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National Practice Variation and Disparities in Pediatric Umbilical Hernia Repair Under Five
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Sean H. Nguyen, *Eileen K. Peterson, Sayeed Ikramuddin, *James Harmon, *Randi L. Lassiter
Surgery, University of Minnesota, Minneapolis, MN
Objective(s):Umbilical hernia is one of the most common pediatric surgical diagnoses. Conventional medical education and literature report most umbilical hernias will spontaneously close by year 5. Despite this, there are limited societal guidelines for the management of umbilical hernias, and practice patterns vary with regard to timing of elective umbilical hernia repair (UHR). We aim to assess the national case trends and predictors of elective pediatric umbilical hernia repair before and after the age of 5.
Methods:The Nationwide Ambulatory Surgery Sample (NASS) was interrogated to identify elective pediatric umbilical hernia repairs performed between 2016-2021. Current Procedural Terminology (CPT) codes were used to label patients who underwent an isolated primary umbilical hernia repair without additional procedures. Patients who underwent UHR were split into an early cohort (Ages 0-4) and a delayed cohort (Ages 5-9). Patient demographics and hospital characteristics were obtained. Outcomes included total charges and disposition. ?2 tests were used for proportions and t- vs Mann-Whitney U tests were used for continuous variables. A sample-weighted logistic regression model was performed controlling for patient demographics and hospital characteristics.
Results:A weighted total of 72,384 patients were included, with early (n = 35,222, 48.7%) and delayed (n = 37,162, 51.3%) groups showing similar case volume. Early UHR is more common in females (54.4% vs. 50.7%, p < 0.001). Early UHR is also proportionally higher in non-white patients (64.1% vs. 61.9%, p = 0.014), non-private payers (60.4% vs 55%, p < 0.001), those within the lower 50th income percentile (59% vs. 55.2%, p<0.001), and in patients from micropolitan/rural areas (12.7% vs. 10.3%, p < 0.001). Hospital bed size and teaching status did not differ between groups. Early UHR was associated with higher total charges ($13,679 vs. $13,229, p = 0.003) and a greater proportion of non-home discharges (0.18% vs. 0.01%, p = 0.022). Adjusted multivariate regression identified female sex, micropolitan/rural patient location, non-private payer status, and hospital urban status as factors associated with lower odds of delayed repair, while income above the 50th percentile and year 2021 were associated with higher odds of delayed repair (Figure 1).
Conclusions:Nationwide, nearly half (48.7%) of elective umbilical hernia repairs occur before age 5, despite the high likelihood of spontaneous closure. Independent predictors for early repair include female sex, micropolitan/rural patient location, lower income, and non-private payer status. Early repair is also associated with higher total cost and non-home discharge. We highlight the need for development and adherence to standardized surgical guidelines to address national variability and disparities in management of pediatric UHR.
Figure 1: Multivariate Logistic Regression Predicting Delayed Umbilical Hernia Repair
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