Predictors of emergency ventral hernia repair: Targets to improve patient access and guide patient selection for elective repair

doi:10.1016/j.surg.2016.06.027

Surgery

Volume 160, Issue 5, November 2016, Pages 1379-1391

Presented as an oral presentation at the 11th Annual Academic Surgical Conference in Jacksonville, FL, February 2–4, 2016.

https://doi.org/10.1016/j.surg.2016.06.027 Get rights and content

Background

Emergency operations are associated with worse outcomes than elective operations. If not repaired electively, ventral hernias are at risk of strangulating and requiring emergency repair. We sought to identify patient- and hospital-level factors associated with emergency ventral hernia repair in a nationally representative, United States sample.

Methods

We abstracted data from the 2003–2011 Nationwide Inpatient Sample for adults (≥18 years) who underwent inpatient ventral hernia repair. Our primary outcome was emergency repair. We assessed differences in patient- and hospital-level factors as possible predictors of emergency repair using multivariable logistic regression. We examined secondary outcomes (mortality, total hospital cost, duration of stay) using multivariable logistic and generalized linear (family gamma; link log) regression.

Results

After weighting to the United States population, we included 453,161 adults (39.5% emergency). Independent predictors of emergency repair included payer status (uninsured: odds ratio 3.50, [3.10, 3.96]; Medicaid: 1.29 [1.20, 1.39] compared with private insurance), race/ethnicity (black: 1.77 [1.64, 1.92]; Hispanic: 1.44 [1.28, 1.61] compared with white), age (≥85 years: 2.23 [2.00, 2.47] compared with <45 years), and comorbidities (Charlson Comorbidity Index ≥3: 1.68 [1.56, 1.80] compared with 0). After risk-adjustment, emergency repair was associated with greater odds of in-hospital death, greater costs, and longer hospital stay.

Conclusion

Inpatient ventral hernia repairs are frequently performed emergently, with worse outcomes in this group. Independent predictors of emergency repair include factors that may limit access to and/or selection for an elective operation. These predictors provide targets for interventions to improve access to elective care and inform patient selection with the goal of improving patient outcomes.

Section snippets

Data source

We abstracted data from the 2003–2011 Nationwide Inpatient Sample (NIS), the largest publicly available source of all-payer hospital discharge abstracts in the United States. The data set is a stratified sample of discharges from 20% of participating hospitals. The hospitals are sampled to represent 95% of the US population and can be weighted to calculate national population estimates. The NIS provides information on patient and hospital factors, including International Classification of

Main results

After weighting the sample to the national population, we included 453,161 patients in the analysis (observed n = 92,295). Overall, 39.5% were “emergency” admissions (25.9% emergency, 13.6% urgent). Mean age was 57.4 years (95% confidence interval [CI]: 57.1, 57.7) in the emergency group compared with 58.3 years (95% CI: 58.0, 58.5) in the elective group (P < .001). In unadjusted analyses, the emergency group was more likely to be nonwhite, have a higher CCI, belong to a lower income quartile,

Discussion

Patients requiring emergency ventral hernia repairs had greater odds of death and concomitant bowel procedure and lesser odds of receiving a laparoscopic procedure than patients undergoing elective repairs. Total hospital cost and duration of stay were increased in patients undergoing an emergency operation. A patient's age, race/ethnicity, CCI, insurance status, hospital region, and hospital teaching status all independently predicted the need for emergency ventral hernia repair. Understanding

References (41)

A.M. Ingraham et al.
Comparison of hospital performance in emergency versus elective general surgery operations at 198 hospitals
J Am Coll Surg
(2011)
S. Thaddeus et al.
Too far to walk: maternal mortality in context
Soc Sci Med
(1994)
M.E. Charlson et al.
A new method of classifying prognostic comorbidity in longitudinal studies: development and validation
J Chronic Dis
(1987)
A.J. Henry et al.
Comparative methods for handling missing data in large databases
J Vasc Surg
(2013)
D.A. Schwartz et al.
Worse outcomes among uninsured general surgery patients: does the need for an emergency operation explain these disparities?
Surgery
(2014)
T.L. Sutton et al.
Acute appendicitis: variation in outcomes by insurance status
J Surg Res
(2016)
A.H. Haider et al.
Racial disparities in surgical care and outcomes in the United States: a comprehensive review of patient, provider, and systemic factors
J Am Coll Surg
(2013)
J.W. Scott et al.
Racial and regional disparities in the effect of the Affordable Care Act’s dependent coverage provision on young adult trauma patients
J Am Coll Surg
(2015)
T. Augustin et al.
Emergent surgery does not independently predict 30-day mortality after paraesophageal hernia repair: results from the ACS NSQIP database
J Gastrointest Surg
(2015)
G.O. Ogola et al.
The financial burden of emergency general surgery: national estimates 2010 to 2060
J Trauma Acute Care Surg
(2015)

S.C. Gale et al.

The public health burden of emergency general surgery in the United States: a 10-year analysis of the Nationwide Inpatient Sample–2001 to 2010

J Trauma Acute Care Surg

(2014)

J.M. Havens et al.

The excess morbidity and mortality of emergency general surgery

J Trauma Acute Care Surg

(2015)

A.H. Haider et al.

Incremental cost of emergency versus elective surgery

Ann Surg

(2015)

J.W. Scott et al.

Impact of the ACA insurance coverage expansion on rates of appendicitis perforation among young adults

Med Care

(2016)

Healthcare Cost and Utilization Project. HCUP Nationwide Inpatient Sample. In: Quality AfHRa, Ed. Rockville (MD):...

NIS description of data elements

(2016)

Healthcare Cost and Utilization Project Methods Series

(2004)

Consumer price index

(2016)

C.Y. Kang et al.

Laparoscopic colorectal surgery: a better look into the latest trends

Arch Surg

(2012)

F. Helgstrand et al.

Outcomes after emergency versus elective ventral hernia repair: a prospective nationwide study

World J Surg

(2013)

Cited by (27)

Determining the Association Between Insurance Type and Myofascial Release in Large Ventral Hernias
2024, Journal of Surgical Research
Abdominal wall reconstruction (AWR) utilizes advanced myofascial releases to perform complex ventral hernia repair (VHR). The relationship between the performance of AWR and disparities in insurance type is unknown.
The Abdominal Core Health Quality Collaborative was queried for adults who had undergone an elective VHR between 2013 and 2020 with a hernia size ≥10 cm. Patients with missing insurance data were excluded. Comparison groups were divided by insurance type: favorable (private, Medicare, Veteran's Administration, Tricare) or unfavorable (Medicaid and self-pay). Propensity score matching compared the cumulative incidence of AWR between the favorable and unfavorable insurance comparison groups.
In total, 26,447 subjects met inclusion criteria. The majority (89%, n = 23,617) had favorable insurance, while (11%, n = 2830) had unfavorable insurance. After propensity score matching, 2821 patients with unfavorable insurance were matched to 7875 patients with favorable insurance. The rate of AWR with external oblique release or transversus abdominis release was significantly higher (23%, n = 655) among the unfavorable insurance group compared to those with favorable insurance (21%, n = 1651; P = 0.013).
This study provides evidence that patients with unfavorable insurance may undergo AWR with external oblique or transversus abdominis release at a greater rate than similar patients with favorable insurance. Understanding the mechanisms contributing to this difference and evaluating the financial implications of these trends represent important directions for future research in elective VHR.
Association of social vulnerability with receipt of hernia repair in Texas
2024, Surgery (United States)
The effect of social health determinants on hernia surgery receipt is unclear. We aimed to assess the association of the social vulnerability index with the likelihood of undergoing elective and emergency hernia repair in Texas.
This is a retrospective cohort analysis of the Texas Hospital Inpatient Discharge Public Use Data File and Texas Outpatient Surgical and Radiological Procedure Public Use Data File from 2016 to 2019. Patients ≥18 years old with inguinal or umbilical hernia were included. Social vulnerability index and urban/rural status were merged with the database at the county level. Patients were stratified based on social vulnerability index quartiles, with the lowest quartile (Q1) designated as low vulnerability, Q2 and Q3 as average, and Q4 as high vulnerability. Wilcoxon rank sum, t test, and χ² analysis were used, as appropriate. The relative risk of undergoing surgery was calculated with subgroup sensitivity analysis.
Of 234,843 patients assessed, 148,139 (63.1%) underwent surgery. Compared to patients with an average social vulnerability index, the low social vulnerability index group was 36% more likely to receive surgery (relative risk: 1.36, 95% CI 1.34–1.37), whereas the high social vulnerability index group was 14% less likely to receive surgery (relative risk: 0.86, 95% CI 0.85–0.86). This remained significant after stratifying for age, sex, insurance status, ethnicity, and urban/rural status (P < .05). For emergency admissions, there was no difference in receipt of surgery by social vulnerability index.
Vulnerable patients are less likely to undergo elective surgical hernia repair, even after adjusting for demographics, insurance, and urbanicity. The social vulnerability index may be a useful indicator of social determinants of health barriers to hernia repair.
High Body Mass Index is Associated With Increased Risk of Complications After Emergency Ventral Hernia Repair
2024, Journal of Surgical Research
Emergency general surgery is a risk factor for postoperative morbidity and mortality. Patients with obesity are at greater risk for complications following ventral hernia repair (VHR). Our study aimed to determine the association of obesity with postoperative outcomes in patients requiring emergency VHR.
Our retrospective study used the 2016-2020 National Surgical Quality Improvement Program database to identify patients undergoing emergency VHR. Patients were classified by body mass index (BMI): normal weight 18.5-24.9 kg/m², overweight 25-29.9 kg/m², obesity 30-39.9 kg/m², morbid obesity 40-49.9 kg/m², and super morbid obesity (SMO) ≥50 kg/m². The primary outcome of interest was surgical site infection (SSI).
From 2016 to 2020, a total 11,593 patients underwent emergency VHR. Patients with higher BMI had increased incidences of postoperative complications. Compared to other patients with obesity, SMO patients had higher rates of SSI (11.5% versus 5.5%, P < 0.001), prolonged ventilatory support (4.0% versus 1.5%, P < 0.001), length of stay ≥4 d (52.7% versus 42.2%, P < 0.001), reoperation (6.4% versus 3.4%, P < 0.001), and readmission (11.3% versus 7.2%, P < 0.001). Super morbid obesity (SMO) patients had increased odds of SSI (odds ratio [OR] 5.55, 95% confidence interval [CI] 3.47-8.88), prolonged ventilatory support (OR 1.92, 95% CI 1.07-3.45), and reoperation (OR 1.97, 95% CI 1.26-3.09) compared to normal weight patients.
Patients with BMI ≥50 kg/m² undergoing emergency VHR have increased overall incidences of SSIs, prolonged mechanical ventilation, reoperation, and readmission, and this remains significant when compared to other patients with obesity. This population is at significant risk for postoperative morbidity, and increased vigilance in perioperative management is imperative to ensure safe, high-quality care.
Age-Related Risk Factors in Ventral Hernia Repairs: A Review and Call to Action
2021, Journal of Surgical Research
Citation Excerpt :
As opposed to those returning home, patients facing discharge to a facility tend to experience a greater number of complications and readmissions. Multimorbid patients (CCI ≥ 3) are also at increased risk of requiring an emergency VHR relative to patients without comorbidites.21 As compared to elective VHRs, emergency procedures are associated with increased in-hospital mortality, greater cost, and longer hospital stays, even after risk-adjustment.21
As the population ages, the incidence of ventral hernias in older adults is increasing. Ventral hernia repairs (VHR) should not be considered low risk operations, particularly in older adults who are disproportionately affected by multiple age-related factors that can complicate surgery and adversely affect outcomes. Although age-related risk factors have been well established in other surgical fields, there is currently little data describing their impact on VHR.
We performed a systematic review of the literature to identify studies that examine the effects of age-related risk factors on VHR outcomes. This was conducted using Cochrane Library, Embase, PubMed (Medline), and Google Scholar databases, all updated through June 2020. We selected relevant studies using the keywords, multimorbidity, comorbidities, polypharmacy, functional dependence, functional status, frailty, cognitive impairment, dementia, sarcopenia, and malnutrition. Primary outcomes include mortality and overall complications following VHR.
We summarize the evidence basis for the significance of age-related risk factors in elective surgery and discuss how these factors increase the risk of adverse outcomes following VHR. In particular, we explore the impact of the following risk factors: multimorbidity, polypharmacy, functional dependence, frailty, cognitive impairment, sarcopenia, and malnutrition. As opposed to chronological age itself, age-related risk factors are more clinically relevant in determining VHR outcomes.
Given the increasing complexity of VHR, addressing age-related risk factors pre-operatively has the potential to improve surgical outcomes in older adults. Preoperative risk assessment and individualized prehabilitation programs aimed at improving patient-centered outcomes may be particularly useful in this population.
Improved Understanding of Acute Incisional Hernia Incarceration: Implications for Addressing the Excess Mortality of Emergent Repair
2020, Journal of the American College of Surgeons
Incisional hernia develops in up to 20% of patients undergoing abdominal operations. We sought to identify characteristics associated with poor outcomes after acute incisional hernia incarceration.
We performed a retrospective cohort study of adult patients with incisional hernias undergoing elective repair or with acute incarceration between 2010 and 2017. The primary end point was 30-day mortality. Logistic regression was used to determine adjusted odds associated with 30-day mortality. The American College of Surgeons Surgical Risk Calculator was used to estimate outcomes had these patients undergone elective repair.
A total of 483 patients experienced acute incarceration; 30-day mortality was 9.52%. Increasing age (adjusted odds ratio 1.05; 95% CI, 1.02 to 1.08) and bowel resection (adjusted odds ratio 3.18; 95% CI, 1.45 to 6.95) were associated with mortality. Among those with acute incarceration, 231 patients (47.9%) had no documentation of an earlier surgical evaluation and 252 (52.2%) had been evaluated but had not undergone elective repair. Among patients 80 years and older, 30-day mortality after emergent repair was high (22.9%) compared with estimated 30-day mortality for elective repair (0.73%), based on the American College of Surgeons Surgical Risk Calculator. Estimated mortality was comparable with observed elective repair mortality (0.82%) in an age-matched cohort. Similar mortality trends were noted for patients younger than 60 years and aged 60 to 79 years.
Comparison of predicted elective repair and observed emergent repair mortality in patients with acute incarceration suggests that acceptable outcomes could have been achieved with elective repair. Almost one-half of acute incarceration patients had no earlier surgical evaluation, therefore, targeted interventions to address surgical referral can potentially result in fewer incarceration-related deaths.
National trends in ventral hernia repairs for patients with intra-abdominal metastases
2020, Surgery (United States)
Citation Excerpt :
Nonelective repairs also occurred more frequently at smaller and rural hospitals, possibly because of proximity and convenience for patients needing urgent care. Disparities based on race and socioeconomic status have been demonstrated across a variety of healthcare settings, including in the presentation and treatment of ventral hernias.41-47 Patients’ functional and physiologic status may also drive the decision to forego elective surgery; older age and greater number of comorbidities were associated with nonelective VHR, consistent with previous findings.41
Ventral hernias in patients with intra-abdominal metastases may not be addressed owing to other oncologic priorities, but they can affect quality of life and lead to sequelae necessitating an emergency operation. We compared the national trends and perioperative outcomes for elective and nonelective ventral hernia repairs for patients with intra-abdominal metastases.
Patients were identified from the National Inpatient Sample (2003−2015). Temporal trends were described using average annual percent change. Perioperative outcomes between elective and nonelective ventral hernia repairs were compared using multivariable regressions.
An estimated 947,112 ventral hernia repairs were performed nationally, including 5,602 (0.6%) in patients with intra-abdominal metastases. Among patients with intra-abdominal metastases, 40.1% had a nonelective ventral hernia repair, mean (standard deviation) age was 64 (12) years, and 65.1% were women. Between 2003 and 2015, the total number of ventral hernia repairs performed nationally did not change (average annual percent change 0.062, P = .84). For patients with intra-abdominal metastases, although there was no change in the number of elective ventral hernia repairs (average annual percent change 0.65, P = .59), the number of nonelective ventral hernia repairs increased significantly (average annual percent change 2.7, P = .025). By multivariable analyses, patients with intra-abdominal metastases who underwent a nonelective repair were more likely to experience complications (odds ratio 1.76, P = .001), nonroutine discharge (odds ratio 1.93, P < .001), and mortality (odds ratio 2.27, P = .035). Nonelective ventral hernia repairs was also associated with a 38.5% (P < .001) longer hospital stay and 24.4% (P < .001) higher charges.
The number of nonelective ventral hernia repairs, which is associated with substantial perioperative morbidity, has increased significantly among patients with intra-abdominal metastases. Surgeons should consider a nonemergency operation for select patients to mitigate the burden of nonelective ventral hernia repairs.

View all citing articles on Scopus

: Supported by the American College of Surgeons Resident Research Scholarship to L.L.W. This funding was used to support the salary of L.L.W. Not related to this work, A.H.H. is the PI of a contract (AD-1306-03980) with the Patient-Centered Outcomes Research Institute entitled Patient-Centered Approaches to Collect Sexual Orientation/Gender Identity in the ED and a Harvard Surgery Affinity Research Collaborative (ARC) Program Grant entitled Mitigating Disparities Through Enhancing Surgeons' Ability To Provide Culturally Relevant Care. A.H.H. also is the cofounder and an equity holder in Patient Doctor Technologies Inc, which owns and operates the website http://www.doctella.com.

View full text

Presented at the Academic Surgical Congress 2016Predictors of emergency ventral hernia repair: Targets to improve patient access and guide patient selection for elective repair

Background

Methods

Results

Conclusion

Section snippets

Data source

Main results

Discussion

J Am Coll Surg

Soc Sci Med

J Chronic Dis

J Vasc Surg

Surgery

J Surg Res

J Am Coll Surg

J Am Coll Surg

J Gastrointest Surg

The financial burden of emergency general surgery: national estimates 2010 to 2060

J Trauma Acute Care Surg

The public health burden of emergency general surgery in the United States: a 10-year analysis of the Nationwide Inpatient Sample–2001 to 2010

J Trauma Acute Care Surg

The excess morbidity and mortality of emergency general surgery

J Trauma Acute Care Surg

Incremental cost of emergency versus elective surgery

Ann Surg

Impact of the ACA insurance coverage expansion on rates of appendicitis perforation among young adults

Med Care

NIS description of data elements

Healthcare Cost and Utilization Project Methods Series

Consumer price index

Laparoscopic colorectal surgery: a better look into the latest trends

Arch Surg

Outcomes after emergency versus elective ventral hernia repair: a prospective nationwide study

World J Surg

Presented at the Academic Surgical Congress 2016
Predictors of emergency ventral hernia repair: Targets to improve patient access and guide patient selection for elective repair