HERNIA REGISTERS AND SPECIALIZATION

Since the time of Bassini, 4 hernia surgeons have gained information about surgical techniques by examining their patients postoperatively. Few case series have reached the completeness of follow-up achieved by Bassini, and few surgeons who have used his eponym for their herniorrhaphies can claim better results on reducible hernias than he. For any unit (hospital or group of surgeons) to be able to follow the outcome of patients treated, it is necessary to use some form of registration more detailed than hospital discharge data. If such a registration is carried out on a larger scale, it may also provide information concerning the effectiveness of hernia surgery, that is, the outcome of techniques used in routine practice as distinct from their efficacy, that is, the outcome when the same methods are applied to appropriate patients by experts. 22 This article discusses issues concerning hernia registers and specialization of hernia surgery. A register is defined as "an official or formal list recording names, events, or transactions." 19 In this article, register is used in a restricted sense, indicating the prospective recording of information concerning diagnosis and operations of individual patients followed over time beyond the mere coding according to official classifications. Hospital discharge databases and administrative databases, therefore, are not discussed in this context, although these can provide valuable information concerning regional differences in operation rates and outcomes following common surgical procedures. 7,10,27 Registers as just defined may have their usefulness greatly improved by linkage to sources of vital statistics, thereby connecting registers to epidemiology. Whereas hernia registers have received little attention, specialization is frequently taken up when discussing outcomes reported from specialized and nonspecialized units. The authors' aim is to analyze prerequisites for hernia registers and to see whether conclusions reached with their help lend support to the proponents of specialization in hernia surgery. To achieve this goal, two main endpoints are used: (1) recurrence or its proxy variable reoperation for recurrence, and (2) outpatient surgery as a crude indicator of cost-effectiveness. This does not imply underestimation of the importance of convalescence and patient satisfaction; however, such data tend to be lacking in registers, and these variables are, to a great extent, influenced by advice given to patients 26,32,43 and by socioeconomic factors. 3,42 Furthermore, when patients were asked whether they considered recurrence of hernia or speed of recovery to be most important, most regarded lack of recurrence to be the most important outcome. 28