Recurrent emergent hernia repairs: who is at risk?

Our nationally representative study on the risk factors associated with recurrent emergent hernia repairs among Medicare beneficiaries has three main findings. First, the 10-year cumulative incidence of undergoing recurrent emergent hernia repair was 6.4%. Second, female, Hispanic, or socially vulnerable patients are at highest risk of recurrent emergent repair. Lastly, initial repairs done open or at for-profit hospitals are associated with increased risk of recurrent emergent repair. Taken together, these findings provide insight into patient populations that may benefit from tailored care and opportunities for system-level intervention to improve outcomes for this common preference sensitive condition.

Prior literature has evaluated surgical disparities as it relates to “access-sensitive” conditions—i.e. diagnoses requiring surgery that preferably is planned, but when access is limited, may be delayed until worsening symptoms require riskier and costlier emergent surgery. For example, patients from minority populations, patients with higher social vulnerability, and patients from primary care HPSA’s are more susceptible to emergent operations and poor outcomes in these conditions [2, 19, 20]. In hernia care, existing literature has focused primarily on clinical risk factors that place patients at risk for initial emergent operations, such as age, comorbidities, and hernia characteristics [6, 7]. Studies of social factors are more limited, but have identified Black patients, patients on Medicaid, and socially vulnerable patients at increased risk as well [21, 22]. However, these studies were done in significantly smaller cohorts.

Our study extends these findings in several ways using a large nationally representative surgical cohort. First, we describe a group previously unexplored—patients that experience more than one emergent operation, arguably representing a population that exposes the widest vulnerabilities in our system. A 6.4% incidence of multiple emergent repairs is not insignificant and, given the prevalence of hernias, represents a notable opportunity for cost savings and prevention of harmful adverse outcomes for patients. Second, we evaluate the multidimensional risk factors that may be impacting this population, from a patient (demographic and socioeconomic), provider (surgeon volume, repair approach, hospital profit status), and community (rurality, SVI, HPSA) level. This contributes to the growing understanding of recognizing and addressing non-clinical factors that are driving health and surgical outcomes.

Opportunities for improvement should focus on strategies to address the at-risk populations we have identified and tailoring care for these patients. Hernia is unique in being preference sensitive, meaning surgery is not always recommended and is contingent on patient and surgeon decision making. This adds an additional layer of risk for vulnerable patients, as they may be susceptible to provider bias, lower engagement in shared decision making, lower health literacy, lower access to surgical expertise, and lower rates of meeting “optimization” cut offs that can lead to exclusion from surgery [3, 23‐26]. However, an emergent operation has consistently worse outcomes than a “non-optimized” elective repair. For patients that may be at risk of recurrent emergent repairs and who are unlikely to have the resources for prehabilitation efforts (which have low success rates even in ideal circumstances [27, 28]), this presents an opportunity to make more nuanced decisions about repairing their hernia electively even in non-ideal settings. For example, much of the additional risk attributed to smoking or BMI can be mitigated by minimally invasive repairs, which is significantly more likely in an elective setting [29, 30]. As racial/ethnic minority patients have lower access to MIS surgeons, this is another potential intervention point [26]. Our study indicates that the use of MIS in the emergent setting, when feasible, could also help prevent additional need for emergent repairs.

From a systems level perspective, our study highlights a few key opportunities. First, despite a recent study finding that patients with access-sensitive surgical conditions (including hernia) have higher rates of emergent surgery in primary care HPSA’s, we did not see the same association in our study (nor an association with rural residence) [2]. This may indicate that the findings in that study were driven by the other included conditions, or that patients with multiple emergent operations face a more complex set of barriers aside from access to primary care. However, the association of for-profit hospital status and repeated emergent operations should prompt additional inquiry. One potential explanation for this is that for-profit hospitals tend to serve areas with higher unemployment and uninsured rates [31]. There may be unmeasured socioeconomic confounders contributing to this finding despite our risk-adjustment. However, there is a paucity of studies evaluating how hospital profit status may impact surgical care and further research is needed to understand this relationship.

Our study has several limitations. First, claims data may lack the clinical granularity needed to capture potential confounding factors influencing our outcomes, such as enterotomies, hernia size, the type of mesh used, the layer of the abdominal wall where the mesh was placed. These factors could influence the need for a subsequent emergent repair. However, a strength of this study is the population level analysis of risk after emergent hernia repair, among hernia specialists and general surgeons alike, that has limited the generalizability of previous studies. Additionally, we were unable to identify clinical recurrence without an operation, which would have provided a more direct comparison group. We performed an analysis comparing the emergent versus elective operative recurrences as a sensitivity check, and found that the characteristics of the elective repair group closely matched those of the no recurrent repair group, indicating these populations are similar. Lastly, the Medicare population may not be generalizable to all patients undergoing emergent hernia surgery. Reoperative recurrence rates may be lower than expected given the older patient population with an increased comorbidity burden. Despite this, hernia repair is more common in older adults both due to aging and the higher likelihood of developing an incisional hernia from a prior operation.

Our study highlights multi-level risk factors associated with recurrent emergent hernia repairs, including patients that are female, Hispanic, and with high social vulnerability as well as patients receiving an open index repair and care at for-profit hospitals. This provides opportunities to intervene for populations that may benefit from different upfront approaches, closer follow-up, and earlier elective intervention for hernia recurrence.