Primary Care Drivers of Early Pediatric Umbilical Hernia Referral: Opportunities for Surgeon-Led Referral Stewardship.

BACKGROUND AND

OBJECTIVES

Early surgical referral for asymptomatic umbilical hernias in children is common despite recommendations to defer until 4-5 years of age. This study evaluated clinician perceptions and referral decision-making to identify opportunities for pediatric surgeon-led referral stewardship.

METHODS

A sequential mixed-methods study was conducted among pediatric primary care clinicians in a statewide practice network. A web-based survey assessed referral timing, perceived risk of emergency operation, perceived likelihood of spontaneous closure, and factors influencing early referral. Semi-structured interviews were subsequently conducted using purposive sampling to explore drivers of referral variation.

RESULTS

The survey response rate was 41% (244/592), representing 85% (71/83) of network practice groups. Overall, 18.0% reported routinely referring children with asymptomatic umbilical hernias at age 3 years or younger. Early-referring clinicians more frequently overestimated emergency operation risk (50.0% vs 30.7% estimating risk >1%; P=0.021) and underestimated spontaneous closure rate (90.9% vs 74.5% estimating rate <90%; P=0.022). Parental anxiety about incarceration influenced referral for 85.8% of respondents and was more frequently influential among early-referring clinicians (95.5% vs 80.4%; P=0.019). Qualitative interviews identified three central themes: parental anxiety as a primary driver of early referral, clinician role identity as a gatekeeper or facilitator of referrals, and the need for a strong collaborative relationship with surgeons in shaping referral behaviors.

CONCLUSIONS

Early referral for asymptomatic umbilical hernia reflects modifiable knowledge, communication, and relationship-based factors. Pediatric surgeons can use these findings to develop referral guidance, caregiver education, and feedback interventions that support evidence-based observation and reduce potentially avoidable early consultation.