The clinical effectiveness and cost-effectiveness of open mesh repairs in adults presenting with a clinically diagnosed primary unilateral inguinal hernia who are operated in an elective setting: systematic review and economic evaluation

Lichtenstein versus TIPP versus TAPP versus TEP for primary inguinal hernia, a matched propensity score study on the French Club Hernie Registry

PURPOSE

Groin hernia repair is one of the most frequent operation performed worldwide. Chronic postoperative inguinal pain (CPIP) is the most common and challenging complication after surgical repair with subsequent high socio-economic impact. The aim of this study was to compare the one-year CPIP rates between Lichtenstein, trans-inguinal pre-peritoneal (TIPP), trans-abdominal pre-peritoneal (TAPP) and totally extra-peritoneal (TEP) repair techniques on the French Hernia Registry.

METHODS

Between 2011 and 2021, 15,161 primary groin hernia repairs with 1-year follow-up were available on the register. Using propensity score (PS) matching, matched pairs were formed. Each group was compared in pairs independently; Lichtenstein versus TIPP, TEP and TAPP, TIPP versus TEP and TAPP and finally TEP versus TAPP.

RESULTS

After PS matching analysis, Lichtenstein group showed disadvantage over TIPP, TAPP and TEP groups with significantly more CPIP at one year (15.2% vs 9.6%, p < 0.0001; 15.9% vs. 10.0%, p < 0.0001 and 16.1% vs. 12.4%, p = 0.002, respectively). The 1-year CPIP rates were similar comparing TIPP versus TAPP and TEP groups (9.3% vs 10.5%, p = 0.19 and 9.8% vs 11.8%, p = 0.05, respectively). There was significantly less CPIP rate after TAPP versus TEP repair (1.00% vs 11.9%, p = 0.02).

CONCLUSION

This register-based study confirms the higher CPIP risk after Lichtenstein repair compared to the pre-peritoneal repair techniques. TIPP leads to comparable CPIP rates than TAPP and TEP repairs.

Oral anticoagulants: a systematic overview of reviews on efficacy and safety, genotyping, self-monitoring, and stakeholder experiences

BACKGROUND

This systematic overview was commissioned by England's Department of Health and Social Care (DHSC) to assess the evidence on direct (previously 'novel') oral anticoagulants (OACs), compared with usual care, in adults, to prevent stroke related to atrial fibrillation (AF), and to prevent and treat venous thromboembolism (VTE). Specifically, to assess efficacy and safety, genotyping, self-monitoring, and patient and clinician experiences of OACs.

METHODS

We searched MEDLINE, Embase, ASSIA, and CINAHL, in October, 2017, updated in November 2021. We included systematic reviews, published from 2014, in English, assessing OACs, in adults. We rated review quality using AMSTAR2 or the JBI checklist. Two reviewers extracted and synthesised the main findings from the included reviews.

RESULTS

We included 49 systematic reviews; one evaluated efficacy, safety, and cost-effectiveness, 17 assessed genotyping, 23 self-monitoring or adherence, and 15 experiences (seven assessed two topics). Generally, the direct OACs, particularly apixaban (5 mg twice daily), were more effective and safer than warfarin in preventing AF-related stroke. For VTE, there was little evidence of differences in efficacy between direct OACs and low-molecular-weight heparin (prevention), warfarin (treatment), and warfarin or aspirin (secondary prevention). The evidence suggested that some direct OACs may reduce the risk of bleeding, compared with warfarin. One review of genotype-guided warfarin dosing assessed AF patients; no significant differences in stroke prevention were reported. Education about OACs, in patients with AF, could improve adherence. Pharmacist management of coagulation may be better than primary care management. Patients were more adherent to direct OACs than warfarin. Drug efficacy was highly valued by patients and most clinicians, followed by safety. No other factors consistently affected patients' choice of anticoagulant and adherence to treatment. Patients were more satisfied with direct OACs than warfarin.

CONCLUSIONS

For stroke prevention in AF, direct OACs seem to be more effective and safer than usual care, and apixaban (5 mg twice daily) had the best profile. For VTE, there was no strong evidence that direct OACs were better than usual care. Education and pharmacist management could improve coagulation control. Both clinicians and patients rated efficacy and safety as the most important factors in managing AF and VTE.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42017084263-one deviation; efficacy and safety were from one review.

A Cost-Utility Analysis of Mesh Prophylaxis in the Prevention of Incisional Hernias following Stoma Closure Surgery

BACKGROUND

Stoma closure is a widely performed surgical procedure, with 6295 undertaken in England in 2018 alone. This procedure is associated with significant complications; incisional hernias are the most severe, occurring in 30% of patients. Complications place considerable financial burden on the NHS; hernia costs are estimated at GBP 114 million annually. As recent evidence (ROCSS, 2020) found that prophylactic meshes significantly reduce rates of incisional hernias following stoma closure surgery, an evaluation of this intervention vs. standard procedure is essential.

METHODS

A cost-utility analysis (CUA) was conducted using data from the ROCSS prospective multi-centre trial, which followed 790 patients, randomly assigned to mesh closure (n = 394) and standard closure (n = 396). Quality of life was assessed using mean EQ-5D-3L scores from the trial, and costs in GBP using UK-based sources over a 2-year time horizon.

RESULTS

The CUA yielded an incremental cost-effectiveness ratio (ICER) of GBP 128,356.25 per QALY. Additionally, three univariate sensitivity analyses were performed to test the robustness of the model.

CONCLUSION

The results demonstrate an increased benefit with mesh prophylaxis, but at an increased cost. Although the intervention is cost-ineffective and greater than the ICER threshold of GBP 30,000/QALY (NICE), further investigation into mesh prophylaxis for at risk population groups is needed.

Evaluation of the quality of life after implantation of light or standard polypropylene hernia meshes

Abstract.

Cost-Utility Analysis of Open Hernia Operations in Bulgaria

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.

Benefits and Pitfalls of Point-of-Care Coagulation Testing for Anticoagulation Management: An ACLPS Critical Review

Objectives

Point-of-care (POC) testing is generally less precise and has higher reagent costs per test than laboratory-based assays. However, POC hemostasis testing can offer significant advantages in particular situations: patient-managed warfarin therapy as well as rapid turnaround time heparin management for intraoperative patients. Of note, POC hemostasis testing is generally approved for the purposes of anticoagulation monitoring and is inferior to laboratory coagulation testing for the diagnosis of congenital or acquired coagulopathy.

Methods

The frequently used POC coagulation instruments for POC international normalized ratio and activated clotting time are reviewed, as well as their typical performance relative to central laboratory testing (where available).

Results

Several cases are discussed that highlight the benefits, as well as pitfalls, of POC coagulation testing.

Conclusions

POC coagulation testing for anticoagulation monitoring offers advantages in particular situations. Clear policies and protocols must be developed to guide proper use of POC versus central laboratory hemostasis testing.

Office-Based Point of Care Testing (IgA/IgG-Deamidated Gliadin Peptide) for Celiac Disease

OBJECTIVES

Celiac disease (CD) is common yet under-detected. A point of care test (POCT) may improve CD detection. We aimed to assess the diagnostic performance of an IgA/IgG-deamidated gliadin peptide (DGP)-based POCT for CD detection, patient acceptability, and inter-observer variability of the POCT results.

METHODS

From 2013-2017, we prospectively recruited patients referred to secondary care with gastrointestinal symptoms, anemia and/or weight loss (group 1); and patients with self-reported gluten sensitivity with unknown CD status (group 2). All patients had concurrent POCT, IgA-tissue transglutaminase (IgA-TTG), IgA-endomysial antibodies (IgA-EMA), total IgA levels, and duodenal biopsies. Five hundred patients completed acceptability questionnaires, and inter-observer variability of the POCT results was compared among five clinical staff for 400 cases.

RESULTS

Group 1: 1000 patients, 58.5% female, age 16-91, median age 57. Forty-one patients (4.1%) were diagnosed with CD. The sensitivities of the POCT, IgA-TTG, and IgA-EMA were 82.9, 78.1, and 70.7%; the specificities were 85.4, 96.3, and 99.8%. Group 2: 61 patients, 83% female; age 17-73, median age 35. The POCT had 100% sensitivity and negative predictive value in detecting CD in group 2. Most patients preferred the POCT to venepuncture (90.4% vs. 2.8%). There was good inter-observer agreement on the POCT results with a Fleiss Kappa coefficient of 0.895.

CONCLUSIONS

The POCT had comparable sensitivities to serology, and correctly identified all CD cases in a gluten sensitive cohort. However, its low specificity may increase unnecessary investigations. Despite its advantage of convenience and rapid results, it may not add significant value to case finding in an office-based setting.

Comparison between self-gripping, semi re-absorbable meshes with polyethylene meshes in Lichtenstein, tension-free hernia repair: preliminary results from a single center

Even tough inguinal hernia repair is among the commonest operations in general surgery, the choice for an optimal approach continues to be a controversial topic. Because of the low recurrence rates and low prevalence of complications, tension-free mesh augmented operation has become the standard technique in inguinal hernia surgery, significantly reducing hernia recurrence rates. On the contrary, prevalence of chronic postoperative groin pain (CPGI) i.e. pain beyond a three month-postoperative period still remains significant: as rates of CPGI may range between 15% and 53%, surgical approaches aimed to avoid chronic post-hernioplasty pain have been extensively debated, and the avoidance of CPGI has become one of the primary endpoints of surgical research on inguinal hernia repair). Recently, a sound base of evidence suggested that the entrapment of peripheral nervous fibers innervating part of the structures in the inguinal canal and stemming from ilioinguinal (Th12), iliohypogastric (L1) nerves as well as from the genital branch of the genito-femoral nerve (L1, L2), may eventually elicit CPGI (1-10). Consequently, innovative fixation modalities (e.g. self-gripping meshes, glue fixation, absorbable sutures), and new material types (e.g. large-pored meshes) with self-adhesive sticking or mechanical characteristics, have been developed in order to avoid penetrating fixings such as sutures, clips and tacks. However, some uncertainties still remain about the pros and cons of such meshes in terms of chronic pain, as new, innovative mesh apparently does not significantly reduce the rate of CPGI. Parietex ProGrip® (Medtronics^TM) is a bicomponent mesh comprising of monofilament polyester and a semi re-absorbable polylactic acid gripping system that allows sutureless fixation of prosthetic mesh to the posterior inguinal wall. As ProGrip® does not requires additional fixation, inguinal canal may be closed within minutes after adequate groin dissection, ultimately shortening operating time. In other words, ProGrip® has the potential for significant savings, in terms of surgical and post-operating costs as well (10). The aim of our study is therefore to compare the results of the same technique with two different mesh materials (ProGrip® mesh vs. polyethylene mesh), in terms of operative time, post-operative pain, complications, and recurrence rates. (www.actabiomedica.it)

Savings from reducing low-value general surgical interventions

Background

Finding opportunities for improving efficiency is important, given the pressure on national health budgets. Identifying and reducing low-value interventions that deliver little benefit is key. A systematic literature evaluation was done to identify low-value interventions in general surgery, with further assessment of their cost.

Methods

A multiplatform method of identifying low value interventions was undertaken, including a broad literature search, a targeted database search, and opportunistic sampling. The results were then stratified by impact, assessing both frequency and cost.

Results

Seventy-one low-value general surgical procedures were identified, of which five were of high frequency and high cost (highest impact), 22 were of high cost and low frequency, 23 were of low cost and high frequency, and 21 were of low cost and low frequency (lowest impact). Highest impact interventions included inguinal hernia repair in minimally symptomatic patients, inappropriate gastroscopy, interval cholecystectomy, CT to diagnose appendicitis and routine endoscopy in those who had CT-confirmed diverticulitis. Their estimated cost was €153 383 953.

Conclusion

Low-value services place a burden on health budgets. Stopping only five high-volume, high-cost general surgical procedures could save the National Health Service €153 million per annum.

Donaldson L, Carson-Stevens A. Sources of unsafe primary care for older adults: a mixed-methods analysis of patient safety incident reports

Background

older adults are frequent users of primary healthcare services, but are at increased risk of healthcare-related harm in this setting.

Objectives

to describe the factors associated with actual or potential harm to patients aged 65 years and older, treated in primary care, to identify action to produce safer care.

Design and Setting

a cross-sectional mixed-methods analysis of a national (England and Wales) database of patient safety incident reports from 2005 to 2013.

Subjects

1,591 primary care patient safety incident reports regarding patients aged 65 years and older.

Methods

we developed a classification system for the analysis of patient safety incident reports to describe: the incident and preceding chain of incidents; other contributory factors; and patient harm outcome. We combined findings from exploratory descriptive and thematic analyses to identify key sources of unsafe care.

Results

the main sources of unsafe care in our weighted sample were due to: medication-related incidents e.g. prescribing, dispensing and administering (n = 486, 31%; 15% serious patient harm); communication-related incidents e.g. incomplete or non-transfer of information across care boundaries (n = 390, 25%; 12% serious patient harm); and clinical decision-making incidents which led to the most serious patient harm outcomes (n = 203, 13%; 41% serious patient harm).

Conclusion

priority areas for further research to determine the burden and preventability of unsafe primary care for older adults, include: the timely electronic tools for prescribing, dispensing and administering medication in the community; electronic transfer of information between healthcare settings; and, better clinical decision-making support and guidance.

Predictors of anticoagulation quality in 15 834 patients performing patient self-management of oral anticoagulation with vitamin K antagonists in real-life practice: a survey of the International Self-Monitoring Association of Orally Anticoagulated Patients

Although patient self-management (PSM) of oral anticoagulation with vitamin K antagonists is recommended for patients requiring long-term anticoagulation, important aspects are still unclear. Using data from a large international survey (n = 15 834; median age 72 years; 30·1% female), we studied predictors of poor anticoagulation control (percentage of International Normalized Ratio values within therapeutic range below 75%) and developed a simple prediction model. The following variables were identified as risk factors for poor anticoagulation control and included in the final model: higher intensity of therapeutic range (odds ratio [OR] on every level 1·9; 95% confidence interval [CI] 1·8-2·0), long intervals between measurements (>14 d; 1·5; 95% CI 1·3-1·7), female sex (OR 1·3; 95% CI 1·2-1·4), and management other than PSM (OR 1·4; 95% CI 1·2-1·6). At a threshold of 0·2 (at least one variable present), the model predicted poor anticoagulation control with a sensitivity of 85·3% (95% CI: 84·0, 86·4) and a specificity of 28·5% (27·6, 29·5). The area under the receiver operated characteristic curve was 0·65. Using the proposed prediction model, physicians will be able to identify patients with a low chance of performing well, considering additional training, regular follow-up, or adjustment of therapeutic ranges.