Audit and recurrence rates after hernia surgery

Objective: To study the effect of quality assurance on the recurrence rate after hernia repair. Design: A prospective longitudinal cohort study. Setting: District hospital, Sweden. Subjects: All (tr = 1232) patients aged 15-80 years operated upon for ingui nal or femoral hernia in Motala 1984, 1986-1988, 1990, and 1992-1994. Intervention: A questionnaire enquiring about pain or a lump in the operate d area was sent 3-6 years postoperatively to all patients, excluding those who had already been operated on for recurrence and those who had died. Sel ected cases were examined depending on the answers to the questionnaire. Main outcome measures: Recurrence rate estimated by adding already confirme d recurrences to those found at the clinical examination; reoperation for r ecurrence; hospital stay; and number of day cases. Cumulative incidence of reoperation was analysed by actuarial analysis of all patients operated on from 1986-1997. Results: The recurrence rate decreased from 18% in 1984 and 1986 to 3% in 1 993 and 1994. The reoperation rate for recurrence at three years was 10.8% (95% confidence interval, CI: 9.3 to 12.2%). 3.6% (2.6 to 4.4%) and 2.2% (1 .7 to 2.7%) for patients operated on between 1986-1988, 1989-1991 and 1992- 1997, respectively. Differences between the first and the second and betwee n the first and the third period were both highly significant (p < 0.001) w hereas the difference between the second and third period was not (p = 0.09 ). Mean hospital stay decreased from 3.5 days in 1984 to 0.9 days in 1994. Conclusion: By recording recurrence rate or its surrogate endpoint, reopera tion rate for recurrence, or both, hospital stay, and number of day cases, and presenting these results to participating surgeons, we provided incenti ves to improve outcome. This has resulted in a rapid decrease in recurrence rate and a shortened hospital stay, thereby improving cost-effectiveness.