Division of Minimally Invasive Surgery, Department of Surgery, University of Michigan, Ann Arbor.
University of Michigan Medical School, Ann Arbor.
JAMA Netw Open. 2021 May 3;4(5):e216836. doi: 10.1001/jamanetworkopen.2021.6836.
Real-world surgical practice often lags behind the best scientific evidence. For example, although optimizing comorbidities such as smoking and morbid obesity before ventral and incisional hernia repair improves outcomes, as many as 25% of these patients have a high-risk characteristic at the time of surgery. Implementation strategies may effectively increase use of evidence-based practice.
To describe current trends in preoperative optimization among patients undergoing ventral hernia repair, identify barriers to optimization, develop interventions to address these barriers, and then pilot these interventions.
DESIGN, SETTING, AND PARTICIPANTS: This quality improvement study used a retrospective medical record review to identify hospital-level trends in preoperative optimization among patients undergoing ventral and incisional hernia repair. Semistructured interviews with 21 practicing surgeons were conducted to elicit barriers to optimizing high-risk patients before surgery. Next, a task force of experts was convened to develop pragmatic interventions to increase surgeon use of preoperative optimization. Finally, these interventions were piloted at 2 sites to assess acceptability and feasibility. This study was performed from January 1, 2014, to December 31, 2019.
The main outcome was rate of referrals for preoperative patient optimization at the 2 pilot sites.
Among 23 000 patients undergoing ventral hernia repair, the mean (SD) age was 53.9 (14.3) years, and 12 315 (53.5%) were men. Of these, 8786 patients (38.2%) had at least 1 high-risk characteristic at the time of surgery, including 7683 with 1, 1079 with 2, and 24 with 3. At the hospital level, the mean proportion of patients with at least 1 of 3 high-risk characteristics at the time of surgery was 38.2% (95% CI, 38.1%-38.3%). This proportion varied widely from 21.5% (95% CI, 17.6%-25.5%) to 52.8% (95% CI, 43.9%-61.8%) across hospitals. Interviews with surgeons identified 3 major barriers to improving this practice: lost financial opportunity by not offering a patient an operation, lack of surgeon awareness of available resources for optimization, and organizational barriers. A task force therefore developed 3 interventions: a financial incentive to optimize high-risk patients, an educational intervention to make surgeons aware of available optimization resources, and on-site facilitation. These strategies were piloted at 2 sites where preoperative risk optimization referrals increased 860%.
This study demonstrates a stepwise process of identifying a practice gap, eliciting barriers that contribute to this gap, using expert consensus and local resources to develop strategies to address these barriers, and piloting these strategies. This implementation strategy can be adopted to diverse settings given that it relies on developing and implementing strategies based on local practice patterns.
真实世界的外科实践往往落后于最佳科学证据。例如，尽管在进行腹侧和切口疝修复之前优化吸烟和病态肥胖等合并症可以改善预后，但多达 25%的患者在手术时具有高危特征。实施策略可能会有效地增加循证实践的应用。
描述接受腹侧疝修复患者术前优化的当前趋势，确定优化的障碍，制定解决这些障碍的干预措施，然后对这些干预措施进行试点。
设计、地点和参与者：本质量改进研究使用回顾性病历审查，确定了在进行腹侧和切口疝修复的患者中术前优化的医院水平趋势。对 21 名执业外科医生进行半结构化访谈，以了解手术前优化高危患者的障碍。接下来，召集一个专家工作组制定切实可行的干预措施，以增加外科医生对术前优化的使用。最后，在 2 个地点对这些干预措施进行试点，以评估可接受性和可行性。这项研究是在 2014 年 1 月 1 日至 2019 年 12 月 31 日进行的。
主要结果是在 2 个试点地点进行术前患者优化转诊的比例。
在 23000 例接受腹侧疝修复的患者中，平均（SD）年龄为 53.9（14.3）岁，其中 12315 例（53.5%）为男性。其中，8786 例（38.2%）患者在手术时至少有 1 个高危特征，包括 7683 例（38.2%）有 1 个，1079 例（38.2%）有 2 个，24 例（38.2%）有 3 个。在医院层面，至少有 3 个高危特征之一的患者比例为 38.2%（95%置信区间，38.1%-38.3%）。这一比例在医院之间差异很大，从 21.5%（95%置信区间，17.6%-25.5%）到 52.8%（95%置信区间，43.9%-61.8%）不等。对外科医生的访谈确定了改善这一做法的 3 个主要障碍：不向患者提供手术机会而丧失的经济机会、外科医生对优化可用资源缺乏认识，以及组织障碍。因此，一个工作组制定了 3 项干预措施：为优化高危患者提供经济激励，开展教育干预使外科医生了解可用的优化资源，以及现场协助。这些策略在 2 个地点进行了试点，术前风险优化转诊率增加了 860%。
本研究展示了一个逐步识别实践差距的过程，了解导致这一差距的障碍，利用专家共识和当地资源制定解决这些障碍的策略，并对这些策略进行试点。由于该实施策略依赖于基于当地实践模式制定和实施策略，因此可以在不同的环境中采用。
