Emergency department utilization and predictors of mortality for inpatient inguinal hernia repairs

Abstract

Background: Although inguinal hernias are common surgical diagnoses, minimally symptomatic patients are often not scheduled for repairs and are asked to seek medical attention if they develop symptoms. We investigated factors associated with emergency department (ED) utilization for inguinal hernia repairs and determined whether ED utilization affected mortality for this otherwise electively treated condition. Methods: We performed a retrospective analysis of the 2009–2013 Nationwide Inpatient Sample to identify patients who presented through the ED and were then admitted for unilateral inguinal hernia repairs. Multivariable logistic regressions that adjusted for several patient and hospital characteristics determined predictors of both ED admission and postoperative mortality. Results: There were 116,357 inpatient hospitalizations. The majority (57%) resulted from ED admissions, of which most (85%) had a diagnosis of obstruction or gangrene. Notable predictors of ED admission from the multivariable analysis included obstruction (odds ratio, 9.77 [95% confidence interval: 9.05–10.55]), gangrene (18.24 [13.00–25.59]), Black race (1.47 [1.29–1.69]), Hispanic ethnicity (1.35 [1.18–1.54]), self-pay (2.29 [1.97–2.66]) and Medicaid insurance (1.76 [1.50–2.06]). While overall mortality decreased from 2.03% in 2009 to 1.36% in 2013, admission through the ED was independently associated with higher mortality compared with elective repair (1.67 [1.21–2.29]), even after adjusting for the diagnosis of obstruction and gangrene. Other predictors of mortality included patient age and comorbidities. Conclusions: In our study, Black, Hispanic, and self-pay patients were more likely to present through the ED. After adjusting for obstruction or gangrene, simply presenting through the ED was independently associated with a 67% higher postoperative mortality rate compared with that of an elective operation. Our findings suggest both a difference in ED utilization and subsequent difference in mortality by patient race and ethnicity and insurance for this common surgical condition.

Surgeon utilization of minimally invasive techniques for inguinal hernia repair: a population-based study

“…Selection by clinical indication may also have contributed to our findings, as older and black patients may present with more advanced hernias less amenable to MIS repair. [21][22][23] Additionally, older patients may have had unmeasured comorbidities, especially as we had no measure of overall frailty in our dataset. However, octogenarians have been shown to have equivalent clinical outcomes after MIS repair compared to younger patients, and there is no evidence that race has an independent effect on hernia repair outcomes.…”

The Impact of the COVID-19 Pandemic on Sociodemographic Disparities in Rates of Elective Hernia Surgeries

“… 9 These emergent repairs have been associated with increased length of stay, higher costs, and increased risk of in-hospital mortality. 10 Given these concerns, future work should assess whether there were any changes in the demand for non-elective surgery as a result of the pandemic and if that is linked to health care disparities.…”

The impact of the affordable care act (ACA) Medicaid Expansion on access to minimally invasive surgical care

“…ICD-9 codes have been used and validated in previous studies. [4][5][6][7][8][9][10][11][12][13][14] The list of ICD-9 clinical diagnosis and procedure codes used in our analysis are provided in supplemental Table 1. Patients younger than 18 years of age, older than 64 years of age or on Medicare insurance were excluded as they were not eligible for the ACA's Medicaid expansion.…”