Costs Associated With Modifiable Risk Factors in Ventral and Incisional Hernia Repair

Howard, Ryan; Thompson, Michael P.; Fan, Zhaohui; Englesbe, Michael J.; Dimick, Justin B.; Telem, Dana A.

doi:10.1001/jamanetworkopen.2019.16330

Cited by 54 publications

(50 citation statements)

References 40 publications

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“…A previous report by Howard et al 4 found that 15% to 25% of patients with ventral hernia have highrisk characteristics at the time of surgery. The present study aims to understand hospital-level optimization of these risks.…”

Section: Understanding the Practice Gapmentioning

confidence: 95%

“…For instance, patients with physical deconditioning, excessive weight, active substance abuse, or poorly controlled diabetes have markedly higher rates of surgical complications. 4 In fact, these factors are considered relative contraindications to elective procedures such as joint replacement and hernia surgery. [5][6][7][8][9][10][11][12] Data suggest that delaying surgery and optimizing or improving patients' risk factors preoperatively can reduce surgical complication rates by as much as 40%.…”

Section: Introductionmentioning

confidence: 99%

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Development and Implementation of Preoperative Optimization for High-Risk Patients With Abdominal Wall Hernia

et al. 2021

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IMPORTANCE Real-world surgical practice often lags behind the best scientific evidence. For example, although optimizing comorbidities such as smoking and morbid obesity before ventral and incisional hernia repair improves outcomes, as many as 25% of these patients have a high-risk characteristic at the time of surgery. Implementation strategies may effectively increase use of evidence-based practice.OBJECTIVE To describe current trends in preoperative optimization among patients undergoing ventral hernia repair, identify barriers to optimization, develop interventions to address these barriers, and then pilot these interventions. DESIGN, SETTING, AND PARTICIPANTSThis quality improvement study used a retrospective medical record review to identify hospital-level trends in preoperative optimization among patients undergoing ventral and incisional hernia repair. Semistructured interviews with 21 practicing surgeons were conducted to elicit barriers to optimizing high-risk patients before surgery. Next, a task force of experts was convened to develop pragmatic interventions to increase surgeon use of preoperative optimization. Finally, these interventions were piloted at 2 sites to assess acceptability and feasibility. This study was performed from January 1, 2014, to December 31, 2019. MAIN OUTCOMES AND MEASURESThe main outcome was rate of referrals for preoperative patient optimization at the 2 pilot sites. RESULTS Among 23 000 patients undergoing ventral hernia repair, the mean (SD) age was 53.9 (14.3) years, and 12 315 (53.5%) were men. Of these, 8786 patients (38.2%) had at least 1 high-risk characteristic at the time of surgery, including 7683 with 1, 1079 with 2, and 24 with 3. At the hospital level, the mean proportion of patients with at least 1 of 3 high-risk characteristics at the time of surgery was 38.2% (95% CI, 38.1%-38.3%). This proportion varied widely from 21.5% (95% CI, 17.6%-25.5%) to 52.8% (95% CI, 43.9%-61.8%) across hospitals. Interviews with surgeons identified 3 major barriers to improving this practice: lost financial opportunity by not offering a patient an operation, lack of surgeon awareness of available resources for optimization, and organizational barriers. A task force therefore developed 3 interventions: a financial incentive to optimize high-risk patients, an educational intervention to make surgeons aware of available optimization resources, and on-site facilitation. These strategies were piloted at 2 sites where preoperative risk optimization referrals increased 860%. CONCLUSIONS AND RELEVANCEThis study demonstrates a stepwise process of identifying a practice gap, eliciting barriers that contribute to this gap, using expert consensus and local resources to develop strategies to address these barriers, and piloting these strategies. This implementation (continued) Key Points Question Is a stepwise implementation intervention associated with increased use of preoperative optimization by surgeons for patients with abdominal wall hernia? Findings In this quality improvement study in...

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Section: Understanding the Practice Gapmentioning

confidence: 95%

Section: Introductionmentioning

confidence: 99%

Development and Implementation of Preoperative Optimization for High-Risk Patients With Abdominal Wall Hernia

et al. 2021

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“… 9 Surgical procedures and patient groups are often studied in isolation, and large-scale studies often do not include information about tobacco use at the time of surgery. 10 , 11 , 12 For example, smoking prevalence can vary more than 2-fold depending on the population under analysis. 11 , 13 In the general population, the prevalence of smoking also varies significantly based on insurance status, with individuals without insurance having a higher prevalence of smoking than those with private insurance.…”

Section: Introductionmentioning

confidence: 99%

“… 10 , 11 , 12 For example, smoking prevalence can vary more than 2-fold depending on the population under analysis. 11 , 13 In the general population, the prevalence of smoking also varies significantly based on insurance status, with individuals without insurance having a higher prevalence of smoking than those with private insurance. 14 Identifying whether this trend translates to a surgical population is critical, given that a surgical episode may represent among the only interactions a patient without insurance has with the health care system and, therefore, an opportunity to improve health.…”

Section: Introductionmentioning

confidence: 99%

Prevalence and Trends in Smoking Among Surgical Patients in Michigan, 2012-2019

Howard

Singh²,

Englesbe

2021

JAMA Netw Open

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IMPORTANCESurgery is a teachable moment, and smoking cessation interventions that coincide with an episode of surgical care are especially effective. Implementing these interventions at a large scale requires understanding the prevalence and characteristics of smoking among surgical patients. OBJECTIVES To describe the prevalence of smoking in a population of patients undergoing common surgical procedures and to identify any clinical or demographic characteristics associated with smoking. DESIGN, SETTING, AND PARTICIPANTS This cross-sectional study included all adult patients (aged Ն18 years) in a statewide registry who underwent general and vascular surgical procedures from 2012 to 2019 at 70 hospitals in Michigan. Data analysis was conducted from August to October 2020.EXPOSURES Undergoing a surgical procedure in any of the following categories: appendectomy, cholecystectomy, colon procedures, gastric or esophageal procedures, hepatopancreatobiliary procedures, hernia repair, small-bowel procedures, hysterectomy, vascular procedures, thyroidectomy, and other unspecific abdominal procedures. MAIN OUTCOMES AND MEASURESThe prevalence of smoking prior to surgery, defined as cigarette use in the year prior to surgery, obtained from medical record review. Multivariable logistic regression was performed to analyze smoking prevalence based on insurance type and year of surgery while adjusting for demographic and clinical factors, including age, sex, race/ethnicity (determined from the medical record), insurance type, geographic region, comorbidities (ie, hypertension, diabetes, congestive heart failure, chronic obstructive pulmonary disease, chronic steroid use, and obstructive sleep apnea), American Society of Anesthesiologists classification, admission status, surgical priority, procedure type, and year of surgery. RESULTSFrom 2012 to 2019, 328 578 patients underwent surgery and were included in analysis.Mean (SD) age was 54.0 (17.0) years, and 197 501 patients (60.1%) were women. The overall prevalence of smoking was 24.1% (79 152 patients). Prevalence varied regionally from 21.5% (95% CI, 21.0%-21.9%; 6686 of 31 172 patients) in southeast Michigan to 28.0% (95% CI, 27.1%-28.9%; 2696 of 9614 patients) in northeast Michigan. When adjusting for clinical and demographic factors, there were greater odds of smoking among patients with Medicaid (odds ratio [OR], 2.75; 95% CI, 2.69-2.82) and patients without insurance (OR, 2.21; 95% CI, 2.10-2.33) compared with patients with private insurance. Among procedure categories, patients undergoing vascular surgery had greater odds of smoking (OR, 3.24; 95% CI, than those undergoing cholecystectomy. Compared with 2012, the adjusted odds of smoking decreased significantly each year (eg, 2019: OR, 0.78; 95% CI, 0.74-0.81). In 2019, the adjusted prevalence of smoking was 22.3% (95% CI, 22.0%-22.7%) among all patients, 43.0% (95% CI, 42.4%-43.6%) among patients with Medicaid, and 36.3% (95% CI, 35.2%-37.4%) among patients without insurance. (continued) Key Points Question What is the ...

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“… 15 , 16 , 17 These data demonstrate deviation from evidence-based guidelines, which is associated with suboptimal patient outcomes and increased episodes of care payments resulting from readmissions, recurrences, and complications for persons undergoing abdominal wall hernia repair. 24 , 25 , 26 The underlying causes of variation in adoption of evidence-based hernia guidelines are unknown, with the motivations and behaviors associated with individual surgeon practice largely unexplored. Consequently, the optimal mechanism for widespread, sustainable implementation of evidence-based guidelines remains unknown.…”

Section: Introductionmentioning

confidence: 99%

Exploration of Surgeon Motivations in Management of Abdominal Wall Hernias

et al. 2020

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Key Points Question How can implementation frameworks such as the Theoretical Domains Framework be used to identify domains associated with the adoption of best practices in surgery? Findings This qualitative study used abdominal wall hernia as a case study and found that the surgeon knowledge, beliefs about the consequences, social or professional role and identity, environmental context and resources, and social influences domains were associated with decision-making. Meaning These findings suggest that implementation frameworks offer a method for better understanding which factors motivate behavior change among surgeons.

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Costs Associated With Modifiable Risk Factors in Ventral and Incisional Hernia Repair

Abstract: This cross-sectional study examines the attributable association of modifiable risk factors for adverse outcomes after hernia repair and increased health care spending associated with these adverse outcomes.

Cited by 54 publications

References 40 publications

Development and Implementation of Preoperative Optimization for High-Risk Patients With Abdominal Wall Hernia

Development and Implementation of Preoperative Optimization for High-Risk Patients With Abdominal Wall Hernia

Prevalence and Trends in Smoking Among Surgical Patients in Michigan, 2012-2019

Exploration of Surgeon Motivations in Management of Abdominal Wall Hernias

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