title: Recurrence of inguinal hernias repaired in a large hernia surgical specialty hospital and general hospitals in Ontario, Canada.
abstract: BACKGROUND
  The effect of hospital specialization on the risk of hernia recurrence after inguinal hernia repair is not well described.
  
  
  METHODS
  We studied Ontario residents who had primary elective inguinal hernia repair at an Ontario hospital between 1993 and 2007 using population-based, administrative health data. We compared patients from a large hernia specialty hospital (Shouldice Hospital) with those from general hospitals to determine the risk of recurrence.
  
  
  RESULTS
  We studied 235 192 patients, 27.7% of whom had surgery at Shouldice hospital. The age-standardized proportion of patients who had a recurrence ranged from 5.21% (95% confidence interval [CI] 4.94%-5.49%) among patients who had surgery at the lowest volume general hospitals to 4.79% (95% CI 4.54%-5.04%) who had surgery at the highest volume general hospitals. In contrast, patients who had surgery at the Shouldice Hospital had an age-standardized recurrence risk of 1.15% (95% CI 1.05%-1.25%). Compared with patients who had surgery at the lowest volume hospitals, hernia recurrence among those treated at the Shouldice Hospital was significantly lower after adjustment for the effects of age, sex, comorbidity and income level (adjusted hazard ratio 0.21, 95% CI 0.19-0.23, p < 0.001).
  
  
  CONCLUSIONS
  Inguinal hernia repair at Shouldice Hospital was associated with a significantly lower risk of subsequent surgery for recurrence than repair at a general hospital. While specialty hospitals may have better outcomes for treatment of common surgical conditions than general hospitals, these benefits must be weighed against potential negative impacts on clinical care and the financial sustainability of general hospitals.
authors.affiliation: From the Institute of Medical Science, University of Toronto, Toronto, Ont. (Malik, Urbach); the Toronto General Research Institute, Toronto, Ont. (Malik, Urbach); the Department of Surgery, University Health Network, Toronto, Ont. (Urbach); the Department of Medicine, Mount Sinai Hospital, Toronto, Ont. (Bell); and the Institute for Clinical Evaluative Sciences, Toronto, Ont. (Malik, Stukel, Urbach).
authors.forename: Atiqa
authors.initials: A
authors.lastname: Malik
authors.affiliation: From the Institute of Medical Science, University of Toronto, Toronto, Ont. (Malik, Urbach); the Toronto General Research Institute, Toronto, Ont. (Malik, Urbach); the Department of Surgery, University Health Network, Toronto, Ont. (Urbach); the Department of Medicine, Mount Sinai Hospital, Toronto, Ont. (Bell); and the Institute for Clinical Evaluative Sciences, Toronto, Ont. (Malik, Stukel, Urbach).
authors.forename: Chaim M
authors.initials: CM
authors.lastname: Bell
authors.affiliation: From the Institute of Medical Science, University of Toronto, Toronto, Ont. (Malik, Urbach); the Toronto General Research Institute, Toronto, Ont. (Malik, Urbach); the Department of Surgery, University Health Network, Toronto, Ont. (Urbach); the Department of Medicine, Mount Sinai Hospital, Toronto, Ont. (Bell); and the Institute for Clinical Evaluative Sciences, Toronto, Ont. (Malik, Stukel, Urbach).
authors.forename: Thérèse A
authors.initials: TA
authors.lastname: Stukel
authors.affiliation: From the Institute of Medical Science, University of Toronto, Toronto, Ont. (Malik, Urbach); the Toronto General Research Institute, Toronto, Ont. (Malik, Urbach); the Department of Surgery, University Health Network, Toronto, Ont. (Urbach); the Department of Medicine, Mount Sinai Hospital, Toronto, Ont. (Bell); and the Institute for Clinical Evaluative Sciences, Toronto, Ont. (Malik, Stukel, Urbach).
authors.forename: David R
authors.initials: DR
authors.lastname: Urbach
mesh_terms: D005260:Female; D006552:Hernia, Inguinal / Q000601:surgery*; D006769:Hospitals, General / Q000706:statistics & numerical data*; D006782:Hospitals, Special / Q000706:statistics & numerical data*; D006801:Humans; D008297:Male; D008875:Middle Aged; D009864:Ontario; D017063:Outcome Assessment, Health Care / Q000706:statistics & numerical data*; D012008:Recurrence; D012086:Reoperation / Q000706:statistics & numerical data*; D013531:Surgicenters / Q000706:statistics & numerical data