Unintended consequences of policy change to watchful waiting for asymptomatic inguinal hernias

Abstract

Introduction In 2009 the Department of Health instructed McKinsey & Company to provide advice on how commissioners might achieve world class National Health Service productivity. Asymptomatic inguinal hernia repair was identified as a potentially cosmetic procedure, with limited clinical benefit. The Birmingham and Solihull primary care trust cluster introduced a policy of watchful waiting for asymptomatic inguinal hernia, which was implemented across the health economy in December 2010. This retrospective cohort study aimed to examine the effect of a change in clinical commissioning policy concerning elective surgical repair of asymptomatic inguinal hernias. Methods A total of 1,032 patients undergoing inguinal hernia repair in the 16 months after the policy change were compared with 978 patients in the 16 months before. The main outcome measure was relative proportion of emergency repair in groups before and after the policy change. Multivariate binary logistic regression was used to adjust the main outcome for age, sex and hernia type. Results The period after the policy change was associated with 59% higher odds of emergency repair (3.6% vs 5.5%, adjusted odds ratio [OR]: 1.59, 95% confidence interval [CI]: 1.03–2.47). In turn, emergency repair was associated with higher odds of adverse events (4.7% vs 18.5%, adjusted OR: 3.68, 95% CI: 2.04–6.63) and mortality (0.1% vs 5.4%, p<0.001, Fisher’s exact test). Conclusions Introduction of a watchful waiting policy for asymptomatic inguinal hernias was associated with a significant increase in need for emergency repair, which was in turn associated with an increased risk of adverse events. Current policies may be placing patients at risk.

International guidelines for groin hernia management

“…A 2014 study reported on clinical consequences after the inception of a watchful waiting strategy. 141 Regionally, a WW policy was instituted in the United Kingdom for those with asymptomatic IHs. Outcomes of approximately 1000 patients before, and 1000 patients after, the policy’s inception were compared retrospectively.…”

Measurement of patient-reported outcomes. 2: Are current measures failing us?

“…Eight Clinical Commissioning Groups in England and Wales (15%) subsequently required a history of incarceration and/or that the hernia to increase in size each month before surgery should be considered 65 , which Sanders and Kurzer 62 considered "a draconian and impractical requirement". A study published in 2014 66 examined the effect of a local policy change for asymptomatic inguinal hernias. Patients underwent watchful waiting instead of elective repair.…”

Orientações da Sociedade Brasileira de Hérnia (SBH) para o manejo das hérnias inguinocrurais em adultos.

“…• Observation may be a safe alternative for male patients with comorbidities that increase surgical risk and those with poorly symptomatic or asymptomatic hernia, but it is noteworthy that the latter subgroup has a 70% chance of developing symptoms throughout observation and ultimately requiring surgical treatment. Many patients can be securely observed, with a very low probability of developing complications, such as incarceration and requiring urgency operation, with increased morbidity 3,4 .…”