Defining the Natural History and Drivers of Surgical Referral of Pediatric Umbilical Hernias to Reduce Unnecessary Surgery

项目摘要/摘要 拟议研究的目标是：1)确定随时间推移的自闭率 儿童无症状脐疝(UHS)，以及2)早期手术转诊的驱动因素 初级保健提供者(PCP)的无症状UHS。UHS在儿童中很常见，大多数人会 在4-5岁时自发接近。基于以下风险，一般建议在此年龄段后进行修复 症状的扩大和发展。基于这些观察，美国科学院 儿科(AAP)建议将手术转诊和修复推迟到4-5岁，以允许 自发关闭。尽管有这些指南，许多患有无症状UHS的儿童被转诊为早期 手术(即3岁或以下)，30%最终接受修复。现有数据表明， 早期修复不是良性的，可能与潜在的可预防的照顾者焦虑有关，失去了几天的时间 来自工作和学校的，增加的医疗费用，增加的医院复诊，复发，以及潜在的 不必要的手术。早期转诊是“暴露”于早期手术的必经之路。 我们假设，不遵守AAP转诊指南的原因是缺乏健全的 流行病学数据。尽管人们普遍认为5岁后不太可能自然闭合，但 3-5岁儿童的自然闭合率并不是很好的特征。在我们之前的调查中 儿科外科医生，修复时首选年龄差异的最常见原因是 外科医生在3-5岁之间感知的自发闭合率。我们的假设是 类似的PCP信念推动了手术修复的早期转诊。为了解决现有的知识差距，我们将使用 用自然语言处理和混合方法技术来定义大型数据库分析的速度 无症状UH的自发缓解和早期PCP转诊的原因分别为。这个项目的目的是 阐明UH的自然病史和手术转诊的驱动因素，以减轻不必要的负担 对患者、照顾者和医疗保健系统进行转介和手术。 奖学金将在波士顿儿童医院(BCH)举行，由Dr。 肖恩·兰格尔是卫生服务研究(HSR)奖学金的一部分。BCH附属于哈佛大学 提供了无与伦比的跨哈佛商学院、医院、 和研究网站。发展团契的三个主要领域是1)设计的技术技能和 执行健康结果研究，2)运营研究实验室所需的领导力和软技能，以及3) 策略性地推动循证临床护理的政策技能。这些目标将得到赞助商的支持 以及自然语言处理、生物统计方法、电子病历数据库方面的合作者 管理，以及混合的方法。研究金培训计划的目标是为赠款接受者做好准备 作为一名学院派儿科外科医生和严谨的卫生服务研究人员的成功职业生涯。

Project Summary/Abstract The objectives of the proposed study are: 1) to define the rate of spontaneous closure over time for asymptomatic umbilical hernias (UHs) in children, and 2) to characterize the drivers of early surgical referral for asymptomatic UHs by primary care providers (PCPs). UHs are common in children and most will spontaneously close by 4-5 years of age. Repair is generally recommended after this age based on the risk of enlargement and development of symptoms. Based on these observations, the American Academy of Pediatrics (AAP) recommends delaying surgical referral and repair until 4-5 years of age to allow for spontaneous closure. Despite these guidelines, many children with asymptomatic UHs are referred for early surgery (i.e. at 3 years of age or younger), with 30% ultimately undergoing repair. Available data indicate that early repair is not benign, and may be associated with potentially preventable caregiver anxiety, lost days away from work and school, increased health care costs, increased hospital revisits, recurrence, and potentially unnecessary surgery. Early referral is an obligatory step in the “exposure” to early surgery. We hypothesize that the lack of compliance with AAP referral guidelines is driven by lack of sound epidemiologic data. Although there is general consensus that spontaneous closure after age 5 is unlikely, the rate of spontaneous closure between 3 and 5 years of age is not well characterized. In our prior survey of pediatric surgeons, the most common reason for variability in preferred age at repair was differences among surgeons in the perceived rate of spontaneous closure between 3 and 5 years of age. It is our hypothesis that similar PCP beliefs drive early referral for surgical repair. To address the existing knowledge gap, we will use large database analysis with natural language processing and mixed methods techniques to define the rate of spontaneous resolution of asymptomatic UH and reasons for early PCP referral, respectively. This project aims to elucidate the natural history of UH and drivers of surgical referral to reduce the burden of unnecessary referrals and surgeries on patients, caregivers, and the healthcare system. The fellowship will take place in the Boston Children’s Hospital (BCH) under the sponsorship of Dr. Shawn Rangel as part of the Health Services Research (HSR) Fellowship. BCH is affiliated with Harvard Medical School and provides unparalleled opportunities for collaboration across Harvard schools, hospitals, and research sites. The three main areas of fellowship development are 1) technical skills to design and execute health outcomes research, 2) leadership and soft skills necessary to run a research laboratory, and 3) policy skills to strategically drive evidence-based clinical care. These goals will be supported by the sponsor and collaborators in natural language processing, biostatistical methods, electronic medical record database management, and mixed methods. The goal of the fellowship training plan is to prepare the grant recipient for a successful career as an academic pediatric surgeon and rigorous health services researcher.