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Henchcliffe BE, Holihan JL, Flores-Gonzalez JR, et al. Barriers to Participation in Preoperative Risk-Reduction Programs Prior to Ventral Hernia Repair: An Assessment of Underserved Patients at a Safety-Net Hospital. JAMA Surg. 2016;151(5):488–490. doi:https://doi.org/10.1001/jamasurg.2015.4452
Nearly 80% of patients presenting with a ventral hernia have modifiable risk factors such as obesity, poor fitness, smoking, and poorly controlled diabetes mellitus.1 Preoperative risk-reduction programs have been shown to be effective in behavior modification. However, generalizability of these outcomes to underserved patients may be hindered by unrecognized barriers.2 The aim of this study was to identify patient-reported barriers to successful implementation of a preoperative risk-reduction program at a safety-net hospital.
This was a prospective, qualitative study of patients evaluated at an outpatient hernia clinic at Lyndon B. Johnson General Hospital, Houston, Texas. The study was initiated concurrently with the development of a preoperative risk-reduction program.3 Interviews were conducted to investigate patient perspectives of their current health status, desire for risk modification, and barriers to participation. Sampling was continued until thematic saturation was achieved. Responses were correlated with clinical data. National guidelines were used to define standards for obesity and quality of diabetic control.4
This study was approved by the institutional review board of the Harris Health System (HSC-MS-14-1025). Oral consent was obtained from all study participants.
Of 43 consecutive patients with ventral hernias, all consented to participate. The mean age (SD) was 49.9 (12.2) years. Of these patients, 46.5% (n = 20) were men. Patients were largely uninsured or underinsured (self-pay = 81.4%, Medicaid/Comprehensive Health Insurance Plan = 11.6%, Medicare = 2.3%, and commercial = 4.7%) and minority patients (Hispanic = 67.4%, African American = 20.9%, and white = 11.6%). Most participants were unemployed and/or had a disability (77.1%). The median education level was 11th grade (range, 0-14).
Self-reported health assessments compared with objective data are in Table 1. Most patients (79.1%; n = 34) stated their current physical condition was a health risk; however, half of the overweight patients stated their weight had no effect on their lives. Many patients (79.1%; n = 34) believed they were able to independently resolve and improve their comorbidities. When asked, “how would you go about accomplishing this task?” the typical response was “exercise and diet.” Among the self-reported smokers, the most common answer was “just quit.” Despite this, most patients (79.1%; n = 34) expressed interest in a preoperative risk-reduction program.
Self-reported barriers to participating in a preoperative program and potential methods to overcome these challenges are in Table 2. Most patients (83.7%) felt compensation would motivate participation. The median compensation requested was $25 (range, $0-$60) per visit. The feasibility of online courses was assessed. The level of interest in online classes strongly correlated with Internet access: 15 patients (42.0%) had Internet access and 16 patients (45.7%) would consider participating in an online class.
Prior to integrating this survey in the enrollment process of the preoperative risk-reduction program, 20.8% (5 of 24) of eligible patients chose to participate. Following use of the survey, enrollment improved to 66.7% (10 of 15) (P = .006; power = 83.8%).
Patients at the highest risk for surgical complications following ventral hernia repair often have a poor understanding of their health status and overestimate their ability to manage their comorbidities. These patients commonly have poor health literacy and seek care at safety-net hospitals owing to lack of insurance and low socioeconomic status.6 This potentially represents one-third of the US population.
Most overweight patients felt their weight had no effect on their lives and that they could independently resolve and improve their comorbidities. However, they also responded that their current physical condition was a health risk and were interested participating in the program. To overcome common barriers, we provided transportation or parking vouchers for all study visits and used feedback from the surveys to adjust meeting times. Program enrollment rates dramatically improved with implementation of patient surveys. As participants considered survey questions, it appeared self-reflection increased interest in joining the trial. Patients believed the program would provide “accountability [by] explaining yourself to the trainer/coach” and make them “feel more motivated to achieve [their] goals.”
Patients report numerous barriers to participation in a preoperative risk-reduction program despite significant potential benefits. Integrating patients as key stakeholders in the development of clinical programs may stimulate self-reflection and patient interest, improving program enrollment and effectiveness.
Corresponding Author: Julie L. Holihan, MD, 6431 Fannin St, MSB 5.254, Houston, Texas (firstname.lastname@example.org).
Published Online: February 17, 2016. doi:10.1001/jamasurg.2015.4452.
Author Contributions: Drs Holihan and Liang had full access to all the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.
Study concept and design: All authors.
Acquisition, analysis, or interpretation of data: Henchcliffe, Holihan, Flores, Mitchell, Liang.
Drafting of the manuscript: Henchcliffe, Holihan, Flores.
Critical revision of the manuscript for important intellectual content: All authors.
Statistical analysis: Henchcliffe, Flores, Mitchell, Liang.
Obtained funding: Ko, Liang.
Administrative, technical, or material support: Henchcliffe, Flores, Liang.
Study supervision: Holihan, Kao, Liang.
Conflict of Interest Disclosures: None reported.
Funding/Support: This work was supported by the Center for Clinical and Translational Sciences, which is funded by National Institutes of Health Clinical and Translational Award UL1 TR000371 and KL2 TR000370 from the National Center for Advancing Translational Sciences.
Role of the Funder/Sponsor: No funding organization had a role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; and preparation, review, or approval of the manuscript.
Disclaimer: The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Center for Research Resources or the National Institutes of Health.
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