Hernia (2016) 20:819–830 DOI 10.1007/s10029-016-1480-z

ORIGINAL ARTICLE

The economic burden of incisional ventral repair: a multicentric cost analysis

1 2 3 4 J-F Gillion • D. Sanders • M. Miserez • F. Muysoms

Received: 27 September 2015 / Accepted: 17 February 2016 / Published online: 1 March 2016 Ó Springer-Verlag France 2016

Abstract whose indirect costs (5376€) were slightly higher than the Purpose A systematic review of literature led us to take direct costs. note that little was known about the costs of incisional Conclusion Reducing the incidence of incisional hernia ventral (IVHR). after abdominal surgery with 5 % for instance by imple- Methods Therefore we wanted to assess the actual costs mentation of the European Hernia Society Guidelines on of IVHR. The total costs are the sum of direct (hospital closure of abdominal wall incisions, or maybe even by use costs) and indirect (sick leave) costs. The direct costs were of prophylactic mesh augmentation in high risk patients retrieved from a multi-centric cost analysis done among a could result in a national cost savings of 4 million Euros. large panel of 51 French public hospitals, involving 3239 IVHR. One hundred and thirty-two unitary expenditure Keywords Incisional hernia Á Prevention Á Cost analysis Á items were thoroughly evaluated by the accountants of a Health economics Á Mesh augmentation specialized public agency (ATIH) dedicated to investigate the costs of the French Health Care system. The indirect costs (costs of the post-operative inability to work and loss Introduction of profit due to the disruption in the ongoing work) were estimated from the data the Hernia Club registry, involving Incisional are a frequent complication of abdominal 790 patients, and over a large panel of different Collective surgery and some patient variables including obesity, Agreements. postoperative surgical site infections and the presence of Results The mean total cost for an IVHR in France in abdominal aortic aneurysm have been identified as risk 2011 was estimated to be 6451€, ranging from 4731€ for factors [1–3]. The surgical technique and material to close unemployed patients to 10,107€ for employed patients abdominal wall incisions are also of utmost importance to avoid a high frequency of incisional hernias [4, 5]. The The data of the present study were presented by J-F Gillion during the European Hernia Society has recently developed and 36th Annual Congress of the European Hernia Society in Edinburgh published guidelines on the closure of abdominal wall on 31 May 2014. incisions [6]. As part of this initiative, the Guidelines Development Group ‘‘The Bonham Group’’ has tried to & J-F Gillion determine the economic burden related to the treatment of [email protected] an incisional hernia according to previously published 1 Unite´ de Chirurgie Visce´rale et Digestive, Hoˆpital Prive´ recommendations [7]. Apart from the known negative d’Antony, Antony, France impact of an incisional hernia on the patients’ quality of 2 Department of Surgery, Derriford Hospital, Plymouth, UK life and body image, patients with an incisional hernia are 3 Department of Abdominal Surgery, University Hospitals, at risk of potential serious complications [8]. The repair of KU Leuven, Leuven, Belgium incisional hernia has direct costs and indirect costs. Esti- 4 Department of Abdominal Surgery, AZ Maria Middelares, mation of the costs related to the treatment of incisional Ghent, Belgium hernias can reflect the socio-economic gain to be made by 123 820 Hernia (2016) 20:819–830 optimizing abdominal wall closure technique and reduction such cost analysis serve as a basis to determine the amount of the incidence of incisional ventral hernia. of money to be reimbursed to the hospitals for each GHM. The magnitude on a national level of the costs related to The reimbursement of every GHM is not calculated for incisional hernias has been reported for Sweden, where every patient, it is a package, annually updated. It has to be about 2000 incisional hernias are repaired annually with a noted that the reimbursed prices may be different from the direct cost approximately 170 million Swedish Krona actual costs, especially if the National Health Policy targets (SEK) (±18 million Euro). The direct and indirect costs for to promote certain healthcare priorities and therefore an incisional hernia have been calculated to be 86,257 SEK adjusts the tariff to make the procedure more attractive to (±9112€)[9]. In a nationwide study for the United State healthcare providers. (US) an estimated 348,000 ventral hernia repairs were The ATIH data are actual observed costs, written in the performed in 2006 with a direct cost for inpatient proce- general ledger. Among these ATIH data, we extracted dures of 15,899 US dollar (±13,000€) and for outpatient those concerning Incisional Ventral Hernia Repair in procedures 3873 US dollar (±3168€)[10]. This amounts to adults, gathered in five GHM (Table 2). One of them is a total cost of ventral hernia repair for the US in 2006 of dedicated to day-care surgery (06C24J), the four others 3.2 billion US dollar (±2.6 billion Euro). concern the inpatients, classified into four levels of severity The objective of this study was to perform a review of (06C241, 06C242, 06C243, 06C244). the literature on the costs related to incisional hernia repair Patients are grouped into four levels to determine the and to make an estimate of the direct and indirect costs for complexity of their care and hence the costs involved. incisional hernia repair in France using nationwide data. Levels 1–4 are calculated using a National Health Care System (National Security Fund) software named ‘group- eur’, taking into account the severity of the co-morbidities, Materials and methods the associated intra-hospital events (such as pulmonary embolism, cardiac failure), the length of stay out of the A systematic review of the literature was performed on 25 target. Not many surgical items are taken into account, February 2014 in Pubmed, Medline and EmBase, limited to such as: complications related to a previous mesh, bowel Human data with the search terms: ‘‘Incisional hernia OR necrosis, or a bacteriologically proven deep infection. For ventral hernia AND health planning/economics/cost and instance, this financial classification does not take into cost analysis/vital statistics/demography/population char- account whether the procedure is done laparoscopically or acteristics/quality adjusted life years/health burden’’. The through an open approach, even though it probably carries Prisma flow diagram of the records found is shown in some financial implications. The list of the relevant items is Fig. 1. The results [9–16] are displayed in Table 1. annually updated. Clinical conditions, which do not have The cost of an incisional hernia repair is the sum of any impact on finance, are removed from the list at the direct costs and indirect costs [10]. The direct costs com- annual review. prise all consumption of resources resulting from the In the ATIH multi-centric study, every observed unitary treatment. The indirect costs are those related to the out- piece of expenditure was detailed by specialized accoun- patient care during the sick leave, but mainly related to the tants, classified into 132 sub-groups of expenditure, and 6 inability to work, such as the costs of a substitute, the loss chapters (medical expenses, technical-medical expenses, of productivity, and the costs of the daily allowance. management, direct charges, structural expenses) registered and averaged for each GHM (Table 3). Direct costs Calculations based on the ATIH data Analysis of the ATIH data We wanted to calculate the average direct cost regardless In our study the direct costs were estimated from a cost of the level of severity: analysis [17] performed in 2011 among 51 public French The average cost for each GHM was then weighted hospitals by the Agence Technique de l’ Information sur l’ according to the prevalence of the corresponding GHM Hospitalisation (ATIH). The ATIH (www.atih.sante.fr)isa (Table 3) resulting in a ‘‘weighted average of the direct public agency dedicated to investigate the costs of the cost for an average incisional hernia repair’’. French Health Care system, especially the intra-hospital costs of various diseases, classified in more than 3000 Indirect costs GHM (Groupes Homoge`nes de Malades = Homogeneous groups of patients), the French version of the DRG (Di- The sick leave and the inability to work (including the agnosis-Related Groups). The actual costs, observed in hospital stay) were estimated using data extracted from the 123 Hernia (2016) 20:819–830 821

Fig. 1 Prisma flow diagram

prospective registry on abdominal wall hernias from the The average cost of inability to work and loss of pro- ‘‘Club Hernie’’. This is a collaborative registry of nearly 50 ductivity, were estimated, firstly from the mean wages in French surgeons with a specific interest in abdominal wall France in 2011 (Table 5), published by the National surgery. Each participant accepts and signs the charter of Institute of Statistics (INSEE), and secondly using a quality stating that ‘‘all input must be registered consecu- table taking into account the most frequent Collective tive, unselected, exhaustive and in real time’’. The partic- Agreement among the myriad of the different French social ipants allow peer review control of the original medical public and private contracts (Table 6). chart of randomly selected patients. Follow-up is obtained by a clinical research assistant, independent from the individual participants and blinded for the surgical proce- Results dure. Consecutive patients with an IVH operated between September 30th, 2011 and August 31st, 2014, were used Systematic review for the estimation of the indirect cost. Data on hospital stay and postoperative absence from work were extracted from The results of our systematic review are shown in the the database to determine the estimated average duration of Prisma flow diagram in Fig. 1. Initially 402 records were inability to work (Table 4). identified, after removal of duplicates and non-relevant

123 822 123 Table 1 Summary of findings table Summary of evidence table for ‘‘the cost of incisional hernia repair’’ Reference Study type Level of Number Patient characteristics Intervention Comparison Length of Outcome measure Source of citation evidence of follow-up (currency) funding GRADE patients

[9] Economic Moderate 691 Matched Small stitch closure Large stitch closure 5 years Cost direct and indirect University evaluation (n = 321) (n = 370) (SEK = Swedish Grant from RCT Krona) Effect size 1. Cost reduction with small stitches 1339 SEK per patient 2. Direct costs of incisional hernia repair 59909 SEK and indirect costs 26348 SEK [11] Economic Low 44 Consecutive patients Mesh repair Suture repair [1 year Cost direct and indirect Not stated evaluation (SEK = Swedish Krona) Effect size Cost saving of 6034 SEK with mesh repair [10] Economic Very low N/A Patients from healthcare cost and Inpatient ventral None 5 years 1. Total number of Not stated evaluation utilization project hernia repair repairs 2. Mean costs (US $ = US Dollar) Effect size 1. 154, 278 ventral hernia repairs in US in 2006 2. Cost per operation US$15,899 3. Total cost US$3.2billion 4. US$32 million dollar reduction in cost for every 1 % decrease in incisional hernias [12] Economic Moderate 861 Consecutive patients 1988-1992 having Suture length to Suture length to 1 year 1. Incisional hernia rate None evaluation midline wound length wound length 2. Costs ratio C4 ratio \4 (SEK = Swedish Krona) Effect size 1. Relative risk reduction 0.016 with S:W C 4 2. Cost reduction SEK 686 3. Saving per patient of SEK116 4. Estimated nationwide saving of SEK2, 107,140 (2000) per year [13] Economic Low 884 Consecutive patients undergoing Laparoscopic Open incisional 30 days 1. Operative time Not stated evaluation incisional hernia repairs incisional hernia hernia repair 2. Cost (US $ = US repair Dollar) 3. Length of stay 4. 30 days postoperative

hospital encounters 20:819–830 (2016) Hernia Effect size 1. Shorter stay with lap 2. Longer op time with lap 3. Higher supply costs with lap (US$6396 vs US$664) 4. Higher 30 days hospital encounters with lap (15 vs 13 %) [14] Economic Low N/A Theoretical patients with incisional Open mesh repair Open suture repair N/A 1. Costs (US $ = US Educational evaluation hernia. Placed into decision analysis Dollar) Grant model 2. Cost effectiveness Olympus Hernia (2016) 20:819–830 823

records, eight records remained for qualitative evaluation. The Summary of Findings of the systematic review is shown in Table 1. Significant heterogeneity in time periods Not stated Source of funding and the different currencies of the studies make it impos- sible to perform quantitative evaluation. US

= Direct cost of IVHR in our study

In this multi-centric study the direct costs were studied

Dollar) among 3239 patients treated in 51 French public hospitals. Costs (US $ Outcome measure (currency) The average direct costs for incisional hernia repair are shown in Table 3. They were, respectively, 3497€, 4652€, 8402€, 16,367€ for the level 1, level 2, level 3 and level 4 1 year

follow-up GHM and 2041€ for day-case incisional hernia repair. Each of these five average costs was then weighted according to the prevalence of the related GHM resulting in the weighted average direct cost of a mean incisional hernia repair, which is 4731€.

Indirect cost of incisional hernia repair in our study

From 30 September 2011 till 31 August 2014, 10,529 patients were registered in the Hernia Club Registries, including 7851 patients operated on for groin hernias and

N/A N/A Mean 2678 patients for ventral hernias, including 991 patients operated on for incisional ventral hernias. Sick leave, hospital stay and nature of employment were properly recorded in 790 of these 991 patients (Table 4). One-third of our patients were employed. The hospital stay was 2.6 days for employed and 3.7 days when including unemployed patients. The mean sick leave duration for employed patients, including the hospital stay was 29.6 (range 0–90) days. The mean monthly wages for employees in France in 2011, retrieved from the National Institute of Statistics are operation

Patient characteristics Intervention Comparison Length of reported Table 5. The average monthly wages were as follows: Net wages: 2130€, Gross wages: 2830, Total wages 4671€, corresponding to weekly Net wages of 492€, Gross wages of 654€ and Total wages of 1078€. The dif- Number of patients ferences between these different wages are explained in Table 5. The estimation of the value of one-week sick leave among the most frequent French collective agreements for Moderate 1008 All surgical patients undergoing an evidence GRADE this mean wages is reported in Table 6. The value of a weekly sick leave for employed widely ranged across these collective agreements from 359 to 1977€. The weighted mean value of a weekly sick leave for

evaluation employed was estimated at 1271€ (Table 6). 2. Total cost of mesh3. repair Incremental US$16,947 costs to prevent one recurrence with mesh US$1878 Study type Level of 2. Median hospital costs if3. minor Median complications hospital occurred: cost US$14,094 if major complications occurred: US$28,536 Therefore the average sick leave cost for our employed continued patients was 5376€ (1271€ per week/7 9 29.6) while the values ranged from 1518€ (359/7 9 29.6) to 8360€ (1977/ ] Economic ] Review Very low N/A Incisional hernias N/A N/A N/A N/A None 15 16 Effect size 1. Total cost of suture repair US$16,355 [ Effect size 1. Median hospital costs if no complication: US$4487 [ Effect size Mesh incisional hernia is more cost effective than suture repair Table 1 Summary of evidence table for ‘‘the costReference of incisional herniacitation repair’’ 7 9 29.6) [Tables 4, 6]. 123 824 Hernia (2016) 20:819–830

Table 2 The five IVHR-GHM (Homogeneous groups of patients for Incisional Ventral Hernia repairs) GHM Description Relevant comorbidities Relevant associated Hospital stay \ or [ or risk factors intra-hospital events to the target

06C241 IVHR [ 17 years, level 1 0 0 0 06C242 IVHR [ 17 years, level 2 Level calculated using the French National Health Care computerized device ‘groupeur’ taking into 06C243 IVHR [ 17 years, level 3 account severity and combinations of items annually updated according to their financial relevance 06C244 IVHR [ 17 years, level 4 06C24J IVHR [ 17 years, D case Low risk 0 0 Levels are calculated using the National Health Care computerized device (‘groupeur’) taking into account severity and combinations of the co- morbidities, the associated intra-hospital events (such as pulmonary embolism, cardiac failure), the length of stay out of the target; Not many surgical items are taken into account such as complications related to a previous mesh, bowel necrosis, or a bacteriologically proven deep infection. For instance, this classification does not take into account whether the procedure is done laparoscopically or through an open approach These items are annually updated. If one of these items does not have any financial relevance, it is withdrawn from the list IVH incisional ventral hernia repair, y year, D case day case surgery

Table 3 Prevalence and observed direct costs of the five IVHR-GHM in the ATIH multicentric study, and calculation of the weighted average direct cost of an average IVHR GHM Description Prevalence Costsa Weightingb Weighted average Cases % €€9 %

06C241 IVHR [ 17 years, level 1 1.285 39.7 3497 1388 06C242 IVHR [ 17 years, level 2 1.516 46.8 4652 2177 06C243 IVHR [ 17 years, level 3 221 6.8 8402 571 06C244 IVHR [ 17 years, level 4 105 3.2 16,367 524 06C24J IVHR [ 17 years, D case 112 3.5 2041 71 3.239 100 4731€ Weighted average of the direct cost of an average IVHR a Observed costs per case b Each cost was weighted according to the prevalence of the corresponding GHM

Table 4 Average sick leave duration, in IVHR registered in the Hernia Club registry Occupation (item available for 790 patients) Average hospital stay (days, range) Average sick leave including the hospital stay (days, range) Employed Unemployed Employed Total Employed

251 539 2.6 3.7 29.6 32 % 68 % (0–11) (0–29) (0–90)

Total cost of incisional hernia repair in our study of indication concerning the rate, the duration, and the (Table 7) prices. For unemployed we took into account the direct costs, For employed persons the global average cost (di- because of the difficulty to evaluate in Euros the impact of rect ? indirect costs) in 2011 of an incisional hernia repair surgery on their daily life. in France was estimated at 10,107€. For these employed Finally the average total costs of IHR, regardless to the patients, the indirect costs were higher than the direct costs. employment was 4731 9 68 ? 10,107 9 32 % = 6451€. Some of our patients, mainly unemployed and/or In other words: ‘‘the average total cost for an average elderly, probably spent their recovery in convalescent incisional hernia repair in an average patient’’ in France in home, but we could not evaluate these costs due to the lack 2011 was estimated to be 6451€.

123 Hernia (2016) 20:819–830 825

Table 5 Wages in France in Net wagesa (€) Gross wagesb (€) Total wagesc Total wagesd 2011 (INSEE) Monthly (€) Weekly (€)

Senior manager 3988 5385 Intermediate professions 2182 2910 Employees 1554 2049 Workers 1635 2137 Average 2130 2830 4671 1078€e INSEE National Institute of Statistics and Economic Studies (www.insee.fr/) a Net wages: take home wages after payment of the compulsory social contributions (employer and employee’s parts) and before payment of the direct taxes b Gross wages (Net 9 1.329): wages paid to the employee minus the compulsory employer’s part of social contributions c Total wages (Net 9 2.195 or Gross 9 1.65): net wages ? employee’s and employer’s compulsory social contributions = the real employee’s wages = the actual cost of the employee for his employer d Weekly wages = Monthly wages/4.33 e An average monthly gross wages of 2830€ is equivalent to weekly net wages of 492€, gross wages of 654€, total wages of 1,078€

Table 6 Estimation of the value of 1 week sick leave among the most frequent French Collective Agreements for the average gross wages of 2830€ Collective Sickness, benefita, Waiting Income, Substituted Profit Valuef, Prevalence Weighted, agreement (CA) (SB) % periodb, supplementc, loss (%)e (€) (%)g valueh (€) of wages before SB up to 100 %

Private sector 80 Income supplement, not 50 % 3 days No No 15 359 8 29 included in CA 50 % 3 days No Yes 20 1196 8 96 Income supplement, 50 % 3 days Yes No 15 947 16 152 included in CA 50 % 3 days Yes Yes 20 1896 16 303 50 % Assumed, by Yes No 15 1028 16 164 employer 50 % Assumed, by Yes Yes 20 1977 16 316 employer Public sector 20 100 % 0 day – No 15 505 10 51 100 % 0 day – Yes 20 1603 10 160 Weighted average value 1271 of a weekly, sick leavei Note it is almost the double of the gross wage and 2 times and a half more than the net wage CA collective agreement a The Sickness Benefit, or Daily Allowance, is directly paid to the employee by the National Social Security Insurance (Se´curite´ Sociale), usually after a waiting period of 3 days, except in Public sector, or if it is assumed by the employer b During their sickness, the public employers are given 100 % of their wages, the private employees are given 50 % of their wages c Some private employees are given income supplement up to 100 % wages depending on their contracts d The cost of a substitute is comparable with the total wage of the substituted (1078€) e Due to the work disruption a profit loss of 15–20 % is generally estimated f Value of a one-week sick leave taking into account the former items g Estimated prevalence of each collective agreement h Weighted value (value 9 prevalence) i Weighted average value of a weekly sick leave (1271€) for a weekly gross wage of 654€

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Table 7 Total (direct and indirect) costs of IVHR for employed and unemployed patients Employment % Average direct, Average indirect, costs (€) Average, costs (€) total cost Average sick leave Cost per week Cost Per day Duration (days) Total cost

Unemployed 68 4731 – – 4731€ Employed 32 4731 1271 182 29.6 5376a 10,107€ Irrespective, (0.68 9 4731) ? 6451€ of employment (0.32 9 10,107) = a (1271/7) 9 29.6

Key results Poulouse et al. reporting on the cost of ventral hernia repair (including both primary ventral and incisional hernias), the The mean total cost for an incisional hernia repair in France direct cost for inpatient procedures was 15,899 US dollar in 2011 was estimated to be 6451€, ranging from 4731€ for (±13,000€) and for outpatient procedures 3873 US dollar unemployed patients to 10,107€ for employed patients (±3168€)[10]. Overall we can conclude that most authors whose indirect costs were slightly higher than the direct see an important cost saving in the prevention of incisional costs. The average direct cost was 4731€, but direct costs hernias. widely ranged from 3497€ for level 1 to 16,367€ for level 4 Significant heterogeneity in time periods and the dif- of severity (Tables 2, 3). The mean cost of a day-case IVHR ferent currencies of the studies, made it is not possible to was 2041. The average indirect cost for employed patients perform quantitative evaluation. Therefore we wanted to was 5376€ (Table 7), but the indirect costs spread across a assess the actual costs of IVHR. wide range of 1518€–8360€ (Tables 4, 6). Financial study

Discussion In this multi-centric cost analysis, the mean total cost for an incisional hernia repair in France in 2011 was estimated to Systematic review be 6451€, ranging from 4731€ for unemployed patients (68 % of patients) to 10,107€ for employed patients (32 % The summary of findings of the systematic review is shown of patients) whose indirect costs were slightly higher than in Table 1. Three records were from the Sundsvall Hospital the direct costs. The average direct cost was 4731€, but in Sweden [9, 11, 12]. In their most recent publication the direct costs widely ranged from 3497€ for level 1 to overall mean cost for an incisional hernia repair was 16,367€ for level 4 of severity (Tables 2, 3). The mean cost 86,257 SEK (±9060€), with a direct cost of 59,909 SEK of a day-case IVHR was 2041. The average indirect cost (±6294€) and an indirect cost of 26,348 SEK (±2768€) for employed patients was 5376€ (Table 7) but the indirect [9]. They estimated that by adopting the technique of small costs spread across a wide range of 1518€ to 8360€ bites during closure of a midline laparotomy, the antici- (Tables 4, 6). pated reduction of incisional hernias results in a cost Around 13.000 incisional hernia repairs are performed reduction for each patient of 1339 SEK (±141€). in France each year. The global yearly cost for incisional Four other studies reported data from the United States hernia repair in France can be estimated to be almost 84 and one record is a recent review on the topic [10, 13–16]. million Euros, with a direct cost of 62 million Euros. In this Dimick et al. showed that the incidence of postoperative study the costs were calculated for public hospitals. In complications in surgical procedures, including hernia France, 50–55 % of surgery is performed in private hos- surgery, increases the costs related to the procedure sig- pitals. From data of the ATIH we know that the direct costs nificantly [15]: after adjusting for differences in patient are 25–50 % lower in private hospitals [17] even after characteristics, major complications were associated with reintegration of the medical fees, not included in the pri- an increase of $11,626 (95 % CI $9419 to $13,832; vate hospital costs. Therefore the direct overall cost in p \ 0.001). France (private and public) are probably closer to 45 mil- Bower et al. concluded that mesh repair of incisional lion Euros. hernias is more cost effective than suture repair, because of Nevertheless, reducing the incidence of incisional hernia the significant higher need for subsequent repair of recur- repair after abdominal surgery by 5 % (13.000 9 5%= rent incisional hernia [16]. In the most recent study by 650) would result in a yearly national cost savings (direct 123 Hernia (2016) 20:819–830 827 and indirect cost) of approximately 4 million Euros been performed in the CH cohort, and more level 4 cases (6451 9 650 = 4193,150€). could be treated in the ATIH cohort. The difference, if it Implementation of the recently published European exists, may have a slight impact because the relative Hernia Society guidelines on the closure of abdominal wall financial weight of the level 4 is not prominent (Table 3). incisions [6], thus hold a good potential not only to avoid The indirect costs, mainly for unemployed patients, are postoperative morbidity related to incisional hernias, but probably slightly underestimated: also to a significant cost saving from avoiding subsequent Unemployed and elderly patients may have spent some incisional hernia repair operations. Prevention of incisional of their recovery in convalescent homes, for which costs hernias in patients at high risk for this complication with a could not be evaluated. Furthermore the Quality of Life is primary mesh augmentation is currently being studied in not a financial variable, so we could not evaluate in several studies and the evidence on the efficacy and the unemployed patients the cost of the daily life impairment safety of this approach is increasing rapidly [6, 18, 19]. The during the sick leave. The costs of a redo surgery in case of resulting decrease in incisional hernias will undoubtedly recurrent IVHR, the costs of further medical care and work compensate for the additional cost for a primary mesh gaps in case of complications such as chronic pain were augmentation in mesh material and operative time in high- also not taken into account. risk patients. It would have been helpful to split the cost analysis between open and laparoscopic repairs. Unfortunately due Strengths of this study to the lack of specific GHM (DRG) in this financial and not medical ATIH study we could not assess the specific costs This study is the first published multi-centric cost analysis of the laparoscopic repairs. This becomes more relevant as of both direct and indirect costs of IVHR. It was done laparoscopic techniques continue to improve and more among a large panel of 51 French public hospitals, complex cases are being done in this fashion. This will including 3239 patients for the direct costs evaluation and have a direct effect on the direct cost of the procedure as 790 patients for the indirect costs evaluation. The hospital laparoscopic consumables are more costly and the length of costs were retrieved from a thorough analysis of 132 uni- the procedure may be longer. This may be offset by the fact tary expenditure items done by the accountants of a spe- that laparoscopic procedures generally have a shorter cialized public agency (ATIH) dedicated to investigate the length of stay and a quicker return to work. costs of the French Health Care system. Moreover, the Moreover it is really difficult to briefly explain what the ATIH data consist in observed costs (written in the general four levels of hernia repair are and how they differ. Levels ledger) and not reimbursed prices, which may differ from are calculated using the National Health Care computerized actual costs especially if the national health policy targets device (groupeur) taking into account severity and com- to promote some priorities and changes in the sanitary binations of the co-morbidities, the associated intra-hos- behaviours. pital events (such as pulmonary embolism, cardiac failure), The pathology studied (IVHR) is homogeneous and did the length of stay out of the target; Not many surgical items not include primary ventral hernias, which are very dif- are taken into account such as complications related to a ferent in terms of pathology, hospital stay, postoperative previous mesh, bowel necrosis, or a bacteriologically pro- complications, recurrence rate [20] and finally in terms of ven deep infection. These items are annually updated and costs. move: If one of these items has not got any financial rel- Furthermore this study estimates the costs of the post- evance, it is withdrawn from the list. Therefore it is really operative inability to work and loss of profit due to the difficult to briefly explain what these four levels are. disruption in the on-going work over a large panel of dif- We have used the best available data at our disposal to ferent Collective Agreements. estimate the different components of the direct and indirect costs. Although we think the samples are representative Limitations they might not reflect the overall population of French patients undergoing incisional hernia repair, such as inde- The ATIH cost analysis dates back from 2011. Such a wide pendent professionals, farmers, artisans, liberal professions cost analysis is not organized each year. Fortunately, due to whose social systems are different from those of a very low inflation rate over this period these costs are still employees. valid today. The economic evaluations are, a priori, difficult to The ATIH analysis does not address the indirect costs, extrapolate to other countries, because of variations in which were evaluated from the patients registered in the healthcare systems and financing, the changes in currencies Hernia Club Registry. These two populations may slightly and the inflation over time. Nevertheless the costs identi- differ. For instance more laparoscopic repairs could have fied in the current study are very similar to those found in 123 828 Hernia (2016) 20:819–830

Sweden (9, 11–12). Therefore these costs seem represen- Department of Cardiac and , Medical tative for the cost of IVHR in Europe. In the United States University of Gdansk, Poland direct costs (16), are significantly higher than those * G. Campanelli reported in this study. University of Insubria, General and day surgery, Center of research and high specialization for abdominal wall pathology and hernia repair, Istituto Clinico Sant’ Conclusion Ambrogio, Milano, Italy * J. Conze Our study shows that next to a considerable direct cost, also UM Herniacentre, Munich and Department of General, the indirect costs of incisional hernia repair have to be Visceral and Transplantation Surgery, University Hospital accounted for when calculating the potential benefit of of the RWTH Aachen, Aachen, Germany preventive measures to decrease the rate of incisional * D. Cuccurullo hernias after abdominal wall incisions. Upcoming evidence Department of General and Laparoscopic Surgery, on the efficacy and safety of mesh augmentation during Monaldi Hospital, Azienda Ospedaliera dei Colli, Naples, closure of abdominal wall incisions in the prevention of Italy incisional hernias shows an important potential to decrease *A.C. de Beaux the costs related to subsequent incisional hernia repair. Department of , The Royal Infirmary of Edinburgh, Edinburgh, United Kingdom Acknowledgments The authors would like to acknowledge the * E.B. Deerenberg Bonham Group and Hernia Club members (see ) and Guy Department of Sugery, Erasmus MC University Medical Gravet (GG), a specialized accountant, for helping them in the esti- mation of the indirect costs. Center Rotterdam, Rotterdam, the Netherlands * B. East Compliance with ethical standards Department of Surgery, Second Faculty of Medicine, Charles University in Prague, Czech Republic Conflict of interests None for this work: As President of the Her- nia-Club and Organiser of the Mesh Congress, JFG has financial * R.H. Fortelny partnerships with a number of companies. However, he received no Chief of the Hernia Center, Department of General, personal funding for this study. Visceral and Oncological Surgery, Wilhelminenspital, The Hernia-Club is an independent scientific institution whose Vienna, Austria objective is to assess the use of different procedures and prostheses for hernia repair. It therefore has relationships with a number of * N.A. Henriksen companies with an interest in independent evaluation of their Digestive Disease Center, Bispebjerg Hospital and products. Department of , Hvidovre Hospital, Copenhagen, Denmark * L. Israelsson Appendix A: Members of the Bonham Group Department of Surgery and Perioperative science, Umea˚ University, Umea˚, Sweden * F.E. Muysoms * A. Jairam Head of the Department of Abdominal Surgery, AZ Department of Sugery, Erasmus MC University Medical Maria Middelares, Ghent, Belgium Center Rotterdam, Rotterdam, the Netherlands * J-F. Gillion *A.Ja¨nes Unite´ de Chirurgie Visce´rale et Digestive, Hoˆpital Prive´ Head of Upper GI and Trauma Surgery, Department of d’Antony, France Surgery, Sundsvall Hospital, Sundsvall, Sweden * D.L. Sanders * J. Jeekel Department of Surgery, Derriford Hospital, Plymouth, Department of Neurosciences, Erasmus MC University United Kingdom Medical Center Rotterdam, Rotterdam, the Netherlands * M. Miserez *M.Lo´pez-Cano Department of Abdominal Surgery, University Hospi- Abdominal Wall Surgery Unit, Hospital Universitario tals, KU Leuven, Belgium Vall d’Hebro´n. Universidad Auto´noma de Barcelona, 1,2 * S.A. Antoniou Barcelona, Spain 1 Center for Minimally Invasive Surgery, Neuwerk * S. Morales-Conde Hospital, Mo¨nchengladbach, Germany Chief of the Unit of Innovation in Minimally Invasive 2 Department of General Surgery, University Hospital of Surgery, University Hospital Virgen del Rocı´o, Heraklion, University of Crete, Greece Seville, Spain * K. Bury * M.P. Simons 123 Hernia (2016) 20:819–830 829

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