Clinical and systemic determinants of hospital length of stay and minimally invasive training exposure in elective inguinal hernia repair: an inverse probability-weighted cohort study

Abstrakt

Background Inguinal hernia repair (IHR) is a standardized procedure, yet variations in hospital length of stay (LOS) and adoption of minimally invasive techniques persist. This study evaluated whether systemic determinants, including reimbursement pathways and training paradigms, are associated with these practice variations. Methods A 5-year retrospective cohort study (2017–2021) of 1,863 adult patients undergoing elective IHR at a tertiary academic center was conducted. The primary exposure was the financing pathway (government quota vs. commercial insurance). Inverse probability of treatment weighting (IPTW) was applied to adjust for patient-level clinical confounders. Hospital LOS was analyzed using a weighted Gamma Generalized Linear Model. Secondary outcomes included treatment setting and resident exposure to laparoscopic procedures. Results Median LOS was significantly longer in the government-quota cohort (8.0 days; IQR: 6.0–10.0) compared to the commercial cohort (5.0 days; IQR: 4.0–7.0). In the IPTW-adjusted model, government-quota funding remained independently associated with prolonged hospitalization (adjusted Rate Ratio [RR]: 1.29; 95% CI: 1.18–1.41; p < 0.001), corresponding to a standardized adjusted mean difference of +2.05 days (95% CI: 1.68–2.42). Over 99% of procedures were managed on an inpatient basis. Concurrently, resident-led laparoscopic exposure was 8.6% (3/35) in 2018 and 2.4% (1/42) in 2020; this numerical decrease did not reach statistical significance (Fisher's exact test, p = 0.325). No complications or mortality were observed in either resident-led cohort. Conclusion Reimbursement pathways are strongly associated with hospital length of stay for elective IHR, independent of patient clinical complexity. Additionally, persistent reliance on inpatient care coincides with low resident exposure to minimally invasive surgery. These findings support aligning financial models with efficiency guidelines while modernizing surgical training curricula.