare costs (P<0.001). After controlling for surgeon, facility, operative, and patient characteristics, the difference in procedure time and downstream total cost between low-volume and high-volume surgeons was 23 minutes and $763 per patient, respectively. Of note, facility volume had no effect on reoperation rates or procedure time. If elective inguinal hernia repairs were performed by surgeons with a minimum volume of 25 repairs per year, roughly $5.2 million would be saved each year in New York State alone. Extrapolated across the United States, over $180 million could be saved annually.
Conclusion: Surgeon volume < 25 cases per year for elective open inguinal hernia repair was independently associated with higher rates of reoperation for recurrence, worse operative efficiency, and substantially higher healthcare costs. Referral to surgeons who perform at least 25 inguinal hernia repairs per year should be considered to decrease reoperation rates and unnecessary resource utilization.
