Department of Surgery, University of Michigan, Ann Arbor.
Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor.
JAMA Netw Open. 2020 Nov 2;3(11):e2023684. doi: 10.1001/jamanetworkopen.2020.23684.
Despite availability of evidence-based guidelines for surgery, many patients receive guideline-discordant care. Reasons for this are largely unknown. For example, evidence-based guidelines recommend a minimally invasive approach for persons with bilateral or recurrent unilateral inguinal hernias. Benefits are also noted for primary unilateral inguinal hernia. However, findings from previous quantitative research indicate that only 26% of patients receive this treatment and only 42% of surgeons offer a minimally invasive approach, even for recurrent or bilateral hernias.
To explore factors associated with surgeon choice of approach (minimally invasive vs open) in inguinal hernia repair as a tool to gain an understanding of guideline-discordant care.
DESIGN, SETTING, AND PARTICIPANTS: Qualitative study performed as part of a larger explanatory sequential mixed methods design. Purposive sampling was used to recruit 21 practicing surgeons from a large statewide quality collaborative who were diverse with regard to practice type, geographic location, and surgical specialty. Qualitative interviews consisted of a clinical vignette, followed by semi-structured interview questions. Through thematic analysis using qualitive data analysis software, patterns within the data were located, analyzed, and identified. All data were collected between April 24 and July 31, 2018.
Clinical vignette as part of the qualitative interviews.
Capture of surgical approaches and factors motivating decision-making for inguinal hernia repair.
Of the 21 participating surgeons, 17 (81%) were men, 18 (86%) were White, and all were 35 years of age or older. Data revealed 3 dominant themes: surgeon preference and autonomy (eg, favoring one approach over the other), access and resources (eg, availability of robot), and patient characteristics (eg, age, comorbidities).
Decision-making for the approach to inguinal hernia repair is largely influenced by surgeon preference and access to resources rather than patient factors. Although a one-size-fits-all approach is not recommended, the operative approach should ideally be informed by patient factors, including hernia characteristics. Addressing surgeon preference and available resources with a clinician-facing decision aid may provide an opportunity to optimize care for patients undergoing inguinal hernia repair.
尽管有循证指南可用于指导手术，但许多患者仍接受不符合指南的治疗。造成这种情况的原因在很大程度上尚不清楚。例如，循证指南建议对双侧或单侧复发腹股沟疝患者采用微创方法。这种方法对单侧腹股沟疝也有好处。然而，来自之前的定量研究的结果表明，只有 26%的患者接受这种治疗，只有 42%的外科医生提供微创方法，即使是针对复发或双侧疝。
探讨与外科医生选择手术方法（微创与开放）相关的因素，以此作为了解不符合指南的治疗的工具。
设计、地点和参与者：作为一项更大的解释性序贯混合方法设计的一部分进行的定性研究。采用目的性抽样，从一个大型全州质量合作组织中招募了 21 名从事实践的外科医生，他们在实践类型、地理位置和手术专业方面各不相同。定性访谈包括一个临床病例，然后是半结构化访谈问题。通过使用定性数据分析软件进行主题分析，确定了数据中的模式，对其进行了分析和识别。所有数据均于 2018 年 4 月 24 日至 7 月 31 日期间收集。
定性访谈中的临床病例。
记录腹股沟疝修复的手术方法和决策的驱动因素。
在 21 名参与研究的外科医生中，17 名（81%）为男性，18 名（86%）为白人，年龄均在 35 岁或以上。研究结果揭示了 3 个主要主题：外科医生的偏好和自主性（例如，偏爱一种方法而非另一种方法）、获取途径和资源（例如，机器人的可用性）以及患者特征（例如，年龄、合并症）。
腹股沟疝修复方法的决策主要受外科医生的偏好和获取资源的影响，而不是患者因素。虽然不建议采用一刀切的方法，但手术方法应根据患者因素（包括疝的特征）来确定。通过面向临床医生的决策辅助工具解决外科医生的偏好和可用资源问题，可能为优化接受腹股沟疝修复的患者的治疗提供机会。
