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Abosena W, Tedesco A, Han SM, Bugaev N, Hojman HM, Johnson BP, Kim WC, Bawazeer M, Bloom JA. A Cost-Effectiveness Analysis of Wittmann Patch-Assisted Abdominal Closure Compared to Planned Ventral Hernia in Management of the Open Abdomen. Am Surg 2024; 90:1140-1147. [PMID: 38195166 DOI: 10.1177/00031348241227214] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2024]
Abstract
BACKGROUND Inability to achieve primary fascial closure after damage control laparotomy is a frequently encountered problem by acute care and trauma surgeons. This study aims to compare the cost-effectiveness of Wittmann patch-assisted closure to the planned ventral hernia closure. METHODS A literature review was performed to determine the probabilities and outcomes for Wittmann patch-assisted primary closure and planned ventral hernia closure techniques. Average utility scores were obtained by a patient-administered survey for the following: rate of successful surgeries (uncomplicated abdominal wall closure), surgical site infection, wound dehiscence, abdominal hernia and enterocutaneous fistula. A visual analogue scale (VAS) was utilized to assess the survey responses and then converted to quality-adjusted life years (QALYs). Total cost for each strategy was calculated using Medicare billing codes. A decision tree was generated with rollback and incremental cost-utility ratio (ICUR) analyses. Sensitivity analyses were performed to account for uncertainty. RESULTS Wittmann patch-assisted closure was associated with higher clinical effectiveness of 19.43 QALYs compared to planned ventral hernia repair (19.38), with a relative cost reduction of US$7777. Rollback analysis supported Wittmann patch-assisted closure as the more cost-effective strategy. The resulting negative ICUR of -156,679.77 favored Wittmann patch-assisted closure. Monte Carlo analysis demonstrated a confidence of 96.8% that Wittmann patch-assisted closure was cost-effective. CONCLUSIONS This study demonstrates using the Wittmann patch-assisted closure strategy as a more cost-efficient management of the open abdomen compared to the planned ventral hernia approach.
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Affiliation(s)
- Wael Abosena
- Department of Surgery, Tufts Medical Center, Boston, MA, USA
| | | | - Sam M Han
- Department of Surgery, Tufts Medical Center, Boston, MA, USA
| | - Nikolay Bugaev
- Department of Surgery, Tufts Medical Center, Boston, MA, USA
| | | | | | - Woon C Kim
- Department of Surgery, Tufts Medical Center, Boston, MA, USA
| | | | - Joshua A Bloom
- Department of Surgery, Tufts Medical Center, Boston, MA, USA
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Glasgow RE, Mulvihill SJ, Pettit JC, Young J, Smith BK, Vargo DJ, Ray DM, Finlayson SRG. Value Analysis of Methods of Inguinal Hernia Repair. Ann Surg 2021; 274:572-580. [PMID: 34506312 DOI: 10.1097/sla.0000000000005063] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVE Value is defined as health outcomes important to patients relative to cost of achieving those outcomes: Value = Quality/Cost. For inguinal hernia repair, Level 1 evidence shows no differences in long-term functional status or recurrence rates when comparing surgical approaches. Differences in value reside within differences in cost. The aim of this study is to compare the value of different surgical approaches to inguinal hernia repair: Open (Open-IH), Laparoscopic (Lap-IH), and Robotic (R-TAPP). METHODS Variable and fixed hospital costs were compared among consecutive Open-IH, Lap-IH, and R-TAPP repairs (100 each) performed in a university hospital. Variable costs (VC) including direct materials, labor, and variable overhead ($/min operating room [OR] time) were evaluated using Value Driven Outcomes, an internal activity-based costing methodology. Variable and fixed costs were allocated using full absorption costing to evaluate the impact of surgical approach on value. As cost data is proprietary, differences in cost were normalized to Open-IH cost. RESULTS Compared to Open-IH, VC for Lap-IH were 1.02X higher (including a 0.81X reduction in cost for operating room [OR] time). For R-TAPP, VC were 2.11X higher (including 1.36X increased costs for OR time). With allocation of fixed cost, a Lap-IH was 1.03X more costly, whereas R-TAPP was 3.18X more costly than Open-IH. Using equivalent recurrence as the quality metric in the value equation, Lap-IH decreases value by 3% and R-TAPP by 69% compared to Open-IH. CONCLUSIONS Use of higher cost technology to repair inguinal hernias reduces value. Incremental health benefits must be realized to justify increased costs. We expect payors and patients will incorporate value into payment decisions.
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Affiliation(s)
| | | | - Jacob C Pettit
- Department of Decision Support, University of Utah, Salt Lake City, Utah
| | - Jeffrey Young
- Department of Decision Support, University of Utah, Salt Lake City, Utah
| | | | - Daniel J Vargo
- Department of Surgery, University of Utah, Salt Lake City, Utah
| | - David M Ray
- Department of Surgery, University of Utah, Salt Lake City, Utah
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Mayfield CK, Gould DJ, Wong A, Patel KM, Carey J. Value Improvement and Resource Utilization in Complex Abdominal Wall Reconstruction. Am Surg 2019; 85:1113-1117. [PMID: 31657305] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
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.
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Kay G, Eby EL, Brown B, Lyon J, Eggington S, Kumar G, Fenwick E, Sohail MR, Wright DJ. Cost-effectiveness of TYRX absorbable antibacterial envelope for prevention of cardiovascular implantable electronic device infection. J Med Econ 2018; 21:294-300. [PMID: 29171319 DOI: 10.1080/13696998.2017.1409227] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
AIMS Infection is a major complication of cardiovascular implantable electronic device (CIED) therapy that usually requires device extraction and is associated with increased morbidity and mortality. The TYRX Antibacterial Envelope is a polypropylene mesh that stabilizes the CIED and elutes minocycline and rifampin to reduce the risk of post-operative infection. METHODS A decision tree was developed to assess the cost-effectiveness of TYRX vs standard of care (SOC) following implantation of four CIED device types. The model was parameterized for a UK National Health Service perspective. Probabilities were derived from the literature. Resource use included drug acquisition and administration, hospitalization, adverse events, device extraction, and replacement. Incremental cost-effectiveness ratios (ICERs) were calculated from costs and quality-adjusted life-years (QALYs). RESULTS Over a 12-month time horizon, TYRX was less costly and more effective than SOC when utilized in patients with an ICD or CRT-D. TYRX was associated with ICERs of £46,548 and £21,768 per QALY gained in patients with an IPG or CRT-P, respectively. TYRX was cost-effective at a £30,000 threshold at baseline probabilities of infection exceeding 1.65% (CRT-D), 1.95% (CRT-P), 1.87% (IPG), and 1.38% (ICD). LIMITATIONS AND CONCLUSIONS Device-specific infection rates for high-risk patients were not available in the literature and not used in this analysis, potentially under-estimating the impact of TYRX in certain devices. Nevertheless, TYRX is associated with a reduction in post-operative infection risk relative to SOC, resulting in reduced healthcare resource utilization at an initial cost. The ICERs are below the accepted willingness-to-pay thresholds used by UK decision-makers. TYRX, therefore, represents a cost-effective prevention option for CIED patients at high-risk of post-operative infection.
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Affiliation(s)
- Gemma Kay
- a ICON Health Economics and Epidemiology , Abingdon , UK
| | | | - Benedict Brown
- c Medtronic International Trading Sàrl , Tolochenaz , Switzerland
| | | | - Simon Eggington
- c Medtronic International Trading Sàrl , Tolochenaz , Switzerland
| | - Gayathri Kumar
- a ICON Health Economics and Epidemiology , Abingdon , UK
| | | | - M Rizwan Sohail
- e Divisions of Infectious Diseases and Cardiovascular Diseases , Mayo Clinic College of Medicine , Rochester , MN , USA
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Lanni MA, Tecce MG, Shubinets V, Mirzabeigi MN, Fischer JP. The State of Prophylactic Mesh Augmentation. Am Surg 2018; 84:99-108. [PMID: 29428035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
Prophylactic mesh augmentation (PMA) is the implantation of mesh during closure of an index laparotomy to decrease a patient's risk for developing incisional hernia (IH). The current body of evidence lacks refined guidelines for patient selection, mesh placement, and material choice. The purpose of this study is to summarize the literature and identify areas of research needed to foster responsible and appropriate use of PMA as an emerging technique. We conducted a comprehensive review of Scopus, Cochrane, PubMed, and <ext-link ext-link-type="uri" xlink:href="http://clinicaltrials.gov">clinicaltrials.gov</ext-link> for articles and trials related to using PMA for IH risk reduction. We further supplemented our review by including select papers on patient-reported outcomes, cost utility, risk modeling, surgical techniques, and available materials highly relevant to PMA. Five-hundred-fifty-one unique articles and 357 trials were reviewed. Multiple studies note a significant decrease in IH incidence with PMA compared with primary suture-only-based closure. No multicenter randomized control trial has been conducted in the United States, and only two such trials are currently active worldwide. Evidence exists supporting the use of PMA, with practical cost utility and models for selecting high-risk patients, but standard PMA guidelines are lacking. Although Europe has progressed with this technique, widespread adoption of PMA requires large-scale pragmatic randomized control trial research, strong evidence-based guidelines, current procedural terminology coding, and resolution of several barriers.
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Shubinets V, Fox JP, Lanni MA, Tecce MG, Pauli EM, Hope WW, Kovach SJ, Fischer JP. Incisional Hernia in the United States: Trends in Hospital Encounters and Corresponding Healthcare Charges. Am Surg 2018; 84:118-125. [PMID: 29428038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
Incisional hernia (IH) is a challenging, potentially morbid condition. This study evaluates recent trends in hospital encounters associated with IH care in the United States. Using Nationwide Inpatient Sample databases from 2007 to 2011, annual estimates of IH-related hospital discharges, charges, and serious adverse events were identified. Significance in observed trends was tested using regression modeling. From 2007 to 2011, there were 583,054 hospital discharges associated with a diagnosis of IH. 81.1 per cent had a concurrent procedure for IH repair. The average discharge included a female patient (63.2%), 59.8 years of age, with either Medicare (45.3%) or Private insurance (38.3%) as the anticipated primary payer. Comparing 2007 to 2011, significant increases in IH discharges (12%; 2007 = 109,702 vs 2011 = 123,034, P = 0.009) and IH repairs (10%; 2007 = 90,588 vs 2011 = 99,622, P < 0.001) were observed. This was accompanied by a 37 per cent increase in hospital charges (2007 = $44,587 vs 2011 = $60,968, P < 0.001), resulting in a total healthcare bill of $7.3 billion in 2011. Significant trends toward greater patient age (2007 = 59.7 years vs 2011 = 60.2 years, P < 0.001), higher comorbidity index (2007 = 3.0 vs 2011 = 3.5, P < 0.001), and increased frequency of serious adverse events (2007 = 13.5% vs 2011 = 17.7%, P < 0.001) were noted. Further work is needed to identify interventions to mitigate the risk of IH development.
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Löfgren J, Nordin P, Wladis A. [From articles to patient benefit]. Lakartidningen 2017; 114:ESAF. [PMID: 28829481] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Affiliation(s)
- Jenny Löfgren
- Doktorand, institutionen för kirurgisk och perioperativ vetenskap, Umeå Universitet - AT-läkare, Östersunds sjukhus. Östersund, Sweden Institutionen för kirurgisk och perioperativ vetenskap - Umeå, Sweden
| | - Pär Nordin
- Docent, institutionen för kirurgisk och perioperativ vetenskap, Umeå Universitet, överläkare i kirurgi, Östersunds sjukhus - Östersund, Sweden Docent, institutionen för kirurgisk och perioperativ vetenskap, Umeå Universitet, överläkare i kirurgi, Östersunds sjukhus - Östersund, Sweden
| | - Andreas Wladis
- Docent, institutionen för klinisk forskning och utbildning, KI-SÖS - Överläkare i kirurgi, Capio S:t Görans sjukhus, Stockholm Stockholm, Sweden Docent, institutionen för klinisk forskning och utbildning, KI-SÖS. - Överläkare i kirurgi, Capio S:t Görans sjukhus, Stockholm Stockholm, Sweden
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Yenli EMT, Abanga J, Tabiri S, Kpangkpari S, Tigwii A, Nsor A, Amesiya R, Ekremet K, Abantanga FA. Our Experience with the Use of Low Cost Mesh in Tension-Free Inguinal Hernioplasty in Northern Ghana. Ghana Med J 2017; 51:78-82. [PMID: 28955103 PMCID: PMC5611906] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2023] Open
Abstract
OBJECTIVES To describe our experience and success in the use of low cost mesh for the repair of inguinal hernias in consenting adult patients. METHODS A prospective study was carried out from August 2010 to December 2013 in ten district hospitals across Northern Ghana. The patients were divided into four groups according to Kingsnorth's classification of hernias. Low cost mesh was used to repair uncomplicated groin hernia. Those hernias associated with complications were excluded. We assessed the patients for wound infection, long term incisional pain and recurrence of hernia. The data collected was entered, cleaned, validated and analyzed. RESULTS One hundred and eighty-four patients had tension-free repair of their inguinal hernias using non-insecticide impregnated mosquito net mesh. The median age of the patients was 51 years. The male to female ratio was 7:1. Using Kingsnorth's classification, H3 hernias were (62, 33.7%), followed by the H1 group (56, 30.4%). Local anaesthesia was used in 70% and less than 5% had general anaesthesia. The cost of low cost mesh to each patient was calculated to be $ 1.8(GH¢7.2) vs $ 45(GH¢ 180) for commercial mesh of same size. The benefit to the patient and the facility was enormous. Wound hematoma was noticed in 7% while superficial surgical site infection was 3%. No patient reported of long term wound pain. There was no recurrence of hernia. CONCLUSION Low cost mesh such as sterilized mosquito net mesh for use in hernioplasty in resource-limited settings is reasonable, acceptable and cost-effective, it should be widely propagated. FUNDING None declared.
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Affiliation(s)
- Edwin M T Yenli
- Department of Surgery, University for Development Studies, School of Medicine and Health Sciences and Tamale Teaching Hospital, Tamale,-Ghana
| | - John Abanga
- Department of Surgery, Tamale Teaching Hospital, Tamale, Ghana
| | - Stephen Tabiri
- Department of Surgery, University for Development Studies, School of Medicine and Health Sciences and Tamale Teaching Hospital, Tamale,-Ghana
| | | | - Aubrey Tigwii
- Department of Surgery, Wa Regional Hospital, Wa, Ghana
| | - Azare Nsor
- Sunyani Regional Hospital, Sunyani, Ghana
| | - Robert Amesiya
- Department of Surgery, St. Theresa's Hospital Nandom, Ghana
| | - Kwame Ekremet
- Department of Accident and Emergency, Tamale Teaching Hospital, Tamale, Ghana
| | - Francis A Abantanga
- Department of Surgery, University for Development Studies, School of Medicine and Health Sciences and Tamale Teaching Hospital, Tamale,-Ghana
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Affiliation(s)
- Girish Desai
- Department of Surgery, School of Medicine, University of Zambia, Lusaka, Zambia.
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Abstract
BACKGROUND The most effective method for repair of a groin hernia involves the use of a synthetic mesh, but this type of mesh is unaffordable for many patients in low- and middle-income countries. Sterilized mosquito meshes have been used as a lower-cost alternative but have not been rigorously studied. METHODS We performed a double-blind, randomized, controlled trial comparing low-cost mesh with commercial mesh (both lightweight) for the repair of a groin hernia in adult men in eastern Uganda who had primary, unilateral, reducible groin hernias. Surgery was performed by four qualified surgeons. The primary outcomes were hernia recurrence at 1 year and postoperative complications. RESULTS A total of 302 patients were included in the study. The follow-up rate was 97.3% after 2 weeks and 95.6% after 1 year. Hernia recurred in 1 patient (0.7%) assigned to the low-cost mesh and in no patients assigned to the commercial mesh (absolute risk difference, 0.7 percentage points; 95% confidence interval [CI], -1.2 to 2.6; P=1.0). Postoperative complications occurred in 44 patients (30.8%) assigned to the low-cost mesh and in 44 patients (29.7%) assigned to the commercial mesh (absolute risk difference, 1.0 percentage point; 95% CI, -9.5 to 11.6; P=1.0). CONCLUSIONS Rates of hernia recurrence and postoperative complications did not differ significantly between men undergoing hernia repair with low-cost mesh and those undergoing hernia repair with commercial mesh. (Funded by the Swedish Research Council and others; Current Controlled Trials number, ISRCTN20596933.).
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Affiliation(s)
- Jenny Löfgren
- From the Department of Public Health and Clinical Medicine, Unit of Research, Education, and Development, Östersund, Umeå University, Umeå (J.L., P.N.), and the Department of Clinical Science and Education, Södersjukhuset, Karolinska Institutet, Stockholm (A.W.) - both in Sweden; and the Schools of Biomedical Sciences (C.I.) and Medicine (A.M.), Makerere University, and the Mulago National Referral Hospital (C.I.), Kampala, and the School of Public Health, Iganga-Mayuge Health and Demographic Surveillance Site, Iganga (E.G.) - all in Uganda
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14
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ElSheemy MS, Elsergany R, ElShenoufy A. Low-cost transobturator vaginal tape inside-out procedure for the treatment of female stress urinary incontinence using ordinary polypropylene mesh. Int Urogynecol J 2014; 26:577-84. [PMID: 25352073 DOI: 10.1007/s00192-014-2552-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2014] [Accepted: 10/13/2014] [Indexed: 11/27/2022]
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Ekdahl T, Löfgren J, Wladis A, Nordin P. [Mosquito nets in hernia surgery is an option in low-income countries. Interim analysis of a controlled randomized trial shows positive results]. Lakartidningen 2014; 111:1358-1361. [PMID: 25221831] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
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Achelrod D, Stargardt T. Cost-utility analysis comparing heavy-weight and light-weight mesh in laparoscopic surgery for unilateral inguinal hernias. Appl Health Econ Health Policy 2014; 12:151-163. [PMID: 24526592 DOI: 10.1007/s40258-014-0082-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
BACKGROUND Hernioplasty is one of the most frequent surgeries in the UK. Light-weight mesh (LWM) has the potential to reduce chronic groin pain but its cost-effectiveness compared with heavy-weight mesh (HWM) is unknown. OBJECTIVE Our objective was to conduct a cost-utility analysis between laparoscopic hernioplasty with HWM and LWM for unilateral inguinal hernias. METHODS A Markov model simulated costs and health outcomes over a period of 1 year (2012) from the societal and National Health Service (NHS) perspective (England). The main outcome was cost per quality-adjusted life-year (QALY) gained. Surgery results were gleaned from the randomized control trial by Bittner et al. Other input parameters were drawn from the literature and public sources of the NHS. RESULTS From the societal perspective, LWM induces lower incremental costs (-£88.85) than HWM but yields a slightly smaller incremental effect (-0.00094 QALYs). The deterministic incremental cost-effectiveness ratio (ICER) for HWM compared with LWM amounts to £94,899 per QALY, while the probabilistic ICER is £118,750 (95 % confidence interval [CI] £57,603-180,920). Owing to the withdrawal of productivity losses from the NHS perspective, LWM causes higher incremental costs (£13.09) and an inferior incremental effect (-0.00093), resulting in a dominance of HWM over LWM (ICER 95 % CI -£12,382 to -£21,590). CONCLUSIONS There is no support for the adoption of LWM as standard treatment from an NHS perspective. However, given the small differences between HWM and LWM, LWM has at least the potential of improving patient outcomes and reducing expenditure from the societal perspective.
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Affiliation(s)
- Dmitrij Achelrod
- Hamburg Center for Health Economics (HCHE), University of Hamburg, Esplanade 36, 20354, Hamburg, Germany,
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Abstract
The economic aspects of abdominal wall reconstruction are frequently overlooked, although understandings of the financial implications are essential in providing cost-efficient health care. Ventral hernia repairs are frequently performed surgical procedures with significant economic ramifications for employers, insurers, providers, and patients because of the volume of procedures, complication rates, the significant rate of recurrence, and escalating costs. Because biological mesh materials add significant expense to the costs of treating complex abdominal wall hernias, the role of such costly materials needs to be better defined to ensure the most cost-efficient and effective treatments for ventral abdominal wall hernias.
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Affiliation(s)
- Curtis Bower
- Section of Gastrointestinal & Minimally Invasive Surgery, Division of General Surgery, A. B. Chandler Medical Center, University of Kentucky, 800 Rose Street, UKMC - C224, Lexington, KY 40536-0298, USA
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Prins MW, Koning GG, Keus EF, Vriens PWHE, Mollen RMHG, Akkersdijk WL, van Laarhoven CJHM. Study protocol for a randomized controlled trial for anterior inguinal hernia repair: transrectus sheath preperitoneal mesh repair compared to transinguinal preperitoneal procedure. Trials 2013; 14:65. [PMID: 23452397 PMCID: PMC3598762 DOI: 10.1186/1745-6215-14-65] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2012] [Accepted: 02/12/2013] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Anterior open treatment of the inguinal hernia with a tension-free mesh has reduced the incidence of hernia recurrence. The Lichtenstein procedure is the current reference technique for inguinal hernia treatment. Chronic pain has become the main postoperative complication after surgical inguinal hernia repair, especially following Lichtenstein. Preliminary experiences with a soft mesh positioned in the preperitoneal space (PPS) by transinguinal preperitoneal (TIPP) or total extraperitoneal (TEP) technique, showed promising results considering the reduction of postoperative chronic pain. Evolution of surgical innovations for inguinal hernia repair led to an open, direct approach with preperitoneal mesh position, such as TIPP. Based on the TIPP procedure, another preperitoneal repair has been recently developed, the transrectus sheath preperitoneal (TREPP) mesh repair. METHODS The ENTREPPMENT trial is a multicentre randomized clinical trial. Patients will be randomly allocated to anterior inguinal hernia repair according to the TREPP mesh repair or TIPP procedure. All patients with a primary unilateral inguinal hernia, eligible for operation, will be invited to participate in the trial. The primary outcome measure will be the number of patients with postoperative chronic pain. Secondary outcome measures will be serious adverse events (SAEs), including recurrence, hemorrhage, return to daily activities (for example work), operative time and hospital stay. Alongside the trial health status, an economic evaluation will be performed. To demonstrate that inguinal hernia repair according to the TREPP technique reduces the percentage of patients with postoperative chronic pain from 12% to <6%, a sample size of 800 patients is required (two-sided test, α = 0.05, 80% power).The ENTREPPMENT trial aims to evaluate the TREPP and TIPP procedures from patients' perspective. It is hypothesized that the TREPP technique may reduce the number of patients with any form of postoperative chronic pain by 50% compared to the TIPP procedure. TRIAL REGISTRATION Current Controlled Trials: ISRCTN18591339.
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Affiliation(s)
- M Wiesje Prins
- Department of Surgery, Radboud University Nijmegen Medical Centre, Geert Grooteplein Zuid 10, 6525 GA, Nijmegen, Gelderland, The Netherlands
| | - Giel G Koning
- Department of Surgery, Radboud University Nijmegen Medical Centre, Geert Grooteplein Zuid 10, 6525 GA, Nijmegen, Gelderland, The Netherlands
| | - Eric F Keus
- Department of Surgery, Radboud University Nijmegen Medical Centre, Geert Grooteplein Zuid 10, 6525 GA, Nijmegen, Gelderland, The Netherlands
| | - Patrick WHE Vriens
- St Elisabeth Hospital, Hilvarenbeekse Weg 60, 5022GC, Tilburg, The Netherlands
- TweeSteden Hospital, Kasteellaan 2, 5141 BM, Waalwijk, The Netherlands
| | - Roland MHG Mollen
- Gelderse Vallei Hospital, Willy Brandtlaan 10, 6716 RP, Ede, The Netherlands
| | - Willem L Akkersdijk
- St Jansdal Hospital, Wethouder Jansenlaan 90, 3844 DG, Harderwijk, The Netherlands
| | - Cees JHM van Laarhoven
- Department of Surgery, Radboud University Nijmegen Medical Centre, Geert Grooteplein Zuid 10, 6525 GA, Nijmegen, Gelderland, The Netherlands
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Figel NA, Rostas JW, Ellis CN. Outcomes using a bioprosthetic mesh at the time of permanent stoma creation in preventing a parastomal hernia: a value analysis. Am J Surg 2012; 203:323-6; discussion 326. [PMID: 22364901 DOI: 10.1016/j.amjsurg.2011.10.006] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2011] [Revised: 10/16/2011] [Accepted: 10/16/2011] [Indexed: 12/21/2022]
Abstract
PURPOSE/METHODS A retrospective review of the medical records of all patients who had a prosthetic placed at the time of stoma creation for the prevention of a parastomal hernia was performed. The purpose of this study was to evaluate the safety, efficacy, and cost-effectiveness of bioprosthetics. RESULTS A bioprosthetic was used in 16 patients to prevent the occurrence of a parastomal hernia. The median follow-up was 38 months. There were no mesh-related complications, and no parastomal hernias occurred. On value analysis, to be cost-effective, the percentage of patients who would have subsequently needed surgical repair of a parastomal hernia would have to be in excess of 39% or the bioprosthetic would have to cost less than $2,267 to $4,312. CONCLUSIONS These data show the safety and efficacy of using a bioprosthetic at the time of permanent stoma creation in preventing a parastomal hernia and defines the parameters for this approach to be cost-effective.
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Affiliation(s)
- Nicole A Figel
- Department of Surgery, West Penn Allegheny Health System, Pittsburgh, PA 15212, USA
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Affiliation(s)
- Brian M Stephenson
- Department of Surgery, Royal Gwent Hospital, Newport, South Wales NP20 2UB, UK.
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Teng YJ, Pan SM, Liu YL, Yang KH, Zhang YC, Tian JH, Han JX. A meta-analysis of randomized controlled trials of fixation versus nonfixation of mesh in laparoscopic total extraperitoneal inguinal hernia repair. Surg Endosc 2011; 25:2849-58. [PMID: 21487873 DOI: 10.1007/s00464-011-1668-3] [Citation(s) in RCA: 79] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2010] [Accepted: 03/10/2011] [Indexed: 12/29/2022]
Abstract
BACKGROUND Mesh fixation during laparoscopic total extraperitoneal (TEP) inguinal hernia repair is still controversial. Although many surgeons considered it necessary to fix the mesh, some published studies supported elimination of mesh fixation. Therefore, a meta-analysis based on randomized controlled trials (RCTs) was conducted to compare the effectiveness and safety of fixation versus nonfixation of mesh in TEP. METHODS RCTs were identified from PubMed, Embase, the Cochrane Library, SCI, and the Chinese Biomedical Literature Database (CBM). Two reviewers assessed the quality of the studies and extracted data independently. The methodological quality was evaluated according to the Cochrane Handbook 5.0.2. Statistical analysis was conducted using the Cochrane software RevMan 5.0.21. RESULTS Six RCTs involving 772 patients were included. The nonfixation group had advantages in length of hospital stay [MD =-0.37, 95% CI (-0.57, -0.17), p = 0.0003], operative time [MD = -4.19, 95% CI (-7.77, -0.61), p = 0.02], and costs. However, there was no statistically significant difference in hernia recurrence [OR = 2.01, 95% CI (0.37, 11.03), p = 0.42], time to return to normal activities [MD = -0.13, 95% CI (-0.45, 0.19), p = 0.43], seroma [OR = 1.25, 95% CI (0.30, 5.18), p = 0.75], and postoperative pain on postoperative day 1 [MD = -0.21, 95% CI (-0.52, 0.10), p = 0.18] and day 7 [MD = -0.11, 95% CI (-0.42, 0.20), p = 0.47]. CONCLUSIONS Without increasing the risk of early hernia recurrence, the nonfixation of mesh in TEP appears to be a safe alternative that is associated with less costs, shorter operative time, and hospital stay for the selected patients. Further adequately powered RCTs are required to clarify whether mesh fixation is necessary for the patients with different types of hernias and larger hernia defects.
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Affiliation(s)
- Yuan Jun Teng
- Evidence-Based Medicine Center, School of Basic Medical Sciences, Lanzhou University, Dong Gang West Road No. 199, Chengguan, Lanzhou, Gansu 730000, China
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Bansal VK, Misra MC, Kumar S, Rao YK, Singhal P, Goswami A, Guleria S, Arora MK, Chabra A. A prospective randomized study comparing suture mesh fixation versus tacker mesh fixation for laparoscopic repair of incisional and ventral hernias. Surg Endosc 2010; 25:1431-8. [PMID: 20976495 DOI: 10.1007/s00464-010-1410-6] [Citation(s) in RCA: 60] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2010] [Accepted: 09/03/2010] [Indexed: 11/25/2022]
Abstract
INTRODUCTION After the first report of laparoscopic incisional and ventral hernia repair (LIVHR) in 1993, several studies have proven its efficacy over open method. Among the technical issues, the technique of mesh fixation to the abdominal wall is still an area of debate. This prospective randomized study was done to compare two techniques of mesh fixation, i.e., tacker with four corner transfascial sutures versus transfascial sutures alone. MATERIALS AND METHODS 68 patients admitted for LIVHR repair (defect size less than 25 cm2) were randomized in two groups: group I, tacker fixation (36 patients) and group II, suture fixation (32 patients). Various intraoperative variables and postoperative outcomes were recorded and analyzed. RESULTS The patients in the two groups were well matched in terms of age, sex, body mass index (BMI), and hernia characteristics. Mean BMI was 29.0 kg/m2. Operative time was found to be significantly higher in group II (77.5 versus 52.6 min, p=0.000). Patients in group I were found to have significantly higher pain scores at 1 h, 6 h, 24 h, 1 week, 1 month, and 3 months postoperatively. At follow-up, incidence of seromas was higher in group II but the difference was not significant (7 versus 4, p=0.219). During long-term follow-up, patients in group II were satisfied cosmetically. CONCLUSION Suture fixation is a cost-effective alternative to tacker fixation, for small and medium-sized defects in anatomically accessible areas. However, suture fixation requires significantly longer operation time, but patients have statistically significantly less postoperative pain.
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Affiliation(s)
- Virinder Kumar Bansal
- Department of Surgical Disciplines, All India Institute of Medical Sciences, Ansari Nagar, Room No. 5021, 5th Floor, Teaching Block, New Delhi, India.
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Boldo E, Armelles A, Perez de Lucia G, Martin F, Aracil JP, Miralles JM, Martinez D, Escrig J. Pain after laparascopic bilateral hernioplasty. Surg Endosc 2007; 22:1206-9. [PMID: 17943371 DOI: 10.1007/s00464-007-9587-z] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2006] [Revised: 04/18/2007] [Accepted: 05/07/2007] [Indexed: 11/25/2022]
Affiliation(s)
- E Boldo
- Surgery, Consorcio Hospitalario Provincial Castellon, Castellon, Castellon, Spain.
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Wu JM, Visco AG, Weidner AC, Myers ER. Is Burch colposuspension ever cost-effective compared with tension-free vaginal tape for stress incontinence? Am J Obstet Gynecol 2007; 197:62.e1-5. [PMID: 17618760 DOI: 10.1016/j.ajog.2007.02.039] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2006] [Revised: 01/05/2007] [Accepted: 02/26/2007] [Indexed: 12/01/2022]
Abstract
OBJECTIVE This study was undertaken to evaluate the cost-effectiveness of Burch colposuspension compared with tension-free vaginal tape. STUDY DESIGN A Markov decision model was developed to compare costs (2005 US dollars) and effectiveness (quality-adjusted life years) of Burch and tension-free vaginal tape for stress urinary incontinence over 10 years from a health care system perspective. After surgery, outcomes included cure, persistent stress urinary incontinence followed by second surgery, and persistent stress urinary incontinence and mesh erosion after tension-free vaginal tape. An incremental cost-effectiveness ratio of less than $50,000 per quality-adjusted life year was considered cost-effective. RESULTS For the base-case, the Burch strategy cost more than tension-free vaginal tape ($9320 vs $8081), but was slightly more effective (7.260 vs 7.248 quality-adjusted life years). The incremental cost-effectiveness ratio was $98,755 per quality-adjusted life year. The incremental cost-effectiveness ratio was less than $50,000 per quality-adjusted life year when the relative risk of cure after Burch to tension-free vaginal tape was greater than 1.09. CONCLUSION Burch colposuspension was not cost-effective compared with tension-free vaginal tape. However, if the tension-free vaginal tape failure rate was to increase over time, Burch may become cost-effective.
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Affiliation(s)
- Jennifer M Wu
- Department of Obstetrics and Gynecology, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, NC, USA
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Wilhelm TJ, Freudenberg S, Jonas E, Grobholz R, Post S, Kyamanywa P. Sterilized Mosquito Net versus Commercial Mesh for Hernia Repair. Eur Surg Res 2007; 39:312-7. [PMID: 17595545 DOI: 10.1159/000104402] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2007] [Accepted: 04/30/2007] [Indexed: 11/19/2022]
Abstract
BACKGROUND In industrialized countries alloplastic meshes are routinely used for hernia repair. However, in developing countries they are rarely available or affordable. This study compares textile properties and tissue response of commercial polypropylene mesh (PM) vs. sterilized nylon mosquito net (MN). METHODS Textile properties were examined in vitro. In 12 goats one MN and one PM (5.5 x 8 cm) were implanted onto the posterior layer of the rectus sheath. Wound healing was clinically assessed. Histology was assessed after 4 or 16 weeks. RESULTS MN was thinner and lighter, but weaker than PM. All wounds healed without complications. After 16 weeks foreign body granulomas in the MN group contained a higher proportion of inflammatory tissue (32.7 vs. 22.1%) and more giant cells (3.1 vs. 1.7/10 granulomas) with a significantly lower partial volume of foreign body (23.2 vs. 36.9%). Partial volume of fibrotic tissue was similar. MN was 1,000-fold cheaper than PM. CONCLUSIONS PM was superior concerning strength and extent of inflammatory response. However, the findings indicate that MN might serve as a cheap substitute if an alloplastic mesh is needed but no commercial one is available or affordable. Further studies are justified which should include mosquito nets of different materials and long-term outcome.
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Affiliation(s)
- T J Wilhelm
- Department of Surgery, Klinikum Mannheim, University of Heidelberg, Mannheim, Germany
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Bátorfi J. [Recommendation of the surgical specialty college for the correction of the financing for inguinal hernia repairs]. Magy Seb 2007; 60:116-7. [PMID: 17695083] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/16/2023]
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Wéber G, Bátorfi J, Bende S. [Use of implants for the tension-free surgical treatment of hernias]. Magy Seb 2007; 60:114-5. [PMID: 17695082 DOI: 10.1556/maseb.60.2007.2.10] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/16/2023]
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Kondo A, Isobe Y, Kimura K, Kamihira O, Matsuura O, Gotoh M, Ozawa H. Efficacy, safety and hospital costs of tension-free vaginal tape and pubovaginal sling in the surgical treatment of stress incontinence. J Obstet Gynaecol Res 2007; 32:539-44. [PMID: 17100814 DOI: 10.1111/j.1447-0756.2006.00469.x] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
AIM The efficacy, safety and hospital costs of the tension-free vaginal tape procedure were compared with the pubovaginal sling operation. METHODS A total of 60 women urodynamically diagnosed as having stress or mixed urinary incontinence were operated on using either the tension-free vaginal tape or pubovaginal sling operation in a prospective manner. Preoperative characteristics of the women were not significantly different for the groups. The women were followed for up to 24 months. RESULTS In the tension-free vaginal tape group, the operation time was shorter, numbers of analgesics postoperatively required were less and hospital charges were less expensive compared to those in the pubovaginal sling operation (P < 0.01). Kaplan-Meier survival analysis showed a marginal significant difference (P = 0.059) in the objective cumulative cure rates at 24 months between the groups receiving the former (70.3%) and latter (48.3%) procedures. Subjective cure rates were not significantly different (P = 0.101). In both groups, an improvement in quality of life was significant and surgical complications were identical. De novo urge incontinence developed in 6% and 10% in the former and latter, respectively. CONCLUSIONS The tension-free tape was significantly superior to the pubovaginal sling in terms of operation time, postoperative pain, and hospital charges, but not in cure rates. A longer follow up with a larger sample size is necessary to draw definite conclusions.
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Affiliation(s)
- Atsuo Kondo
- Department of Urology, Komaki Shimin Hospital, Komaki, Japan.
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Kilic D, Gungor A, Kavukcu S, Okten I, Ozdemir N, Akal M, Yavuzer S, Akay H. Comparison of mersilene mesh-methyl metacrylate sandwich and polytetrafluoroethylene grafts for chest wall reconstruction. J INVEST SURG 2006; 19:353-60. [PMID: 17101604 DOI: 10.1080/08941930600985694] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
We report the outcomes of patients who underwent reconstruction with Mersilene mesh-methyl methacrylate (MM-MM) sandwich and polytetrafluoroethylene (PTFE) grafts after a large chest wall resection. Between June 1990 and September 2001, 59 consecutive patients (37 men, 22 women; mean age, 48.1 +/- 11.8 years; range 22-74 years) underwent large chest wall resection (greater than 5 cm diameter) and reconstruction with prosthetic material in our department. Twenty-one patients (33%) underwent reconstruction with a PTFE graft (group 2) between 1990 and 1994, and 38 patients (67%) underwent reconstruction with an MM-MM sandwich graft (group 1) between 1994 and 2001. Operative morbidity ratios were 5.2% (2/38) in group 1 and 24% (5/21) in group 2 (p = .036). The paradoxical respiration ratio was significantly higher (p = .018) in group 2 (5/21: 24%) than it was in group 1 (1/38: 2.6%). The operative mortality ratio was 4.5% (1/21) in group 2 and 0% in group 1. Mean hospital stay was 10.6 days (range 5-21 days) in group 1 and 13.3 days (range 7-36 days) in group 2 (p = .015). The MM-MM graft is inexpensive and easy to apply, provides better cosmetic options, and offers minimal morbidity. We therefore recommend that the MM-MM sandwich graft be used rather than the PTFE graft for large defects of the anterolateral chest wall and sternum where successful prevention of paradoxical respiration is required.
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Affiliation(s)
- Dalokay Kilic
- Department of Thoracic Surgery, School of Medicine, Baskent University Hospital, Baskent University, Adana, Turkey.
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Stroupe KT, Manheim LM, Luo P, Giobbie-Hurder A, Hynes DM, Jonasson O, Reda DJ, Gibbs JO, Dunlop DD, Fitzgibbons RJ. Tension-Free Repair Versus Watchful Waiting for Men with Asymptomatic or Minimally Symptomatic Inguinal Hernias: A Cost-Effectiveness Analysis. J Am Coll Surg 2006; 203:458-68. [PMID: 17000388 DOI: 10.1016/j.jamcollsurg.2006.06.010] [Citation(s) in RCA: 46] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2006] [Revised: 06/10/2006] [Accepted: 06/12/2006] [Indexed: 11/23/2022]
Abstract
BACKGROUND Watchful waiting (WW) has been shown to be an acceptable option in men with asymptomatic or minimally symptomatic inguinal hernias when clinical and patient-reported outcomes are considered. Although WW is likely to be less costly initially when compared with tension-free repair (TFR) because of the cost of the operation, it is not clear whether WW remains the least costly option when longer-term costs are considered. STUDY DESIGN We conducted a cost-effectiveness analysis of a randomized controlled trial at six community and academic centers. We examined costs, quality-adjusted life-years (QALY), and cost-effectiveness at 2 years of followup. Costs were assessed by applying Medicare reimbursement rates to patients' health-care use, which was obtained by contacting patients' health-care providers. Quality of life was assessed using the Short Form-36 version 2 health-related quality-of-life survey. Of the 724 men randomized, 641 were available for the economic analysis: 317 were randomized to TFR and 324 were randomized to watchful waiting. RESULTS At 2 years, TFR patients had $1,831 higher mean costs than WW patients (95% CI, $409-$3,044), with 0.031 higher QALY (95% CI, 0.001-0.058). The cost per additional QALY for TFR patients was $59,065 (95% CI, $1,358-$322,765). The probability that TFR was cost-effective at the $50,000 per QALY level was 40%. CONCLUSION At 2 years, WW was a cost-effective treatment option for men with minimal or no hernia symptoms.
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Affiliation(s)
- Kevin T Stroupe
- Cooperative Studies Program Coordinating Center, Edward Hines Jr VA Hospital, 5th Avenue and Roosevelt Road, Hines, IL 60141, USA.
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Hynes DM, Stroupe KT, Luo P, Giobbie-Hurder A, Reda D, Kraft M, Itani K, Fitzgibbons R, Jonasson O, Neumayer L. Cost effectiveness of laparoscopic versus open mesh hernia operation: results of a Department of Veterans Affairs randomized clinical trial. J Am Coll Surg 2006; 203:447-57. [PMID: 17000387 DOI: 10.1016/j.jamcollsurg.2006.05.019] [Citation(s) in RCA: 54] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2006] [Revised: 04/27/2006] [Accepted: 05/10/2006] [Indexed: 02/08/2023]
Abstract
BACKGROUND Evidence comparing laparoscopic versus open hernia repair has varied with time and with changes in techniques used. Cost effectiveness is an important consideration when evidence for predominance of one surgical technique is lacking. Current cost estimates of hernia repair are not available. STUDY DESIGN This study is a cost effectiveness analysis within a randomized controlled trial comparing open (OPEN) versus laparoscopic (LAP) hernia repair using mesh at 14 Department of Veterans Affairs medical centers, with 2-year followup for each patient. Between January 1999 and November 2001, 2,164 men with inguinal hernia were randomized and 1,983 had an operation; 1,395 patients (708 OPEN and 687 LAP) with outpatient hernia operations were included in the cost effectiveness analysis. Outcomes included surgical and postoperative costs, quality adjusted life years (QALY), and incremental cost per QALY gained or the incremental cost effectiveness ratio (ICER). RESULTS Over 2 years, LAP cost an average of $638 more than OPEN. QALYs at 2 years were similar, resulting in $45,899 per QALY gained (95% CI: -$669,045, $722,457). The probability that LAP is cost effective at the $50,000 per QALY level (slightly more costly but more effective), was 51%. For unilateral primary and unilateral recurrent hernia repair, the probabilities that LAP is cost effective at the $50,000 per QALY level were 64% and 81%, respectively. For bilateral hernia repair, OPEN was less costly and more effective. CONCLUSIONS Overall, laparoscopic hernia repair is not cost effective compared with open repair. For patients with unilateral (primary or recurrent) hernia, laparoscopic repair is a cost effective treatment option.
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Affiliation(s)
- Denise M Hynes
- Cooperative Studies Program Coordinating Center, Midwest Center for Health Services and Policy Research, Edward Hines Jr. VA Hospital, PO Box 5000 (151-V), 5th Avenue and Roosevelt Road, Hines, IL 60141, USA
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Valpas A, Rissanen P, Kujansuu E, Nilsson CG. A cost-effectiveness analysis of tension-free vaginal tape versus laparoscopic mesh colposuspension for primary female stress incontinence. Acta Obstet Gynecol Scand 2006; 85:1485-90. [PMID: 17260226 DOI: 10.1080/00016340601033584] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
BACKGROUND Evaluation of cost-effectiveness of new surgical techniques is important. As the data on incontinence procedures are scarce, we evaluated the cost-effectiveness of tension-free vaginal tape procedure and laparoscopic mesh colposuspension as a primary surgical treatment for female stress urinary incontinence. METHODS In four university teaching hospitals and two central hospitals 128 stress incontinent women were randomized to tension-free vaginal tape procedure (n=70) or laparoscopic mesh colposuspension (n=51) in order to investigate the clinical performance of these two procedures. Primary objective clinical outcome measures were: stress test and 48-h pad test. Secondary subjective outcome measures were health-related quality of life measured in terms of visual analogue scale and Urinary Incontinence Severity Score. Alongside the clinical trial, a cost-effectiveness analysis for the main outcome measures was performed. RESULTS The changes in the 48-h pad test result did not reach statistical significance (p=0.105). When the visual analogue scale or Urinary Incontinence Severity Score are used as the outcome measure, the tension-free vaginal tape is more cost-effective than laparoscopic mesh colposuspension over a follow-up period of one year (p<0.000). CONCLUSION The clinical and economic data of the present study suggest that over a follow-up period of one year the tension-free vaginal tape procedure is more cost-effective than laparoscopic mesh colposuspension as a primary treatment for female stress urinary incontinence.
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Affiliation(s)
- Antti Valpas
- Department of Obstetrics and Gynecology, Helsinki University Central Hospital, Helsinki, Finland.
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Kuthe A. Invited comment to the paper of S. Basu: Cost-effective laparoscopic TEP inguinal hernia repair: the Portsmouth Technique (DOI: 10.1007/s10029-005-0007-9). Hernia 2005; 10:102. [PMID: 16328155 DOI: 10.1007/s10029-005-0021-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2005] [Accepted: 06/07/2005] [Indexed: 11/28/2022]
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Denué PO, Destrumelle N, Guinier D, Lacroix V, Destrumelle AS, Mathieu P, Heyd B, Woronoff-Lemsi MC, Mantion G. Étude comparative rétrospective de l'impact médicoéconomique d'un renfort innovant dans la cure des éventrations de la paroi abdominale antérieure. ACTA ACUST UNITED AC 2005; 130:466-9. [PMID: 15925319 DOI: 10.1016/j.anchir.2005.04.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2004] [Accepted: 04/13/2005] [Indexed: 10/25/2022]
Abstract
STUDY AIM Determine the gain of hospitalization cost using a new intraperitoneal mesh compared to the retro-muscular pre-fascial implantation of a polyester mesh. PATIENTS AND METHODS From January 1998 to June 2000, 52 patients with incisional hernia of the anterior abdominal wall were operated using intraperitoneal Parietex composite Mesh. The cost of surgery, anesthesia and hospitalization in this group were compared to similar data from a group of 21 patient where a Mesrsuture mesh in a prefascial retromuscular position was used. RESULTS Parietex Composite Mesh in intraperitoneal position allows a significative reduction in surgery time, anesthesia time and hospitalization. The clinical results were confirmed by cost savings. CONCLUSION Using new innovative medical device changing surgery technique insures significant cost saving despite its initial additional cost and increases patient's comfort during hospitalization.
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Affiliation(s)
- P O Denué
- Service de chirurgie viscérale, digestive et cancérologique, unité de transplantation hépatique, hôpital Jean-Minjoz, boulevard Fleming, 25030 Besançon cedex, France.
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McCormack K, Wake B, Perez J, Fraser C, Cook J, McIntosh E, Vale L, Grant A. Laparoscopic surgery for inguinal hernia repair: systematic review of effectiveness and economic evaluation. Health Technol Assess 2005; 9:1-203, iii-iv. [PMID: 15842951 DOI: 10.3310/hta9140] [Citation(s) in RCA: 219] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
OBJECTIVES To determine whether laparoscopic methods are more effective and cost-effective than open mesh methods of inguinal hernia repair, and then whether laparoscopic transabdominal preperitoneal (TAPP) repair is more effective and cost-effective than laparoscopic totally extraperitoneal (TEP). DATA SOURCES Electronic databases. Conference proceedings. Manufacturers' submissions to the National Institute for Clinical Excellence (NICE) were reviewed. REVIEW METHODS Selected studies were rigorously assessed. Dichotomous outcome data were combined using the relative risk method and continuous outcomes were combined using the Mantel-Haenszel weighted mean difference method. Time to return to usual activities was described using hazard ratios derived from individual patient data reanalysis. A review of economic evaluations undertaken by NICE in 2001 was updated and an economic evaluation was performed. The estimation of cost-effectiveness focused on the comparison of laparoscopic repair with open flat mesh. A Markov model incorporating the data from the systematic review was used to estimate cost-effectiveness for a time horizon up to 25 years. RESULTS Thirty-seven randomised control trials (RCTs) and quasi-RCTs met the inclusion criteria on effectiveness. Fourteen studies were included in the review of economic evaluations. Laparoscopic repair was associated with a faster return to usual activities and less persisting pain and numbness. There also appeared to be fewer cases of wound/superficial infection and haematoma. However, operation times are longer and there appears to be a higher rate of serious complications in respect of visceral (especially bladder) injuries. Mesh infection is very uncommon with similar rates noted between the surgical approaches. There is no apparent difference in the rate of hernia recurrence. Laparoscopic repair was more costly to the health service than open repair, with an estimated extra cost from studies conducted in the UK of about 300-350 pounds per patient. The point estimates of cost provided by the economic model also suggest that the laparoscopic techniques are more costly (approximately 100-200 pounds more per patient after 5 years). From the review of economic evaluations, the estimates of incremental cost per additional day at usual activities were between 86 pounds and 130 pounds. Where productivity costs were included, they eliminated the cost differential between laparoscopic and open repair. Additional analysis incorporating new trial evidence suggested that TEP was associated with significantly more recurrences than open mesh but these data did not greatly influence cost-effectiveness. CONCLUSIONS For the management of unilateral hernias, the base-case analysis and most of the sensitivity analysis suggest that open flat mesh is the least costly option but provides less quality adjusted life years (QALYs) than TEP or TAPP. TEP is likely to dominate TAPP (on average TEP is estimated to be less costly and more effective). It is likely that, for management of symptomatic bilateral hernias, laparoscopic repair would be more cost-effective as differences in operation time (a key cost driver) may be reduced and differences in convalescence time are more marked (hence QALYs will increase) for laparoscopic compared with open mesh repair. When possible repair of contralateral occult hernias is taken into account, TEP repair is most likely to be considered cost-effective at threshold values for the cost per additional QALY above 20,000 pounds. The increased adoption of laparoscopic techniques may allow patients to return to usual activities faster. This may, for some people, reduce any loss of income. For the NHS, increased use of laparoscopic repair would lead to an increased requirement for training and the risk of serious complications may be higher. Chronic pain should now be addressed prospectively using standard definitions and allowing assessment of the degree of pain. More evidence is required on the loss of utility caused by persisting pain and numbness, as well as serious complications resulting from minor surgery. Prospective population-based registries of new surgical procedures may be the best way to address this, as a complement to randomised trials assessing effectiveness. Further research relating to whether the balance of advantages and disadvantages changes when hernias are recurrent or bilateral is also required as current data are limited. Methodologically sound RCTs are needed to consider the relative merits and risks of TAPP and TEP. Further methodological research is required into the complexity of laparoscopic groin hernia repair and the improvement of performance that accompanies experience.
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Affiliation(s)
- K McCormack
- Health Services Research Unit, Institute of Applied Health Sciences, University of Aberdeen, UK
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Pierściński S, Szopinśki J, Szmytkowski J, Dabrowiecki S. [Attempted assessment of the incidence and cost of surgical treatment of inginal hernias in Poland in the years 2001-2002]. Przegl Epidemiol 2005; 59:981-6. [PMID: 16729440] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/09/2023]
Abstract
A comprehensive, up-to-date assessment of the incidence and treatment cost of inguinal hernias in Poland is made difficult by the lack of a central data registry and insufficient accuracy of the data available. Therefore, research was undertaken in order to evaluate the incidence and cost of inguinal hernia treatment in the years 2001-2002 in Poland. Survey-derived data was collected from Regional Health Funds operating similar data management systems in 2002 and the Regional Branches of the National Health Fund in 2003. The number of inguinal hernia repairs, length of hospital stay, as well as the cost of these procedures and the overall number of insured people in the region were assessed. Data was obtained from 11 units (Regional Health Funds, Branches of the National Health Fund). The length of hospital stay differed between individual Regional Health Funds. The annual cost of inguinal hernia treatment amounts to approximately 100 million PLN.
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Affiliation(s)
- Stanisław Pierściński
- Katedra i Klinika Chirurgii Ogólnej i Endokrynologicznej Collegium Medicum im Ludwika Rydygiera w Bydgoszczy UMK w Toruniu.
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Moreno-Egea A, Torralba Martínez JA, Morales Cuenca G, Aguayo Albasini JL. Randomized Clinical Trial of Fixation vs Nonfixation of Mesh in Total Extraperitoneal Inguinal Hernioplasty. ACTA ACUST UNITED AC 2004; 139:1376-9. [PMID: 15611465 DOI: 10.1001/archsurg.139.12.1376] [Citation(s) in RCA: 76] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
HYPOTHESIS Mesh fixation in the extraperitoneal space during endoscopic total extraperitoneal inguinal hernioplasty might be related to an increase in postoperative pain, morbidity rate, and hospital costs. DESIGN Randomized clinical trial. SETTING University teaching hospital. PATIENTS From January 1999 to December 2001, 170 patients with inguinal hernia were invited to participate; 85 patients were randomized to each group. INTERVENTION Total extraperitoneal inguinal hernioplasty with or without mesh fixation using staples. MAIN OUTCOME MEASURES Operating time, morbidity rate, chronic pain, recurrences, and hospital cost were analyzed. Follow-up was considered complete when it included a physical examination at 24 months (mean, 36 +/- 12 months). RESULTS The statistical study showed no significant differences with regard to epidemiological factors, hernia type, operating time, morbidity, or recurrences when the mesh was stapled, although the total cost of the process was higher (P<.001). CONCLUSIONS Stapling the mesh in total extraperitoneal inguinal hernioplasty offers no advantages and increases the cost of the process. Our results suggest the possibility of limiting the use of mesh fixation in total extraperitoneal inguinal hernioplasty to cases of direct bilateral hernias.
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Affiliation(s)
- Alfredo Moreno-Egea
- Abdominal Wall Unit, Department of General Surgery, JM Morales Meseguer Hospital, Murcia, Spain.
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38
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Abstract
Objectives:To assess the relative cost-effectiveness of laparoscopic methods of inguinal hernia repair compared with open flat mesh and open non-mesh repair.Methods:Data on the effectiveness of these alternatives came from three systematic reviews comparing: (i) laparoscopic methods with open flat mesh or non-mesh methods; (ii) open flat mesh with open non-mesh repair; and (iii) methods that used synthetic mesh to repair the hernia defect with those that did not. Data on costs were obtained from the authors of economic evaluations previously conducted alongside trials included in the reviews. A Markov model was used to model cost-effectiveness for a five-year period after the initial operation. The outcomes of the model were presented using a balance sheet approach and as cost per hernia recurrence avoided and cost per extra day at usual activities.Results:Open flat mesh was the most cost-effective method of preventing recurrences. Laparoscopic repair provided a shorter period of convalescence and less long-term pain compared with open flat mesh but was more costly. The mean incremental cost per additional day back at usual activities compared with open flat mesh was €38 and €80 for totally extraperitoneal and transabdominal preperitoneal repair, respectively.Conclusions:Laparoscopic repair is not cost-effective compared with open flat mesh repair in terms of cost per recurrence avoided. Decisions about the use of laparoscopic repair depend on whether the benefits (reduced pain and earlier return to usual activities) outweigh the extra costs and intraoperative risks. On the evidence presented here, these extra costs are unlikely to be offset by the short-term benefits of laparoscopic repair.
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Affiliation(s)
- Luke Vale
- Health Economics Research Unit, University of Aberdeen, Foresterhill, UK.
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Tamme C, Köckerling F. [Surgery of primary inguinal hernias]. Chirurg 2004; 75:315-6; author reply 317-8. [PMID: 15024481 DOI: 10.1007/s00104-004-0846-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Pürschner F, Paschtalka V, Sauerland S. [Surgery of primary inguinal hernias]. Chirurg 2004; 75:317; author reply 318. [PMID: 15080087] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/29/2023]
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41
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Abstract
The objective was to make a cost analysis of incisional hernia repair by suture repair or prosthetic mesh repair. The study included 44 patients who underwent hernia repair between 1991 and 2000. The rate of recurrent incisional hernia after more than 1 year with associated costs was registered. In 1996, the technique of incisional hernia repair was changed from suture repair to mesh repair. With a mesh repair, zero out of 19 patients presented with a recurrence at follow-up, and with suture repair, five out of 13 had a recurrence (P<0.01). The duration of anaesthetic and operation was longer, but stay in the surgical ward, and sick leave was shorter for patients with a mesh repair than for those with a suture repair. For working patients, costs in the operating theatre were 4,095 Swedish kronor (SEK) higher with a mesh repair, and the costs for surgical ward, sick leave, and examination were 10,129 SEK lower than with a suture repair. Thus, with a mesh repair, the total costs were 6,034 SEK lower than with a suture repair. For retired patients, the total costs with a mesh repair were 1,898 SEK lower than with a suture repair. We conclude that in this setting, mesh repair of incisional hernias produced lower costs than suture repair.
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Affiliation(s)
- L A Israelsson
- Department of Surgery and Perioperative Science, Umeå University, Umeå, Sweden.
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42
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Manca A, Sculpher MJ, Ward K, Hilton P. A cost-utility analysis of tension-free vaginal tape versus colposuspension for primary urodynamic stress incontinence. BJOG 2003; 110:255-62. [PMID: 12628263] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/01/2023]
Abstract
OBJECTIVE To assess the cost effectiveness of tension-free vaginal tape compared with open Burch colposuspension as a primary treatment for urodynamic stress incontinence. DESIGN Cost-utility analysis alongside a multicentre randomised comparative trial. SETTING Gynaecology or Urology departments in 14 centres in the UK and Ireland, including University-associated teaching hospitals and district general hospitals. POPULATION Women with urodynamic stress incontinence. Exclusion criteria were: (1) detrusor overactivity; (2) major voiding problems; (3) prolapse; (4) previous surgery for incontinence or prolapse. METHODS Resource use data were collected on all 344 patients in the trial, including length of hospital stay, time in theatre and management of complications; resource use was costed using UK unit costs at 1999-2000 prices. MAIN OUTCOME MEASURES Health outcomes were expressed in terms of quality-adjusted life years (QALYs) between baseline and six months follow up, based on women's responses to the EQ-5D health questionnaire. RESULTS Tension-free vaginal tape resulted in a mean cost saving of pound 243 (95% CI pound 341 to pound 201) compared with colposuspension. Differential mean QALYs per patient (tension-free vaginal tape - colposuspension) was 0.01 (95% CI -0.01 to 0.03). The probability of tension-free vaginal tape being, on average, less costly than colposuspension, was 100%, and the probability of tension-free vaginal tape being more cost effective than colposuspension was 94.6% if the decision-maker was willing to pay pound 30,000 per additional QALY. CONCLUSIONS The results from this trial suggest that, over a post-operative period of six months, tension-free vaginal tape is a cost effective alternative to colposuspension. The results will need to be reassessed on the basis of longer follow up.
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Affiliation(s)
- Andrea Manca
- Centre for Health Economics, University of York, UK
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43
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Vrijland WW, van den Tol MP, Luijendijk RW, Hop WCJ, Busschbach JJV, de Lange DCD, van Geldere D, Rottier AB, Vegt PA, IJzermans JNM, Jeekel J. Randomized clinical trial of non-mesh versus mesh repair of primary inguinal hernia. Br J Surg 2002; 89:293-7. [PMID: 11872052 DOI: 10.1046/j.0007-1323.2001.02030.x] [Citation(s) in RCA: 123] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND The optimum method for inguinal hernia repair has not yet been determined. The recurrence rate for non-mesh methods varies between 0.2 and 33 per cent. The value of tension-free repair with prosthetic mesh remains to be confirmed. The aim of this study was to compare mesh and non-mesh suture repair of primary inguinal hernias with respect to clinical outcome, quality of life and cost in a multicentre randomized trial in general hospitals. METHODS Between September 1993 and January 1996, all patients scheduled for repair of a unilateral primary inguinal hernia were randomized to non-mesh or mesh repair. The patients were followed up at 1 week and at 1, 6, 12, 18, 24 and 36 months. Clinical outcome, quality of life and costs were registered. RESULTS Three hundred patients were randomized of whom 11 were excluded. Three-year recurrence rates differed significantly: 7 per cent for non-mesh repair (n = 143) and 1 per cent for mesh repair (n = 146) (P = 0.009). There were no differences in clinical variables, quality of life and costs. CONCLUSION Mesh repair of primary inguinal hernia repair is superior to non-mesh repair with regard to hernia recurrence and is cost-effective. Postoperative complications, pain and quality of life did not differ between groups.
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Affiliation(s)
- W W Vrijland
- Departments of Surgery, University Hospital Rotterdam--Dijkzigt, The Netherlands
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44
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Di Mauro S, Salibra M, Belnome NA, Barbera S, Turrisi M, Di Mauro F, Nucera ML. [Use of monofilament prosthesis in inguinal hernia treatment: cost-benefit ratio]. MINERVA CHIR 2001; 56:283-6. [PMID: 11423795] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/20/2023]
Abstract
BACKGROUND The authors aimed to demonstrate the real advantages in terms of cost and patient comfort of inguinal hernia surgery using monofilament prostheses. METHODS A retrospective survey was carried out on two groups of patients: the first group, consisting of 1032 patients who underwent inguinal hernia surgery under general anesthetic between 1985 and 1995 at the Institute of General Surgery at the University Polyclinic of Messina, included cases of both emergency and elective surgery that did not use monofilament prosthesis. The second group, consisting of 348 patients operated under local anesthesia between 1996 and 1999 at the IV Division of General Surgery at the University Polyclinic of Messina, included cases of both emergency and elective surgery using tension-free techniques and polypropylene mesh. The numbers of recidivations and complications were compared, together with the relative costs of the methods used in both groups. CONCLUSIONS In the light of these experimental results, it is clear that the use of biocompatible alloplastic materials in monofilament considerably reduces the risks of recidivation, without no significant increase in the number of dehiscences, infections or postoperative complications. Moreover, there was a striking reduction in costs linked not only to the shorter hospitalisation of patients and the reduced use of painkillers, but also a fall in the number of future hospital admissions owing to recidivation.
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Affiliation(s)
- S Di Mauro
- Dipartimento di Patologia Umana, Divisione di Chirurgia Generale IV, Policlinico Universitario di Messina, Università degli Studi, Messina, Italy
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Johansson B, Hallerbäck B, Glise H, Anesten B, Smedberg S, Román J. Laparoscopic mesh versus open preperitoneal mesh versus conventional technique for inguinal hernia repair: a randomized multicenter trial (SCUR Hernia Repair Study). Ann Surg 1999; 230:225-31. [PMID: 10450737 PMCID: PMC1420865 DOI: 10.1097/00000658-199908000-00013] [Citation(s) in RCA: 145] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
OBJECTIVE To evaluate the influence of the laparoscopic technique in hernia repair regarding time to full recovery and return to work, complications, recurrence rate, and economic aspects. SUMMARY BACKGROUND DATA Several studies have shown advantages in terms of less pain and faster recovery after laparoscopic hernia repair, whereas others have not, and the cost-effectiveness has been questioned. The laparoscopic technique must be thoroughly compared with the open procedures before its true place in hernia surgery can be defined. METHODS Six hundred thirteen male patients aged 40 to 75 years were randomized to the conventional procedure, preperitoneal mesh placed by the open technique, or laparoscopic preperitoneal mesh (TAPP). Follow-up was after 7 days, 8 weeks, and 1 year. RESULTS Of 613 patients undergoing surgery, 604 (98.5%) were followed for 1 year. Patients who underwent TAPP gained full recovery after 18.4 days, compared with 24.2 days for open mesh (p < 0.001) and 26.4 days for the conventional procedure (p < 0.001). Patients who underwent TAPP returned to work after 14.7 days, compared with 17.7 days for open mesh (p = 0.05) and 17.9 days for the conventional procedure (p = 0.04). They also had significantly less restriction in physical activities after 7 days. The TAPP procedure was more expensive, mainly as a result of longer surgical time and equipment costs, even after compensation for earlier return to work. Complications were more common in the TAPP group, with a varying pattern between the groups. Four recurrences in the conventional, 11 in the open mesh, and 4 in the TAPP group were recorded after 1 year (p = n.s.). CONCLUSION The laparoscopic technique results in both shorter time to full recovery and shorter time to return to work, at the price of substantially increased costs.
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Affiliation(s)
- B Johansson
- Department of Surgery, Norra Alvsborgs Länssjukhus, Trollhättan, Sweden
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46
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Abstract
Such important, yet basic, questions as the percentage chance that an individual will over the course of his or her life be in need of or actually undergo a groin herniorrhaphy or the absolute number and type of hernias that exist in a given society on any particular day continue to be statistically undefined. A review of epidemiologic data provides come preliminary answers. Recent studies from the National Center for Health Statistics show that approximately 750,000 groin herniorrhaphies are completed annually in the United States. More than 80% of these operations involve the use of mesh prosthesis and are performed on an outpatient basis. Despite the large number of hernioplasties completed, the public's understanding of hernias and their management remains unsophisticated.
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Affiliation(s)
- I M Rutkow
- Hernia Center, Freehold, New Jersey, USA
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47
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Perniceni T, Danès M, Boudet MJ, Levard H, Gayet B. [Laparoscopy versus the Shouldice intervention in the treatment of unilateral inguinal hernia: can the operative surcosts be minimized?]. Gastroenterol Clin Biol 1998; 22:1061-4. [PMID: 10051982] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/11/2023]
Abstract
AIMS Laparoscopy is more expensive than Shouldice procedure for inguinal hernia repair. The aims of this study were to evaluate the overcost, to look for its causes and to propose a strategy of cost reduction. METHODS One hundred and sixty three unilateral inguinal hernia repairs were performed from January 1995 to June 1996 in our institution, functioning under financial rule of total endowment. Forty five of the 163 procedures were laparoscopic procedures. The mean operative cost of each procedure was calculated from physician, personnel and equipment costs (amortization, consumable products and maintenance). RESULTS The mean costs were 2,210 FF and 6,779 FF for Shouldice and laparoscopic procedures, respectively. This overcost of 4,569 FF was reduced to 893 FF by increasing surgeon's experience, which shortened operative duration and ward cost, and by the use of a non specific mesh fastened in place with threads. The mean operative cost of laparoscopy was then 3,103 FF. CONCLUSION A change in surgical practice allows a reduction in the operative overcost of laparoscopic unilateral inguinal hernia repair by 80.4%.
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Affiliation(s)
- T Perniceni
- Département Médico-Chirurgical de Pathologie Digestive, Institut Mutualiste Montsouris et Université Paris VI
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Damamme A, Samama G, D'Alche-Gautier MJ, Chanavel N, Bréfort JL, Le Roux Y. [Medico-economic evaluation of treatment of inguinal hernia: Shouldice vs. laparoscopy]. Ann Chir 1998; 52:11-6. [PMID: 9752402] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Between May 1994 and September 1995, 64 men were included in a randomized prospective study comparing conventional Shouldice repair (S group) and transperitoneal laparoscopic repair with polypropylene mesh (L group). Cost evaluation was divided into distinct parts: drugs, non usable surgical materials, medico-technical procedures food and employees costs. In group S, mean operating time was 56', total cost was 3,922 FF in the case of unilateral hernia and 4,808 FF and respectively 77' in the case of bilateral hernia. In group L, mean operative time was 89', total cost 8,949 FF (disposable trocars) and 7,136 FF (non-disposable trocars) in the case of unilateral hernia and 116', 9,570 FF and 7,763 FF in case of bilateral hernia. Postoperative stay was 4.2 days in group S and 4 days in group L. Return to work was 28.6 days in group L and 35.5 days in group S (ns). In conclusion laparoscopic hernia repair does not decrease post operative pain, hospital stay and return to work, but is twice as expensive.
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Affiliation(s)
- A Damamme
- Service de Chirurgie Générale Viscérale et Digestive, CHU Côte de Nacre, Caen
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Wellwood J, Sculpher MJ, Stoker D, Nicholls GJ, Geddes C, Whitehead A, Singh R, Spiegelhalter D. Randomised controlled trial of laparoscopic versus open mesh repair for inguinal hernia: outcome and cost. BMJ 1998; 317:103-10. [PMID: 9657784 PMCID: PMC28600 DOI: 10.1136/bmj.317.7151.103] [Citation(s) in RCA: 213] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
OBJECTIVE To compare tension-free open mesh hernioplasty under local anaesthetic with transabdominal preperitoneal laparoscopic hernia repair under general anaesthetic. DESIGN A randomised controlled trial of 403 patients with inguinal hernias. SETTING Two acute general hospitals in London between May 1995 and December 1996. SUBJECTS 400 patients with a diagnosis of groin hernia, 200 in each group. MAIN OUTCOME MEASURES Time until discharge, postoperative pain, and complications; patients' perceived health (SF-36), duration of convalescence, and patients' satisfaction with surgery; and health service costs. RESULTS More patients in the open group (96%) than in the laparoscopic group (89%) were discharged on the same day as the operation (chi2 = 6.7; 1 df; P=0.01). Although pain scores were lower in the open group while the effect of the local anaesthetic persisted (proportional odds ratio at 2 hours 3.5 (2.3 to 5.1)), scores after open repair were significantly higher for each day of the first week (0.5 (0.3 to 0.7) on day 7) and during the second week (0.7 (0.5 to 0.9)). At 1 month there was a greater improvement (or less deterioration) in mean SF-36 scores over baseline in the laparoscopic group compared with the open group on seven of eight dimensions, reaching significance on five. For every activity considered the median time until return to normal was significantly shorter for the laparoscopic group. Patients randomised to laparoscopic repair were more satisfied with surgery at 1 month and 3 months after surgery. The mean cost per patient of laparoscopic repair was 335 pounds (95% confidence interval 228 pounds to 441 pounds) more than the cost of open repair. CONCLUSION This study confirms that laparoscopic hernia repair has considerable short term clinical advantages after discharge compared with open mesh hernioplasty, although it was more expensive.
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Leardi S, Navarra L, Pietroletti R, Risetti A, De Santis C, Simi M. [The use of prosthetic meshes in the surgical treatment of inguinal hernia: the costs and profits for the local health screening unit]. MINERVA CHIR 1998; 53:581-5. [PMID: 9774857] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/09/2023]
Abstract
BACKGROUND Inguinal hernioplasty represents one of the most frequently performed surgical operation. The recent introduction of prosthetic mesh made Bassini operation obsolete, with more space gained by the newly developed "tension-free" and "sutureless" surgical techniques. This new approach, however, results in increased initial costs for the hospital, due to the purchase of mesh materials. On the other hand a reduction of overall expenses for a single hernia repair should be expected. In this work an attempt is made to verify this, by calculating the cost-benefit ratio of different techniques for hernia repair. METHODS The type and amount of materials used in a standard Bassini hernia repair, Lichtenstein and Trabucco have been examined. The amount of anesthetic drugs required, the average hospital stay and time away from work were recorded too. The costs of the three operations considered, not including routine expenses (operating room, bed sheet, etc.) have been estimated. RESULTS Lichtenstein and Trabucco repair performed in local anesthesia (L. 1.354.120, L. 1.567.120) were cheaper than Bassini (L. 2.820.950). CONCLUSIONS Since the system of diagnosis-related group offers a fixed amount of reimbursement for hernia repair (L. 3.247.000), the extensive use of tension free and sutureless methods, offers better profit for the Hospital. Last but not least, tension free hernia repair ensures short hospital stay, less postoperative pain, good compliance and better quality of life for the patient.
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Affiliation(s)
- S Leardi
- Clinica Chirurgica, Università degli Studi, L'Aquila
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