乌鸦传媒

A presurgical optimization clinic for high-risk patients seeking elective hernia surgery was safe and improved patient outcomes, researchers found in a quality improvement study.

In an analysis involving 165 patients enrolled in the perioperative optimization program for a year, 9.1% were optimized for surgery after the program, only 3.0% required emergent surgery due to hernia incarceration, and 13.8% of the smokers in the group were able to stop smoking, reported Dana Telem, MD, MPH, of the University of Michigan in Ann Arbor, and colleagues.

"Some may see a 9.1% crossover rate from nonoperative to operative status as dismal results," the authors wrote in . "However, this clinic was designed to capture nonoperative candidates, because of the presence of relative contraindications that could undergo mitigation."

Surgical yield in the standard hernia clinic also increased by 19%, according to the study.

"These findings suggest that this model represents a scalable and sustainable framework for preoperative optimization with the potential to improve the care of patients with hernias," wrote Telem and co-authors.

Over 350,000 ventral and incisional hernia repairs are performed annually, but these procedures are associated with a high risk for postoperative complications, the researchers noted. The perioperative timeframe may provide an opportunity to encourage patients to change certain behaviors.

Nearly 25% of patients undergoing elective abdominal hernia repairs are "not optimized with respect to weight or substance use," the group noted. "Simply denying operative management for high-risk patients, while avoiding the risks associated with surgery, is associated with poor quality of life."

Telem and colleagues retrospectively evaluated data on 165 high-risk patients seeking elective hernia surgery enrolled in a presurgical hernia "low-cost optimization clinic" at the University of Michigan in 2019.

Active smokers, those with a BMI of 40 or greater, or age 75 or older were considered high risk. Patients who screened positive for any of these risk factors had the option of a 30-minute appointment in the optimization clinic instead of with the surgeon. At the clinic, the clinician and patient agreed to an "individualized optimization goal."

Follow-up occurred via in-person appointments and phone calls every 6 to 8 weeks. If a patient met their predefined health goals, such as quitting smoking or losing weight, they were referred back to a surgeon.

The authors noted that patients had no minimum or limit on the number of visits to the optimization clinic during this pilot period.

Primary outcome assessed surgical eligibility and safety after clinic participation. The secondary outcome assessed program costs.

Of the 165 patients evaluated, most were white (88%) and over half women (55%), with a mean age of 59 and average BMI of about 38. BMI was the most common reason for referral (37%), followed by smoking (26%) and age (24%). Median range of follow-up was 197 days. Nearly 70% (n=115) had ventral or incisional hernia repairs, and 27% had umbilical hernias.

Overall, 15 patients in the optimization clinic met their goals and became eligible for surgery, 12 of which qualified by achieving their health goals. Eight active smokers had a negative cotinine test, and three patients achieved eligibility through weight loss. Three patients ages 75 and up were eligible for surgery following an evaluation of their functional status.

"It is important to note that this program was able to leverage interactions in the preoperative period to provide an intervention to a patient population that may not have taken steps otherwise," they wrote.

Cost-wise, the program required an investment of $41,536, but saw a 58% increase in hernia-attributed "relative value units" versus 2019, and "without altering surgeon workflow," the authors noted.

The analysis had several limitations, including the small cohort. The wide variety of hernia types may limit generalizability about risk of delayed surgery for patients with straightforward, small hernias, as well as for those with complex ventral hernias, the group acknowledged.

Comment