Surg Endosc (2015) 29:2061–2071 DOI 10.1007/s00464-015-4309-4
and Other Interventional Techniques
SAGES HERNIA TASK FORCE
Raising the quality of hernia care: Is there a need? Adrian E. Park1 • Hamid Reza Zahiri1 • Carla M. Pugh2 • Melina Vassiliou3 Guy Voeller4
•
Received: 2 April 2015 / Accepted: 2 June 2015 / Published online: 30 June 2015 Ó Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) 2015
Abstract Introduction With a focus on raising the quality of hernia care through creation of educational programs, SAGES formed the Hernia Task Force (HTF). This study used needs assessment survey to target opportunities for improving surgical training and thus patient outcomes and experience. Methods This qualitative study included structured interviews and online surveys of key stakeholders: HTF members, surgeons, nurses, patients, hospital administrators, healthcare payers and medical suppliers. Questions included perceptions of recurrence and complication rates, their etiologies, perceived deficits in current hernia care and the most effective and training modalities. Results A total of 841 participants included 665 surgeons, 66 patient care team members, 12 hospital administrators and 14 medical supply providers. Assessment of technical approach revealed that nearly 26 % of surgeons apply the same, limited range of techniques to all patients without Presented at the SAGES 2015 Annual Meeting, April 15–18, 2015, Nashville, Tennessee. & Hamid Reza Zahiri
[email protected] Adrian E. Park
[email protected] 1
Department of Surgery, Anne Arundel Medical Center, 2000 Medical Parkway Dr., 1st Floor, Annapolis, MD 21401, USA
2
Department of Surgery, University of Wisconsin School of Medicine, Madison, WI, USA
3
Department of Surgery, McGill University School of Medicine, Montreal, Canada
4
Department of Surgery, University of Tennessee School of Medicine, Memphis, TN, USA
evaluation of patient-specific factors. The majority (71 %) of surgeon respondents related hernia recurrence rates nearing 25 % or more. HTF members implicated surgeon factors (deficits in knowledge/technique, etc.) as primary determinants of recurrences, whereas nurses, medical supply providers and hospital administrators implicated patient health factors. Surgeons preferred attending conferences (82 %), reading periodicals/publications (71 %), watching videos (59 %) and communicating with peers (57 %) for learning and skill improvement. Topics of the greatest interest were advanced techniques for hernia repairs (71 %), preoperative and intraoperative decision making (56 %) and patient outcomes (64 %). Eighty-six percent of nurses felt that there was room for improvement in hernia patient safety and teamwork in the OR. Only 24 % believed that the patients had adequate preoperative education. Conclusions Major reported deficits in hernia care include: lack of standardization in training and care, ‘‘one size fits all’’ technical approach and inadequate patient follow-up/outcome measures. There is a need for a comprehensive, flexible and tailored educational program to equip surgeons and their teams to raise the quality of hernia care and bring greater value to their patients. Keywords Hernia Outcomes Quality control Education Deficits Stakeholders
Ventral/incisional and inguinal hernias constitute some of the most common surgical diseases addressed by general surgeons. Cited as the most frequent general surgical operation [1], inguinal herniorrhaphies account for nearly 2800 cases per million population annually in the USA and Europe [2]. Yearly, this amounts to over 800,000 inguinal
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hernia repairs just in the USA [3–5]. Ventral/incisional herniorrhaphies account for over 400,000 surgeries yearly with a projected increase of 11,000 cases annually [6]. These numbers include re-operations for recurrences with estimated ranges of 24–43 and 1–15 % for ventral [7] and inguinal [8–13] hernia repairs, respectively. These recurrences are in spite of mesh use in 70–85 % of inguinal [14, 15] and 85.8 % of ventral hernia repairs [16]. The laparoscopic techniques for repair of ventral [17] and inguinal hernias [18, 19] were introduced in the early 1990s. The potential for less invasive surgery for patients facilitated the rapid incorporation of laparoscopic approaches for hernia repair. Since their introduction, studies have concluded that laparoscopic approaches for ventral [20–26] and inguinal [10, 27–30] hernias produce less pain, earlier discharge from the hospital, faster recovery and equivalent recurrence rates in comparison with open approaches. Other studies have supported laparoscopy as cost-effective [31]. Yet, despite extensive experience and advancements in treating hernia disease, concerns have been raised regarding deficits in the quality of current hernia care. Specifically, nonstandardized approaches to care, high recurrence rates, lack of long-term patient follow-up after surgery, paucity of federal funding for hernia research and insufficient educational and training resources for surgeons have been related by key stakeholders in hernia care [6, 16]. These deficits prompted the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) to focus on raising the quality of hernia care. One of their initial efforts was the formation of the Hernia Task Force (HTF) in 2011, charged with the development of a flexible, cutting edge and comprehensive hernia education program for practicing surgeons with emphasis on the fundamentals of hernia disease and repair. The specific goals of HTF were to: (1) improve the quality of patient care by promoting evidence-based approaches to difficult problems; (2) assist surgeons in the development of greater clinical decision-making ability and surgical skills; (3) increase safety and teamwork in the operating room; (4) decrease complication rates; (5) and improve patient outcomes. To meet these goals, the HTF has been charged with developing a novel, engaging and practical educational program focused on hernia care and tailored to optimizing adult learning. To this end, the HTF conducted a needs assessment study to engage hernia care providers regarding their views on hernia disease, hernia quality of care and its deficits and the needs for hernia education.
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Methods Data gathering tools After obtaining institutional review board (IRB) approval, this qualitative study was conducted utilizing structured interviews and surveys. The surveys were administered using various approaches (online surveys, phone interviews, e-mail). Stakeholder analysis Based on the information gathered during interviews with HTF members, eight stakeholder groups were identified and surveyed as the focus group including HTF members, academic and private practice surgeons, allied health professionals (RNs, PAs, etc.), patients, hospital administrators, healthcare payers and medical supply providers. Stakeholders were grouped into categories with defined values and involvement. Subsequently, the information to be collected from each group and their target response rates were developed. Needs assessment Key stakeholders were targeted at their affiliated organizations, institutions and companies with online survey inquiry regarding the need for hernia care improvement and education. Professional organizations included SAGES, the American College of Surgeons (ACS), the Association of Perioperative Registered Nurses (AORN) and the American Association of Surgical Physician Assistants (AASPA). Healthcare institutions included 62 university and community hospitals across the nation. Finally, healthcare companies included insurance payers (Humana, Aetna, Well Point, United, Cigna) and suppliers of medical supplies (Covidien, Bard Medical, Medline). Overall, more than 20,000 individuals were surveyed with a targeted 2 % response rate or 400 respondents. Survey questions included: years of clinical experience, hernia recurrence and complication rates, possible etiologies of recurrence, perceived deficits in current hernia care, preferred or most effective training modalities and technical preference for repair. Data analysis Responses were calculated as percentages of total respondents or according to ranked options. All percentage calculations were rounded to the nearest whole number.
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Results Response rates The response rate was more than double the targeted 400 with 841 total respondents. Surgeons and patient care team members comprised top respondent groups with 665 and 58 responses, respectively. The lowest response rates were from hospital administrators, 12, and health insurers, 3. Fourteen respondents categorized as ‘‘Other,’’ included administrative assistants, research fellows, research assistants, health economists, medical consultants, journal editors and medical students. Table 1 summarizes the targeted and actual response rates for each group. HTF surgeon responses Eighteen of 24 HTF members were interviewed for this study and completed survey questions. On average, they related 15 years of experience (Fig. 1) in surgical practice with 94 % holding academic appointments in addition to their clinical practice. Seventy-one percent reported hernia recurrence rates of [25 %, according to their experience. They also related a lack of consistent long-term patient follow-up. The main etiologies of recurrences after hernia repair were described as poor surgical technique, improper technique selection, infections and other complications with patient factors deemed least important. With regard to enhancing practice patterns, 50 % of HTF members identified the need for surgeons to improve their technical skills and fund of knowledge to better tailor their hernia care to the unique features of each patient and their disease. HTF respondents suggested that specific areas to target improvement were proper mesh selection and use (17 %), a more standardized approach for hernia repairs (17 %) and better understanding of anatomy and its impact. Twenty-two percent of them related that better patient follow-up, outcome measures and feedback from patients and surgeons would facilitate the growth of surgical skill. HTF members also identified the leading topics for hernia education. These include effective measures for surgical performance and patient outcomes (39 %), Table 1 Survey responses
Fig. 1 Years as a licensed surgeon (HTF members)
definition of standardized techniques for inguinal and ventral hernia repairs (28 %), patient-centered judgment and decision-making (28 %) and database information sharing (17 %). HTF members thought that the most effective hernia training program should be cutting edge and integrate a variety of teaching modalities with didactics (22 %) and hands-on simulation training (27 %) most preferred. The ideal training delivery was felt to be through live face-toface instruction (76 %). Additional preferred delivery methods were conferences (24 %), online videos (24 %), simulation (24 %) and shadowing experience (24 %). Non-HTF surgeon responses Non-HTF respondents had diverse backgrounds but comparable experience to HTF members (Fig. 2). Overall, 48 % had completed a minimally invasive surgery fellowship, 43 % had an exclusively clinical practice, while 38 % had both clinical and academic appointments. Over 68 % reported caring for up to ten inguinal and ventral hernia patients per month. The majority of surgeons (37 %) equally utilized both open and laparoscopic approaches for hernia repair, and the remaining surgeons primarily preferred laparoscopic (32 %) or open (31 %) techniques. Of note, 26 % of surgeons related being experienced in only a few techniques that they apply broadly to patients.
Stakeholder group
Minimum response rate
Number of responders
Surgeons Patient care team members
100 15
665 66
Patients
25
15
Medical supply providers
15
14
Hospital administrators
15
12
Healthcare payers
15
3
0
14
Others
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With regard to patient outcome measures, 45 % of surgeons related tracking outcomes, 29 % related that they intended to begin outcome measures, and 17 % did not plan to track outcomes (Fig. 5). Surgeons implicated the lack of standardized practices (50 %) and outcome measures (46 %), as well as inadequate training (36 %) as the greatest barriers to enhance hernia care. Patients
Fig. 2 Years as a licensed surgeon
In descending order, surgeons described their six most commonly used means to obtain ongoing hernia education as attending conference, reading journal articles, watching videos, communicating with peers, attending industrysponsored training programs and teaching/training others (Fig. 3). The least utilized training methods were writing/ publishing articles (18 %), web-based training (20 %) and observing/receiving clinical instruction (27 %). Surgeons also thought that combining training modalities would be most effective for their continued education. They most favored videos (90 %), attending conference (89 %), staying abreast of the literature (77 %) and webbased learning (66 %). The most popular topics for hernia education/training were identified as advanced techniques for ventral and inguinal hernia repairs, patient outcome measures and preoperative and intraoperative judgment and decision making. Sixty-nine percent of surgeons also related an interest in education on basic techniques for inguinal and ventral hernia repairs. Figure 4 is a complete summary of the responses.
Fig. 3 I receive training or stay abreast of advances in hernia care through: (please check all that apply)
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Fifteen patient participants related their history of hernia repairs as one (73 %), two (20 %), three (0 %) or four or more surgeries (7 %). Their herniorrhaphies consisted of open inguinal (53 %), laparoscopic inguinal (20 %), open ventral and laparoscopic ventral (7 %) repairs. Nearly 47 % related mesh use in their repair. Nearly 7 % of patients were unsure of their hernia type or mesh use for its repair. The most frequent postoperative complications were urinary retention (20 %), chronic pain (lasting [3 months) (13 %), acute pain (lasting \3 months) (7 %), seroma (7 %) and bowel obstruction (7 %). Most complications occurred within 30 days of surgery. Sixty percent of patients related no complications after their surgery. Nearly 85 % reported that they would return to their original surgeon for care in case of any complications. Patients reported excellent or above-average preoperative care with regard to selection of hernia repair tailored to fit their needs (79 %), their preparation for surgery (79 %), education about the operative procedure (71 %), consideration of their past medical history, demographics and characteristics (70 %), education about the expected recovery after surgery (64 %) and their involvement in the decision-making process (64 %). Patient respondents described being referred to a surgeon and the surgeon’s personality as the most important factors for selecting who performed their surgery. Among
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Fig. 4 My level of interest in the following training topics
Fig. 5 I (or my hospital): please select all that apply
least important factors for surgeon selection was being a hernia specialist (7 %) (Table 2). Additionally, only 28.6 % related that they would feel more confident in their surgeon if he or she had specialty certification for hernia repair (Table 3). Patient care team members Patient care team members mainly included nurses, but also physician assistants and technicians (Table 4). The majority related caring for up to 15 patients monthly (Table 5).
They thought that hernia recurrences were primarily related to patient comorbidities (85 %), infections or wound complications (65 %) and mesh failure (43 %). They also identified educational topics that surgeons could most benefit from including hernia outcome measures and tracking (71 %), techniques for inguinal and ventral hernia repairs (63 %), proper use of hernia surgical materials (i.e., mesh) (63 %) and management of hernia repair complications (57 %). Patient care team members were also asked about measures surgeons could take to improve overall safety and teamwork in the operating room. Communication was
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Table 2 I chose my surgeon(s) because: (please select all that apply) Answer options
Response percent (%)
The surgeon is a hernia repair specialist
Response count
6.70
1
The surgeon was recommended to me
33.30
5
My physician referred me to the surgeon
53.30
8
I have limited surgeons to choose from my area
7
1
I agreed with surgeon’s hernia repair technique for me
26.70
4
The surgeon was thorough in educating and preparing me for the surgery
26.70
4
I liked the surgeon’s personality and felt like I could trust him/her
40.00
6
Other (please specify)
13.30
2
Answered question
15
Skipped question
883
Other (please specify) I know and trust my doctor Knew personally
Table 3 Hernia fellowship training would raise my confidence in my surgeon Answer options
Response percent (%)
Response count
Yes
28.60
4
No
28.60
4
Unsure
42.90
6
Answered question
14
reported to be the top measure by 86 %. Otherwise, preoperative planning (67 %), improved knowledge and skill (53 %) and better intraoperative decision making (44 %) were reported as other important measures. Figure 6 is a summary of the responses. Hospital administrators Twelve hospital administrators participated in this study. They reported the annual number of ventral/inguinal hernia repairs at their hospital (Table 6) and complication rates (Table 7). They attributed the causes of these Table 4 I serve as a
Answer options
Healthcare payers Only three members of this group participated in this study. When asked about common causes of hernia repair failure, Response percent (%)
Response count
Physician assistant
13.80
9
Nurse
69.20
45
Technician
9.20
6
Anesthesiologist
0.00
0
Other
6.20
4
Physician or surgeon; specialty
1.50
1
Answered question Physician or surgeon; specialty Gynecologist oncologist
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recurrences/complications to patient comorbidities (i.e., smoking, diabetes, etc.) (83 %), poor decision making on behalf of the surgeons (50 %), mesh failure (42 %), poor surgical technique or errors (33 %), infections/wound complications (33 %), inappropriate mesh use (25 %) and poor patient selection (8 %). When asked about the greatest barrier to improving hernia care, 58 % ranked lack of outcome measures most important. Other factors were lack of standardized practices (42 %), patient factors (42 %) and lack of training for surgeons (33 %). Only 33 % related their hospital tracked patient outcomes. They felt that measures to improve patient safety and teamwork in the operating room should encompass greater training to improve surgeon knowledge and skills (92 %), better judgment and decision making intraoperatively (42 %) and optimize preoperative planning and preparations (25 %).
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Table 5 I estimate the number of inguinal or ventral hernia repair patients I care for each month to be
Table 7 Average rates of complications and recurrences in inguinal and ventral hernia repair surgeries performed at my hospital
Answer options
Response percent
Response count
Answer options
Response percent (%)
0 patients
15.40
10
0–25 %
58.30
7
1–5 patients
18.50
12
25–50 %
8.30
1
6–10 patients
38.50
25
50 % or greater
0.00
0
11–15 patients
10.80
7
Unsure
33.30
4
16–20 patients
9.20
6
Answered question
20? patients
7.70
5
Answered question
Response count
12
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two related technical errors, one related wound infections or complications, and one related patient comorbidities as causative. Two out of three related that their companies did not support efforts to optimize patient risk factors (i.e., losing weight, smoking cessation, etc.) prior to hernia surgery through incentives. Medical supply providers Eleven medical supply providers participated in this study. They listed the most important reasons for hernia repair failure as poor surgical technique (73 %), patient comorbidities (55 %), inappropriate use of mesh (type, size or fixation) (36 %) and infections/wound complications (27 %). The greatest barriers to improving care were ranked as lack of standardized practices (45 %), hernia reimbursements (36 %) and lack of training (27 %).
They were also asked about how surgeons could improve intraoperative safety and teamwork. They related more training to enhance surgeon knowledge and judgment (73 %), greater preoperative planning (46 %), better intraoperative decision making (27 %) and more communication (18 %).
Discussion More than half a century ago, Sir John Bruce of Edinburgh opined ‘‘The final words on hernia repair will probably never be written’’ [32], accurately reflecting the complexity of this disease and its variable presentations. Since 1500 BC, the earliest recorded case of an inguinal hernia, the diagnosis and management of hernias has clearly evolved. Identification of key anatomic features unique to each hernia type has allowed surgeons to develop numerous technical approaches leading to more effective repairs. Advances have also been made in the pre- and
Fig. 6 I feel surgeons can increase safety and teamwork in the operating room by improving
Table 6 Average number of inguinal and ventral hernia repairs performed annually at my hospital
Answer options
Response percent (%)
0–499 inguinal and ventral hernia repairs
25.50
3
8.30
1
1000–1999 inguinal and ventral hernia repairs
33.30
4
2000? inguinal and ventral hernia repairs Unsure
16.70 16.70
2 2
500–999 inguinal and ventral hernia repairs
Answered question
Response count
12
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postoperative care of these patients. Despite the progress in hernia care, hernia patients’ experience of care, recurrence and complication rates often remains stubbornly sub-optimal [33–36]. This has led to the realization that optimized hernia care considers the preferences and the needs of the patient foremost, but also other stakeholders such as patient’s family and employers, the etiology and anatomic features of the defect and patient characteristics and comorbidities. Consequently, both patient/disease factors and quality of care have been analyzed to account for current outcome patterns and elucidate ideal herniorrhaphy practices. Meanwhile, the burden of hernia disease has continued to grow and has extended beyond the patients’ health and quality of life to also have a tremendous socioeconomic impact. The respective yearly healthcare expenditures in the USA for inguinal [8, 37] and ventral/incisional [16] hernias are 40 billion and 3 billion dollars. The portion of these expenditures applied to recurrences and complications is not insignificant. Effective quality improvement measures aimed at lowering recurrences after ventral hernia repair alone would generate procedural cost savings of 32 million dollars annually per one percent reduction in recurrence rate [6]. This has prompted a re-examination of practices, revealing shortfalls in hernia research, outcome measures and surgeon practice patterns. Research initiatives to improve quality of hernia care and outcome measures have been limited in part by minimal federal funding, due possibly to a lack of appreciation of the complexity and economic impact of hernia disease [6]. Despite its intuitive benefit, efforts have lagged at local and national levels to establish broadly subscribed longitudinal outcome registries for patients who have undergone hernia surgery. Arguably, surgeons bear major responsibility for the current unfavorable trends in hernia outcomes. Studies show that laparoscopic techniques have been inconsistently adopted and applied by surgeons at rates of 23–33 % for ventral [16, 35] and 28 % for inguinal [38] herniorrhaphies. Still, studies examining surgeon factors contributing to low laparoscopic utilization are scant. Moreover, while studies have been conducted to develop optimal and evidencebased hernia care, there persists a lack of reliable educational resources with consistent and standardized practice recommendations. These shortfalls combine to complicate the elucidation of ideal hernia care practices. A clear example of this is the continuing contention regarding the true benefits of laparoscopy, with some studies still arguing against the outcome [39–41] and overall cost–benefits [5, 42–45] of laparoscopic hernia repair. Consistent with the current hernia care climate, our study found some inconsistencies among key stakeholders regarding contemporary hernia practices. The majority of
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patient participants were satisfied with all aspects of their hernia care with most relating that they would return to their original surgeon for further care. Nonetheless, patient satisfaction must be considered in the correct context, as most patients are not in a position to completely appreciate the impact of additional surgeon education/training on their outcomes. This is reflected in our study based on their main methods of surgeon selection, referral or surgeon personality, rather than qualifications. Another area of inconsistency uncovered in this survey concerned high recurrence rates after hernia repair. While the majority of respondents agreed it is a significant shortcoming of current hernia care, the reported or presumed reasons for this were also very varied. Surgeons tended to implicate poor surgical technique, misapplication of technique, infection and complications as primary determinants of recurrence. In contrast, nurses, medical supply providers and hospital administrators implicated patient health factors as the primary determinants. These differences in perception are not completely unexpected. Surgeons are in a position to better appreciate the impact of their training and technique on outcomes. Professionally, surgeons have historically and rightfully been encouraged to take full responsibility for their patients and taught to apply rigorous self-criticism to their practice. Discrepancies were also found concerning preoperative patient education, teamwork and communication. Nurses suggested these as areas needing major improvements, advocating for more effective preoperative planning and communication in the OR. While HTF members echoed the need for better preoperative planning, the majority of surgeons and patients did not cite it as a major area needing development. Additionally, intraoperative communication was not related as a major concern by surgeons. This is consistent with prior studies showing a significant discrepancy between surgeons and nurses in their perception of operating room communication quality [46, 47]. Implementation of surgical checklists and other communication tools has been promoted to attempt to overcome these disparities [47]. Despite these discrepancies, our study did find broad consensus among stakeholder groups with regard to several key deficits in current hernia care. A critical deficiency of contemporary hernia care highlighted by HTF and non-HTF surgeons, nurses (the majority of care team respondents), hospital administrators, healthcare payers and medical supply companies is the lack of consistent long-term patient follow-up and outcome measures. HTF and non-HTF surgeons, nurses and hospital administrators related appropriate patient follow-up and outcome measures as critical for growth and practice refinement for surgeons, yet only 45 % of surgeons related tracking patient outcomes after hernia repair. Only 33 % of hospital administrators reported their hospital tracked outcomes for
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patients after hernia repair. While some reported an intention to begin outcome measures, our study found that current outcomes were not tracked by the majority of providers. These findings are consistent with results from studies which describe the lack of hernia outcome measures at the national level and attribute it to underappreciation of hernia disease burden and lack of federal funding [6]. Fortunately, greater efforts are being expended at the national level to record and improve outcomes after hernia surgery. This includes the Americas Hernia Society Quality Collaborative (AHSQC) [48], launched in 2013, which combines data from private and academic hernia practices to promote patient-centered ongoing data collection and provide practitioners with performance and quality results. Most pertinent to surgeons and subject to immediate change, all participants indicated inadequate hernia education/training as a primary barrier to hernia care improvement. Specifically, the need for improvements in the technical skills and knowledge of surgeons providing hernia care was consistently cited. Stakeholders also reported that surgeons need more training with regard to patient-centered decision making and judgment. The necessity for standardization of hernia care practices was also deemed important. Finally, expansive efforts to educate surgeons on proper selection and use of surgical instruments and materials for hernia repairs were determined as critical by nearly all stakeholders. Our study revealed the application of a narrow spectrum of repair techniques by surgeons to a broad range of hernia diseases, reflecting the concerns of multiple stakeholders regarding the adequacy of surgical training in hernia care. Only 49 % of surgeons related being experienced in a wide array of techniques for hernia repair. Almost 26 % related being experienced in only a few techniques that they apply broadly to patients. Furthermore, only 37 % of surgeons related equally applying open and laparoscopic techniques for hernia repair. These findings are consistent with the other studies which show a national trend by surgeons to use a narrow spectrum of treatment strategies to address a broad spectrum of hernia disease, including underutilization of laparoscopy [16, 35, 38]. When asked about preferences for educational topics and training modalities, surgeons preferred conferences, reading periodicals/publications, watching videos and communicating with peers. Topics of the greatest interest were similar among HTF and Non-HTF surgeons with emphasis on basic and advanced techniques for hernia repairs, preoperative and intraoperative decision making and patient outcomes. The desire by the majority of surgeons to review the basic techniques of inguinal and ventral hernia repairs was reflective of the need for continuing education aimed at fundamentals of hernia surgery. Surgeons also uniformly defined the ideal hernia education/training program as
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standardized and comprehensive, applied in a multimodality and flexible fashion. Overall, our study confirms that the final word on hernia repair is far from written and that much room exists to propel the science and art of hernia surgery to achieve optimum outcomes in the hands of surgeons. We discovered broad consensus among key stakeholders regarding the need to develop a comprehensive, flexible and tailored educational program to equip surgeons and their teams to raise the quality of hernia care and bring greater value to their patients. While robust and credible hernia education programs have been generated by surgeons and educators and supported by industry over the past 20 years. Most of these languish (unused or underutilized) for a variety of reasons with a common find of not adequately meeting the practicing surgeon’s needs. To more effectively meet this need, an efficient and engaging educational program must be designed, accommodating adult learning theories [49], which will cultivate learning and change in practice. Accordingly, these educational interventions must incorporate technology (web-based learning, simulation, virtual reality, etc.) with traditional learning modalities (didactics, hands-on labs, direct mentorship) to maximally impact surgeons. They must also afford the surgeon the ability to select and tailor their program to emphasize their individual preferences with respect to the main learning modality and pace of the program. Use of problem-based learning, case-dependent formats and self-assessment tools may further augment educational gains, when applicable. Finally, focus on shortened educational sessions will improve attention among the audience and prove less distracting to the busy schedule of surgeons. These efforts will prove central to optimizing hernia surgery for both the patient and the surgeon. Acknowlegments Gina L. Adrales, Dartmouth-Hitchcock Med Ctr., Lebanon, NH; Igor Belyansky, Anne Arundel Med Ctr., Annapolis, MD; Parag Bhanot, Georgetown Univ Hsp, Washington, DC; Ibrahim Bulent Cetindag, University of Iowa, Iowa City, IA; Andrew J. Duffy, Yale Univ School of Med/New Haven Hsp, New Haven, CT; David Bryan Earle, Baystate Med Ctr., Springfield, MA; Robert J. Fitzgibbons, Creighton Univ Med Ctr., Omaha, NE; B. Todd Heniford, Carolinas Medical Center, Charlotte, NC; Brian P. Jacob, Mount Sinai Medical Center, New York, NY; Dennis R. Klassen, Queen Elizabeth II Health Sciences Center, Halifax, NS; Karl A. Leblanc, Louisiana State Univ, Baton Rouge, LA; Brent D. Matthews, Carolinas Med Ctr., Univ. of N.Carolina, Charlotte, NC; John D. Mellinger, Southern IL Univ School of Med, Dept of Surgery, Springfield, IL; Philip A. Omotosho, Duke University Medical Center, Durham, NC; Adrian Park, Anne Arundel Medical Center, Annapolis, MD; Richard A. Pierce, Vanderbilt University Department of Surgery, Nashville, TN; Carla Marie Pugh, University of Wisconsin, Madison, WI; Bruce J. Ramshaw, Advanced Hernia Solutions, Daytona Beach, FL; John Scott Roth, Univ of KY, Lexington, KY; Douglas S. Smink, Brigham and Women’s Hospital, Boston, MA; Monica Torres-Jimenez, Alexandra Marine and General Hospital (Goderich), Goderich, ON; Shirin Towfigh, Beverly Hills Hernia Center, Beverly Hills, CA;
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