Sociodemographic factors linked to earlier umbilical-hernia repair in asymptomatic children

Last Updated: 2019-05-14

By Will Boggs MD

NEW YORK (Reuters Health) - Several factors are associated with nonadherence to age-specific guidelines for repair of asymptomatic umbilical hernia in children, according to a retrospective database study.

More than 85% of all umbilical hernias in children will close spontaneously by age 4 or 5 years, and few such hernias require emergency repair. Accordingly, current guidelines do not recommend routine surgical repair for children with asymptomatic umbilical hernias until they reach age 4 or 5 years.

Dr. Shawn J. Rangel from Boston Children's Hospital and colleagues used data from the Pediatric Health Information System database to examine the association of sociodemographic factors with adherence to age-specific guidelines for the management of asymptomatic umbilical hernias in children.

Among more than 25,000 children undergoing umbilical hernia repair from 47 children's hospitals, 29.6% were 3 years or younger at the time of repair, and only 3.7% of these early repairs were associated with an emergent or urgent presentation.

On multivariable analysis, public insurance, lower income and female sex were independently associated with increased odds of undergoing early umbilical hernia repair, the researchers report in JAMA Pediatrics, online May 6.

Insurance type and income level were additive factors: children with public insurance in the lowest income quintile had 2.15-fold increased odds of early repair compared with children with commercial insurance in the highest income quintile (P<0.001).

In the subgroup of children who underwent repair associated with an emergent or urgent presentation, no sociodemographic factors were associated with increased odds of early repair.

No individual hospital or group of hospitals accounted for the overall association of public insurance, lower income, or female sex with early repair.

"Strategies to eliminate disparities based on nonclinical sociodemographic factors may include educational efforts and outreach programs that target not only high-risk children but also the primary care clinicians and surgeons who care for them," the authors conclude. "Further investigation should explore how existing differential reimbursement mechanisms may inadvertently support the practice of potentially unnecessary surgery in publicly insured children and whether policy changes surrounding insurance coverage may reduce disparities in care for this at-risk cohort."

Dr. Jonathan Emerson Kohler of the University of Wisconsin School of Medicine and Public Health, in Madison, who recently reported similar early surgery rates from a study of three U.S. states, told Reuters Health by email, "Like any retrospective database study, the reasons for the findings that they show in this paper aren't possible to divine from these results. However, knowing that there is variation in care is a good basis on which to start prospectively investigating why patients get different care, whether those variations lead to different outcomes, and how we can best tailor our approach to make sure all patients get the right operation at the right time."

"There aren't yet real, formal guidelines for managing umbilical hernias," he said. "Data like this and the similar results that we've seen in my work suggest that formal guidelines from the pediatric and pediatric surgical societies might help to prevent unnecessary operations in young patients whose umbilical hernias have the potential to go on to close spontaneously."

"The umbilicus is a mystery hiding in plain sight," Dr. Kohler said. "Even something as seemingly straightforward as an umbilical hernia can generate deep questions about how we practice medicine."

SOURCE: https://bit.ly/2HAvvN9

JAMA Pediatr 2019.