Hernias are among the most common conditions in the U.S. and for some patients, surgery is recommended to ease the pain and discomfort they typically cause.
But research shows hernia repair surgeries—nearly 1 million are performed every year—aren’t foolproof. Patients can have recurrent hernias or experience continued discomfort that sometimes require additional procedures.
Interested in understanding how effective hernia repair surgery is in improving quality of life for specific patient populations, Dr. John Fischer, associate professor of surgery at Penn Medicine who performs the procedure, began over five years ago exploring a patient-reported outcomes tool specifically for this surgery. Patient-reported outcomes are quality measures that assess quality of life for a patient and have become increasingly more popular in recent years across disease states.
“There really wasn’t a robust instrument in the field that characterized the important things that patients experienced through having hernias, living with it and being treated for it, particularly the complex ones,” Fischer said.
The result is a tool that is helping physicians better understand patient outcomes following surgery and, eventually, how to identify who the best candidates are for hernia repair.
“These tools might help us understand who not to operate on as part of a governing framework,” he said. “Who is not going to get a benefit from surgery and expose themselves to risk? That is kind of the ultimate goal.”
The tool was developed with insight from patients, surgeons and qualitative researchers at Penn. It involves two patient questionnaires, one prior to surgery and another afterward. The preoperative questions are related to how the hernia impacts the patient including their sleep, daily routine and independence. The post-surgery form includes questions about sleep and daily routine as well, but also asks if the patient is feeling increased anxiety or if the surgery made them “feel less attractive without my clothes on.” The questionnaire also asks how well the patient thought the surgical team prepared them for the procedure and the emotional impact from the procedure.
The tool was studied for validity and user burden. Research published in late December 2020 found the median time it takes for patients to complete the pre-operative questionnaire was just 67 seconds. The post-operative questionnaire took 161 seconds. Further, the study shows that patients with lower scores on the post-operative questionnaire were more likely to experience readmissions, complications and recurrence of hernias.
“We have a pretty good tool that can really capture the multiple facets of what a patient experiences with the disease state and a surgical intervention like a reconstruction or repair,” Fischer said.
At Penn, the tool is being used in clinical practice by a few surgeons. The questionnaires are currently presented to patients either on paper or a tablet while they wait to be seen by the surgeon. The results are manually entered by a physician assistant to the electronic health record and a score is generated based on the responses. The surgeon then reviews the scores in the patient’s medical chart. The medical chart also shows all scores from all the questionnaires the patient has taken before surgery and after so the surgeon can compare responses. Patients can take the post-surgery questionnaire multiple times.
Fischer said Penn is working on integrating the tool into the patient portal, so the patient gets an email with a link to the questionnaire that they fill out in advance of visits. He said that will be least disruptive to clinical flow.
Dr. Sean Harbison, another Penn surgeon, uses the tool with his hernia patients. He said it has been helpful in understanding how his patients are doing post-surgery. He added he’s excited about the data the tool can generate in terms of understanding who would benefit the most from hernia repairs.
There isn’t currently enough data to find such trends, though. “We aren’t there yet,” Fischer said.