CHICAGO: Surgical researchers have developed an online app that patients and surgeons can use to help guide preoperative planning and establish expectations for how a patient’s ventral hernia repair operation will turn out, according to study findings published as an “article in press” on the website of the Journal of the American College of Surgeons ahead of print.
The basis of the app is a tool called the Outcomes Reporting App for CLinical and Patient Engagement (ORACLE). “The purpose of the tool is to facilitate patient engagement and activation,” said lead author Ivy Haskins, MD, a general surgery chief resident at George Washington University, Washington, DC. Dr. Haskins worked on developing the ORACLE tool while she was a clinical research fellow at the Cleveland Clinic (Ohio). This tool helps surgeons speak with patients about modifiable patient factors, which are the behavior or lifestyle choices that a patient can change. “Ideally, the ORACLE was developed as a tool to be used in the clinic during the preoperative evaluation of patients considering ventral hernia repair,” Dr. Haskins said. “The point of the tool is really to show patients visually how their outcomes will be affected if, for example, they lose weight or stop smoking, or if the surgeon chooses a specific technique.”
Dr. Haskins and the research team developed ORACLE specifically for patients having operations to correct ventral hernias, which are defects in the abdominal muscles that bulge when organs and fatty tissue fill the defects. Most ventral hernias occur at the site of an incision from a previous abdominal surgery. More than 300,000 people undergo ventral hernia repair operations annually in the United States.*
The researchers developed ORACLE by studying 10,690 ventral hernia repair cases available within the Americas Hernia Society Quality Collaborative (AHSQC) database, a registry of 46,000 hernia patients to which 325 U.S. surgeons currently submit case data.
Other predictive tools have been developed for hernia operations, but Dr. Haskins explains what sets ORACLE apart. “Unfortunately, the utility of the other currently available applications is limited because they only predict one or two outcomes,” she said. “Our tool predicts five outcomes that seem to be the most important for hernia surgeons and for patients when they’re deciding when to proceed with an operation and what type of surgical repair is best for them.”
The five surgical outcomes for which ORACLE provides predictive data are: risk of surgical site infection within 30 days of the operation; 30-day risk of a recurrent ventral hernia requiring another operation; 30-day risk of unplanned hospital readmission; one-year risk of hernia recurrence; and length of hospital stay. The researchers came up with the five outcomes after receiving input from the surgeons in the AHSQC.
ORACLE was launched in October 2017 and since then has been accessed more than 1,500 times. Patients and surgeons can access ORACLE at www.ahsqc.org. A surgeon can print results from the tool and use the printout to review risk factors with the patient. “The ability to print the predictive models is one of the strengths of our tool,” Dr. Haskins, said. “This [feature] allows the patient to review their predictive risks even after leaving their clinic appointment. We hope that seeing, side-by-side, how their risk for postoperative outcomes changes based on their ability to lose weight, quit smoking, and make other behavior modifications will further facilitate patient activation.”
She added, “The objective of the tool is to have patients not just take responsibility for good outcomes, but to know that some of their lifestyle behaviors contribute to both good and bad outcomes postoperatively, and to have surgeons make sure that the expectations are realistic for the patient.”
Currently, study coauthor Michael J. Rosen, MD, FACS, and the Cleveland Clinic staff are developing a phone-based application drawing on the ORACLE tool, Dr. Haskins said. The next step is to generate feedback from AHSQC surgeons who use the tool to determine if it has been a factor in directing patient conversations and setting patient expectations, “and, if they’ve found the tool to be reliable,” Dr. Haskins added.
In addition to Dr. Rosen, Dr. Haskins’ coauthors are Molly Olson, MS, and Thomas Stewart, PhD, of the Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tenn.; and Benjamin K. Poulose, MD, MPH, FACS, of the Center for Abdominal Core Health, department of surgery, Ohio State University Wexner Medical Center, Columbus. Dr. Rosen is with the Comprehensive Hernia Center, department of general surgery, Cleveland Clinic Foundation
Note: Dr. Haskins disclosed that she received an Americas Hernia Society Resident Research Grant for the original proposal to develop the ORACLE tool in 2016. Since that time, Dr. Haskins and the listed coauthors have revised this tool to its currently available online form based on the feedback that they have received from the members of the AHSQC. Drs. Rosen and Poulose receive salary support from AHSQC, of which they are also governing board members.
“FACS” designates that a surgeon is a Fellow of the American College of Surgeons.
Citation: Development and Validation of the Ventral Hernia Repair Outcomes Reporting App for CLinician and Patient Engagement (ORACLE). Journal of the American College of Surgeons. Available at: https://doi.org/10.1016/j.jamcollsurg.2019.03.014.
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*Poulose PK, Shelton J, Phillips S, et al. Epidemiology and cost of ventral hernia repair: making the case for hernia research. Hernia. 2012;16:179-183.
