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Unintended consequences of policy change to watchful waiting for asymptomatic inguinal hernias.
Ann R Coll Surg Engl 2014; 96(5):343-7AR

Abstract

INTRODUCTION

In 2009 the Department of Health instructed McKinsey & Company to provide advice on how commissioners might achieve world class National Health Service productivity. Asymptomatic inguinal hernia repair was identified as a potentially cosmetic procedure, with limited clinical benefit. The Birmingham and Solihull primary care trust cluster introduced a policy of watchful waiting for asymptomatic inguinal hernia, which was implemented across the health economy in December 2010. This retrospective cohort study aimed to examine the effect of a change in clinical commissioning policy concerning elective surgical repair of asymptomatic inguinal hernias.

METHODS

A total of 1,032 patients undergoing inguinal hernia repair in the 16 months after the policy change were compared with 978 patients in the 16 months before. The main outcome measure was relative proportion of emergency repair in groups before and after the policy change. Multivariate binary logistic regression was used to adjust the main outcome for age, sex and hernia type.

RESULTS

The period after the policy change was associated with 59% higher odds of emergency repair (3.6% vs 5.5%, adjusted odds ratio [OR]: 1.59, 95% confidence interval [CI]: 1.03-2.47). In turn, emergency repair was associated with higher odds of adverse events (4.7% vs 18.5%, adjusted OR: 3.68, 95% CI: 2.04-6.63) and mortality (0.1% vs 5.4%, p<0.001, Fisher's exact test).

CONCLUSIONS

Introduction of a watchful waiting policy for asymptomatic inguinal hernias was associated with a significant increase in need for emergency repair, which was in turn associated with an increased risk of adverse events. Current policies may be placing patients at risk.

Authors+Show Affiliations

Heart of England NHS Foundation Trust, UK.No affiliation info availableNo affiliation info availableNo affiliation info availableNo affiliation info availableNo affiliation info available

Pub Type(s)

Journal Article

Language

eng

PubMed ID

24992416

Citation

Hwang, M J., et al. "Unintended Consequences of Policy Change to Watchful Waiting for Asymptomatic Inguinal Hernias." Annals of the Royal College of Surgeons of England, vol. 96, no. 5, 2014, pp. 343-7.
Hwang MJ, Bhangu A, Webster CE, et al. Unintended consequences of policy change to watchful waiting for asymptomatic inguinal hernias. Ann R Coll Surg Engl. 2014;96(5):343-7.
Hwang, M. J., Bhangu, A., Webster, C. E., Bowley, D. M., Gannon, M. X., & Karandikar, S. S. (2014). Unintended consequences of policy change to watchful waiting for asymptomatic inguinal hernias. Annals of the Royal College of Surgeons of England, 96(5), pp. 343-7. doi:10.1308/003588414X13946184902000.
Hwang MJ, et al. Unintended Consequences of Policy Change to Watchful Waiting for Asymptomatic Inguinal Hernias. Ann R Coll Surg Engl. 2014;96(5):343-7. PubMed PMID: 24992416.
* Article titles in AMA citation format should be in sentence-case
TY - JOUR T1 - Unintended consequences of policy change to watchful waiting for asymptomatic inguinal hernias. AU - Hwang,M J, AU - Bhangu,A, AU - Webster,C E, AU - Bowley,D M, AU - Gannon,M X, AU - Karandikar,S S, PY - 2014/7/4/entrez PY - 2014/7/6/pubmed PY - 2014/9/4/medline SP - 343 EP - 7 JF - Annals of the Royal College of Surgeons of England JO - Ann R Coll Surg Engl VL - 96 IS - 5 N2 - INTRODUCTION: In 2009 the Department of Health instructed McKinsey & Company to provide advice on how commissioners might achieve world class National Health Service productivity. Asymptomatic inguinal hernia repair was identified as a potentially cosmetic procedure, with limited clinical benefit. The Birmingham and Solihull primary care trust cluster introduced a policy of watchful waiting for asymptomatic inguinal hernia, which was implemented across the health economy in December 2010. This retrospective cohort study aimed to examine the effect of a change in clinical commissioning policy concerning elective surgical repair of asymptomatic inguinal hernias. METHODS: A total of 1,032 patients undergoing inguinal hernia repair in the 16 months after the policy change were compared with 978 patients in the 16 months before. The main outcome measure was relative proportion of emergency repair in groups before and after the policy change. Multivariate binary logistic regression was used to adjust the main outcome for age, sex and hernia type. RESULTS: The period after the policy change was associated with 59% higher odds of emergency repair (3.6% vs 5.5%, adjusted odds ratio [OR]: 1.59, 95% confidence interval [CI]: 1.03-2.47). In turn, emergency repair was associated with higher odds of adverse events (4.7% vs 18.5%, adjusted OR: 3.68, 95% CI: 2.04-6.63) and mortality (0.1% vs 5.4%, p<0.001, Fisher's exact test). CONCLUSIONS: Introduction of a watchful waiting policy for asymptomatic inguinal hernias was associated with a significant increase in need for emergency repair, which was in turn associated with an increased risk of adverse events. Current policies may be placing patients at risk. SN - 1478-7083 UR - https://www.unboundmedicine.com/medline/citation/24992416/Unintended_consequences_of_policy_change_to_watchful_waiting_for_asymptomatic_inguinal_hernias_ L2 - http://publishing.rcseng.ac.uk/doi/full/10.1308/003588414X13946184902000?url_ver=Z39.88-2003&amp;rfr_id=ori:rid:crossref.org&amp;rfr_dat=cr_pub=pubmed DB - PRIME DP - Unbound Medicine ER -