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Outcomes research and innovation
Analysis of outcomes and participation in clinical research has been demonstrated to have an association
with improved postoperative outcomes. Involvement in multicenter hernia registry has also been linked
to improved outcomes due to awareness of surveillance (Hawthorne effect), or self-selection bias in which
participating centers have higher vested interest in overall hernia outcomes [37,38,61,62] . The ability to maintain
a prospective database with long-term analysis of hernia recurrence rates, quality of life, and postoperative
outcomes is the only way to understand if implemented techniques and interventions achieve their goal
and meet patient satisfaction [63-66] .

Promotion of a rich research environment by having a diverse group of research personnel for each step
of the process will streamline data collection, consent of patients, institutional review board approval,
data analysis, and ultimately abstract submissions, presentations, and preparation of manuscripts for
publication. These tasks can be done with dedicated research staff including research managers, data
collection specialists, residents, and fellows. Having a surgical fellowship encourages continual learning,
improvement, introduction of new techniques and the ability to sustain academic productivity [29-31] . In
many ways, academic research can complement a clinically busy workload. Research can also be funded
by obtaining sponsors and grants, including but not limited to national sponsors (National Institutes of
Health, Department of Defense), surgical associations, industry, and hospital-specific internal funding.

Collaboration with other hernia centers encourages shared learning, data collection, and increased
statistical power. It also allows for the identification of reproducible outcomes that can then be generalized.
Participation in hernia registries can go a long way in terms of gaining new data and information.
Collaboration can be more formalized through registered databases, at national and international academic
meetings, but it can also be informal through social media and other various idea and information sharing
platforms.

Financial independence and sustainability
The financial investment needed for establishing an AWR COE can be substantial but will be offset by
the financial benefits of having a tertiary care referral center that will generate revenue from a growing
patient network, referral patterns, and decreasing cost of complications, recurrence, and reoperations.
Negotiation of resources is unique in each institution and building a COE will be a long-term investment
that will ultimately improve the reputation of the parent institution, establish patient care practices that will
decrease postoperative cost, length of stay and financial burden of complex patients. Building a sustainable
and streamlined process only leads to a more efficient and cost-effective system that focuses on decreasing
healthcare costs. A recent review demonstrated that by modifying risk factors alone in over 700 patients,
there was a decrease in postoperative wound-related complications from 40.8% to 20.6%, with an estimated
[46]
savings of over $4 million . Postoperative billing should also reflect the complexity of the work performed
by the healthcare team and should consider recurrence, incarceration, mesh excisions, components
separation, and documentation of advancement flaps and soft tissue rearrangements needed after the
hernia repair itself. These combined interventions of generating referral patterns, increasing productivity
in clinical activity, research reputation, and decreasing healthcare costs are worthwhile institutional
investments.

CONCLUSION
The marker of a successful AWR program is multifactorial with many key components. In a system
that works well, all participants should collaborate and benefit from the COE, including the institution,
surgeons, physicians, care providers, and above all the patients. Increased case volume, complexity and
referrals together will be one indication of success, but other measurable indicators include long-term
patient outcomes and hernia recurrence rates.