Outpatient inguinal hernia repair in Spain: a population-based study of 1,163,039 patients-clinical and socioeconomic factors associated with the choice of day surgery

Which factors influence the decision of hospitals to provide procedures on an outpatient basis? -Mixed-methods evidence from Germany

Shifting care from the resource-intensive inpatient setting to the more economically efficient outpatient sector is being promoted internationally by policymakers. Financial incentives are a major focus of such efforts because low levels of hospital outpatient care are attributed to differences in payment for inpatient and outpatient services. In Germany, however, there is significant variation in the extent to which hospitals provide outpatient care despite a uniform payment system. Therefore, other factors must be influencing German hospitals' strategic decisions whether to offer outpatient care. While most research has focused on specific procedures or lacks empirical support, our study provides a comprehensive analysis of the factors beyond financial incentives that influence the provision of hospital outpatient services in Germany. We employed a mixed-methods approach, first contacting health care experts with in-depth knowledge of the hospital outpatient landscape to identify possible influencing factors and then conducting a comprehensive quantitative analysis of all German hospitals. Our findings suggest that policymakers seeking to promote hospital outpatient care should consider a broad range of factors. We found that a hospital's service mix, size, procedure volume, and emergency care infrastructure significantly affected the proportion of outpatient services it offered. Strategic hospital planning emphasizing specialization and adherence to minimum volume standards might therefore be a valuable policy tool. Our analysis also highlights the importance of demographic and socioeconomic factors, such as the regional share of single-person households, suggesting that a comprehensive policy framework should account for broader population characteristics and not just elements directly related to hospital care.

Outpatient Surgery and Unplanned Overnight Admission in Bilateral Inguinal Hernia Repair: A Population-based Study

PURPOSE

The use of outpatient surgery in inguinal hernia is heterogeneous despite clinical recommendations. This study aimed to analyze the utilization trend of outpatient surgery for bilateral inguinal hernia repair (BHIR) in Spain and identify the factors associated with outpatient surgery choice and unplanned overnight admission.

METHODS

A retrospective observational study of patients undergoing BIHR from 2016 to 2021 was conducted. The clinical-administrative database of the Spanish Ministry of Health RAE-CMBD was used. Patient characteristics undergoing outpatient and inpatient surgery were compared. A multivariable logistic regression analysis was performed to identify factors associated with outpatient surgery choice and unplanned overnight admission.

RESULTS

A total of 30,940 RHIBs were performed; 63% were inpatient surgery, and 37% were outpatient surgery. The rate of outpatient surgery increased from 30% in 2016 to 41% in 2021 (p < 0.001). Higher rates of outpatient surgery were observed across hospitals with a higher number of cases per year (p < 0.001). Factors associated with outpatient surgery choice were: age under 65 years (OR: 2.01, 95% CI: 1.92-2.11), hospital volume (OR: 1.59, 95% CI: 1.47-1.72), primary hernia (OR: 1.89, 95% CI: 1.71-2.08), and laparoscopic surgery (OR: 1.47, 95% CI: 1.39-1.56). Comorbidities were negatively associated with outpatient surgery. Open surgery was associated (OR: 1.26, 95% CI: 1.09-1.47) with unplanned overnight admission.

CONCLUSIONS

Outpatient surgery for BHIR has increased in recent years but is still low. Older age and comorbidities were associated with lower rates of outpatient surgery. However, the laparoscopic repair was associated with increased outpatient surgery and lower unplanned overnight admission.

Scheduled and urgent inguinal hernia repair in Ontario, Canada between 2010 and 2022: Population-based cross sectional analysis of trends and outcomes

INTRODUCTION

We examine trends in inguinal hernia repairs with respect to the COVID-19 pandemic and secular trends in Ontario, Canada.

METHODS

This was a retrospective cohort study. Hernia repairs performed January 1, 2010-December 31, 2022 were captured from health administrative inpatient and outpatient databases. Patients managed in three clinical settings were examined: public hospital in-patient, semi-private hospital in-patient (Shouldice Hospital), and public hospital out-patient. We examined the effect of the COVID-19 pandemic on surgical volumes, clinical setting, patient characteristics by setting, time from diagnosis until surgery, hospital length-of-stay, and patient outcomes (90-day readmissions, 1-year reoperations). We used multivariable logistic regression to examine whether patient outcomes were comparable between the COVID-19 period and the pre-pandemic period, adjusted sociodemographic and clinical factors. Shouldice Hospital is the only semi-private hospital in Ontario specializing in hernia repair (patients pay for the mandated admission, but not for the procedure).

RESULTS

During the pandemic (March 2020-December 2022), there were 8,162 fewer (15%) scheduled inguinal hernia repairs than expected, but the age-sex standardized rate of urgent repairs remained unchanged. Shouldice Hospital performed more surgeries in the COVID-19 era than pre-pandemic and had a shorter average LOS by 24 hours, despite treating more patients with older age, higher ASA score [adjusted odds ratio (aOR) 2.13 (1.93-2.35) III vs I-II] and greater comorbidity [aOR 1.36 (1.08-1.70) for 2 vs none] than pre-pandemic. Patients treated in the COVID-19 era experienced a longer time until surgery, being the longest in 2022 (median 133 days). Ninety-day readmissions and 1-year reoperations were lower in the COVID-19 era and lower for patients receiving surgery at Shouldice Hospital.

CONCLUSION

During the COVID-19 pandemic, there were 8,162 fewer scheduled hernia repairs than expected, longer wait-times until surgery, shorter length-of-stay, and more patients with comorbidities, but outcomes were not worse compared with the pre-pandemic period.

Implementing an outpatient surgical management in moderated-high risk patients with groin hernia repair

PURPOSE

There is a growing trend to expand Ambulatory Surgery (AS) criteria in abdominal wall surgery. No Admission (NOADS) circuit. The present study aimed to assess the impact of classification criteria on postoperative results and hospital stays in a NOADS versus a conventional admission circuit to throw some light on surgical circuit inclusion.

METHODS

A retrospective analysis of a prospective;y maintained database was performed comparing groin hernia's interventions in a NOADS vs Admission circuit in our center in 2018-2021. A multiple regression predictive model followed by a retrospective retest were dessigned to assess the impact of each criterion on hospital stay. In total, 743 patients were included, 399 in the Admission circuit (ADC) and 344 in NOADS circuit (NOADS).

RESULTS

There were no statistical differences in complication or readmission rates (p = 0.343 and p = 0.563), nevertheless, a shorter hospital stay was observed in NOADS (p = 0.000). A hierarchical multiple regression predictive model proposed two opposite scenarios. The best scenario, not likely to need admission, was a female patient operated via the laparoscopic approach of a unilateral primary hernia (Estimated Postoperative Stay: 0.049 days). The worst scenario, likely to need admission, was a male patient operated via the open approach of a bilateral and recurrent hernia (Estimated Postoperative Stay: 1.505 Days).

CONCLUSION

Groin hernia patients could safely benefit from a No Admission (NOADS) circuit. Our model could be useful for surgical circuit decision-making, especially for best/worst scenarios.

Bilateral inguinal hernia repair by laparoscopic totally extraperitoneal (TEP) vs. laparoscopic transabdominal preperitoneal (TAPP)

BACKGROUND

The guidelines recommend laparoscopic repair for bilateral inguinal hernia. However, few studies compare the totally extraperitoneal (TEP) and transabdominal preperitoneal (TAPP) techniques in bilateral inguinal hernias. This study aimed to compare the outcomes of TEP and TAPP in bilateral inguinal hernia.

METHODS

We conducted a retrospective cohort study of patients operated on for bilateral inguinal hernia by TEP and TAPP repair from 2016 to 2020. Intraoperative complications, operative time, acute postoperative pain, hospital stay, postoperative complications, chronic inguinal pain, and recurrence were compared.

RESULTS

A total of 155 patients were included in the study. TEP was performed in 71 patients (46%) and TAPP in 84 patients (54%). The mean operative time was longer in the TAPP group than in the TEP group (107 min vs. 82 min, p < 0.001). The conversion rate to open surgery was higher in the TEP group than in the TAPP group (8.5% vs. 0%, p = 0.008). The mean hospital stay was longer in the TAPP group than in the TEP group (p < 0.001). We did not observe significant differences in the proportion of postoperative complications (p = 0.672), postoperative pain at 24 h (p = 0.851), chronic groin pain (p = 0.593), and recurrence (p = 0.471). We did not observe an association between the choice of surgical technique (TEP vs. TAPP) with conversion rate, operative time, hospital stay, postoperative complications, chronic inguinal pain, or hernia recurrence when performing a multivariable analysis adjusted for the male sex, age, BMI, ASA, recurrent hernia repair, surgeon, and hernia size > 3cm.

CONCLUSIONS

Bilateral inguinal hernia repair by TEP and TAP presented similar outcomes in our study.