PM1051: Impact of American Academy of Pediatrics Age-specific Guidelines for Asymptomatic Umbilical Hernia Referral on Early Repair Rates and Associated Disparities

Background: With the goal of reducing potentially unnecessary early surgery, the AAP Section on Surgery (AAP-SOSu) released guidelines in November 2019 recommending delay of surgical referral for asymptomatic umbilical hernias (UH) until 4-5 years of age. The purpose of this analysis was to assess the impact of these guidelines on rates of early repair, hospital-level practice variation, and sociodemographic disparities across a large cohort of children’s hospitals.

Methods: Multicenter retrospective cohort study of children undergoing umbilical hernia repair over a 7-year period (5-year period before and 2-year period following guideline release) at 37 children’s hospitals participating in the Pediatric Health Information System database. Children who underwent multiple procedures (in addition to UH repair) and repair of recurrent umbilical hernias were excluded. Children undergoing surgery at 3 years of age or younger were categorized as having an early repair. Multivariable logistic regression was used to calculate overall and hospital-level observed-to-expected (O/E) ratios for early repair before and after guideline release, adjusting for demographic characteristics, presence of complex chronic conditions, and emergent/urgent presentation. Secondary models adjusting for hospital-level effect were developed to explore the association of income and insurance type on early repair before and after guideline release.

Results: 28,597 children were included (21,811 before and 6,786 after release, respectively). Demographic and clinical characteristics were similar between the two time periods. The relative rate of early repair decreased by 30% following guideline release (19% vs. 27%, p< 0.0001), however, a consistent decline in early repair was identified across the entire measurement period (7.1% relative decrease per year, p< 0.0001). At the hospital level, rates of early repair were lower at 78% (29/37) of hospitals following guideline release, although rates still varied significantly among hospitals (8.7-fold variation before guideline release [5.6%-48.8%, p< 0.001] vs. 9.5-fold after [5.2%-49.2%, p< 0.001], figure 1). Early repair was associated with public insurance and lower income, and both the presence and magnitude of these disparities were similar before and after guideline release (figure 2).

Conclusion: Rates of early UH repair decreased following release of AAP-SOSu guidelines, however, the gradual decrease over time suggests other factors have also played a role. While the decrease in overall rate is promising, relatively high rates persist at many hospitals and socioeconomic disparities remain unchanged. Further collaboration is needed within the AAP to improve compliance with existing guidelines, particularly for at-risk children with public insurance and low-income backgrounds.