Hospital-level variation in mesh use for ventral and incisional hernia repair

Ryan Howard; Anne Ehlers; Lia Delaney; Quintin Solano; Mary Shen; Michael Englesbe; Justin Dimick; Dana Telem

doi:10.1007/s00464-022-09357-w

Hospital-level variation in mesh use for ventral and incisional hernia repair

Surg Endosc. 2023 Feb;37(2):1501-1507. doi: 10.1007/s00464-022-09357-w. Epub 2022 Jul 18.

Authors

Ryan Howard^{1

2}, Anne Ehlers^{1

2}, Lia Delaney³, Quintin Solano³, Mary Shen^{1

2}, Michael Englesbe^{1

4}, Justin Dimick^{1

5}, Dana Telem^{6

7}

Affiliations

¹ Department of Surgery, University of Michigan, Ann Arbor, MI, USA.
² Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, MI, USA.
³ University of Michigan Medical School, Ann Arbor, MI, USA.
⁴ Michigan Surgical Quality Collaborative, Ann Arbor, MI, USA.
⁵ Division of Minimally Invasive Surgery, Department of Surgery, Michigan Medicine, 2926 Taubman Center, 1500 E Medical Center Dr SPC 5331, Ann Arbor, MI, 48109-5331, USA.
⁶ Department of Surgery, University of Michigan, Ann Arbor, MI, USA. dtelem@med.umich.edu.
⁷ Division of Minimally Invasive Surgery, Department of Surgery, Michigan Medicine, 2926 Taubman Center, 1500 E Medical Center Dr SPC 5331, Ann Arbor, MI, 48109-5331, USA. dtelem@med.umich.edu.

PMID: 35851814
DOI: 10.1007/s00464-022-09357-w

Abstract

Background: Placement of prosthetic mesh during ventral and incisional hernia repair has been shown to reduce the incidence of postoperative hernia recurrence. Consequently, multiple consensus guidelines recommend the use of mesh for ventral hernias of any size. However, the extent to which real-world practice patterns reflect these recommendations is unclear.

Methods: We performed a retrospective review of the Michigan Surgical Quality Collaborative Hernia Registry (MSQC-HR) to identify patients undergoing clean ventral or incisional hernia repair between January 1, 2020 and December 31, 2021. The primary outcome was mesh use. We used two-step hierarchical logistic regression modeling with empirical Bayes estimates to evaluate the association of hospital-level mesh use with patient, operative, and hernia characteristics.

Results: A total of 5262 patients underwent ventral and incisional hernia repair at 65 hospitals with a mean age of 53.8 (14.5) years, 2292 (43.6%) females, and a mean hernia width of 3.2 (3.4) cm. Mean hospital volume was 81 (49) cases. Mesh was used in 4098 (77.9%) patients. At the patient level, hernia width and surgical approach were significantly associated with mesh use. Specifically, mesh use was 6.2% (95% CI 4.8-7.5%) more likely with each additional centimeter of hernia width and 28.0% (95% CI 26.1-29.8%) more likely for minimally invasive repair compared to open repair. At the hospital level, there was wide variation in mesh use, ranging from 38.0% (95% CI 31.5-44.9%) to 96.4% (95% CI 95.3-97.2%). Hospital-level mesh use was not associated with differences in hernia size (β = - 0.003, P = 0.978), surgical approach (β = - 1.109, P = 0.414), or any other patient factors.

Conclusions: Despite strong evidence supporting the use of mesh in ventral and incisional hernia repair, there is substantial variation in mesh use between hospitals that is not explained by differences in patient characteristics or operative approach. This suggests that opportunities exist to standardize surgical practice to better align with evidence supporting the use of mesh in the management of these hernias.

Keywords: Best practice; Hernia; Mesh; Practice improvement; Variation.

MeSH terms

Bayes Theorem
Female
Hernia, Ventral* / surgery
Herniorrhaphy
Humans
Incisional Hernia* / surgery
Laparoscopy*
Male
Middle Aged
Recurrence
Surgical Mesh