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

项目总结/摘要 拟议研究的目的是：1）确定随时间推移的自发闭合率， 儿童无症状脐疝（UHs），2）描述早期手术转诊的驱动因素， 无症状UH由初级保健提供者（PCP）。UH在儿童中很常见， 在4-5岁时自发闭合。根据以下风险，通常建议在此年龄后进行修复 症状的扩大和发展。根据这些观察，美国科学院 儿科（AAP）建议推迟手术转诊和修复，直到4-5岁，以允许 自发关闭。尽管有这些指导方针，许多无症状UH的儿童被早期转诊， 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， 从工作和学校，增加医疗保健费用，增加医院复诊，复发，并可能 不必要的手术早期转诊是“暴露”于早期手术的必要步骤。 我们假设，缺乏遵守AAP转诊指南是由于缺乏健全的 流行病学数据。尽管普遍认为5岁以后自发闭合的可能性不大， 3至5岁之间的自发闭合率尚未得到很好的表征。在我们之前的调查中， 在儿科外科医生中，修复时首选年龄变化的最常见原因是 外科医生对3 - 5岁之间的自发闭合率的感知。我们假设 类似的PCP信念促使早期转诊进行手术修复。为了解决现有的知识差距，我们将使用 大型数据库分析与自然语言处理和混合方法技术，以确定率 无症状UH的自发消退和早期PCP转诊的原因。该项目旨在 阐明UH的自然史和外科转诊的驱动因素，以减少不必要的负担 患者、护理人员和医疗保健系统的转诊和手术。 该奖学金将在波士顿儿童医院（BCH）的赞助下，博士。 Shawn Rangel是卫生服务研究（HSR）奖学金的一部分。BCH附属于哈佛大学 医学院，并提供了无与伦比的合作机会，在哈佛学校，医院， 和研究网站。研究金发展的三个主要领域是：1）设计和 执行健康成果研究，2）领导和软技能，运行一个研究实验室，和3） 政策技能，以战略性地推动循证临床护理。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、电子病历数据库等方面的合作者 管理和混合方法。研究金培训计划的目标是使赠款接受者做好准备， 一个成功的职业生涯作为一个学术儿科外科医生和严格的卫生服务研究员。

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.