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Published on: November 30, 2010
Frequency of Potentially Avoidable Surgical Referrals for Asymptomatic Umbilical Hernias in Children
Katherine He1, Jonathan L Hills-Dunlap2, Mark A Kashtan3
1Department of Surgery, Boston Children's Hospital, Boston, Massachusetts.
Insights
Potentially avoidable referrals for asymptomatic umbilical hernias in children did not decrease after 2019 guidelines. One-third of referrals remain avoidable, highlighting a need for better provider education on pediatric hernia management.
Area of Science:
- Pediatric Surgery
- Clinical Guidelines
- Healthcare Management
Background:
- The American Academy of Pediatrics (AAP) issued guidelines in 2019 recommending delayed surgical referral for asymptomatic umbilical hernias in children until 4-5 years of age.
- Umbilical hernias are common in children, and guidelines aim to reduce unnecessary surgical interventions and healthcare resource utilization.
Purpose of the Study:
- To evaluate the rates of potentially avoidable referrals (PAR) for pediatric umbilical hernias after the AAP guideline release.
- To determine if the incidence of PAR has changed following the implementation of the 2019 AAP guidelines.
Main Methods:
- A retrospective analysis of 803 umbilical hernia referrals to a pediatric surgery clinic from October 2014 to August 2021.
- Potentially avoidable referrals were defined as asymptomatic, non-enlarging umbilical hernias in children aged 3 years or younger without prior incarceration.
- Referral indications, outcomes, and PAR rates were compared before and after the 2019 AAP guideline publication.
Main Results:
- Out of 803 referrals, 48% were in children 3 years or younger. 33% of all referrals and 68% of early referrals were classified as PAR.
- The rates of PAR remained statistically unchanged post-guideline release (all referrals: 32% vs. 33%, P=0.94; early referrals: 68% vs. 67%, P=0.94).
- Among 333 early referrals managed expectantly, only 2 (0.6%) experienced incarceration, successfully managed with reduction and interval repair.
Conclusions:
- A significant proportion (one-third) of umbilical hernia referrals are potentially avoidable, and this rate has not decreased since the 2019 AAP guidelines.
- Improved communication and education between pediatric surgeons and referring providers are necessary to align expectations and reduce unnecessary visits.
- Reducing avoidable referrals can decrease healthcare costs, improve caregiver productivity, and prevent unnecessary surgical procedures in children.
Introduction:
The American Association of Pediatrics released guidelines in 2019 recommending delay of surgical referral in children with asymptomatic umbilical hernias until 4-5 y of age. The purpose of this study was to assess contemporary rates of potentially avoidable referrals in this cohort of children, and to assess whether rates have decreased following guideline release.
Methods:
Retrospective analysis of umbilical hernias referrals evaluated at a single pediatric surgery clinic from October 2014 to August 2021. Potentially avoidable referrals (PAR) were defined as asymptomatic, non-enlarging umbilical hernia referrals in a child 3 y of age or younger without a history of incarceration. Referral indication, disposition following clinic visit, and rates of PAR were compared before and after guideline release.
Results:
A total of 803 umbilical hernia referrals were evaluated, of which 48% were in children 3 y of age or younger at time of evaluation ("early" referrals). 33% of all referrals and 68% of early referrals were categorized as a PAR, and rates were similar before and after guideline release (all referrals: 32% versus 33%, P = 0.94; early referrals: 68% versus 67%, P = 0.94). Of the 333 early referrals who were managed expectantly per guideline recommendations, 2 (0.6%) developed incarceration which was managed with successful reduction and interval repair.
Conclusions:
One-third of all referrals for umbilical hernia evaluation are potentially avoidable, and this rate did not change following release of American Academy of Pediatrics guidelines. Aligning expectations between surgeons and referring providers through improved education and guideline dissemination may reduce avoidable visits, lost caregiver productivity, and exposure to potentially avoidable surgery.
