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IIR 03-247 – HSR&D Study

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IIR 03-247
Mesh Repair for Ventral Hernia: Which Rate is Right?
Mary T Hawn MD MPH BS
Birmingham VA Medical Center, Birmingham, AL
Birmingham, AL
Funding Period: July 2004 - December 2009

BACKGROUND/RATIONALE:
Abdominal wall hernias are one of the most common conditions treated by the general surgeon. Well over 100,000 repairs are performed annually. Despite this fact, there is no standard or uniformly accepted technical method to repair abdominal wall hernias. Hernias can be repaired with or without the use of a mesh prosthesis, the mesh can be placed in different locations within the abdominal wall, and the operation can be done via an open or laparoscopic approach. This study hypothesized that variability in the method of repair, specifically the rate at which mesh is used for the repair, is directly related to surgical outcome. Consistent with this hypothesis, the overall hernia recurrence rates are as high as 24-40%. This rate would be unacceptable to any individual practicing surgeon. Without adequate data to support the superiority of one type of technical repair, surgeons will continue their current practice style.

OBJECTIVE(S):
1. To determine whether there are surgeon- and/or hospital-specific differences in mesh implantation rates, recurrence rates and complications rates. Specifically, we examined whether there is variability across surgeons and facilities in the method and rate of mesh implantation for ventral hernia repair (VHR) which are unexplained by patient comorbidity or other clinical characteristics.
2. To identify key variables associated with recurrence and wound complications following ventral hernia repair.
3. To determine the impact of hernia recurrence and wound complications on patient quality of life.

METHODS:
The VA National Surgical Quality Improvement Program (NSQIP) was started in 1991. This program collects pre-operative and intra-operative risk factors and 30-day morbidity and mortality data. These data are used as feedback to individual sites, and significant improvement in morbidity and mortality for surgical patients has been achieved. This was an observational study of the NSQIP dataset together with a subject survey on the outcomes of ventral hernia repair in the VA population. Patients who underwent ventral hernia repair at the 16 highest volume centers from 1998-2002 were included in the study. Subjects were mailed a survey to determine whether they had developed a recurrence or complication in the follow-up period. Health-related quality of life and pain were assessed in the survey. The analysis was an outcomes assessment, and risk-adjustment was performed. We applied multi-level statistical techniques to control for surgeon and hospital styles. Practice styles of individual VAMC sites were studied to determine if certain practice styles are associated with optimal outcomes (i.e., low recurrence and low wound complication rates).

FINDINGS/RESULTS:
In our study of incisional hernia repair (IHR) performed at 16 VA hospitals, we found a greater than 2-fold difference in hospital rate of mesh use and hospital recurrence rates. Of the 1,612 IHRs, the rate of mesh use at the hospital level was significantly associated with hospital recurrence rate for all cases (R2=0.27, p=0.04) and elective cases (R2=0.31, p=0.02). These data validate that observed variation in repair approaches for IHR is significantly associated with different outcomes. The main finding from the patient-level analysis is that recurrence remains problematic, with a greater than 25% recurrence rate at 5 years following repair. Of the 1,346 elective incisional hernia repairs analyzed at median follow-up of 73.4 months, there were 383 recurrences (28.5%), 23 mesh removals (1.7%), and seven enterocutaneous fistulas (ECF) (0.5%). On Cox regression modeling with adjustment for hernia and VA site characteristics, the effectiveness of mesh varied by position. Compared to suture repair, laparoscopic (hazard ratio [HR] 0.49, p=0.006) and open underlay mesh repair (HR 0.72, p=0.02) significantly reduced the recurrence risk, but onlay or inlay mesh repair did not. Mesh position did not affect mesh removal or ECF rates. A quality of life (QOL) analysis of survey data found that patients with active hernia recurrences at the time of survey reported significantly worse QOL on the Physical Function (p= 0.03) and General Health (p=0.05) domains as compared to patients with intact repairs at the time of survey.

IMPACT:
Ventral hernia repairs are performed frequently, yet the outcomes remain poor. The main finding from the patient level analysis is that underlay mesh technique (laparoscopic or open) was associated with lower recurrence rates without significant increase in complications when compared to other mesh techniques and suture repair. These data provide further evidence that the effectiveness of mesh is dependent on the technique employed for mesh placement and that factors limiting the use of permanent mesh implantation, such as intra-operative enterotomy, increase the likelihood of recurrence. Performance metrics for this operation should be established and measured to ensure consistent quality across VA hospitals.

PUBLICATIONS:

Journal Articles

  1. Gajdos C, Hawn MT, Kile D, Robinson TN, Henderson WG. Risk of major nonemergent inpatient general surgical procedures in patients on long-term dialysis. JAMA surgery. 2013 Feb 1; 148(2):137-43.
  2. Hollis RH, Graham LA, Richman JS, Deierhoi RJ, Hawn MT. Adverse cardiac events in patients with coronary stents undergoing noncardiac surgery: a systematic review. American journal of surgery. 2012 Oct 1; 204(4):494-501.
  3. Altom LK, Graham LA, Gray SH, Snyder CW, Vick CC, Hawn MT. Outcomes for incisional hernia repair in patients undergoing concomitant surgical procedures. The American surgeon. 2012 Feb 1; 78(2):243-9.
  4. Porterfield JR, Altom LK, Graham LA, Gray SH, Urist MM, Hawn MT. Descriptive operative reports: teaching, learning, and milestones to safe surgery. Journal of surgical education. 2011 Nov 1; 68(6):452-8.
  5. Graham LA, Altom LK, Vick CC, Snyder CW, Deierhoi RJ, Hawn MT. Agreement between patient survey and medical chart: Pitfalls in measurement strategies for hernia recurrence. Surgery. 2011 Sep 1; 150(3):371-8.
  6. Altom LK, Snyder CW, Gray SH, Graham LA, Vick CC, Hawn MT. Outcomes of emergent incisional hernia repair. The American surgeon. 2011 Aug 1; 77(8):971-6.
  7. Hawn MT, Gray SH, Snyder CW, Graham LA, Finan KR, Vick CC. Predictors of mesh explantation after incisional hernia repair. American journal of surgery. 2011 Jul 1; 202(1):28-33.
  8. Snyder CW, Graham LA, Gray SH, Vick CC, Hawn MT. Effect of mesh type and position on subsequent abdominal operations after incisional hernia repair. Journal of the American College of Surgeons. 2011 Apr 1; 212(4):496-502; discussion 502-4.
  9. Snyder CW, Graham LA, Vick CC, Gray SH, Finan KR, Hawn MT. Patient satisfaction, chronic pain, and quality of life after elective incisional hernia repair: effects of recurrence and repair technique. Hernia : The Journal of Hernias and Abdominal Wall Surgery. 2011 Apr 1; 15(2):123-9.
  10. Hawn MT, Snyder CW, Graham LA, Gray SH, Finan KR, Vick CC. Hospital-level variability in incisional hernia repair technique affects patient outcomes. Surgery. 2011 Feb 1; 149(2):185-91.
  11. Snyder CW, Vandromme MJ, Tyra SL, Porterfield JR, Clements RH, Hawn MT. Effects of virtual reality simulator training method and observational learning on surgical performance. World Journal of Surgery. 2011 Feb 1; 35(2):245-52.
  12. Hawn MT, Snyder CW, Graham LA, Gray SH, Finan KR, Vick CC. Long-term follow-up of technical outcomes for incisional hernia repair. Journal of the American College of Surgeons. 2010 May 1; 210(5):648-55, 655-7.
  13. Finan KR, Kilgore ML, Hawn MT. Open suture versus mesh repair of primary incisional hernias: a cost-utility analysis. Hernia : The Journal of Hernias and Abdominal Wall Surgery. 2009 Apr 1; 13(2):173-82.
  14. Gray SH, Vick CC, Graham LA, Finan KR, Neumayer LA, Hawn MT. Variation in mesh placement for ventral hernia repair: an opportunity for process improvement? American journal of surgery. 2008 Aug 1; 196(2):201-6.
  15. Gray SH, Vick CC, Graham LA, Finan KR, Neumayer LA, Hawn MT. Risk of complications from enterotomy or unplanned bowel resection during elective hernia repair. Archives of Surgery. 2008 Jun 1; 143(6):582-6.
  16. Hawn MT, Itani KM, Gray SH, Vick CC, Henderson W, Houston TK. Association of timely administration of prophylactic antibiotics for major surgical procedures and surgical site infection. Journal of the American College of Surgeons. 2008 May 1; 206(5):814-9; discussion 819-21.
  17. Gray SH, Vick CC, Graham LA, Finan KR, Neumayer LA, Hawn MT. Umbilical herniorrhaphy in cirrhosis: improved outcomes with elective repair. Journal of Gastrointestinal Surgery : Official Journal of The Society For Surgery of The Alimentary Tract. 2008 Apr 1; 12(4):675-81.
  18. Gray SH, Hawn MT, Itani KM. Surgical progress in inguinal and ventral incisional hernia repair. The Surgical Clinics of North America. 2008 Feb 1; 88(1):17-26, vii.
  19. Itani KM, Hawn MT. Advances in abdominal wall hernia repair. Preface. The Surgical Clinics of North America. 2008 Feb 1; 88(1):xvii-xix.
  20. Hawn MT, Gray SH, Vick CC, Itani KM, Bishop MJ, Ordin DL, Houston TK. Timely administration of prophylactic antibiotics for major surgical procedures. Journal of the American College of Surgeons. 2006 Dec 1; 203(6):803-11.
  21. Finan KR, Vick CC, Kiefe CI, Neumayer L, Hawn MT. Predictors of wound infection in ventral hernia repair. American journal of surgery. 2005 Nov 1; 190(5):676-81.
  22. Vick CC, Finan KR, Kiefe C, Neumayer L, Hawn MT. Variation in Institutional Review processes for a multisite observational study. American journal of surgery. 2005 Nov 1; 190(5):805-9.
Magazine/Popular Press Articles

  1. Hawn MT. Tailor Hernia Repair to Individual Patient. American College of Sugeons - Surgery News. 2011 Feb 1; 7(2):1 to 8.
Conference Presentations

  1. Hawn MT. Quality Control in Incisional Hernia Repair. Paper presented at: Mercer University School of Medicine Department of Surgery Grand Rounds; 2012 Aug 23; Macon, GA.
  2. Hawn MT. Quality Control in Hernia Surgery: the United States Experience. Paper presented at: European Hernia Society EuraHS Working Group Symposium; 2012 Jun 8; Brussels, Belgium.
  3. Hawn MT. Measuring Outcomes and Quality in Hernia Surgery. Paper presented at: University of Arkansas for Medical Sciences Department of Surgery Monthly Grand Rounds; 2012 Jan 12; Little Rock, AR.
  4. Hawn MT. Mesh Complications in Ventral Hernia Repair. Paper presented at: Pelvic Floor Disorders Network Annual Board Meeting; 2012 Jan 4; Washington, DC.
  5. Graham LA, Snyder CW, Vick CC, Hawn MT, Gray SH. Concomitant General Surgical Procedures with Incisional Hernia Repair: High Complications with MESH use. Paper presented at: VA Association of Surgeons Annual Meeting; 2010 May 10; Indianapolis, IN.
  6. Hawn MT, Gray SH, Snyder CW, Graham LA, Vick CC. Predictors of Mesh Explantation Following Incisional Hernia Repair. Paper presented at: Digestive Disease Week Annual Meeting; 2010 May 5; New Orleans, LA.
  7. Hawn MT. Variation in Incisional Hernia Repair Technique: Effect on Patient Outcomes. Poster session presented at: Academic Surgical Congress; 2010 Feb 5; San Antonio, TX.
  8. Hawn MT. Variation in Mesh Utilization for Incisional Hernia Repair: Effect on Recurrence. Paper presented at: Academic Surgical Congress; 2010 Feb 5; San Antonio, TX.
  9. Hawn MT. Long term follow up of technical outcomes for incisional hernia repair. Paper presented at: Southern Surgical Association Annual Meeting; 2009 Dec 7; Hot Springs, VA.
  10. Argo JL, Hawn MT, Vick CC, Graham LA, Crawford MS, Afshari AL, Bishop MJ, Hawn MT. Elective Surgical Care Cancellation in the Veterans Health Administration System: Identifying Areas for Improvement. Paper presented at: VA Association of Surgeons Annual Meeting; 2009 Apr 20; Cambridge, MA.
  11. Snyder CW, Hawn MT, Vick CC, Graham LA. Does Incisional Hernia Repair Improve Quality of Life? Paper presented at: VA Association of Surgeons Annual Meeting; 2009 Apr 20; Cambridge, MA.
  12. Vick CC, Snyder CW, Gray SH, Finan KR, Graham LA, Hawn MT. Non-Response Bias to Mailed Outcomes Survey in a Patients Undergoing Ventral Hernia Repair. Poster session presented at: VA Association of Surgeons Annual Meeting; 2009 Apr 20; Cambridge, MA.
  13. Hawn MT. Effect of comorbidities and incomplete evaluation on elective surgery cancellation: A case for coordinated multidisciplinary preoperative evaluation. Paper presented at: VA HSR&D National Meeting; 2009 Feb 12; Baltimore, MD.
  14. Snyder CW, Vick CC, Hawn MT. Patient Reported Outcomes After Ventral Hernia Repair: What Matters to the Patient. Paper presented at: Academic Surgical Congress; 2009 Feb 3; Fort Myers, FL.
  15. Hawn MT. Cause and Outcome of Unplanned Reintubation after Surgical Procedures. Paper presented at: American College of Surgeons National Surgical Quality Improvement Program Annual Meeting; 2008 Jun 20; Boca Raton, FL.
  16. Hawn MT, Graham LA, Vick CC. Elective Surgical Case Cancellation in the Veterans Health Administration System: Rates and Reasons. Paper presented at: VA Association of Surgeons Annual Meeting; 2008 May 5; Dallas, TX.
  17. Argo JLA, Hawn MT. Ventral herniorrhaphy in contaminated operative fields using Permacol mesh. Poster session presented at: Southeastern Surgical Annual Congress; 2008 Feb 1; Birmingham, AL.
  18. Vick CC, Houston TK, Hawn MT. Association of Timely Administration of Prophylactic Antibiotics for Major Surgical Procedures and Surgical site Infection. Paper presented at: Southern Surgical Association Annual Meeting; 2007 Dec 3; Hot Springs, VA.
  19. Hawn MT. Elective umbilical hernia repair in patient with Cirrhosis. Paper presented at: Society for Surgery of the Alimentary Tract Annual Conference; 2007 May 21; Washington, DC.
  20. Vick CC, Gray SH, Graham LA, Wesley M, Hawn MT. Do Variations in IRB Requirements for Patient Contact Effect Survey Response Rate? Paper presented at: VA Association of Surgeons Annual Meeting; 2007 May 10; Little Rock, AR.
  21. Hawn MT, Gray SH, Vick CC, Finan KR, Neumayer LA. Unplanned Enterotomy or bowel resection during elective hernia repair increases complications. Paper presented at: American College of Surgeons Spring Meeting; 2006 Oct 1; Chicago, IL.
  22. Hawn MT. Patient Reported Outcomes After Inguinal Hernia Repair. Paper presented at: Society of University Surgeons Academic Surgical Annual Congress; 2006 Feb 9; San Diego, CA.
  23. Hawn MT, Finan KR, Vick CC, Arguedas MR. Open Suture versus Mesh Repair of Primary Ventral Hernias: A Cost-Utility Analysis. Paper presented at: American College of Surgeons Surgical Forum; 2005 Oct 11; San Francisco, CA.
  24. Hawn M. Modern Day Hernia Repair. Paper presented at: American College of Surgeons Spring Meeting; 2005 Apr 18; Hollywood, FL.
  25. Hawn MT. Improvement in Gastrointestinal Symptoms and Quality of Life Following Cholecystectomy. Paper presented at: Society of American Gastrointestinal Endoscopic Surgeons Annual Meeting; 2005 Apr 14; Fort Lauderdale, FL.
  26. Hawn MT, Vick CC, Finan KR, Kiefe CI, Neumayer LA. Predictors of Wound Infection in Ventral Hernia Repair. Paper presented at: VA Association of Surgeons Annual Meeting; 2005 Mar 12; Salt Lake City, UT.
  27. Vick CC, Finan KR, Kiefe CI, Neumayer LA, Hawn MT. Variation in IRB processes for a Multisite Study. Paper presented at: VA Association of Surgeons Annual Meeting; 2005 Mar 12; Salt Lake City, UT.


DRA: Health Systems
DRE: none
Keywords: Clinical practice guidelines, Comorbidity, Education (provider)
MeSH Terms: none

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