PDF(Pubmed)
Abstract：
Background: Health disparities are pervasive in surgical care. Particularly racial and socioeconomic inequalities have been demonstrated in emergency general surgery outcomes, but less so in elective abdominal wall reconstruction (AWR). The goal of this study was to evaluate the disparities in referrals to a tertiary hernia center. Methods: A prospectively maintained hernia database was queried for patients who underwent open ventral hernia (OVHR) or minimally invasive surgical (MISR) repair from 2011 to 2022 with complete insurance and address information. Patients were divided by home address into in-state (IS) and out-of-state (OOS) referrals as well as by operative technique. Demographic data and outcomes were compared. Standard and inferential statistical analyses were performed. Results: Of 554 patients, most were IS (59.0%); 334 underwent OVHR, and 220 underwent MISR. IS patients were more likely to undergo MISR (OVHR: 45.6% vs. 81.5%, laparoscopic: 38.2% vs. 14.1%, robotic: 16.2% vs. 4.4%; p < 0.001) when compared to OOS referrals. Of OVHR patients, 44.6% were IS and 55.4% were OOS. Patients\' average age and BMI, sex, ASA score, and insurance payer were similar between IS and OOS groups. IS patients were more often Black (White: 77.9% vs. 93.5%, Black: 16.8% vs. 4.3%; p < 0.001). IS patients had more smokers (12.1% vs. 3.2%; p = 0.001), fewer recurrent hernias (45.0% vs. 69.7%; p < 0.001), and smaller defects (155.7 ± 142.2 vs. 256.4 ± 202.9 cm2; p < 0.001). Wound class, mesh type, and rate of fascial closure were similar, but IS patients underwent fewer panniculectomies (13.4% vs. 34.1%; p < 0.001), component separations (26.2% vs. 51.4%; p < 0.001), received smaller mesh (744.2 ± 495.6 vs. 975.7 ± 442.3 cm2; p < 0.001), and had shorter length-of-stay (4.8 ± 2.0 vs. 7.0 ± 5.5 days; p < 0.001). There was no difference in wound breakdown, seroma requiring intervention, hematoma, mesh infection, or recurrence; however, IS patients had decreased wound infections (2.0% vs. 8.6%; p = 0.009), overall wound complications (11.4% vs. 21.1%; p = 0.016), readmissions (2.7% vs. 13.0%; p = 0.001), and reoperations (3.4% vs. 11.4%; p = 0.007). Of MISR patients, 80.9% were IS and 19.1% were OOS. In contrast to OVHR, MISR IS and OOS patients had similar demographics, preoperative characteristics, intraoperative details, and postoperative outcomes. Conclusion: Although there were no differences in referred patients for MISR, this study demonstrates the racial disparities that exist among our IS and OOS complex, open AWR patients. Awareness of these disparities can help clinicians work towards equitable access to care and equal referrals to tertiary hernia centers.
摘要：
背景：健康差异在外科护理中普遍存在。特别是种族和社会经济不平等已经证明在紧急普外科手术的结果，但在选择性腹壁重建术（AWR）中的情况较少。这项研究的目的是评估转诊到三级疝中心的差异。方法：在前瞻性维护的疝数据库中查询2011年至2022年接受开放式腹侧疝（OVHR）或微创手术（MISR）修复的患者，并提供完整的保险和地址信息。根据家庭住址将患者分为州内（IS）和州外（OOS）转诊以及手术技术。比较了人口统计数据和结果。进行标准和推理统计分析。结果：554例患者中，大多数是IS(59.0%)；334人接受了OVHR，220人接受了MISR。IS患者更有可能接受MISR(OVHR：45.6%vs.81.5%,腹腔镜：38.2%vs.14.1%,机器人：16.2%vs.4.4%；p<0.001)与OOS转诊相比。OVHR患者，44.6%为IS，55.4%为OOS。患者平均年龄和BMI，性别,ASA得分,IS组和OOS组的保险付款人相似。IS患者更常见的是黑人(白人：77.9%vs.93.5%,黑色：16.8%与4.3%；p<0.001）。IS患者的吸烟者更多（12.1%vs.3.2%；p=0.001)，复发性疝较少(45.0%vs.69.7%；p<0.001)，和更小的缺陷(155.7±142.2vs.256.4±202.9cm2；p<0.001）。伤口类别,网格类型,筋膜闭合率相似，但IS患者接受脂膜切除术较少(13.4%vs.34.1%；p<0.001)，组分分离(26.2%与51.4%；p<0.001)，收到较小的网眼(744.2±495.6vs.975.7±442.3cm2;p<0.001),并且住院时间较短(4.8±2.0vs.7.0±5.5天；p<0.001）。伤口破裂没有区别，需要干预的血清肿，血肿,网状感染,或复发；然而，IS患者伤口感染减少(2.0%vs.8.6%；p=0.009)，整体伤口并发症（11.4%vs.21.1%；p=0.016)，再入院（2.7%与13.0%；p=0.001），和重新手术（3.4%与11.4%；p=0.007）。在MISR患者中，80.9%为IS，19.1%为OOS。与OVHR相比，MISRIS和OOS患者的人口统计学特征相似，术前特征,术中细节,和术后结果。结论：虽然转诊患者的MISR没有差异，这项研究证明了我们的IS和OOS复合体之间存在的种族差异，开放AWR患者。对这些差异的认识可以帮助临床医生努力实现公平获得护理和向三级疝气中心的平等转诊。
