Elsevier

Surgery

Volume 158, Issue 3, September 2015, Pages 736-746
Surgery

Clinical Outcomes/General Surgery
The pitfalls of inguinal herniorrhaphy: Surgeon volume matters

Presented at the 10th Annual Academic Surgical Congress in Las Vegas, NV, February 3−5, 2015.
https://doi.org/10.1016/j.surg.2015.03.058Get rights and content

Background

There is currently little information regarding the impact of procedure volume on outcomes after open inguinal hernia repair in the United States. Our hypothesis was that increasing procedure volume is associated with lesser rates of reoperation and resource use.

Methods

The database of the Statewide Planning and Research Cooperative System was queried for elective open initial inguinal hernia repairs performed in New York State from 2001 to 2008 via the use of International Classification of Diseases, 9th Revision and Current Procedural Terminology codes. Surgeon and hospital procedure volumes were grouped into tertiles based on the number of open inguinal hernia repairs performed per year. Bivariate, hierarchical mixed effects Cox proportional-hazards, and negative binomial regression analyses were performed assessing for factors associated with reoperation for recurrence, procedure time, and downstream total charges.

Results

Among 151,322 patients who underwent open inguinal hernia repair, the overall rate of reoperation for recurrence within 5 years was 1.7% with a median time to reoperation of 1.9 years. An inverse relationship was seen between surgeon volume and reoperation rate, procedure time, and health care costs (P < .001). After we controlled for surgeon, facility, operative and patient characteristics, low-volume surgeons (<25 repairs/year) had greater rates of reoperation (hazard ratio 1.23,95% confidence interval [95% CI] 1.11–1.36), longer procedure times (incidence rate ratio 1.22, 95% CI 1.21–1.24), and greater downstream costs (incidence rate ratio 1.13,95% CI 1.10–1.17) than high-volume surgeons (≥25 repairs/year).

Conclusion

Surgeon volume <25 cases per year for open inguinal hernia repair was independently associated with greater rates of reoperation for recurrence, worse operative efficiency, and greater health care costs. Referral to surgeons who perform ≥25 inguinal hernia repairs per year should be considered to decrease reoperation rates and resource use.

Section snippets

Methods

We used the Statewide Planning and Research Cooperative System (SPARCS), a New York State hospital discharge database created in 1979 and maintained by the New York Department of Health. SPARCS contains patient-level data abstracted from medical records by trained medical records personnel, including information on all hospital admissions, ambulatory operative procedures, and visits to the emergency department in New York State. Specific data elements that are collected include patient age,

Results

Of 155,191 patients who underwent open initial inguinal hernia repair from 2001 to 2008 in New York State, 151,322 patients met inclusion criteria. Of the 3,869 patients who were excluded, 424 had a concurrent, unilateral recurrent inguinal hernia, 3,157 had a permanent residence outside of New York State, 35 had a missing unique surgeon identifier, and 253 died within 90 days of operation. Characteristics of the patient, surgeon, and facility are presented in Table I. Overall, there were 2,821

Discussion

Overall, this study found that surgeon volume was associated with reoperation rates for recurrence of inguinal hernia, operative efficiency, and downstream costs after open initial inguinal hernia repair. After adjustment for other relevant clinical factors, we found that low-volume surgeons performing less than 25 open inguinal hernia repairs per year had a 23% greater rate of reoperation for inguinal hernia recurrence compared with high-volume surgeons performing at least 25 open inguinal

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