Use of statewide financial incentives to improve documentation of hernia and mesh characteristics in ventral hernia repair.

BACKGROUND: Documentation of intraoperative details is critical for understanding and advancing hernia care, but is inconsistent in practice. Therefore, to improve data capture on a statewide level, we implemented a financial incentive targeting documentation of hernia defect size and mesh use. METHODS: The Abdominal Hernia Care Pathway (AHCP), a voluntary pay for performance (P4P) initiative, was introduced in 2021 within the statewide Michigan Surgical Quality Collaborative (MSQC). This consisted of an organizational-level financial incentive for achieving 80% performance on eight specific process measures for ventral hernia surgery, including complete documentation of hernia defect size and location, as well as mesh characteristics and fixation technique. Comparisons were made between AHCP and non-AHCP sites in 2021. RESULTS: Of 69 eligible sites, 47 participated in the AHCP in 2021. There were N = 5362 operations (4169 at AHCP sites; 1193 at non-AHCP sites). At AHCP sites, 69.8% of operations had complete hernia documentation, compared to 50.5% at non-AHCP sites (p < 0.0001). At AHCP sites, 91.4% of operations had complete mesh documentation, compared to 86.5% at non-AHCP sites (p < 0.0001). The site-level hernia documentation goal of 80% was reached by 14 of 47 sites (range 14-100%). The mesh documentation goal was reached by 41 of 47 sites (range 4-100%). CONCLUSIONS: Addition of an organizational-level financial incentive produced marked gains in documentation of intra-operative details across a statewide surgical collaborative. The relatively large effect size-19.3% for hernia-is remarkable among P4P initiatives. This result may have been facilitated by surgeons' direct role in documenting hernia size and mesh use. These improvements in data capture will foster understanding of current hernia practices on a large scale and may serve as a model for improvement in collaboratives nationally.

Operative time tracking for umbilical hernia patients.

BACKGROUND: Army medical treatment facilities (MTFs) use a surgery scheduling system that reviews historical OR times to dictate expected procedural time when posting new cases. At a single military institution there was a noted inflation to umbilical hernia repair (UHR) times that was leading to issues with under-utilized operating rooms. METHODS: This is a retrospective review determining what variables correlate with longer UHR operative time. Umbilical, ventral, epigastric, and incisional hernia repairs (both open and laparoscopic) were pulled from the local OR scheduling system at Dwight D. Eisenhower Army Medical Center from January 2013 to June 2018. RESULTS: A total of 442 patients were included in the study with a mean age of 45.74 years and 54.98% male. Patient ASA level (p 0.045), primary vs. mesh repair (p < 0.001), number of hernias repaired (p 0.05), hernia size (p < 0.001), and absence of student nurse anesthetist (SRNA) (p 0.05) all correlated with longer UHR OR times. For the aggregated open hernia repair data, almost all independent variables of interest were statistically significant including age, PGY level, history of DM, case acuity, presence of SRNA, patient ASA level, patient's BMI, hernia defect size, number of hernias, history of prior repair, and history prior abdominal surgery. Multivariate regression analysis was done on the open hernia repair variables with only age and size of hernia being significant. CONCLUSION: This data were used to create a new case request option (open UHR without mesh and open UHR with mesh) to more effectively utilize available OR time.

Retrospective study of an incisional hernia after laparoscopic colectomy for colorectal cancer.

PURPOSE: This study aimed to examine the incidence of incisional hernia (IH) in elective laparoscopic colorectal surgery (LC) using regulated computed tomography (CT) images at intervals every 6 months. METHODS: We retrospectively examined the diagnosis of IH in patients who underwent LC for colorectal cancer at Kansai Medical University Hospital from January 2014 to August 2018. The diagnosis of IH was defined as loss of continuity of the fascia in the axial CT images. RESULTS: 470 patients were included in the analysis. IH was diagnosed in 47 cases at 1 year after LC. The IH size was 7.8 cm2 [1.3-55.6]. In total, 38 patients with IH underwent CT examination 6 months after LC, and 37 were already diagnosed with IH. The IH size was 4.1 cm2 [0-58.9]. The IH size increased in 17 cases between 6 months and 1 year postoperatively, and in 1 case, a new IH occurred. 47%(18/38) of them continued to grow until 1 year after LC. A multivariate analysis was performed on the risk of IH occurrence. SSI was most significantly associated with IH occurrence (OR:5.28 [2.14-13.05], p = 0.0003). CONCLUSION: IH occurred in 10% and 7.9% at 1 year and 6 months after LC. By examining CT images taken for the postoperative surveillance of colorectal cancer, we were able to investigate the occurrence of IH in detail.

Use of computed tomography volumetric measurements to predict operative techniques in paraesophageal hernia repair.

BACKGROUND: Despite advances in diagnostic imaging capabilities, little information exists concerning the impact of physical dimensions of a paraesophageal hernia (PEH) on intraoperative decision making. The authors hypothesized that computerized volumetric analysis and multidimensional visualization to measure hiatal defect area (HDA) and intrathoracic hernia sac volume (HSV) would correlate to operative findings and required surgical techniques performed. METHODS: Using volumetric analysis software (Aquarius iNtuition, TeraRecon, Inc), HDA and HSV were measured in PEH patients with preoperative computerized tomography (CT) scans, and used to predict the likelihood of intraoperative variables. Multidimensional rotation of images enabled visualization of the entire hiatal defect in a plane mimicking the surgeon's view during repair. The intrathoracic hernia sac was outlined producing volume measurements based on a summation of exact dimensions. RESULTS: A total of 213 PEHR patients had preoperative CT imaging, with 14.1% performed emergently. Primary cruroplasty was performed in 89.2%, salvage gastropexy in 10.3%, and diaphragmatic relaxing incisions in 4.2%. Median HDA was 25.7 cm2 (IQR17.8-35.6 cm2); median HSV was 365.0 cm3 (IQR150.0-611.0 cm3). Incremental 5 cm2 increase in HDA was associated with greater likelihood of presenting emergently (OR 1.27; 95%CI 1.124-1.428, p = 0.0001), incarceration (OR 1.27; 1.074-1.499, p = 0.005), gastric volvulus (OR 1.13; 1.021-1.248, p = 0.02), and requiring either relaxing incision (OR 1.43; 1.203-1.709, p < 0.0001) or salvage gastropexy (OR 1.13; 1.001-1.274, p = 0.04). Similarly, HSV increases of 100 cm3 were associated with 23% greater likelihood of emergent repair (CI 1.121-1.353, p < 0.0001), and were more likely to require a relaxing incision (OR 1.18; 1.043-1.339, p = 0.009) or salvage gastropexy (1.19; 1.083-1.312, p = 0.0003). CONCLUSIONS: Utilization of CT volumetric measurements is a valuable adjunct in preoperative planning, allowing the surgeon to anticipate complexity of repair and operative approach, as incremental increases in HSV by 100 cm3 and HDA by 5 cm2 are more likely to require complex techniques or bailout procedures and/or present emergently.