Cost of complex abdominal wall reconstruction with biological prostheses in a French public hospital

The Gap Between the Actual Cost and Tariffs of Global Surgical Procedures: A Retrospective Cross-sectional Study in Qazvin Province, Iran

BACKGROUND

Iran's healthcare system has a significant discrepancy between the national tariff and the cost of global surgical procedures (GSPs). This study aimed to compare the actual costs of GSPs with national tariffs in Iran's public hospitals.

METHODS

This retrospective cross-sectional study was conducted in 2017. Using the census method, 6126 GSPs performed in three public hospitals were investigated in this study. Additionally, national tariffs from the Supreme Council of Health Insurance were obtained. The tariff-cost gap was the discrepancy between a GSP's actual costs and tariff. Multiple linear regression analysis determined factors affecting the tariff-cost gap.

RESULTS

The average actual cost of GSPs was 637 USD, while the average tariff was 495 USD. The reimbursement covered only 78% of the costs. The gap was higher in older (B=1.05, 95% CI: 0.76-1.35, P<0.001), females (B=26.7, 95% CI: 15.5-37.9, P<0.001), patients with a longer stay (B=81.2, 95% CI: 77.5-84.8, P<0.001), and procedures performed by full-time surgeons (B=67.3, 95% CI: 56.9-77.5, P<0.001). Furthermore, neurosurgery had the highest effect on forecasting the gap between actual costs and tariffs among surgical specialties (B=346.9, 95% CI: 214.3-479.5, P<0.001).

CONCLUSION

Public hospitals suffer from large financial losses due to the national tariff for many GSPs not covering their actual costs. It is suggested that tariffs be increased for certain customer segments that can bear higher costs and global tariffs be adjusted to match actual service delivery costs.

Cost-effectiveness analysis of resorbable biosynthetic mesh in contaminated ventral hernia repair

BACKGROUND

The aim of this study was to compare, in terms of cost and serious complications, the use of biosynthetic resorbable parietal mesh with biologic mesh in patients undergoing contaminated ventral hernia repair (modified Ventral Hernia Working Group grade 3). Poly-4-hydroxy-butyrate (P4HB) biosynthetic mesh has rarely been the subject of comparative studies in the context of contamination. Data are required to confirm the effects of a transition from biological mesh to biosynthetic resorbable mesh.

PATIENTS AND METHODS

A cost-effectiveness analysis was conducted. It was based on a decision analysis model built with clinical and economic data issued from a before-after study that included 94 patients hospitalized for ventral hernia repair at the University Hospital of Strasbourg (France) from June 2011 to February 2018. The effectiveness endpoint was the number of patients presenting with a serious specific complication or a general complication at 6 months. Data for surgical hospitalization stays, home hospitalizations and ambulatory care costs were included.

RESULTS

We found fewer serious complications with biosynthetic mesh: 21% versus 33% with biologic mesh. A cost savings of US $5146 was determined. Deterministic sensitivity analyses and a probabilistic analysis confirmed our findings and the robustness of the model.

CONCLUSION

P4HB biosynthetic resorbable mesh appeared to be the most effective and the least costly option. Additional data will be needed to confirm the superiority of biosynthetic mesh in terms of the recurrence risk reduction over a longer period.

The use of Permacol® biological mesh for complex abdominal wall repair

BACKGROUND

Complex abdominal wall repair (CAWR) remains challenging, especially in contaminated fields where the use of a synthetic mesh is associated with prohibitively complication rates. Consequently, biological mesh has been proposed as an alternative. The aim of our study was to evaluate the safety and efficacy of using Permacol® in patients who had CAWR.

METHODS

We retrospectively reviewed the files of patients who had CAWR using the Permacol® mesh. Analysis included patients' preoperative characteristics, procedural parameters, and early and late post-operative complications including mainly recurrence. A multivariate regression model was performed to determine factors that influence 24-months recurrence rate.

RESULTS

Between January 2009 and December 2018, 75 patients. The most common indication was hernia in a contaminated field (48.0%) and abdominal wall defect greater than 10 cm in diameter (36%). Overall, 44% of our patients were Centers for Disease Control (CDC) class II or III and 81.3% fall into category II or III according to the Ventral Hernia Working Group (VHWG) classification. Recurrence rate of our series was 9.3%. Complete fascial closure was achieved in 60 patients (80%). Upon univariate analysis complete fascial closure, posterior component separation, seroma drainage, BMI >30 kg/m2 and age >65 years, VHWD grade >2, DINDO CLAVIEN class > 2 affected the recurrence rate at 2 years follow up. When subcutaneous drains are placed prophylactically, recurrence rates drop from 38.7% (5/14) to 3.3% (2/61 patients) when drains are placed at the time of operation (p=0.02). Only fascial closure affected the 24-months recurrence rate on multivariate analysis (p<0.001).

CONCLUSIONS

Permacol® surgical implant use for CAWR is safe with a relatively low rate of hernia recurrence at 2 years. Prophylactic subcutaneous drain placement may reduce the risk of hernia recurrence. The presence of contaminated fields does not appear to influence hernia recurrence when Permacol® is used, in fact, the only factor that affects recurrence rate at 24-months on multivariate analysis is completeness of the fascial closure.

Hospital volume is associated with cost and outcomes variation in 2,942 pelvic reconstructions

BACKGROUND

Complex pelvic reconstruction is challenging for plastic and reconstructive surgeons following surgical resection of the lower gastrointestinal or genitourinary tract. Complication rates and hospital costs are variable and may be linked to the hospital case volume of pelvic reconstructions performed. A comprehensive examination of these factors has yet to be performed.

METHODS

Data were retrieved for patients undergoing pedicled flap reconstruction after pelvic resections in the American National Inpatient Sample database between 2010 and 2014. Patients were then separated into three groups based on hospital case volume for pelvic reconstruction. Multivariate logistic regression and gamma regression with log-link function were used to analyze associations between hospital case volume, surgical outcomes, and cost.

RESULTS

In total, 2,942 patients underwent pelvic flap reconstruction with surgical complications occurring in 1,466 patients (49.8%). Total median cost was $38,469.40. Pelvic reconstructions performed at high-volume hospitals were significantly associated with fewer surgical complications (low: 51.4%, medium: 52.8%, high: 34.8%; p < 0.001) and increased costs (low: $35,645.14, medium: $38,714.92, high: $44,967.29; p < 0.001). After regression adjustment, high hospital volume was the strongest independently associated factor for decreased surgical complications (Exp[β], 0.454; 95% Confidence Interval, 0.346-0.596; p < 0.001) and increased hospital cost (Exp[β], 1.351; 95% Confidence Interval, 1.285-1.421; p < 0.001).

CONCLUSIONS

Patients undergoing pelvic flap reconstruction after oncologic resections experience high complication rates. High case volume hospitals were independently associated with significantly fewer surgical complications but increased hospital costs. Reconstructive surgeons may approach these challenging patients with greater awareness of these associations to improve outcomes and address cost drivers.

What results can be expected one year after complex incisional hernia repair with biosynthetic mesh?

BACKGROUND

Incisional hernia is a frequent complication after midline laparotomy. The current standard repair includes the use of a synthetic mesh to prevent recurrence. However, the use of a synthetic mesh in a contaminated field carries a higher risk of mesh infection. In this setting biologic and biosynthetic meshes can be used as they resist to infection, but these are absorbable meshes. This raises the question of the risk of recurrence as the mesh disappears. Phasix® is a biosynthetic mesh getting absorbed in 12-18 months. The aim of this study was to assess the 1-year recurrence rate after abdominal-wall repair with a Phasix® mesh.

METHODS

All patients undergoing ventral hernia repair between 2016 and 2018 at the University Hospital of Dijon using a Phasix® mesh were prospectively included in a database. They were all followed-up with a physical exam and a routine CT scan at one year. All postoperative complications were recorded.

RESULTS

Twenty-nine patients were included in the study (55.2% women), with a mean BMI of 30,25 kg/m². Nineteen meshes were sublay and 10 intraperitoneal. Complications at 1 month were mainly mild: Clavien-Dindo I and II (61.1%). No mesh was explanted. There was no chronic infection. The mean length of stay was 11.5 days. The 1-year recurrence rate was 10.3%.

CONCLUSION

Patients having undergone complex ventral hernia repair with a Phasix® mesh have a 1-year recurrence rate of 10.3%. No severe surgical site occurrence was detected. A longer follow-up in a larger number of patients could confirm the place of this mesh in abdominal-wall repair.

Value Improvement and Resource Utilization in Complex Abdominal Wall Reconstruction

Although recommendations help guide surgeons’ mesh choice in abdominal wall reconstruction (AWR), financial and institutional pressures may play a bigger role. Standardization of an AWR algorithm may help reduce costs and change mesh preferences. We performed a retrospective review of high- and low-risk patients who underwent inpatient AWR between 2014 and 2016. High risk was defined as immunosuppression and/or history of infection/contamination. Patients were stratified by the type of mesh as biologic/biosynthetic or synthetic. These cohorts were analyzed for outcome, complications, and cost. One hundred twelve patients underwent complex AWR. The recurrence rate at two years was not statistically different between high- and low-risk cohorts. No significant difference was found in the recurrence rate between biologic and synthetic meshes when comparing both high- and low-risk cohorts. The average cost of biologic mesh was $9,414.80 versus $524.60 for synthetic. The estimated cost saved when using synthetic mesh for low-risk patients was $295,391.20. In conclusion, recurrence rates for complex AWR seem to be unrelated to mesh selection. There seems to be an excess use of biologic mesh in low-risk patients, adding significant cost. Implementing a critical process to evaluate indications for biologic mesh use could decrease costs without impacting the quality of care, thus improving the overall value of AWR.