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

Abstract

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...

Anesthesiologists in the modern medical school curriculum: importance and opportunity

“…6 The vast majority of students agree that working with anesthesiologists offers the opportunity for skill development, regardless of their chosen specialty. 11 Given this clear educational value, it has been argued that all medical students should rotate through the service, yet only 12/17 Canadian medical schools have a mandatory anesthesia rotation. 6,11 Additionally, there is evidence that pairing the anesthesia and surgery rotations can add further value by improving medical student knowledge of perioperative medicine.…”

“…11 Given this clear educational value, it has been argued that all medical students should rotate through the service, yet only 12/17 Canadian medical schools have a mandatory anesthesia rotation. 6,11 Additionally, there is evidence that pairing the anesthesia and surgery rotations can add further value by improving medical student knowledge of perioperative medicine. 2 This, in its own right, ought to be an essential skill for all physicians.…”

“…11 However, surgeons often feel that they lack the expertise to adequately optimize their patients preoperative health. 11 While some centers have the luxury of stand-alone pre-anesthetic assessments for high-risk patients, 11 it is not feasible for anesthesiologists to perform these extensive optimizations with all operative candidates. Further, comorbidities often require an extended lead-time to leverage the best possible outcomes.…”

Robotic hernia surgery IV. English version

“…If this is the case, stomal reversal should be performed instead of PH repair. Like patients with other types of ventral and incisional hernias, medical comorbidities are optimized before the operation [ 15 , 16 ]. A body mass index (BMI) of less than 35 kg/m 2 is generally strived for.…”

Robotische Hernienchirurgie Teil IV

“…B. Gastroenterologen, Kolorektalchirurgen und Urologen) evaluiert werden, ob das Stoma gegebenenfalls zurückverlegt werden kann. Wie auch bei Patienten mit anderen ventralen und inzisionalen Hernien, werden die beeinflussbaren perioperativen Risikofaktoren vor der Operation optimiert [ 14 , 15 ]. Im Allgemeinen wird ein Body-Mass-Index (BMI) von weniger als 35 kg/m 2 angestrebt.…”