New Orleans—New research on incisional hernia shows patients who fall into disadvantaged groups are more likely to present with surgical emergencies, and to experience the higher rates of complications and longer hospital stay associated with them.

“Incisional hernia is largely preventable, and there are unique opportunities for intervention to avoid a much more difficult operation,” said Clarissa Mulloy, MD, a surgical resident. “Addressing this issue will lead to better outcomes and lower cost burden on the patient and the health care system.”

Based on reports in the ventral hernia literature, Dr. Mulloy and her colleagues at Louisiana State University in New Orleans hypothesized that patients in minority groups—such as older patients, female patients, those at lower socioeconomic levels (using insurance status as a surrogate), and nonwhite race—will present more frequently with emergent/urgent incisional hernia cases compared with majority group members.

For the study, the researchers obtained data on admissions related to incisional hernia from the Healthcare Cost and Utilization Project National Inpatient Sample from 2012 to 2014. Their biostatistician performed analyses in two tiers; a database characterized admission type as elective, emergent admissions (people who came through the emergency department), and urgent (everyone not in the first two groups).

The study included a total of 39,296 cases, most of which were elective (61%). There was a significant difference in the rate of urgent admissions between age groups, with the greatest proportion seen in patients over 65 years of age. Similarly, women accounted for 40% of urgent admissions, while men accounted for 35%. In terms of socioeconomics, self-paying patients had the highest proportion of urgent admissions followed by patients with Medicaid coverage.

“The lowest proportion of urgent admission was among patients with private insurance,” Dr. Mulloy said, who is now a surgical resident at Temple University, in Philadelphia.

White patients made up the lowest proportion of urgent cases, while Black patients had the highest rate of urgent admissions. When controlling for age, insurance status and sex, race disparities remained significant.

“Compared with white patients, the odds of admission being urgent were significantly higher for racial minorities; it was highest amongst Black patients,” Dr. Mulloy said.

In the future, she and her colleagues plan to compare local outcomes with national findings and use that information to develop and fund clinical trials aimed at addressing the disparities in incisional hernia presentations.

Dr. Mulloy presented her research, which she described as the first national-level health disparities study of incisional hernia, at the 2020 Southeastern Surgical Congress.

“As we continue to work to improve health disparities in America, we first need to identify them and understand their underlying causes,” said Jessica Burgess, MD, an assistant professor of surgery at Eastern Virginia Medical School, in Norfolk, who had a couple of questions for Dr. Mulloy.

“Patients who present for emergent/urgent hernia repairs have a higher rate of complication and increased cost associated with their hospitalization. Do you advocate for more elective repair instead of watchful waiting in these at-risk populations? Also, what do you think is a possible solution to this problem?”

Dr. Mulloy said she and her colleagues support early repair for patients at the highest risk for urgent care, particularly self-paying patients. “We think it’s better to intervene early, when cases are still elective.”

As for possible solutions, she and her team have come up with two complementary strategies, the first of which is surgeon and physician education, “as we are the ones who have to educate our patients on the risks of taking a watch-and-wait approach to incisional hernia,” Dr. Mulloy said.

“The second component is prevention of incisional hernia to avoid the problem entirely.” Recent work from her group has found a 60% to 80% reduction in incisional hernia formation using amniotic tissues. “Prophylactic mesh reinforcement of laparotomy closures has also been shown to be effective at preventing incisional hernia,” she said.