title: Unintended consequences of policy change to watchful waiting for asymptomatic inguinal hernias.
abstract: BACKGROUND
  In 2009 the Department of Health instructed McKinsey & Company to provide advice on how commissioners might achieve world class National Health Service productivity. Asymptomatic inguinal hernia repair was identified as a potentially cosmetic procedure, with limited clinical benefit. The Birmingham and Solihull primary care trust cluster introduced a policy of watchful waiting for asymptomatic inguinal hernia, which was implemented across the health economy in December 2010. This retrospective cohort study aimed to examine the effect of a change in clinical commissioning policy concerning elective surgical repair of asymptomatic inguinal hernias.
  
  
  METHODS
  A total of 1,032 patients undergoing inguinal hernia repair in the 16 months after the policy change were compared with 978 patients in the 16 months before. The main outcome measure was relative proportion of emergency repair in groups before and after the policy change. Multivariate binary logistic regression was used to adjust the main outcome for age, sex and hernia type.
  
  
  RESULTS
  The period after the policy change was associated with 59% higher odds of emergency repair (3.6% vs 5.5%, adjusted odds ratio [OR]: 1.59, 95% confidence interval [CI]: 1.03-2.47). In turn, emergency repair was associated with higher odds of adverse events (4.7% vs 18.5%, adjusted OR: 3.68, 95% CI: 2.04-6.63) and mortality (0.1% vs 5.4%, p<0.001, Fisher's exact test).
  
  
  CONCLUSIONS
  Introduction of a watchful waiting policy for asymptomatic inguinal hernias was associated with a significant increase in need for emergency repair, which was in turn associated with an increased risk of adverse events. Current policies may be placing patients at risk.
authors.affiliation: Heart of England NHS Foundation Trust, UK.
authors.forename: M J
authors.initials: MJ
authors.lastname: Hwang
authors.forename: A
authors.initials: A
authors.lastname: Bhangu
authors.forename: C E
authors.initials: CE
authors.lastname: Webster
authors.forename: D M
authors.initials: DM
authors.lastname: Bowley
authors.forename: M X
authors.initials: MX
authors.lastname: Gannon
authors.forename: S S
authors.initials: SS
authors.lastname: Karandikar
mesh_terms: D000368:Aged; D004638:Emergency Treatment / Q000401:mortality / Q000706:statistics & numerical data; D004739:England / Q000453:epidemiology; D005260:Female; D006291:Health Policy; D006552:Hernia, Inguinal / Q000401:mortality / Q000628:therapy*; D059685:Herniorrhaphy / Q000401:mortality / Q000706:statistics & numerical data; D006801:Humans; D008297:Male; D008875:Middle Aged; D011183:Postoperative Complications / Q000209:etiology / Q000401:mortality; D017410:Practice Guidelines as Topic; D012189:Retrospective Studies; D016896:Treatment Outcome; D057832:Watchful Waiting