Massachusetts Chapter of the American College of Surgeons

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Impact of American Academy of Pediatrics Age-Specific Guidelines for Asymptomatic Umbilical Hernia Referral on Early Repair Rates and Associated Disparities
Katherine He, MD, MS1, Dionne A. Graham, PhD2, Jonathan L. Hills-Dunlap, MD, MPH3, Shawn J. Rangel, MD, MSCE1
1Boston Children’s Hospital, Department of Surgery, Boston, MA, 2Boston Children’s Hospital, Center for Applied Pediatric Quality Analytics, Boston, MA; 3Children’s Hospital Colorado, Department of Surgery, Aurora, CO

Background: November 2019 AAP guidelines recommended delaying surgical referral for asymptomatic umbilical hernias (UH) until 4-5 years. This study’s purpose was to assess guideline impact on early repair rates, hospital-level practice variation, and sociodemographic disparities.
Methods: Multicenter retrospective analysis of pediatric umbilical hernia repair over a 7-year period (5-years before, 2-years following guideline release) at 37 Pediatric Health Information System hospitals. Children <4 years undergoing surgery were categorized as an early repair. Multivariable logistic regression was used to calculate adjusted overall and hospital-level observed-to-expected (O/E) ratios for early repair before and after guideline release.
Results: 28,597 children were included. The early repair rate decreased by 30% following guideline release (19% vs. 27%, p<0.0001). At the hospital level, rates of early repair were lower at 78% (29/37) of hospitals following guideline release, although hospital-level rates varied significantly (8.7-fold variation before vs. 9.5-fold after, figure 1). Early repair was associated with public insurance and lower income, both before and after guideline release (figure 2).
Conclusion: Rates of early UH repair decreased following AAP guideline release, however high rates persist at many hospitals and disparities remain unchanged. Further collaboration is needed to improve guideline compliance, particularly for publicly insured or low income children.


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