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Day-case and in-patient elective inguinal hernia repair surgery across England: an observational study of variation and outcomes

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Abstract

Purpose

Elective primary inguinal hernia repair surgery is increasingly being conducted as a day-case procedure. However, in England there is evidence of wide variation in day-case rates across hospitals. Reducing the extent of this variation has the potential to support more efficient use of resources (e.g., clinician time, hospital beds) and help the recovery of elective surgical activity following the COVID-19 pandemic. The aims of this study were to explore the extent of variation in day-case rates across healthcare providers in England and to evaluate the safety of day-case elective primary inguinal hernia repair surgery.

Methods

This was an exploratory, retrospective analysis of observational data from the Hospital Episode Statistics data set for England. All patients aged ≥ 17 years undergoing a first elective inguinal hernia repair between 1st April 2014 and 31st March 2022 were identified. The exposure of interest was day-case or in-patient stay, and the primary outcome of interest was 30-day emergency readmission with an overnight stay. For reporting, providers were aggregated to an Integrated Care Board (ICB) level.

Results

A total of 413,059 elective primary inguinal hernia repairs were identified over the 8-year study period. Of these, 326,833 (79.1%) were day-case procedures. During the most recent financial year (2021–22), the highest day-case rate for an ICB was 93.8% and the lowest 66.1%. After adjusting for covariates, day-case surgery was associated with significantly lower rates of 30-day emergency readmission (odds ratio (OR) 0.61, 95% confidence interval (CI) 0.58–0.64, p < 0.001) and for the secondary outcomes 180-day mortality and haemorrhage, infection and pain at 30-day post-discharge. Rates of 30-day emergency readmission were significantly lower in ICBs with high rates of day-case surgery (OR 0.84, 95% CI 0.74–0.96, p < 0.001) than in ICBs with low rates of day-case surgery, although rates of post-procedural haemorrhage within 30 days of discharge were significantly higher in trusts with high day-case rates (OR 1.20, 95% CI 1.04–1.40, p = 0.015).

Conclusions

For the outcomes studied, we found no consistent evidence that day-case elective inguinal hernia repair was unsafe for selected patients. Currently, there is substantial variation between ICBs in terms of delivering day-case surgery. Reducing this variability may help address the current pressures on the NHS in elective surgery.

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Availability of data

This report does not contain patient identifiable data. Data in this report are anonymised. The underlying HES data cannot be made available directly by the authors as the data were obtained under licence/data sharing agreement from NHS England. HES data are available from NHS England upon application.

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Acknowledgements

We acknowledge NHS Digital for permission to use their data in this report. We also thank all staff within individual NHS trusts who collected and entered the data used in this study. The study protocol was not pre-registered.

Funding

This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

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Authors

Contributions

This study was designed and organised by JJ, WKG, AF and TWRB. Data cleaning and analysis was by WKG. Writing of the first draft was by JJ and WKG. All authors critically reviewed the manuscript and agreed to submission of the final draft.

Corresponding author

Correspondence to J. Joyner.

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Ethical approval was not sought for the present study, because it did not directly involve human participants. This study was completed in accordance with the Helsinki Declaration as revised in 2013.

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Informed consent was not sought for the present study, because it was an analysis of routine clinical data.

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Joyner, J., Ayyaz, F.M., Cheetham, M. et al. Day-case and in-patient elective inguinal hernia repair surgery across England: an observational study of variation and outcomes. Hernia 27, 1439–1449 (2023). https://doi.org/10.1007/s10029-023-02893-x

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