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Comment & Response
September 30, 2019

Need for Consensus Guidelines in Pediatric Umbilical Hernia Repair

Author Affiliations
  • 1Boston Children's Hospital, Department of Surgery, Harvard Medical School, Boston, Massachusetts
  • 2Department of Surgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
JAMA Pediatr. 2019;173(11):1110. doi:10.1001/jamapediatrics.2019.3417

In Reply We read with interest the comments submitted by Kohler et al in response to our analysis exploring the influence of sociodemographic factors on timing of asymptomatic umbilical hernia repair in children.1 In their commentary, they propose that the disparities in care characterized in the analysis may be owing to practice variation arising from a lack of well-established consensus guidelines. While we agree that marked practice variation exists in the timing of umbilical hernia repair across children’s hospitals,2 we would disagree with the notion that a lack of (or compliance with) recommendations is inherently responsible for the observed disparities. Hierarchical regression was used in our analysis to control for hospital-level differences in timing of umbilical hernia repair when assessing potential risk factors. Following adjustment, marked disparities in the risk of early umbilical hernia repair remained for children with public insurance and lower income, and these trends were observed across most children’s hospitals examined. These findings would suggest that disparities associated with disadvantaged sociodemographic backgrounds are not only pervasive but also independent from the broader practice variation that exists across children’s hospitals.

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