Program Modeled on Michigan Bariatric Quality Collaborative

By Christina Frangou

The American Hernia Society (AHS) will launch a new quality collaborative this month that is expected to improve standards for ventral hernia care across the country.

At its annual meeting in March, the society will formally kick off the AHS Quality Collaborative, a voluntary performance-tracking system available for all hernia surgeons in the United States.

The program consists of three components: a database that collects detailed clinical information on practice and outcomes on a case-by-case basis, a system for real-time performance feedback to clinicians and a process for continuous improvement based on analysis of the data collected.

“This will be the first time that continuous quality improvement will be applied to hernia repair in the United States on a national level,” said co-organizer Benjamin K. Poulose, MD, assistant professor of general surgery, Vanderbilt University Medical Center, Nashville, Tenn. Dr. Poulose serves on the AHS Outcomes Committee, which is spearheading the initiative.

“Ventral hernia remains a disease entity that is very common, has wide variation in care (often leading to wasteful care), has less than ideal outcomes, can be very expensive and has many unanswered questions in management. All this leads to poor value for patients and caregivers in the management of ventral hernia,” said Dr. Poulose.

“We hope to not only improve the quality of hernia repair with the [quality collaboration], we hope to improve value as well.”

The program is modeled after the Michigan Bariatric Collaborative, which has been credited with reducing bariatric mortality rates in the state to a fraction of the national average.

“Nothing like this has been done before in the field of hernia. If we can replicate what they’ve done in the field of bariatrics, it’s going to bring tremendous growth and improvement to the wild, Wild West of hernia surgery,” said co-organizer Michael J. Rosen, MD, associate professor of surgery and director of the Case Comprehensive Hernia Center, Case Western Reserve University, Cleveland.


The AHS decided against implementing a Centers of Excellence program, and instead developed a program that focuses on outcomes rather than processes, that includes all hernia surgeons and does not penalize surgeons or hospitals.

For the past several years, the AHS has debated implementing a Centers of Excellence program, similar to the nationwide program that exists in bariatrics. However, the society was turned off by a lack of definitive evidence demonstrating that Centers of Excellence programs produce real improvements in patient outcomes. Moreover, such programs often are polarizing and controversial, and do not have the necessary infrastructure to assess ways to improve the quality of care, said Dr. Rosen.

Instead, the AHS decided to develop its own program that focuses on outcomes rather than processes, includes all hernia surgeons and does not penalize surgeons or hospitals.

Like the Michigan Bariatric Quality Collaborative, the AHS system will employ a database from ArborMetrix, a company founded by John D. Birkmeyer, MD, George D. Zuidema Professor of Surgery at the University of Michigan and a leader in the surgical quality care arena.

ArborMetrix has established quality programs for a number of different national surgical societies and operates nine payer-funded collaboratives for surgical specialties in Michigan.

Dr. Birkmeyer said that the program will focus on long-term measures of effectiveness, things like recurrence, and will capture patient-centered outcomes like pain and functional status. “A couple of years from now, I expect AHS will serve as a model for how to measure and improve surgical effectiveness, not just safety.”

He added, “I’m really excited about the AHS program and, as a surgeon who sees hernia patients, I plan to participate myself.”

Participating surgeons and their staff will input data to the system on a patient-by-patient basis and receive real-time, risk-stratified metrics about the outcomes they can expect. A surgeon would be able to sit down with a patient in front of a computer, plug in the patient’s risk information—things like diabetes, body mass index, hernia size—and get an assessment of the patient’s expected wound infection rate, mesh infection rate, hernia recurrence rate and improvement in quality of life.

Surgeons can access their own data anytime. They’ll see a dashboard that depicts their own data set against that of their peers, all de-identified.

Hospitals will provide basic information about the hospital stay, such as length of stay and time in the operating room. Eventually, coordinators hope to incorporate a patient-access portal where patients can enter their own data directly into the database.

At regular intervals, analysts will review the data to identify what processes are associated with the best outcomes. “We’ll pick the topic, like surgical site infections, and find out what people can do differently—what antibiotics, what type of prep, what type of operation—to get everybody up to a higher level,” said Dr. Rosen.

Organizers have outlined 10 basic initiatives for the program. They are:

  1. Identify the factors contributing to recurrence.
  2. Assess quality of life after hernia repair.
  3. Reduce surgical site complications.
  4. Evaluate potential advantages of laparoscopic repairs.
  5. Explore mechanisms of hernia recurrence.
  6. Identify factors contributing to mesh infection.
  7. Minimize perioperative pain.
  8. Evaluate the effect of hernia characteristics on outcomes.
  9. Evaluate optimal methods of mesh fixation.
  10. Validate an accepted hernia classification system.

To start, the AHS Quality Collaborative will be rolled out to a pilot group of 20 institutions. Eventually, organizers hope to extend the program to inguinal hernia.

The cost of the program had yet to be finalized at press time. Organizers say they expect to charge about $750 per year per surgeon for the first three surgeons at a hospital, and free of charge for additional surgeons. The AHS has invested $250,000 in the Quality Collaboration to date.