Raising the Quality of Hernia Care: Is there a need?

Adrian Park, MD1, Hamid R Zahiri, DO1, Carla Pugh, MD2, Melina Vassiliou, MD3, Guy R Voeller, MD4. 1Anne Arundel Medical Center, 2University of Wisconson, 3McGill University, 4University of Tennessee

Introduction

With a focus on raising the quality of hernia care through creation of educational programs, SAGES formed the Hernia Task Force (HTF). A needs assessment survey was administered to target opportunities for improving surgical training and thus patient outcomes and experience. The goal of this study was to analyze and interpret the resulting surveys.

Methods

This qualitative study included structured interviews and online surveys. Ten stakeholder groups were identified and surveyed as the focus group including: HTF members, academic and private practice surgeons and senior surgical trainees, allied health professionals (RNs, PAs, etc.), patients, hospital administrators, healthcare payers and medical supply providers. The surveys were administered using various approaches (online surveys, phone interviews, email). Subjects were asked several questions including: years of experience, hernia recurrence and complication rates, possible etiologies of recurrence, perceived deficits in current hernia care, preferred or most effective training modalities and technical preference for repair.

Results

Twice the expected response rate yielded 899 participants, including 665 surgeons, 58 residents and fellows, 66 patient care team members, 12 hospital administrators and 14 medical supply providers. Greater than half of the attending surgeons had 10 years of practice experience or more with 48% having completed a minimally invasive fellowship. 69% reported caring for, on average, 10 or less inguinal and ventral hernia repair patients per a month. Assessment of technical approach revealed 32% of surgeons mostly perform laparoscopic repairs versus 31% open and 37% using both approaches equally. Nearly 26% of surgeons apply the same, limited range of techniques to all patients without evaluation of patient-specific factors. The majority (71%) of surgeon respondents related hernia recurrence rates greater than 25%.

When reviewing possible causes of recurrence, HTF members implicated poor surgical technique, misapplication of technique, infection and complication as primary determinants of recurrence. In contrast, medical supply providers and hospital administrators implicated patient health factors as the primary determinants. Regarding options for learning and skill improvement, surgeons preferred attending conferences (82%), reading periodicals/publications (71%), watching videos (59%), and communicating with peers (57%). Topics of greatest interest were advanced techniques for hernia repairs (71%), preoperative and intraoperative decision making (56%), and patient outcomes (64%).

Deficits in knowledge or system-based hernia care and patient outcome measures were noted most among surgeons and surgical trainees. 86% of nurses (the majority of care team respondents) felt there was room for improvement in hernia patient safety & teamwork in the OR. Only 24% believed the patients had adequate preoperative education. HTF members also reported that improved preoperative patient education and outcome tracking would be of significant value to the patient.

Conclusions

Major reported deficits in hernia care include: lack of standardization in training and care, "one size fits all" technical approach and inadequate patient follow-up and outcome measures. There is a need for a comprehensive, flexible and tailored educational program to equip surgeons and their teams to raise the quality of hernia care and bring greater value to their patients.

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