Ventral Hernia: Improving Quality Across the Collaborative

Dana A. Telem MD MPH

Chief, Division of Minimally Invasive and Bariatric SurgeryAssociate Chair for Clinical Affairs

Associate Professor of SurgeryUniversity of Michigan

Disclosures

• AHRQ K08HS025778• Medtronic - research funding• NIH (Co-I) R01DK115408

Hernia

•Common – 1.6M diagnosed, 500,000 fixed

•Costly – 3.2Billion associated healthcare expenditures

•Morbid – Short and long-term (recurrence)

•Why? – Variability in care.

Abdominal Wall Hernia Repair

• Black box

• Lack of standardization• Nomenclature• Operative notes• Operative technique• Patient selection

• Claims data difficult for generalization

How do we improve quality?

Patients Technique

What do we know?

• Factors that increase risk of morbidity and recurrence:ØDiabetes with poor glycemic control*ØObesity*ØSmoking*ØSubstance abuse*ØCollagen disordersØChronic immunosuppressionØWomen of childbearing age

* Modifiable J Am Coll Surg. 2015;221(2):478-85.Hernia. 2014;18(1):19-30.Hernia. 2013;17(5):639-45.

Demographic characteristics

Characteristic N (%)BMI Quartile

1st 5737 (25%)2nd 5844 (26%)3rd 5703 (25%)4th 5343 (24%)

Nonindependent 224 (1%)HTN 10691 (47%)CHF 57 (<1%)COPD 1874 (8%)CAD 2348 (10%)PVD 450 (2%)Bleeding Disorder 473 (2%)DVT 1124 (6%)OSA 5754 (25%)

Characteristic N (%)Age

<45 5945 (26%)45-64 11191 (49%)>65 5528 (24%)

Female 10496 (46%)Race

White 19252 (85%)Black 2452 (11%)Other 960 (4%)

ASA Classification1 1549 (7%)2 11763 (52%)3 8871 (39%)4 467 (2%)

Characteristic N (%)

Alcohol Use 657 (3%)

Smoking 5492 (24%)

Diabetes Classification

None 18472 (81%)

Diet-Controlled 605 (3%)

Non-Insulin Dependent 2487 (11%)

Insulin-Dependent 1100 (5%)

Open 15868 (70%)

Inpatient Status 6974 (31%)

JAMA Network Open. In revisions.

N=22,664

Multilevel mixed-effects logistic regression model of primary outcomes.Increased risk for complication, discharge not to home, ED utilization and 30-day readmission associated with:

•4th quartile obesity (BMI 42)• Insulin Dependent Diabetes• Substance abuse

•Minimally Invasive Surgery was Protective!

Submitted for Peer Review

Median and interquartile range associated with each outcome

Added episode and cumulative spending attributed to significant modifiable risk

Qualitative Assessment:

• Theoretical domains framework (TDF) to understand surgeon motivation and behavior.

• Individual implementation framework that maps to behavior change techniques.

• Design of a theory-informed intervention for identified practice gaps.

Theoretical Domains Framework

Knowledge Skills

Social/Professional

Role and Identity

Beliefs about Capabilities

Optimism Beliefs about Consequences Reinforcement Intentions

GoalsMemory,

Attention and Decision Processes

Environmental Context and Resources

Social Influences

Emotion Behavioral Regulation

Cane et al. Validation of the theoretical domains framework for use in behavior change and implementation research. Implement Sci 2012, 7(1):37.

5 major domains influencing decision making

KnowledgeSocial/

Professional Role and Identity

Beliefs about Consequences

Environmental Context and Resources

Social Influences

Representative Quotes

“And so it’s bad to say this, but I think that also a lot of times it depends on who’s doing what research. Because at one time you’ll have, you know, one of the

recognized top hernia experts in the world talking about one particular repair, and it’s because at that moment in time they’re getting funded by somebody to do that

research. And then a month later when the next person comes up and says, hey, how about this? Then they’re going to change gears and they’re going to be talking

about how this is the best group here.” (Participant 18)Frequency: 9

“It's a little bit of the Wild West, I feel like. So right now, there's a ton of practice variation, even within my small group… And so right now, I'm sort of cherry picking

between the things that seem to have the highest, the greatest concordance.” (Participant 7)

Frequency: 11

What Does this All Mean?

Target for change

• Goal is to optimize patients prior to surgery.

• Modifiable factors:• BMI < 35-40 (surgeon and operation dependent)• Smoking cessation 4-6 weeks preoperative (cotinine test)• AIC levels < 8

• Data from MSQC suggest adherence would decrease complications and episode of care spending.

Venue for Change: Statewide Appropriateness

• Expansion of criteria statewide via a hernia care pathway

• Focus on glycemic control, obesity and substance cessation

• Creating task force and partnerships

Synthesizing Data: Steps moving forward

• Statewide synoptic operative note**

• Addition of data elements to MSQC for abstraction

• Innovative payment models (2020)

Summary

• When to operate à Don’t if possible• Bariatric surgery!

• Pre-habilitation and managing expectations are key

• If OR is needed, MIS preferred approach

Thank you!dtelem@med.umich.edu

@DanaTelem