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Eckert KA, Fife CE, Carter MJ. The Impact of Underlying Conditions on Quality-of-Life Measurement Among Patients with Chronic Wounds, as Measured by Utility Values: A Review with an Additional Study. Adv Wound Care (New Rochelle) 2023; 12:680-695. [PMID: 37815559 PMCID: PMC10615090 DOI: 10.1089/wound.2023.0098] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2023] [Accepted: 08/27/2023] [Indexed: 10/11/2023] Open
Abstract
Significance: Quality of life (QoL) is important to patients with chronic wounds and is rarely formally evaluated. Understanding what comorbidities most affect the individual versus their wounds could be a key metric. Recent Advances: The last 20 years have seen substantial advances in QoL instruments and conversion of patient data to a single value known as the health utilities index (HUI). We review these advances, along with wound-related QoL, and analyze real-world comorbidities challenging wound care. Critical Issues: To understand the impact of underlying comorbidities in a real-world patient population, we examined a convenience sample of 382 patients seen at a hospital-based outpatient wound center. This quality reporting study falls outside the regulations that govern human subject research. Comorbid conditions were used to calculate HUIs using a variety of literature-reported approaches, while Wound-Quality-of-Life (W-QoL) questionnaire data were collected from patients during their first visit. The mean number of conditions per patient was 8; 229 patients (59.9%) had utility values for comorbidities/conditions, which were worse/lower than their wounds' values. Sixty-three (16.5%) patients had depression and/or anxiety, 64 (16.8%) had morbid obesity, and 204 (53.4%) had gait and mobility disorders, all of which could have affected W-QoL scoring. The mean minimum utility value (0.5) was within 0.05 units of an average of 13 studies reporting health utilities from wound care populations using the EuroQol 5 Dimension instrument. Future Directions: The comorbidity associated with the lowest utility value is what might most influence the QoL of patients with chronic wounds. This finding needs further investigation.
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Affiliation(s)
| | - Caroline E. Fife
- Intellicure, LLC, The Woodlands, Texas, USA
- U.S. Wound Registry (501 3C Nonprofit), The Woodlands, Texas, USA
- Baylor College of Medicine, Houston, Texas, USA
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Cost-Utility Analysis of Open Hernia Operations in Bulgaria. ACTA MEDICA BULGARICA 2022. [DOI: 10.2478/amb-2022-0015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Abstract
Background: Hernia surgery procedures are among the most frequently performed in Bulgaria. An open, mesh-based repair is a standard method for hernia repair. From a societal perspective, a cost-utility analysis of open hernia surgical procedures performed in Bulgaria is necessary in light of the economic and social burden that poses this health issue. The aim of the study was to perform an economic evaluation of the quality of health results after a conventional elective hernia operation with implanted light and standard meshes.
Methods: The cost of elective hernia operation with standard and light meshes was calculated as a sum of direct and indirect costs. Incremental cost-effectiveness ratio (ICER) for conventional hernia operation was calculated as health improvement was measured in quality-adjusted life years (QALY) reported in a previous study. Deterministic sensitivity analysis was applied to evaluate the changes in the ICER values in case of planned inguinal hernia operation.
Results: The cost of operation with standard meshes is less than operation with light meshes. The difference is in the range 55-200 EUR. The additional costs per one QALY gained for light meshes are far below the recommended threshold values which identified these meshes as cost-effective.
Conclusions: The study presents evidence for cost-effectiveness of light meshes.
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Ding X, Zhu J, Liu A, Guo Q, Cao Q, Xu Y, Hua Y, Yang Y, Li P. Preparation and Biocompatibility Study of Contrast-Enhanced Hernia Mesh Material. Tissue Eng Regen Med 2022; 19:703-715. [PMID: 35612710 DOI: 10.1007/s13770-022-00460-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2022] [Revised: 04/09/2022] [Accepted: 04/11/2022] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Meshes play a crucial role in hernia repair. However, the displacement of mesh inevitably leads to various associated complications. This process is difficult to be traced by conventional imaging means. The purpose of this study is to create a contrast-enhanced material with high-density property that can be detected by computed tomography (CT). METHODS The contrast-enhanced monofilament was manufactured from barium sulfate nanoparticles and medical polypropylene (PP/Ba). To characterize the composite, stress tensile tests and scanning electron microscopy (SEM) was performed. Toxicity and biocompatibility of PP/Ba materials was verified by in vitro cellular assays. Meanwhile, the inflammatory response was tested by protein adsorption assay. In addition, an animal model was established to demonstrate the long-term radiographic effect of the composite material in vivo. Subsequent pathological tests confirmed its in vivo compatibility. RESULTS The SEM revealed that the main component of the monofilament is carbon. In vitro cell experiments demonstrated that novel material does not affect cell activity and proliferation. Protein adsorption assays indicated that the contrast-enhanced material does not cause additional inflammatory responses. In addition, in vivo experiments illustrated that PP/Ba mesh can be detected by CT and has good in vivo compatibility. CONCLUSION These results highlight the excellent biocompatibility of the contrast-enhanced material, which is suitable for human abdominal wall tissue engineering.
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Affiliation(s)
- Xuzhong Ding
- Department of Gastrointestinal Surgery, Affiliated Hospital of Nantong University, No. 20 Xisi Road, Chongchuan District, Nantong, 226000, China
| | - Jiachen Zhu
- Key Laboratory of Neuroregeneration of Jiangsu and Ministry of Education, Co-Innovation Center of Neuroregeneration, Nantong University, No. 19, Qixiu Road, Chongchuan District, Nantong, Jiangsu, China
| | - Anning Liu
- Department of Gastrointestinal Surgery, Affiliated Hospital of Nantong University, No. 20 Xisi Road, Chongchuan District, Nantong, 226000, China
| | - Qiyang Guo
- Chemistry and Chemical Engineering, Nantong University, Nantong, China
| | - Qing Cao
- Department of Gastrointestinal Surgery, Affiliated Hospital of Nantong University, No. 20 Xisi Road, Chongchuan District, Nantong, 226000, China
| | - Yu Xu
- Department of Gastrointestinal Surgery, Affiliated Hospital of Nantong University, No. 20 Xisi Road, Chongchuan District, Nantong, 226000, China
| | - Ye Hua
- Department of Imaging, Affiliated Hospital of Nantong University, Nantong, China
| | - Yumin Yang
- Key Laboratory of Neuroregeneration of Jiangsu and Ministry of Education, Co-Innovation Center of Neuroregeneration, Nantong University, No. 19, Qixiu Road, Chongchuan District, Nantong, Jiangsu, China.
| | - Peng Li
- Department of Gastrointestinal Surgery, Affiliated Hospital of Nantong University, No. 20 Xisi Road, Chongchuan District, Nantong, 226000, China.
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Bloom JA, Tian T, Homsy C, Singhal D, Salehi P, Chatterjee A. A Cost-Utility Analysis of the Use of Closed-Incision Negative Pressure System in Vascular Surgery Groin Incisions. Am Surg 2022:31348221087395. [PMID: 35392664 DOI: 10.1177/00031348221087395] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVE Closed-incision negative pressure therapy (CINPT) with the Prevena system has been used and clinically evaluated in high-risk groin incisions to reduce the risk of postoperative complications. We performed a cost-effectiveness analysis evaluating CINPT in femoral-popliteal bypass with prosthetic graft. METHODS A literature review looking at prospective randomized trials determined the probabilities and outcomes for femoral-popliteal bypass with and without CINPT. Reported utility scores were used to estimate the quality adjusted life years (QALYs) associated with a successful procedure and postoperative complications. Medicare current procedure terminology and diagnosis-related group codes were used to assess the costs for a successful surgery and associated complications. A decision analysis tree was constructed with rollback analysis to highlight the more cost-effective strategy. An incremental cost-effectiveness ratio (ICER) analysis was performed with a willingness to pay at $50,000. Deterministic and probabilistic sensitivity analyses were performed to validate the robustness of the results, and to accommodate for the uncertainty in the literature. RESULTS Femoral-popliteal bypass with CINPT is less costly ($40,138 vs $41,774) and more effective (6.14 vs 6.13) compared to without CINPT. This resulted in a negative ICER of -234,764.03, which favored CINPT, indicating a dominant strategy. In one-way sensitivity analysis, surgery without CINPT was more cost-effective if the probability of successful surgery falls below 84.9% or if the cost of CINPT exceeds $3139. Monte Carlo analysis showed a confidence of 99.07% that CINPT is more cost-effective. CONCLUSIONS Despite the added device cost of CINPT, it is cost-effective in vascular surgical operations using groin incisions.
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Affiliation(s)
- Joshua A Bloom
- Department of Surgery, 1867Tufts Medical Center, Boston, MA, USA
| | - Tina Tian
- Department of Surgery, 1867Tufts Medical Center, Boston, MA, USA
| | - Christopher Homsy
- Division of Plastic and Reconstructive Surgery, Department of Surgery, 1867Tufts Medical Center, Boston, MA, USA
| | - Dhruv Singhal
- Division of Plastic and Reconstructive Surgery, Department of Surgery, 1859Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Payam Salehi
- Division of Vascular Surgery, Department of Surgery, 1867Tufts Medical Center, Boston, MA, USA
| | - Abhishek Chatterjee
- Division of Plastic and Reconstructive Surgery, Department of Surgery, 1867Tufts Medical Center, Boston, MA, USA
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Abstract
OBJECTIVE To evaluate the cost-effectiveness of surgical treatment pathways for apical prolapse. STUDY DESIGN We constructed a stochastic Markov model to assess the cost-effectiveness of vaginal apical suspension, laparoscopic sacrocolpopexy, and robotic sacrocolpopexy. We modeled over 5 and 10 years, with 9 pathways accounting for up to 2 separate surgical repairs, recurrence of symptomatic apical prolapse, reoperation, and complications, including mesh excision. We calculated costs from the health care system's perspective. RESULTS Over 5 years, compared with expectant management, all surgical treatment pathways cost less than the willingness-to-pay threshold of US $50,000 per quality adjusted life-years. However, among surgical treatments, all but 2 pathways were dominated. Of the remaining 2, laparoscopic sacrocolpopexy followed by vaginal repair for apical recurrence was not cost-effective compared with the vaginal-only approach (incremental cost-effectiveness ratio [ICER], >$500,000). Over 10 years, all but the same 2 pathways were dominated. However, starting with the laparoscopic approach in this case was more cost-effective with an ICER of US $6,176. If the laparoscopic approach was not available, starting with the robotic approach similarly became more cost-effective at 10 years (ICER, US $35,479). CONCLUSIONS All minimally invasive surgical approaches for apical prolapse repair are cost-effective when compared with expectant management. Among surgical treatments, the vaginal-only approach is the only cost-effective option over 5 years. However, over a longer period, starting with a laparoscopic (or robotic) approach becomes cost-effective. These results help inform discussions regarding the surgical approach for prolapse.
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Nenshi R, Bensimon C, Wood T, Wright F, Smith AJ, Brenneman F. Complex abdominal wall hernias as a barrier to quality of life in cancer survivors. Can J Surg 2019; 62:1-7. [PMID: 30900432 PMCID: PMC6738510 DOI: 10.1503/cjs.014917] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/10/2018] [Indexed: 12/24/2022] Open
Abstract
Background Many cancer survivors live with postoperative complex abdominal wall hernias (CAWHs). However, the impact of CAWHs on their quality of life is unknown, and few descriptions of patient experiences exist. We performed a qualitative study to explore cancer survivors’ experience with CAWHs before and after repair. Methods Patients waiting to undergo CAWH repair or who had completed the surgery in the previous 18 months were identified from a single surgeon’s practice in CAWH at a tertiary care centre. Clinical and demographic data were extracted from the electronic patient record. An in-depth semistructured interview guide was developed by experts in CAWH and qualitative methodology. Interviews were conducted in March 2013. We used comparative analysis techniques and coding strategies to identify themes. Results Ten preoperative and 12 postoperative participants were interviewed. The average age of the participants was 64 years in both groups, with an even sex distribution. The most frequently diagnosed cancer in both groups was colorectal cancer. Participants’ views were organized into 5 themes: 1) unable to return to normal life, 2) sense of abandonment, 3) experiencing fear and distress, 4) preoperative: desperate for help and 5) postoperative: “getting my life back.” Conclusion Our findings show the all-encompassing impact of a CAWH on the life of cancer survivors. They strongly suggest that hernia management should be viewed as an integral part in the continuum of cancer treatment to improve the quality of life of cancer survivors with hernias.
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Affiliation(s)
- Rahima Nenshi
- From the Department of Surgery, McMaster University, and St. Joseph’s Healthcare Hamilton, Hamilton, Ont. (Nenshi); Ethics and Professional Affairs, Canadian Medical Association, and the Joint Centre for Bioethics, University of Toronto, Toronto, Ont. (Bensimon); the Division of General Surgery, Department of Surgery, University of Toronto, Toronto, Ont. (Wood, Wright, Smith, Brenneman); and the Division of General Surgery, Department of Surgery, Sunnybrook Health Sciences Centre, Toronto, Ont. (Wright, Smith, Brenneman)
| | - Cécile Bensimon
- From the Department of Surgery, McMaster University, and St. Joseph’s Healthcare Hamilton, Hamilton, Ont. (Nenshi); Ethics and Professional Affairs, Canadian Medical Association, and the Joint Centre for Bioethics, University of Toronto, Toronto, Ont. (Bensimon); the Division of General Surgery, Department of Surgery, University of Toronto, Toronto, Ont. (Wood, Wright, Smith, Brenneman); and the Division of General Surgery, Department of Surgery, Sunnybrook Health Sciences Centre, Toronto, Ont. (Wright, Smith, Brenneman)
| | - Trevor Wood
- From the Department of Surgery, McMaster University, and St. Joseph’s Healthcare Hamilton, Hamilton, Ont. (Nenshi); Ethics and Professional Affairs, Canadian Medical Association, and the Joint Centre for Bioethics, University of Toronto, Toronto, Ont. (Bensimon); the Division of General Surgery, Department of Surgery, University of Toronto, Toronto, Ont. (Wood, Wright, Smith, Brenneman); and the Division of General Surgery, Department of Surgery, Sunnybrook Health Sciences Centre, Toronto, Ont. (Wright, Smith, Brenneman)
| | - Frances Wright
- From the Department of Surgery, McMaster University, and St. Joseph’s Healthcare Hamilton, Hamilton, Ont. (Nenshi); Ethics and Professional Affairs, Canadian Medical Association, and the Joint Centre for Bioethics, University of Toronto, Toronto, Ont. (Bensimon); the Division of General Surgery, Department of Surgery, University of Toronto, Toronto, Ont. (Wood, Wright, Smith, Brenneman); and the Division of General Surgery, Department of Surgery, Sunnybrook Health Sciences Centre, Toronto, Ont. (Wright, Smith, Brenneman)
| | - Andrew J. Smith
- From the Department of Surgery, McMaster University, and St. Joseph’s Healthcare Hamilton, Hamilton, Ont. (Nenshi); Ethics and Professional Affairs, Canadian Medical Association, and the Joint Centre for Bioethics, University of Toronto, Toronto, Ont. (Bensimon); the Division of General Surgery, Department of Surgery, University of Toronto, Toronto, Ont. (Wood, Wright, Smith, Brenneman); and the Division of General Surgery, Department of Surgery, Sunnybrook Health Sciences Centre, Toronto, Ont. (Wright, Smith, Brenneman)
| | - Fred Brenneman
- From the Department of Surgery, McMaster University, and St. Joseph’s Healthcare Hamilton, Hamilton, Ont. (Nenshi); Ethics and Professional Affairs, Canadian Medical Association, and the Joint Centre for Bioethics, University of Toronto, Toronto, Ont. (Bensimon); the Division of General Surgery, Department of Surgery, University of Toronto, Toronto, Ont. (Wood, Wright, Smith, Brenneman); and the Division of General Surgery, Department of Surgery, Sunnybrook Health Sciences Centre, Toronto, Ont. (Wright, Smith, Brenneman)
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7
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Abstract
Incisional and parastomal hernias continue to be vexing problems for patients and surgeons. Risk factors are generally patient-related and/or technical in nature, and in some cases, can be altered, resulting in improved outcomes. Improved fascial closure techniques can only partly reduce the risk of incisional hernia formation. Even under optimal circumstances, using time tested closure techniques and materials, the rate remains high, due primarily to factors that are not modifiable or are unidentifiable. In such cases, there may be a beneficial role for prophylactic mesh augmentation (PMA), wherein mesh is implanted at the time of initial surgery or stoma formation. Several high-risk groups that might benefit from PMA have been identified, including patients undergoing open abdominal aneurysm repair or colorectal procedures, obese patients, and patients requiring creation of permanent gastrointestinal or urological stomas. Although the initial results of PMA are promising, the benefits of this strategy must be weighed against potential risks. Outcome measures to assess efficacy should include not only hernia recurrence but also quality of life, surgical-site occurrences, and cost. Further studies are warranted to predict which specific patient populations might benefit most from PMA and to identify ideal mesh materials as well as preferred implantation sites and methods of mesh fixation.
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Chatterjee A, Asban A, Jonczyk M, Chen L, Czerniecki B, Fisher CS. A cost-utility analysis comparing large volume displacement oncoplastic surgery to mastectomy with free flap reconstruction in the treatment of breast cancer. Am J Surg 2019; 218:597-604. [PMID: 30739739 DOI: 10.1016/j.amjsurg.2019.01.037] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2018] [Revised: 01/01/2019] [Accepted: 01/10/2019] [Indexed: 11/18/2022]
Abstract
PURPOSE Breast cancer surgical treatment may include large volume displacement oncoplastic surgery (LVOS) or mastectomy with free flap reconstruction (MFFR). We investigated the cost-utility between LVOS versus MFFR to determine which approach was most cost-effective. METHODS A literature review was performed to calculate probabilities for clinical outcomes for each surgical option (LVOS versus MFFR), and to obtain utility scores that were converted into quality adjusted life years (QALYs) as measures for clinical effectiveness. Average Medicare payments were surrogates for cost. A decision tree was constructed and an incremental cost-utility ratio (ICUR) was used to calculate cost-effectiveness. RESULTS The decision tree demonstrates associated QALYs and costs with probabilities used to calculate the ICUR of $3699/QALY with gain of 2.7 QALY at an additional cost of $9987 proving that LVOS is a cost-effective surgical option. One-way sensitivity analysis showed that LVOS became cost-ineffective when its clinical effectiveness had a QALY of less than 30.187. Tornado Diagram Analysis and Monte-Carlo simulation supported our conclusion. CONCLUSION LVOS is cost-effective when compared to MFFR for the appropriate breast cancer patient. CLINICAL QUESTION/LEVEL OF EVIDENCE II.
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Affiliation(s)
| | - Ammar Asban
- Department of Surgery, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Michael Jonczyk
- Department of Surgery, Tufts University Medical Center, Boston, MA, USA
| | - Lilian Chen
- Department of Surgery, Tufts University Medical Center, Boston, MA, USA
| | | | - Carla S Fisher
- Department of Surgery, Indiana Medical Center, Indianapolis, IN, USA
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Abstract
Complex abdominal wall defects remain a common problem, though there has been significant advancement in technique and biomaterials over the last decade. The newly developed hybrid meshes are targeted to address several shortcomings of other meshes. Specifically, the marriage of biosynthetic or biologic materials with permanent prosthetic material is designed so that each will counteract the other's negative attributes. There are reports of permanent meshes having been associated with chronic pain, stiffness, and inflammation. However, their utility in maintaining biomechanical strength, thus limiting recurrence, makes them of value. In hybrid meshes, biosynthetic or biologic materials are coupled with permanent prosthetics, potentially protecting them from exhibiting deleterious effects by promoting and hastening tissue ingrowth. The various hybrid meshes currently available and investigational data are reviewed.
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10
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Stabilini C, Cavallaro G, Bocchi P, Campanelli G, Carlucci M, Ceci F, Crovella F, Cuccurullo D, Fei L, Gianetta E, Gossetti F, Greco DP, Iorio O, Ipponi P, Marioni A, Merola G, Negro P, Palombo D, Bracale U. Defining the characteristics of certified hernia centers in Italy: The Italian society of hernia and abdominal wall surgery workgroup consensus on systematic reviews of the best available evidences. Int J Surg 2018; 54:222-235. [PMID: 29730074 DOI: 10.1016/j.ijsu.2018.04.052] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2018] [Revised: 04/06/2018] [Accepted: 04/28/2018] [Indexed: 02/06/2023]
Abstract
BACKGROUND The terms "Hernia Center" (HC) and Hernia Surgeon" (HS) have gained more and more popularity in recent years. Nevertheless, there is lack of protocols and methods for certification of their activities and results. The Italian Society of Hernia and Abdominal Wall Surgery proposes a method for different levels of certification. METHODS The national board created a commission, with the task to define principles and structure of an accreditation program. The discussion of each topic was preceded by a Systematic Review, according to PRISMA Guidelines and Methodology. In case of lack or inadequate data from literature, the parameter was fixed trough a Commission discussion. RESULTS The Commission defined a certification process including: "FLC - First level Certification": restricted to single surgeon, it is given under request and proof of a formal completion of the learning curve process for the basic procedures and an adequate year volume of operations. "Second level certification": Referral Center for Abdominal Wall Surgery. It is a public or private structure run by at least two already certified and confirmed FLC surgeons. "Third level certification": High Specialization Center for Abdominal Wall Surgery. It is a public or private structure, already confirmed as Referral Centers, run by at least three surgeons (two certified and confirmed with FLC and one research fellow in abdominal wall surgery). Both levels of certification have to meet the Surgical Requirements and facilities criteria fixed by the Commission. CONCLUSION The creation of different types of Hernia Centers is directed to create two different entities offering the same surgical quality with separate mission: the Referral Center being more dedicated to clinical and surgical activity and High Specialization Centers being more directed to scientific tasks.
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Affiliation(s)
| | | | | | | | - Michele Carlucci
- Department of General and Emergency Surgery, IRCCS San Raffaele, Milan, Italy
| | - Francesca Ceci
- Department of Surgery "P. Stefanini", Sapienza University, Rome, Italy
| | | | - Diego Cuccurullo
- Department of General, Laparoscopic, and Robotic Surgery, Ospedale Monaldi, Azienda Ospedaliera Dei Colli, Naples, Italy
| | - Landino Fei
- Department of Anaesthesiological, Surgical and Emergency Sciences, Second University of Naples, Italy
| | - Ezio Gianetta
- Department of Surgical Sciences, University of Genoa, Italy
| | | | | | - Olga Iorio
- General Surgery Unit, Aprilia Hospital, Aprilia (RM), Italy
| | - Pierluigi Ipponi
- General Surgery Unit, San Giovanni di Dio Hospital, Florence, Italy
| | | | - Giovanni Merola
- Department of Surgical Spaciailties and Nephrology, Federico II University, Naples, Italy
| | - Paolo Negro
- Department of Surgery "P. Stefanini", Sapienza University, Rome, Italy
| | - Denise Palombo
- Department of Surgical Sciences, University of Genoa, Italy
| | - Umberto Bracale
- Department of Surgical Spaciailties and Nephrology, Federico II University, Naples, Italy
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Chatterjee A, Offodile II AC, Asban A, Minasian RA, Losken A, Graham R, Chen L, Czerniecki BJ, Fisher C. A Cost-Utility Analysis Comparing Oncoplastic Breast Surgery to Standard Lumpectomy in Large Breasted Women. ACTA ACUST UNITED AC 2018. [DOI: 10.4236/abcr.2018.72011] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Laparoscopic Versus Open Cholecystectomy: A Cost-Effectiveness Analysis at Rwanda Military Hospital. World J Surg 2017; 41:1225-1233. [PMID: 27905020 DOI: 10.1007/s00268-016-3851-0] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
BACKGROUND Laparoscopic cholecystectomy is first-line treatment for uncomplicated gallstone disease in high-income countries due to benefits such as shorter hospital stays, reduced morbidity, more rapid return to work, and lower mortality as well-being considered cost-effective. However, there persists a lack of uptake in low- and middle-income countries. Thus, there is a need to evaluate laparoscopic cholecystectomy in comparison with an open approach in these settings. METHODS A cost-effectiveness analysis was performed to evaluate laparoscopic and open cholecystectomies at Rwanda Military Hospital (RMH), a tertiary care referral hospital in Rwanda. Sensitivity and threshold analyses were performed to determine the robustness of the results. RESULTS The laparoscopic and open cholecystectomy costs and effectiveness values were $2664.47 with 0.87 quality-adjusted life years (QALYs) and $2058.72 with 0.75 QALYs, respectively. The incremental cost-effectiveness ratio for laparoscopic over open cholecystectomy was $4946.18. Results are sensitive to the initial laparoscopic equipment investment and number of cases performed annually but robust to other parameters. The laparoscopic intervention is more cost-effective with investment costs less than $91,979, greater than 65 cases annually, or at willingness-to-pay (WTP) thresholds greater than $3975/QALY. CONCLUSIONS At RMH, while laparoscopic cholecystectomy may be a more effective approach, it is also more expensive given the low caseload and high investment costs. At commonly accepted WTP thresholds, it is not cost-effective. However, as investment costs decrease and/or case volume increases, the laparoscopic approach may become favorable. Countries and hospitals should aspire to develop innovative, low-cost options in high volume to combat these barriers and provide laparoscopic surgery.
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Cox TC, Blair LJ, Huntington CR, Colavita PD, Prasad T, Lincourt AE, Heniford BT, Augenstein VA. The cost of preventable comorbidities on wound complications in open ventral hernia repair. J Surg Res 2016; 206:214-222. [DOI: 10.1016/j.jss.2016.08.009] [Citation(s) in RCA: 53] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2015] [Revised: 06/30/2016] [Accepted: 08/02/2016] [Indexed: 10/21/2022]
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A Cost-Utility Assessment of Mesh Selection in Clean-Contaminated Ventral Hernia Repair. Plast Reconstr Surg 2016; 137:647-659. [PMID: 26818303 DOI: 10.1097/01.prs.0000475775.44891.56] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Mesh reinforcement can reduce hernia recurrence, but mesh selection is poorly understood, particularly in contaminated defects. Acellular dermal matrix has enabled single-stage ventral hernia repair in clean-contaminated wounds but can be associated with higher complications and cost compared with synthetic mesh. This study evaluated the cost-utility of synthetic mesh and acellular dermal matrix for clean-contaminated ventral hernia repairs. METHODS A systematic review of articles comparing outcomes for synthetic and acellular dermal matrix repairs identified 14 ventral hernia repair-specific health states. Quality-adjusted life years were determined through Web-based visual analog scale survey of 300 nationally representative individuals. Overall expected cost and quality-adjusted life-years for ventral hernia repair were assessed using a Monte Carlo simulation with sensitivity analyses. RESULTS Synthetic mesh reinforcement had an expected cost of $15,776 and quality-adjusted life-year value gained of 21.03. Biological mesh had an expected cost of $23,844 and quality-adjusted life-year value gained of 20.94. When referencing a common baseline (do nothing), acellular dermal matrix (incremental cost-effectiveness ratio, 3378 ($/quality-adjusted life years)) and synthetic mesh (incremental cost-effectiveness ratio, 2208 ($/quality-adjusted life years)) were judged cost-effective, although synthetic mesh was more strongly favored. Monte Carlo sensitivity analysis demonstrated that synthetic mesh was the preferred and most cost-effective strategy in 94 percent of simulations, supporting its overall greater cost-utility. Despite varying the willingness-to-pay threshold from $0 to $100,000 per quality-adjusted life-year, synthetic mesh remained the optimal strategy across all thresholds in sensitivity analysis. CONCLUSION This cost-utility analysis suggests that synthetic mesh repair of clean-contaminated hernia defects is more cost-effective than acellular dermal matrix.
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The Economic Impact of Closed-Incision Negative-Pressure Therapy in High-Risk Abdominal Incisions. Plast Reconstr Surg 2016; 137:1284-1289. [DOI: 10.1097/prs.0000000000002024] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
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18
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Cost-Utility Analysis: Sartorius Flap versus Negative Pressure Therapy for Infected Vascular Groin Graft Managment. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2016; 3:e566. [PMID: 26893991 PMCID: PMC4727718 DOI: 10.1097/gox.0000000000000551] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2015] [Accepted: 10/06/2015] [Indexed: 11/26/2022]
Abstract
Background: Sartorius flap coverage and adjunctive negative pressure wound therapy (NPWT) have been described in managing infected vascular groin grafts with varying cost and clinical success. We performed a cost–utility analysis comparing sartorius flap with NPWT in managing an infected vascular groin graft. Methods: A literature review compiling outcomes for sartorius flap and NPWT interventions was conducted from peer-reviewed journals in MEDLINE (PubMed) and EMBASE. Utility scores were derived from expert opinion and used to estimate quality-adjusted life years (QALYs). Medicare current procedure terminology and diagnosis-related groups codes were used to assess the costs for successful graft salvage with the associated complications. Incremental cost-effectiveness was assessed at $50,000/QALY, and both univariate and probabilistic sensitivity analyses were conducted to assess robustness of the conclusions. Results: Thirty-two studies were used pooling 384 patients (234 sartorius flaps and 150 NPWT). NPWT had better clinical outcomes (86.7% success rate, 0.9% minor complication rate, and 13.3% major complication rate) than sartorius flap (81.6% success rate, 8.0% minor complication rate, and 18.4% major complication rate). NPWT was less costly ($12,366 versus $23,516) and slightly more effective (12.06 QALY versus 12.05 QALY) compared with sartorius flap. Sensitivity analyses confirmed the robustness of the base case findings; NPWT was either cost-effective at $50,000/QALY or dominated sartorius flap in 81.6% of all probabilistic sensitivity analyses. Conclusion: In our cost–utility analysis, use of adjunctive NPWT, along with debridement and antibiotic treatment, for managing infected vascular groin graft wounds was found to be a more cost-effective option when compared with sartorius flaps.
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Cost-Effectiveness of Laparoscopic Hysterectomy With Morcellation Compared With Abdominal Hysterectomy for Presumed Myomas. J Minim Invasive Gynecol 2015; 23:223-33. [PMID: 26475764 DOI: 10.1016/j.jmig.2015.09.025] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2015] [Revised: 09/13/2015] [Accepted: 09/18/2015] [Indexed: 12/14/2022]
Abstract
STUDY OBJECTIVE Hysterectomy for presumed leiomyomata is 1 of the most common surgical procedures performed in nonpregnant women in the United States. Laparoscopic hysterectomy (LH) with morcellation is an appealing alternative to abdominal hysterectomy (AH) but may result in dissemination of malignant cells and worse outcomes in the setting of an occult leiomyosarcoma (LMS). We sought to evaluate the cost-effectiveness of LH versus AH. DESIGN Decision-analytic model of 100 000 women in the United States assessing the incremental cost-effectiveness ratio (ICER) in dollars per quality-adjusted life-year (QALY) gained (Canadian Task Force classification III). SETTING U.S. hospitals. PATIENTS Adult premenopausal women undergoing LH or AH for presumed benign leiomyomata. INTERVENTIONS We developed a decision-analytic model from a provider perspective across 5 years, comparing the cost-effectiveness of LH to AH in terms of dollar (2014 US dollars) per QALY gained. The model included average total direct medical costs and utilities associated with the procedures, complications, and clinical outcomes. Baseline estimates and ranges for cost and probability data were drawn from the existing literature. MEASUREMENTS AND MAIN RESULTS Estimated overall deaths were lower in LH versus AH (98 vs 103). Death due to LMS was more common in LH versus AH (86 vs 71). Base-case assumptions estimated that average per person costs were lower in LH versus AH, with a savings of $2193 ($24 181 vs $26 374). Over 5 years, women in the LH group experienced 4.99 QALY versus women in the AH group with 4.91 QALY (incremental gain of .085 QALYs). LH dominated AH in base-case estimates: LH was both less expensive and yielded greater QALY gains. The ICER was sensitive to operative costs for LH and AH. Varying operative costs of AH yielded an ICER of $87 651/QALY gained (minimum) to AH being dominated (maximum). Probabilistic sensitivity analyses, in which all input parameters and costs were varied simultaneously, demonstrated a relatively robust model. The AH approach was dominated 68.9% of the time; 17.4% of simulations fell above the willingness-to-pay threshold of $50 000/QALY gained. CONCLUSION When considering total direct hospital costs, complications, and morbidity, LH was less costly and yielded more QALYs gained versus AH. Driven by the rarity of occult LMS and the reduced incidence of intra- and postoperative complications, LH with morcellation may be a more cost-effective and less invasive alternative to AH and should remain an option for women needing hysterectomy for leiomyomata.
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Fischer JP, Basta MN, Wink JD, Krishnan NM, Kovach SJ. Cost-utility analysis of the use of prophylactic mesh augmentation compared with primary fascial suture repair in patients at high risk for incisional hernia. Surgery 2015; 158:700-11. [DOI: 10.1016/j.surg.2015.02.030] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2014] [Revised: 02/17/2015] [Accepted: 02/19/2015] [Indexed: 01/27/2023]
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Pyfer B, Chatterjee A, Chen L, Nigriny J, Czerniecki B, Tchou J, Fisher C. Early Postoperative Outcomes in Breast Conservation Surgery Versus Simple Mastectomy with Implant Reconstruction: A NSQIP Analysis of 11,645 Patients. Ann Surg Oncol 2015. [DOI: 10.1245/s10434-015-4770-2] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
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Siedhoff MT, Wheeler SB, Rutstein SE, Geller EJ, Doll KM, Wu JM, Clarke-Pearson DL. Laparoscopic hysterectomy with morcellation vs abdominal hysterectomy for presumed fibroid tumors in premenopausal women: a decision analysis. Am J Obstet Gynecol 2015; 212:591.e1-8. [PMID: 25817518 PMCID: PMC4970522 DOI: 10.1016/j.ajog.2015.03.006] [Citation(s) in RCA: 84] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2014] [Revised: 01/21/2015] [Accepted: 03/03/2015] [Indexed: 12/19/2022]
Abstract
OBJECTIVE The purpose of this study was to model outcomes in laparoscopic hysterectomy with morcellation compared with abdominal hysterectomy for the presumed fibroid uterus and to examine short- and long-term complications and death. STUDY DESIGN A decision tree was constructed to compare outcomes for a hypothetical cohort of 100,000 premenopausal women who underwent hysterectomy for presumed fibroid tumors over a 5-year time horizon. Parameter and quality-of-life utility estimates were determined from published literature for postoperative complications, leiomyosarcoma incidence, death related to leiomyosarcoma, and procedure-related death. RESULTS The decision-tree analysis predicted fewer overall deaths with laparoscopic hysterectomy compared with abdominal hysterectomy (98 vs 103 per 100,000). Although there were more deaths from leiomyosarcoma after laparoscopic hysterectomy (86 vs 71 per 100,000), there were more hysterectomy-related deaths with abdominal hysterectomy (32 vs 12 per 100,000). The laparoscopic group had lower rates of transfusion (2400 vs 4700 per 100,000), wound infection (1500 vs 6300 per 100,000), venous thromboembolism (690 vs 840 per 100,000) and incisional hernia (710 vs 8800 per 100,000), but a higher rate of vaginal cuff dehiscence (640 vs 290 per 100,000). Laparoscopic hysterectomy resulted in more quality-adjusted life years (499,171 vs 490,711 over 5 years). CONCLUSION The risk of leiomyosarcoma morcellation is balanced by procedure-related complications that are associated with laparotomy, including death. This analysis provides patients and surgeons with estimates of risk and benefit on which patient-centered decisions can be made.
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Affiliation(s)
- Matthew T Siedhoff
- Department of Obstetrics and Gynecology, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC.
| | - Stephanie B Wheeler
- Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Sarah E Rutstein
- Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Elizabeth J Geller
- Department of Obstetrics and Gynecology, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Kemi M Doll
- Department of Obstetrics and Gynecology, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Jennifer M Wu
- Department of Obstetrics and Gynecology, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Daniel L Clarke-Pearson
- Department of Obstetrics and Gynecology, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC
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A Cost-Utility Analysis of the Use of Preoperative Computed Tomographic Angiography in Abdomen-Based Perforator Flap Breast Reconstruction. Plast Reconstr Surg 2015; 135:662e-669e. [DOI: 10.1097/prs.0000000000001133] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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The Use of Mesh versus Primary Fascial Closure of the Abdominal Donor Site When Using a Transverse Rectus Abdominis Myocutaneous Flap for Breast Reconstruction. Plast Reconstr Surg 2015; 135:682-689. [DOI: 10.1097/prs.0000000000000957] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Chatterjee A, Pyfer B, Czerniecki B, Rosenkranz K, Tchou J, Fisher C. Early postoperative outcomes in lumpectomy versus simple mastectomy. J Surg Res 2015; 198:143-8. [PMID: 26070497 DOI: 10.1016/j.jss.2015.01.054] [Citation(s) in RCA: 53] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2014] [Revised: 01/20/2015] [Accepted: 01/29/2015] [Indexed: 11/24/2022]
Abstract
BACKGROUND Relatively scarce outcomes research exists that compares early postoperative complications between breast conservation surgery (BCS) and simple mastectomy (SM). Such information would improve a surgeon's ability to provide informed consent when considering treatment options, especially for women with early stage breast cancer who have the option to receive either BCS or SM. MATERIALS AND METHODS The National Surgical Quality Improvement Program database from years 2009-2012 was analyzed. For each treatment group, we used Current Procedural Terminology codes specific to the treatment modality with sentinel lymph node biopsy as an inclusion criteria. We excluded patients who received axillary lymphadenectomies, bilateral disease or symmetry procedures, and additional breast reconstructive surgery. We compared each group with chi square and two-sample t-tests to look for preoperative comorbidity differences, then used unadjusted odds ratios to compare postoperative complication rates. RESULTS Inclusion and exclusion criteria provided 6682 patients in the BCS group and 3339 patients in the SM group. Baseline comorbid condition characteristics showed no clinical differences between groups except for diabetes (8.5% in SM versus 6.5% in BCS). Statistical analysis between each treatment modality revealed that the SM group had significantly higher wound complications, bleeding, infections, and overall complications than the BCS group. CONCLUSIONS Although both BCS and SM options have low early postoperative complication rates when treating early stage breast cancer, BCS has fewer complications with regard to bleeding, wound complications and infections.
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Affiliation(s)
- Abhishek Chatterjee
- Department of Surgery, University of Pennsylvania Health System, Philadelphia, Pennsylvania
| | - Bryan Pyfer
- Department of Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire.
| | - Brian Czerniecki
- Department of Surgery, University of Pennsylvania Health System, Philadelphia, Pennsylvania
| | - Kari Rosenkranz
- Department of Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
| | - Julia Tchou
- Department of Surgery, University of Pennsylvania Health System, Philadelphia, Pennsylvania
| | - Carla Fisher
- Department of Surgery, University of Pennsylvania Health System, Philadelphia, Pennsylvania
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The Use of Mesh Versus Primary Fascial Closure of the Abdominal Donor Site When Using a Transverse Rectus Abdominus Myocutaneous (TRAM) Flap for Breast Reconstruction. Plast Reconstr Surg 2014. [DOI: 10.1097/01.prs.0000455348.83997.34] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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