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Enodien B, Moser D, Kessler F, Taha-Mehlitz S, Frey DM, Taha A. Cost and Quality Comparison of Hernia Surgery in Stationary, Day-Patient and Outpatient Care. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:12410. [PMID: 36231718 PMCID: PMC9566150 DOI: 10.3390/ijerph191912410] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 08/05/2022] [Revised: 09/21/2022] [Accepted: 09/23/2022] [Indexed: 06/16/2023]
Abstract
BACKGROUND Medical progress is increasingly enabling more and more stationary treatment to be provided in the outpatient sector. This development should be welcomed, as healthcare costs have been rising for years. The design of efficient processes and a needs-based infrastructure enable further savings. According to international recommendations (EHS/IEHS), outpatient treatment of unilateral inguinal hernias is recommended. METHOD Data from patients in GZO Hospital Wetzikon/Zurich between 2019 and 2021 for unilateral inguinal hernia repair was included in this study (n = 234). Any over- or under-coverage correlated with one of the three treatment groups: stationary, partially stationary and patients treated in outpatients clinic. Complications and 30-day readmissions were also monitored. RESULTS Final revenue for all patients is -95.36 CHF. For stationary treatments, the mean shifts down to -575.01 CHF, for partially stationary treatments the mean shifts up to -24.73 CHF, and for patients in outpatient clinic final revenue is 793.12 CHF. This result is also consistent with the operation times, which are lowest in the outpatient clinic with a mean of 36 min, significantly longer in the partially stationary setting with 58 min, and longest in the stationary setting with 76 min. The same applies to the anesthesia times and the relevant care times by the nurses as the most important cost factors in addition to the supply and allocation costs. CONCLUSIONS We show that cost-effective elective unilateral inguinal hernia care in the outpatient clinic with profit (mean 793.12 CHF) is possible. Stationary unilateral hernia care (mean -575.01 CHF) is loss-making. Crucial factors for cost efficiency are optimized processes in the operating room (anesthesia, surgical technique and quality, operating time), as well as optimized care processes with minimal preoperative services and care times for the patient. However, at the same time, these optimizations pose a challenge to surgical and anesthesiology training and structures with high levels of preoperative and Postoperative services and pay-as-you-go costs. The complication rate is 0.91% lower than in a comparable study. The readmission within 30 days post-operation results with a positive deviation of -3.53% (stationary) and with a negative deviation of +2.29% (outpatient clinic) compared to a comparative study.
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Affiliation(s)
- Bassey Enodien
- Department of Surgery, GZO Hospital Wetzikon/Zurich, 8620 Wetzikon, Switzerland
| | - Dominik Moser
- Operations Management, GZO Hospital Wetzikon/Zurich, 8620 Wetzikon, Switzerland
- Department of Health Care Management, Technical University of Berlin, 10623 Berlin, Germany
- Department of Economics and Technology, Swiss Distance University of Applied Sciences (FFHS), 8005 Zurich, Switzerland
- School of Medicine, University of St. Gallen, 9000 St. Gallen, Switzerland
| | - Florian Kessler
- Department of Anesthesiology, GZO Hospital Wetzikon/Zurich, 8620 Wetzikon, Switzerland
| | - Stephanie Taha-Mehlitz
- Department of Visceral Surgery, University Center for Gastrointestinal and Liver Diseases, St. Clara Hospital and University Hospital, 4058 Basel, Switzerland
| | - Daniel M. Frey
- Department of Surgery, GZO Hospital Wetzikon/Zurich, 8620 Wetzikon, Switzerland
- Faculty of Medicine, University of Basel, 4056 Basel, Switzerland
| | - Anas Taha
- Department of Surgery, GZO Hospital Wetzikon/Zurich, 8620 Wetzikon, Switzerland
- Department of Biomedical Engineering, Faculty of Medicine, University of Basel, 4123 Allschwil, Switzerland
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Analysis of Factors Relevant to Revenue Improvement in Ventral Hernia Repair, Their Influence on Surgical Training, and Development of Predictive Models: An Economic Evaluation. Healthcare (Basel) 2021; 9:healthcare9091226. [PMID: 34575000 PMCID: PMC8470166 DOI: 10.3390/healthcare9091226] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2021] [Revised: 09/10/2021] [Accepted: 09/11/2021] [Indexed: 11/30/2022] Open
Abstract
Background: Ventral hernia repairs (VHR) are frequent but loss- making. This study aims to identify epidemiological and procedure related factors in VHR and their influence on surgical training. Methods: Data from 86 consecutive patients who underwent VHR in 2019 was collected. Moreover, 66 primary ventral hernias and 20 incisional hernias were repaired in open procedures. Linear regression models were made. Results: Primary VHR procedures showed a mean deficit of −378.17 CHF per case. Incisional hernia repair procedures resulted in a deficit of −1442.50 CHF per case. The two hernia groups were heterogeneous. For the primary VHR procedures, the surgery time (β = 0.564, p < 0.001) had the greatest influence, followed by the costs of the mesh (β = −0.215, p < 0.001). The epidemiological factors gender (β = 0.143, p < 0.01) and body mass index (BMI) (β = −0.087, p = 0.074) were also influential. For incisional hernia procedures a surgeon’s experience had the most significant influence (β = 0.942, p < 0.001), and the second largest influence was the price of the mesh (β = −0.500, p < 0.001). The epidemiological factor BMI (β = −0.590, p < 0.001), gender (β = −0.113, p = 0.055) and age (β = −0.026, p < 0.050) also had a significant influence. Conclusion: Our analysis shows a way of improving financial results in the field of ventral hernia repair. Costs can be visualized and reduced to optimize revenue enhancement in surgical departments. In our analysis primary ventral hernias are an appropriate training operation, in which the experience of the surgeon has no significant impact on costs. In primary VHR procedures, revenue enhancement is limited when using an expensive mesh. However, the treatment of incisional hernias is recommended by specialists. The financial burden is significantly higher with less experience. Therefore, these operations are not suitable for surgical training. The re-operation rate decreases with increasing experience of the surgeon. This directly affects the Patient Related Outcome (PROM) and quality of treatment. Therefore, high-quality training must be enforced. Since financial pressure on hospitals is increasing further, it is crucial to investigate cost influencing factors. The majority of Swiss public hospitals will no longer be able to operate ventral hernias profitably without new concepts. In addition to purchasing management, new construction projects, and mergers, improving the results of individual departments is a key factor in maintaining the profitability of hospitals in the future regarding hernia repair without losing the scope of teaching procedures.
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Henriksen NA, Montgomery A, Kaufmann R, Berrevoet F, East B, Fischer J, Hope W, Klassen D, Lorenz R, Renard Y, Garcia Urena MA, Simons MP. Guidelines for treatment of umbilical and epigastric hernias from the European Hernia Society and Americas Hernia Society. Br J Surg 2020; 107:171-190. [PMID: 31916607 DOI: 10.1002/bjs.11489] [Citation(s) in RCA: 144] [Impact Index Per Article: 36.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2019] [Revised: 10/31/2019] [Accepted: 12/02/2019] [Indexed: 12/20/2022]
Abstract
BACKGROUND Umbilical and epigastric hernia repairs are frequently performed surgical procedures with an expected low complication rate. Nevertheless, the optimal method of repair with best short- and long-term outcomes remains debatable. The aim was to develop guidelines for the treatment of umbilical and epigastric hernias. METHODS The guideline group consisted of surgeons from Europe and North America including members from the European Hernia Society and the Americas Hernia Society. The Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approach, the Scottish Intercollegiate Guidelines Network (SIGN) critical appraisal checklists, and the Appraisal of Guidelines for Research and Evaluation (AGREE) instrument were used. A systematic literature search was done on 1 May 2018, and updated on 1 February 2019. RESULTS Literature reporting specifically on umbilical and epigastric hernias was limited in quantity and quality, resulting in a majority of the recommendations being graded as weak, based on low-quality evidence. The main recommendation was to use mesh for repair of umbilical and epigastric hernias to reduce the recurrence rate. Most umbilical and epigastric hernias may be repaired by an open approach with a preperitoneal flat mesh. A laparoscopic approach may be considered if the hernia defect is large, or if the patient has an increased risk of wound morbidity. CONCLUSION This is the first European and American guideline on the treatment of umbilical and epigastric hernias. It is recommended that symptomatic umbilical and epigastric hernias are repaired by an open approach with a preperitoneal flat mesh.
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Affiliation(s)
- N A Henriksen
- Department of Surgery, Zealand University Hospital, Koege, Denmark
| | - A Montgomery
- Department of Surgery, Lund University, Skåne University Hospital, Malmö, Sweden
| | - R Kaufmann
- Erasmus University Medical Centre, Rotterdam, the Netherlands.,Tergooi, Hilversum, the Netherlands
| | - F Berrevoet
- Department of General and Hepatopancreatobiliary Surgery, Ghent University Hospital, Ghent, Belgium
| | - B East
- Third Department of Surgery at Motol University Hospital, First and Second Faculty of Medicine at Charles University, Prague, Czech Republic
| | - J Fischer
- University of Pennsylvania Health System, Penn Presbyterian Medical Center, Philadelphia, Pennsylvania, USA
| | - W Hope
- New Hanover Regional Medical Center, Wilmington, North Carolina, USA
| | - D Klassen
- Department of Surgery, Dalhousie University, Halifax, Nova Scotia, Canada
| | - R Lorenz
- Praxis 3+ Chirurgen, Berlin, Germany
| | - Y Renard
- Department of Digestive Surgery, Robert Debré University Hospital, Reims, France
| | - M A Garcia Urena
- Henares University Hospital, Faculty of Health Sciences, Francisco de Vitoria University, Madrid, Spain
| | - M P Simons
- Department of Surgery, OLVG Hospital, Amsterdam, the Netherlands
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Wirth U, Saller ML, von Ahnen T, Köckerling F, Schardey HM, Schopf S. [Inguinal hernia repair in TAPP technique in a day-case surgery setting - at what price?]. Chirurg 2018; 88:792-798. [PMID: 28451730 DOI: 10.1007/s00104-017-0429-9] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND TAPP surgery can be considered as a gold standard in inguinal hernia repair. Patients benefit of a faster reconvalescence and less pain compared to other techniques. TAPP surgery in Germany is performed in an in-patient setting routinely. However, according to European guidelines, inguinal hernia surgery should be considered as day-case surgery whenever possible. OBJECTIVES The safety of day-case surgery was examined in relation to postoperative pain, complications, comorbidities, recurrent inguinal hernia and bilateral procedures. MATERIAL AND METHODS In a retrospective, monocentric study we analyzed 522 elective inguinal hernia repairs using TAPP technique in a specialized hernia center. Supplemental data from Herniamed registry is analyzed. RESULTS Parts of the procedures should be performed in an in-patient setting, whereas a much larger number of cases should be carried out as day-case surgeries. Logistic regression analyses show that "age", "bilateral procedures" and "comorbidities" affect the complication rate. "Age" and "recurrent inguinal hernia" are risk factors for an increased need for analgetic medication. Furthermore, we present an actual distribution of day-case vs. in-patient surgeries in inguinal hernia repair based on data from the Herniamed registry. CONCLUSION A much larger part of procedures could safely be carried out as day-case surgeries. Based on a false incentive there is an incorrect steering in the German health system. These procedures cannot be carried out covering the costs as day-surgery cases. If there is no reevaluation of the proceeds of these procedures in a day-case surgery setting, the reasonable quality in treatment is compromised especially in inguinal hernia surgery.
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Affiliation(s)
- U Wirth
- Klinik für Allgemein-, Viszeral-, Gefäß- und Transplantationschirurgie, Klinikum der Universität München, Marchioninistr. 15, 81377, München, Deutschland. .,Institut für Chirurgische Forschung Oberbayern e. V., Hausham, Deutschland.
| | - M-L Saller
- Institut für Chirurgische Forschung Oberbayern e. V., Hausham, Deutschland.,Klinik für Rehabilitation und Innere Medizin, International Medical Center, Schön Klinik Vogtareuth, Vogtareuth, Deutschland
| | - T von Ahnen
- Institut für Chirurgische Forschung Oberbayern e. V., Hausham, Deutschland.,Abteilung für Allgemein-, Viszeral- und Gefäßchirurgie, Krankenhaus Agatharied, Hausham, Deutschland
| | - F Köckerling
- Klinik für Chirurgie-, Viszeral- und Gefäßchirurgie, Vivantes-Klinikum Spandau, Berlin, Deutschland
| | - H M Schardey
- Institut für Chirurgische Forschung Oberbayern e. V., Hausham, Deutschland.,Abteilung für Allgemein-, Viszeral- und Gefäßchirurgie, Krankenhaus Agatharied, Hausham, Deutschland
| | - S Schopf
- Institut für Chirurgische Forschung Oberbayern e. V., Hausham, Deutschland.,Abteilung für Allgemein-, Viszeral- und Gefäßchirurgie, Krankenhaus Agatharied, Hausham, Deutschland
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Köckerling F. What Is the Influence of Simulation-Based Training Courses, the Learning Curve, Supervision, and Surgeon Volume on the Outcome in Hernia Repair?-A Systematic Review. Front Surg 2018; 5:57. [PMID: 30324107 PMCID: PMC6172312 DOI: 10.3389/fsurg.2018.00057] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2018] [Accepted: 08/28/2018] [Indexed: 12/13/2022] Open
Abstract
Introduction: In hernia surgery, too, the influence of the surgeon on the outcome can be demonstrated. Therefore the role of the learning curve, supervised procedures by surgeons in training, simulation-based training courses and surgeon volume on patient outcome must be identified. Materials and Methods: A systematic search of the available literature was carried out in June 2018 using Medline, PubMed, and the Cochrane Library. For the present analysis 81 publications were identified as relevant. Results: Well-structured simulation-based training courses was found to be associated with a reduced perioperative complication rate for patients operated on by trainees. Open as well as, in particular, laparo-endoscopic hernia surgery procedures have a long learning curve. Its negative impact on the patient can be virtually eliminated through consistent supervision by experienced hernia surgeons. However, this presupposes availability of an adequate trainee caseload and of well-trained hernia surgeons and calls for a certain degree of centralization in hernia surgery. Conclusion: Training courses, learning curve, supervision, and surgeon volume are important aspects in training and outcomes in hernia surgery.
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Affiliation(s)
- Ferdinand Köckerling
- Department of Surgery and Center for Minimally Invasive Surgery, Academic Teaching Hospital of Charité Medical School, Vivantes Hospital, Berlin, Germany
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Khalid U, Jameel M, Szczebiot L. Correspondence to: financial impact of surgical training on hospital economics: an income, analysis of 1184 out-patient clinic consultations. Int J Surg 2013; 11:562. [PMID: 23707985 DOI: 10.1016/j.ijsu.2013.05.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2013] [Accepted: 05/06/2013] [Indexed: 10/26/2022]
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