There have long been more questions than answers when it comes to abdominal hernia repair surgeries, but now, thanks to a database full of information supplied by both surgeons and patients, those answers are coming to light and driving nationwide improvements.
Benjamin Poulose, MD, MPH, director of the Vanderbilt Hernia Center and associate professor of Surgery at Vanderbilt University Medical Center, and Michael Rosen, MD, professor of Surgery and director of Cleveland Clinic’s Comprehensive Hernia Center, formed the Americas Hernia Society Quality Collaborative (AHSQC) in 2013 to better track the outcomes of these surgeries, standardize the best practices and improve patient care.
Five years later, more than 250 surgeons at more than 300 academic medical centers and private practices throughout the United States have contributed data for the AHSQC, representing nearly 28,000 patient cases.
“Although now more than half a million hernia operations occur in this country each year, we are probably about 30 years behind when it comes to research, quality improvement and data collection related to hernias,” said Poulose, who serves as AHSQC vice president and director for quality outcomes. “We often manage hernias from cancer, trauma and transplant patients, so it affects just about every realm of abdominal surgery, yet there is very little information to tell us who we should do which procedure on, when we should use or not use mesh, and what the long-term ramifications and quality of life will be after these operations.”
A hernia happens when inner layers of the abdominal wall weaken, then bulge or tear. The inner lining of the abdomen pushes through the weakened area to form a balloon-like pouch. A loop of intestine or abdominal tissue can then enter the pouch, causing pain and potentially serious complications.
Because hernias have a high rate of recurrence, surgeons often insert mesh to reinforce the abdominal wall. Unfortunately, the current regulatory system allows mesh products to be approved for surgical use with “little to no evaluation in humans beforehand and no effective surveillance of their performance in patients over time,” Poulose said. This has led to mesh products being recalled by the Food and Drug Administration (FDA), and individuals have filed lawsuits or joined class action lawsuits over the past decade blaming hernia mesh for their post-surgical complications.
“It’s pretty simple why this collaborative started,” Poulose said. “I couldn’t answer a basic question from a patient: ‘What is the chance that this implant you’re going to place in me along with the operation you’re doing will be successful in the long run?’ I don’t know the answer to that, and I find that incredibly problematic, especially when what we’re doing can be a very complex operation, with implants that are supposed to last the lifetime of the patient. I didn’t feel comfortable not having that information, and I wanted to try to do something about it.”
Based on analysis of data they’ve collected thus far, the AHSQC has provided several practice recommendations to improve patient care to their surgeon members, such as:
- A post-discharge patient survey can significantly reduce readmissions after ventral hernia repair.
- Using a robotic system for ventral hernia repairs is associated with a reduced length of stay compared to open abdominal surgery (three days vs. two days).
- Using drains after surgery does not appear to increase infections.
- Pre-surgery bowel prep can lead to a higher rate of surgical-site infection in less complex hernia repairs.
- Patient use of chlorhexidine scrubs to clean skin before coming to the hospital is associated with increased wound issues.
The AHSQC has also been approved as a Centers for Medicare and Medicaid Services (CMS) Qualified Clinical Data Registry. This means that surgeons successfully contributing outcome data to the AHSQC can use that data to avoid penalties in the national value-based payment system.
“The important thing for all surgeons to understand is that we’re being measured by the quality of the operations that we perform,” said Rosen, who serves as AHSQC president and medical director. “Unfortunately, quality measures have not historically been designed by surgeons and often tend to measure more of the elements of the processes and not really quality or outcomes. The AHSQC is a huge opportunity for surgeons to be stake holders at the table and have a say in what reasonable quality metrics are appropriate to measure in a fair and risk adjusted manner.”
A next focus of the AHSQC is to track patients’ self-reported quality of life for up to five years after their hernia repair to better determine if the surgery made a long-term, positive difference in their lives, Poulose said. The AHSQC also hopes to better educate patients facing hernia repair surgeries on the importance of choosing their surgeon wisely, Rosen said.
