Surgical and non-surgical treatment of inguinal hernia during non-elective admissions in the Nationwide Readmissions Database

Introduction: Inguinal hernia repair is one of the most common surgical operations, yet the optimal treatment strategy remains undefined. Treatment of symptomatic inguinal hernias include both surgical and non-surgical approaches. The objective of this study was to determine differences in population, readmission rates, and costs between operative and non-operative approaches for patients admitted non-electively for an inguinal hernia in a national dataset. In addition, we sought to define the baseline characteristics of the two groups and identify potential predictive factors in the non-surgically managed subgroup who were readmitted and treated operatively within 90 days of their first visit.

Methods: This study was a retrospective review of data from the Nationwide Readmissions Database (NRD) from 2010 to 2014. Patients above age 18 who were admitted non-electively for a primary diagnosis of inguinal hernia were included. Patients whose length of stay was < 1% or > 95% percentile or died during the initial visit were excluded. Readmissions within 90 days of the initial visit were flagged. Patients were classified according to initial management strategy: operative versus non-operative. Demographic, clinical, and organizational characteristics were compared between the two cohorts.

Results: 14,249 patients met inclusion criteria and were operative (n = 8996, 63.13%) and non-operative (n = 5255, 36.88%) cohorts. When comparing the two groups, readmission rate was lower (0.49% for surgical, 1.78% for non-surgical, p < 0.01), mean length of stay (LOS) longer (3.27 [SE = 0.05] days for surgical, 2.76 days [SE = 0.06] for non-surgical, p < 0.01), and mean total cost higher ($9597 for surgical, $7167 for non-surgical, p < 0.01) in surgically treated patients. The non-surgical population was on average older (63.05 years for surgical, 64.52 years for non-surgical, p < 0.01) with more chronic conditions (3.57 for surgical, 4.05 for non-surgical, p < 0.01). Of the patients initially managed non-surgically, 1.78% (n = 91) were readmitted, and of them, 62.63% (n = 57) were readmitted and managed surgically within 90 days of initial admission (i.e., crossed over from watchful waiting to surgical treatment). Average number of chronic conditions (3.79 versus 4.03, p = 0.74), average number of comorbidities (2.26 versus 2.18, p = 0.87), and average total number of ICD-9 discharge codes (7.44 versus 8.23 p = 0.54 did not differ significantly between the operative versus non-operative sample of the readmitted population. The total cost ($5562.38 versus $8737.28, p = 0.01) was greater in the operative versus non-operative sample.

Conclusion: Watchful-waiting strategy is the most common treatment approach in patients admitted non-electively for symptomatic inguinal hernia. Readmission after non-elective hospitalization for inguinal hernia is rare, but surgical intervention decreased the likelihood of readmission compared to non-operative management, while also increasing LOS and cost of care. Our data supports a patient centric approach to the management; non-surgical treatment is a viable temporary option even in symptomatic inguinal hernias, while surgical treatment may reduce the likelihood of future readmission.