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

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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.