Chapter 18: Abdominal Wall Hernia

The Burden of Digestive Diseases in the United States

James E. Everhart, M.D., M.P.H.

Abdominal wall hernias (AWH) are coded by their anatomical location (direct and indirect inguinal, femoral, and umbilical, plus other or unspecified) and subcoded by complication (obstruction, with or without gangrene) in ICD-10. Coding was different in ICD-9, which had an odd combination of location and complication (Appendix 1). However, the individual codes match up fairly well between the two editions.

The large majority of AWH are inguinal hernias, which frequently occur as a result of incomplete closure of the inguinal canal in male infants. Hence, there was a substantial number of ambulatory care visits among children and more than twice the rate among males as females in 2004 (Table 1). However, among adults, the rate of visits increased progressively with age. Whites had a higher rate than blacks. Rates have not changed appreciably since 1975.¹⁴ AWH was the third leading cause of ambulatory care visits in 2004, after GERD and constipation. Rates of hospital discharges with AWH were higher among blacks and there was little difference by sex.

The definitive treatment of AWH is by surgical repair. Because most repairs no longer require overnight hospitalization, the rate of hospitalizations has declined substantially, largely over a 10-year period between 1983 and 1993 (Figure 1). This decline was mostly accounted for by substantial reduction in the number of direct hernia repairs among males.¹⁵ The same decline did not occur among females, which may account for the similar discharge rates between males and females.

In 2004, more than 1,000 persons died with AWH as the underlying cause (Table 2). The large majority of deaths occurred among persons age 65 years and older. Mortality rates were similar for whites and blacks and for males and females. Mortality rates declined between 1979 and the mid-1990s for AWH as underlying cause and more substantially as underlying or other cause (Figure 2). Mortality rates were then stable through 2004.

Because AWH is primarily a surgical condition, prescriptions filled at retail pharmacies captured through the Verispan database (Appendix 2) may not have captured the extent and nature of medication use for these conditions. In 2004, there were an estimated 3.7 million retail prescriptions filled, at a cost of $59.5 million. More than 97 percent of these prescriptions were for analgesics, with the rest for antimicrobial agents.

References

Table 1. Abdominal Wall Hernia: Number and Age-Adjusted Rates of Ambulatory Care Visits and Hospital Discharges With First-Listed and All-Listed Diagnoses by Age, Race, and Sex in the United States, 2004

Source: National Ambulatory Medical Care Survey (NAMCS) and National Hospital Ambulatory Medical Care Survey (NHAMCS) (3-year average, 2003–2005), and Healthcare Cost and Utilization Project Nationwide Inpatient Sample (HCUP NIS)
Demographic Characteristics	Ambulatory Care Visits First-Listed Diagnosis Number in Thousands	Ambulatory Care Visits First-Listed Diagnosis Rate per 100,000	Ambulatory Care Visits All-Listed Diagnosis Number in Thousands	Ambulatory Care Visits All-Listed Diagnosis Rate per 100,000	Hospital Discharges First-Listed Diagnosis Number in Thousands	Hospital Discharges First-Listed Diagnosis Rate per 100,000	Hospital Discharges All-Listed Diagnosis Number in Thousands	Hospital Discharges All-Listed Diagnosis Rate per 100,000
AGE (Years) Under 15	160	264	417	685	5	8	24	40
AGE (Years) 15–44	1,113	885	1,278	1,016	29	23	65	52
AGE (Years) 45–64	1,492	2,111	1,804	2,552	60	84	124	176
AGE (Years) 65+	976	2,686	1,288	3,545	69	189	158	435
Race White	3,347	1,348	4,223	1,703	130	51	290	115
Race Black	287	858	437	1,275	17	54	47	142
Sex Female	1,056	681	1,526	987	86	54	194	121
Sex Male	2,686	1,902	3,261	2,317	75	56	177	132
Total	3,742	1,274	4,787	1,630	163	55	372	127

Figure 1. Abdominal Wall Hernia: Age-Adjusted Rates of Ambulatory Care Visits and Hospital Discharges With All–Listed Diagnoses in the United States, 1979–2004

The rate of ambulatory care visits over time (age-adjusted to the 2000 U.S. population) is shown by 3-year periods (except for the first period which is 2 years), between 1992 and 2005 (beginning with 1992–1993 and ending with 2003–2005). Ambulatory care visits per 100,000 increased from 1,340 in 1992-1993 to 1,607 in 2003-2005. The rate of hospitalization has declined substantially, largely over a 10-year period between 1983 and 1993. Hospitalizations per 100,000 decreased from 391 in 1979 to 111 in 1995 and then remained stable through 2004 when the rate was 110.

Table 2. Abdominal Wall Hernia: Number and Age-Adjusted Rates of Deaths and Years of Potential Life Lost (to Age 75) by Age, Race, and Sex in the United States, 2004

Source: Vital Statistics of the United States
Demographic Characteristics	Underlying Cause Number of Deaths	Underlying Cause Rate per 100,000	Underlying Cause Years of Potential Life Lost in Thousands	Underlying or Other Cause Number of Deaths	Underlying or Other Cause Rate per 100,000
AGE (Years) Under 15	10	0.0	0.7	21	0.0
AGE (Years) 15–44	43	0.0	1.6	70	0.1
AGE (Years) 45–64	197	0.3	3.8	384	0.5
AGE (Years) 65+	922	2.5	0.8	1,624	4.5
Race White	1,015	0.4	5.3	1,815	0.7
Race Black	133	0.5	1.5	246	0.9
Sex Female	670	0.4	3.2	1,132	0.6
Sex Male	502	0.4	3.7	967	0.8
Total	1,172	0.4	6.9	2,099	0.7

Figure 2. Abdominal Wall Hernia: Age-Adjusted Rates of Death in the United States, 1979–2004

Mortality rates declined between 1979 and the mid-1990s as underlying cause and more substantially as underlying or other cause, and were then stable through 2004. Underlying-cause mortality per 100,000 decreased from 0.61 in 1979 to 0.39 in 2004. All-cause mortality per 100,000 decreased from 1.68 in 1979 to 0.83 in 1991, and was 0.69 in 2004.

Last Reviewed January 2008

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