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Emergency hernia surgery risk predicted by access, age, and race

Key clinical point: Disparities among patients more likely to get emergency rather than elective ventral hernia repair include race, insurance status, and advanced age.

Major finding: Among demographic groups with a significantly higher likelihood of undergoing emergency ventral hernia repair were blacks (odds ratio, 1.64), Hispanics (OR, 1.44), and people over age 85 (OR, 2.23).

Data source: Nationwide Inpatient Sample of 453,000 adults who had inpatient ventral hernia repair from 2003 to 2011.

Disclosures: The study authors reported having no relevant financial disclosures.


 

AT THE ACADEMIC SURGICAL CONGRESS

References

JACKSONVILLE, FLA. – Age and access to medical care may be key drivers of emergency surgery for ventral hernia repair, a large retrospective study has found.

Patients who do not have health insurance, are advanced in age, are black or Hispanic, or have unrelated health problems are at significantly higher risk than other patients with hernias of having emergency surgery for ventral hernia repair, facing a higher risk of death, a higher cost, and a longer hospital stay, Dr. Lindsey Wolf said at the Association for Academic Surgery/Society of University Surgeons Academic Surgical Congress. “This study demonstrates persistent disparities in access to elective surgery care that must be understood and mitigated,” she said. “The strongest predictor was being uninsured. The self-pay group had an odds ratio of 3.5 for undergoing emergency surgery, compared with those who were primarily insured.”

Dr. Lindsey Wolf Richard Mark Kirkner

Dr. Lindsey Wolf

The goal of the study was to identify patient and hospital factors associated with emergency ventral hernia surgery in the U.S. population, said Dr. Wolf of Brigham and Women’s Hospital in Boston. “Prior studies that have been done on predictors of emergency repair are from universally insured populations,” she said. One was a national cohort study in Denmark, and another involved the Veterans Affairs population, she said. “Both of these identified several demographic and clinical risk factors for emergency hernia repair,” she said.

The current Brigham and Women’s study involved a retrospective cross-sectional data analysis of approximately 453,000 elective and emergency ventral hernia repairs performed from 2003 to 2011 in the Nationwide Inpatient Sample. Any cases that involved a trauma diagnosis were excluded. Forty percent of the cases in the sample were emergency admissions.

When considering the effect of age, the investigators found that the aged 65-75 group had the lowest risk of emergency hernia surgery of all age groups with an odds ratio of 0.77, compared with those under 45 years. Those aged 85 and older, however, had the highest risk of all age groups with an odds ratio of 2.23. “The proportion of the cohort undergoing emergency surgery really increases drastically with age after 75 years,” Dr. Wolf said.

Other factors that had an impact on emergency hernia repair were Medicaid coverage (OR, 1.29, compared with private insurance), black race (OR, 1.64, compared with white race), Hispanic ethnicity (OR, 1.44, compared with non-Hispanic white race/ethnicity), and comorbidities, ranging from 1.13 for one comorbidity to 1.68 for three or more, compared with none.

The study also elucidated a few consequences of emergency ventral hernia repair: 2.58 times higher odds of death, a 15% greater cost per hospital stay, and 26% longer hospital stays.

“Looking forward there are both patient and provider areas to target,” Dr. Wolf said. “For patients, interventions must be designed to populations that may have poor access to elective surgical services.” She acknowledged that race was a strong predictor, “but race is a social construct that may be a proxy to many barriers to access and care.”

The study findings may also help inform surgeons on when to operate on ventral hernias. “In the absence of any clinical guidelines for when a hernia should be repaired, our results with regard to age and multiple comorbidities may assist surgeons in risk stratifying patients when considering [whether] to perform an elective repair,” she said.

Dr. Wolf and her coauthors had no relevant financial conflicts to disclose.

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