Previous research has shown that a significant proportion of patients who present to the hospital with a ventral hernia have modifiable risk factors, such as obesity, poor fitness, smoking, and poorly controlled diabetes. Researchers have found that preoperative risk-reduction programs can effectively modify patient behaviors, but the generalizability of these outcomes to underserved patients may be hindered by unrecognized barriers. To address this research gap, Julie L. Holihan, MD, and colleagues had a research letter published in JAMA Surgery that aimed to identify patient-reported barriers to successful implementation of a preoperative risk-reduction program at a safety-net hospital.
In the prospective, qualitative study, investigators looked at patients who were evaluated at an outpatient hernia clinic at Harris Health System’s Lyndon B. Johnson Hospital in Houston. “We conducted interviews with patients to investigate their perspectives on their current health status, their desire for risk modification, and possible barriers to participating in a preoperative risk-reduction program,” explains Dr. Holihan. In total, 43 consecutive patients with ventral hernias consented to participate, and many were uninsured or underinsured and/or minorities. Most participants were unemployed and/or had a disability, and the median education level was 11th grade.
According to the study results, about 79% of patients reported their current physical condition was a health risk, but about half of overweight patients stated that their weight had no effect on their lives. “Most patients also believed they were able to independently resolve and improve their comorbidities,” adds Dr. Holihan. When participants were asked how they would go about accomplishing this task, the typical response was exercise and diet. Among the self-reported smokers, the most common answer was simply quit. “Importantly, most patients expressed having interest in participating in a preoperative risk-reduction program,” Dr. Holihan says.
The analysis also revealed several self-reported barriers to participating in a preoperative risk reduction program and potential methods to overcoming these challenges. Transportation and parking were the most commonly reported barriers. Because of this, nearly 84% of patients felt compensation would motivate participation, and the median compensation requested was $25 per visit. As expected, the level of interest in online classes for a preoperative risk reduction program was higher for patients with internet access; most patients had access to the internet. “After we integrated the survey into the enrollment process for our preoperative risk-reduction program, enrollment improved from about 21% of eligible patients to about 66%,” says Dr. Holihan.
Considering the Big Picture
Patients at the highest risk for surgical complications after ventral hernia repair often have a poor understanding of their health status and overestimate their ability to manage their comorbidities. “We need to talk to patients about their needs in order to find ways to overcome barriers to participating in preoperative risk reduction programs,” Dr. Holihan says. In her study, the authors provided transportation or parking vouchers for all visits and used feedback from the surveys to adjust meeting times.
Dr. Holihan underscores the significance of the finding that program enrollment rates improved dramatically after implementing patient surveys. Patients may believe the program could provide accountability by explaining themselves to their healthcare providers and made them feel more motivated to achieve their goals. “By making patients key stakeholders in the program, we may be able to improve enrollment in these interventions and their overall effectiveness,” adds Dr. Holihan.
Julie L. Holihan, MD, has indicated to Physician’s Weekly that she has no financial disclosures to report.
Readings & Resources (click to view)
Henchcliffe BE, Holihan JL, Flores-Gonzalez JR, et al. Barriers to participation in preoperative risk-reduction programs prior to ventral hernia repair: an assessment of underserved patients at a safety-net hospital. JAMA Surg. 2016 Feb 17 [Epub ahead of print]. Available at: http://archsurg.jamanetwork.com/article.aspx?articleid=2491220.
Liang MK, Goodenough CJ, Martindale RG, Roth JS, Kao LS. External validation of the ventral hernia risk score for prediction of surgical site infections. Surg Infect (Larchmt). 2015;16:36-40.
Zaki A, Abrishami A, Wong J, Chung FF. Interventions in the preoperative clinic for long term smoking cessation: a quantitative systematic review. Can J Anaesth. 2008;55:11-21.
Booth GL, Hux JE. Relationship between avoidable hospitalizations for diabetes mellitus and income level. Arch Intern Med. 2003;163:101-106.