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The Economic Burden of Incisional Ventral Hernia Repair: a Multicentric Cost Analysis

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The Economic Burden of Incisional Ventral Hernia Repair: a Multicentric Cost Analysis Hernia (2016) 20:819–830 DOI 10.1007/s10029-016-1480-z ORIGINAL ARTICLE The economic burden of incisional ventral hernia 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 hernia repair (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 hernias 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.
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