RECONSTRUCTIVE Outcomes Article

Complex Ventral Hernia Repair Using Components Separation with or without Synthetic Mesh: A Cost-Utility Analysis Abhishek Chatterjee, M.D., M.B.A. Naveen M. Krishnan, B.S., M.Phil. Joseph M. Rosen, M.D. Lebanon, N.H.

Background: Components separation provides a useful option among closure choices for complex ventral hernia repairs. The use of synthetic mesh in addition to performing a components separation is controversial. The authors’ goal was to perform the first cost-utility analysis on the use of synthetic mesh in addition to performing components separation when performing a complex ventral hernia repair in a noncontaminated field. Methods: A comprehensive literature review was conducted to identify published complication and recurrence rates for ventral hernia repairs (Ventral Hernia Workgroup I and II) requiring components separation with or without synthetic mesh. The probabilities of the most common complications were combined with Medicare Current Procedural Terminology reimbursement codes, Diagnosis-Related Group reimbursement codes, and expert utility estimates to fit into a decision model to evaluate the cost-effectiveness of components separation with and without synthetic mesh in reconstructing ventral hernias. Results: At average retail costs, the decision model revealed a cost increase of $541.69 and a 0.0357 increase in quality-adjusted life-years when using synthetic mesh, yielding a cost-effective incremental cost-utility ratio of $15,173.39 per quality-adjusted life-year. Univariate sensitivity analysis revealed that synthetic mesh is cost-effective when it costs less than $2049.97. Conclusions: The addition of synthetic mesh when performing components separation in repairing complex ventral hernias is cost-effective when using average retail prices. Physicians and hospitals should use synthetic mesh in patients with noncontaminated wounds.  (Plast. Reconstr. Surg. 133: 137, 2014.)

T

he repair of complex ventral hernias continues to challenge surgeons. Not only is there a slew of techniques present among surgical techniques to address the challenge of closing the hernia, but ventral hernias are also difficult to group and categorize. The Ventral Hernia Working Group’s grading of ventral hernias is based on contamination of fields and patient characteristic complexities.1 Grade 1 and grade 2 ventral hernias represent defects in fields without extensive contamination. In such scenarios, components separation provides a valuable tool that can aid closure in a relatively tension-free manner. The addition of synthetic mesh to components separation is somewhat more controversial, as the addition of mesh is more costly but has been reported to decrease ventral hernia recurrence.2,3 From the Dartmouth Hitchcock Medical Center. Received for publication April 13, 2012; accepted July 23, 2013. Copyright © 2013 by the American Society of Plastic Surgeons DOI: 10.1097/01.prs.0000436835.96194.79

A scenario where the addition of a new technology designed to improve clinical outcomes comes at an increased cost is ideal for a cost-utility analysis.4,5 The goal of this study was to perform a cost-utility analysis of using synthetic mesh in addition to components separation during ventral hernia reconstruction in surgical fields relatively free of contamination (grades 1 and 2). To our knowledge, there has been no previous cost-utility study analyzing this question.

METHODS Cost-utility analysis is composed of costs, probabilities, and utilities of various health outcomes (health states) that are used to evaluate competing interventions (Appendix).

Disclosure: The authors have no financial interest to declare in relation to the content of this article.

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Plastic and Reconstructive Surgery • January 2014 Perspective There are three major perspectives with regard to cost-utility analysis, each of which represents major players in the health care arena. The hospital/provider perspective attempts to use ­cost-utility to assess which technology or procedure can best benefit the patient in the most efficient and least expensive manner. The provider perspective is interchangeable with the hospital perspective if the provider is a salaried employee of the hospital, thus linking the economic fate of the hospital to the provider. Each perspective is equally important, as it allows each health care player to fiscally survive and, in turn, ensure the viability of our health care system. For purposes of this study, the perspectives of both a hospital/ physician and a third-party payer were adopted. Health States The relevant surgical literature was explored to properly identify the most clinically relevant and common outcomes associated with complex ventral hernia repair using components separation. We specifically looked at studies that used components separation with and without synthetic mesh when repairing complex ventral hernias that belonged to grades 1 and 2 (based on the classification of the Ventral Hernia Working Group). These outcomes were separated by time course with early complications (within 30 days) (i.e., wound infection, wound dehiscence, seroma, and hematoma) and late complications (after 30 days) (i.e., enterocutaneous fistula, small bowel obstruction, abdominal bulging/laxity, and hernia recurrence). Infections (e.g., simple cellulitis) requiring oral antibiotics were excluded because these could be from a reaction to the synthetic mesh itself.6 These complications were defined as distinct “health states” with associated probabilities, costs, and utilities for use in the decision model. Costs The costs for complex ventral hernia repair were based on Medicare national average facility reimbursement Current Procedural Terminology codes for inpatients corresponding to “repair initial/recurrent incisional or ventral hernia reducible” (49560/49565), “muscle, myocutaneous, or fasciocutaneous trunk” (15734), “closure of intestinal cutaneous fistula” (44640), “enterolysis” (44005), “secondary closure of dehiscence” (13160), “incision and drainage of hematoma or seroma” (10140), and “incision and drainage for

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complex postoperative wound infection” (10180). The Diagnosis-Related Group code corresponding to hernia repair without complication (355) was used for a successful outcome, hernia repair with complication (354) was used for outcomes with early complications (within 30 days of admission), and separate Diagnosis-Related Group codes (909 and 336) were used for enterocutaneous fistula and small bowel obstruction (require readmission after 30 days). For the other long-term complications (hernia recurrence and abdominal bulging/ laxity) requiring subsequent hernia repair, the Diagnosis-Related Group code for hernia repair without complication (355) was repeated. All payment data were based on 2012 Medicare Current Procedural Terminology and Diagnosis-Related Group reimbursement national averages.7,8 Costs for each health state involved the cost of a successful operation and its complication. The increased cost associated with synthetic mesh was derived under two scenarios. First, we used the Medicare Current Procedural Terminology reimbursement code corresponding to professional reimbursement for “implantation of mesh for ventral hernia repair” (49568). The medical institution receives no other financial reimbursements for the use of synthetic mesh. The reimbursement was the same ($268.22) regardless of the size of retail mesh used. Second, the retail cost of a 10 × 25-cm synthetic mesh was estimated by averaging retail costs of commonly used synthetic mesh [i.e., polypropylene, Vicryl (Ethicon, Inc., Somerville, N.J.), and BioA (W. L. Gore & Associates, Inc., Flagstaff, Ariz.), and polytetrafluoroethylene] (Table 1). This size was chosen based on the average hernia defect size of patients in the study. The costs of synthetic mesh were added to the hospital cost of a complex ventral hernia repair for all health states involving synthetic mesh. Recovery Assumptions were made regarding the appropriate follow-up for health states based on the current practice of plastic surgeons at our institution. In terms of early complications, costs for wound infection assumed that patients required hospital admission and the administration of intravenous antibiotics and patients would recover within 30 days. Patients suffering wound dehiscence were assumed to undergo surgical closure and recover within 30 days. Large hematomas and seromas are drained under anesthesia by the surgeon in the major operating room within 30 days.

Volume 133, Number 1 • Complex Ventral Hernia Repair Table 1.  Probabilities of Complications Using Components Separation Alone First Author Hadeed Ko Ghazi de Vries Clarke de Vries Ramirez Girotto Shestak Cohen Dragu Total Probability

Total No. of Cases 64 91 22 19 63 43 11 33 22 24 11 403 —

Wound Wound EC Infection Dehiscence Seroma Hematoma Fistula — — 0 3 2 6 0 8 2 0 — 21 0.0886

— — — 1 0 1 0 0 2 2 — 6 0.0279

— — — 4 0 2 0 1 1 1 — 9 0.0419

— — — 1 0 5 0 2 0 0 — 8 0.0372

SBO

— — — — — — 0 0 0 0 0 0 0 0 1 1 0 0 0 0 — — 1 1 0.0047 0.0047

Abdominal Bulge/ vLaxity

Hernia Recurrence

Hernia Grade

— — — 0 0 0 0 0 0 0 — 0 0

10 24 5 10 12 12 0 2 1 1 1 78 0.1935

II II II II–III II III III–IV III III–IV III II

EC, enterocutaneous; SBO, small bowel obstruction.

Costs for long-term complications assumed that the patient did not suffer an early complication and required readmission after 30 days. Patients were assumed to recover from long-term (late) complications within 3 months. Patients suffering hernia recurrence could either undergo surgical revision or elect to live with a persistent hernia. Those undergoing surgical revision would either have a successful result or another hernia recurrence, which was assumed to be successfully revised with subsequent surgery. Modeling a maximum of two hernia recurrences after initial presentation with a ventral hernia was felt to cover all published patient outcomes and encompass the population of patients suffering complex ventral hernias. Probabilities The probabilities associated with clinically relevant health states were obtained for complex ventral hernia repair using components separation with or without synthetic mesh. Probabilities of health states when using components separation alone were derived from a thorough review of the literature using the Cochrane and MEDLINE

electronic databases with key words “components separation” and “ventral hernia,” and limiting findings to human subjects undergoing ventral hernia repair (grades 1 and 2) with components separation and English-language articles. In addition, articles resulting from the search for synthetic mesh were examined, with preference given to studies that examined matched cohorts of patients undergoing components separation with and without synthetic mesh. This search revealed 11 published studies that included 403 ventral hernias in patients who underwent components separation without synthetic mesh. Data were extracted, pooled, and weighted by study size as described above (Table 2). The probabilities for synthetic mesh were derived from a comprehensive review of the literature using the Cochrane and MEDLINE electronic databases with key words “components separation,” “mesh,” and “hernia repair” and limiting findings to human subjects, ventral hernia repairs (grade 1 and 2) using components separation with synthetic mesh, and English-language articles. This search revealed six published studies that included 361 ventral hernias in patients who underwent components separation

Table 2.  Probabilities of Complications Using Components Separation with Synthetic Mesh First Author Ko Ko Dragu Moore Broker Sailes Total Probability

Total No. Wound Wound of Cases Infection Dehiscence Seroma Hematoma EC Fistula SBO 23 26 6 90 9 207 361 —

— — — 9 1 3.726* 13.726 0.0449

— — — 9 0 0 9 0.0305

— — — 3 1 10.35* 14.35 0.0486

— — — 3 0 1.656* 4.656 0.0158

— — — 0 0 2 2 0.0065

— 0 — 0 0 0 0 0

Abdominal Bulge/ Hernia Hernia Laxity Recurrence Grade — — — 0 0 0 0 0

1 3 2 5 0 53 64 0.1773

II II II II II II

EC, enterocutaneous; SBO, small bowel obstruction. *Data reported as percentages.

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Plastic and Reconstructive Surgery • January 2014 with synthetic mesh. Data were extracted from the relevant publications, pooled, and weighted by the size of each study (Table 3). Utilities The utilities used in this study were obtained through a survey of 14 surgeons at our institution including both plastic and reconstructive surgeons and general surgeons. The practice of surveying physicians to acquire utility scores to evaluate patient preference has empirical precedent in the literature.9,10 The survey involved evaluating outcomes associated with complex ventral hernia repair with or without synthetic mesh, and all surgeons were given visual analogue models. The response rate was 79 percent for the utility surveys. These experts were presented with identical scenarios involving each health state and were asked to rank their preferences such that the quality of life for each health state was marked on a “feeling thermometer,” a vertical ladder of 10 cm in height ascending from a score of 0 (death) to 1 (perfect health). The overall utility of each health state was the average of the expert opinion. The utilities were converted to quality-adjusted life-years by multiplying the utility of a specific health state by the duration of that health state and adding that to the remaining life-years multiplied by the utility of a successful operation. The remaining life-years was derived from the assumption that the average patient undergoing ventral

hernia repair is 50 years old and has a life expectancy of 78.3 years.11 An example for the “seroma” health state involves the assumption that a seroma would be expected to improve in 30 days, the average utility for experiencing a “seroma” is 0.71, and the utility of a successful operation without complication is 0.81. The following steps were performed for all health states (Table 4). Duration of health state: 30 days/365 days = 0.082 years Remaining life-years = average life expectancy − average age of patient: 78.3 years – 50 years = 28.3 years Quality-adjusted life-years (utility of health state) × (duration of health state) + (utility of successful procedure) × (remaining life years): (0.71)(0.082) + (0.81)(28.3 – 0.082) = 22.91 quality-adjusted life years Analysis A decision model was created for these data (Fig. 1), with the two main branches being components separation with synthetic mesh and components separation alone. The costs and quality-adjusted life-years for each health state were incorporated into this model along with the

Table 3.  Utilities, Costs, and Quality-Adjusted Life-Years for Complex Ventral Hernia Repair* CS with Synthetic Mesh Health States Successful ­surgery Wound infection Wound dehiscence Seroma Hematoma EC fistula SBO Abdominal ­bulging/ laxity Hernia ­recurrence Secondary hernia ­recurrence Persistent hernia Total

CS Alone

Utility (SD)

Cost ($)

Expected Cost ($)

QALY

Expected QALY

Cost ($)

Expected Cost ($)

QALY

Expected QALY

0.81 (0.11) 0.69 (0.10)

7983.53 10,740.01

5396.87 483.3

22.923 22.9132

15.496 1.0311

7715.31 10,471.79

4644.62 931.99

22.923 22.91316

13.7997 2.0393

0.54 (0.16) 0.71 (0.09) 0.71 (0.09) 0.46 (0.12) 0.56 (0.13)

11,372.09 10,678.74 10,678.74 15,429.64 19,894.79

341.16 523.26 170.86 108.01 0

22.9009 22.9148 22.9148 22.8355 22.8605

0.687 1.1228 0.3666 0.1598 0

11,103.87 10,410.52 10,410.52 15,161.42 19,626.57

310.91 437.24 385.19 75.81 98.13

22.90086 22.9148 22.9148 22.8355 22.8605

0.6412 0.9624 0.8478 0.1142 0.1143

0.72 (0.09)

14,620.88

0

22.9005

0

14,352.66

0

22.9005

0

0.60 (0.10)

14,620.88

1535.19

22.8705

2.4014

14,352.66

1650.56

22.8705

2.6301

0.60 (0.10) 0.60 (0.10) —

21,258.23 7983.53 —

191.32 502.96 9245.88

22.818 16.98 —

0.2054 1.0697 22.5382

20,990.01 7715.31 —

188.91 532.36 9245.08

22.818 16.98 —

0.2054 1.1716 22.5025

CS, components separation; QALY, quality-adjusted life-years; EC, enterocutaneous; SBO, small bowel obstruction. *Baseline cost is derived from Medicare Current Procedural Terminology reimbursement; retail cost is derived from using a 10 × 25-cm synthetic mesh; utility surveys were given to 11 plastic and reconstructive surgeons and general surgeons from our institution.

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Volume 133, Number 1 • Complex Ventral Hernia Repair Table 4.  Cost-Utility Analysis: Baseline and Sensitivity Analyses Comparing Complex Ventral Hernia Repair with or without Synthetic Mesh Cost Difference ($) Baseline analysis Sensitivity analysis, using Medicare reimbursement ($268.22) for mesh  Recurrence rate (CS alone) = 18%  Early complications (CS alone) = 0%  Late complications (CS alone) = 0% Sensitivity analysis, using retail cost ($750) for 10 × 25-cm synthetic mesh  Baseline analysis  Recurrence rate (CS alone) = 19% Sensitivity analysis of cost  Cost of mesh = $2049.97

QALY Gained

Cost ($) per QALY Gained (ICUR)

0.8

0.0357

22.41

63.03 552.92 90.92

0.0065 0.0336 0.035

9730.19 16,466.10 2596.13

541.69 557.97

0.0357 0.0281

15,173.39 19,886.75

0.0357

50,000

1785

QALY, quality-adjusted life-year; ICUR, incremental cost-utility ratio; CS, components separation.

probabilities of all health states relevant to complex ventral hernia repair. Expected values for costs and outcomes were derived by multiplying the probability of a health state by its cost and quality-adjusted life-years. These expected values were summed for both arms using the rollback method to derive the overall expected cost and utility (quality-adjusted life-years) for a complex ventral hernia repair with and without synthetic mesh (Table 3). The incremental cost-utility ratio was then calculated using the following formula:

Incremental cost – utility ratio = (Expected

cost of Components Separation with synthetic mesh – Expected cost of Components Separation without synthetic mesh)/ (Expected QALY of Components Separation with synthetic mesh – Expected QALY of Components Separation without synthetic mesh) A novel intervention is “cost-effective” if the incremental cost-utility ratio is greater than 0 and less than the “willingness to pay,” the maximum amount of money society is willing to spend on an item for an added year of perfect health, for which we used the empirically accepted and previously published threshold of $50,000 per qualityadjusted life-year as described below: Cost effective: incremental cost-utility ratio > 0 < willingness to pay, willingness to pay = $50,000/quality-adjusted life-year. One-way sensitivity analysis was performed to determine whether the baseline decision analysis was robust by varying the rate of early and late complications and hernia recurrence without synthetic mesh from 0 to 1 (at 0.01 intervals) while keeping the complication rate when using synthetic mesh fixed and observing how this affected the incremental

cost-utility ratio. Further sensitivity analyses were performed to determine how the price of mesh and the variation in utility estimates altered the costeffectiveness of using synthetic mesh. All of the above mathematical manipulations were performed using TreeAge Pro 2012 (Williamstown, Mass.). Our study was conducted in accordance with the principles outlined in the Declaration of Helsinki.

RESULTS In ventral hernia repair using components separation, using synthetic mesh resulted in a lower rate of hernia recurrence, short-term complications, and long-term complications (Fig. 2). The cost-utility analysis revealed a cost increase of $541.69 when using average retail prices ($3/cm2) for synthetic mesh with a gain in quality-adjusted life-years of 0.0357, yielding an incremental cost-utility ratio of $15,173.39 per quality-adjusted life-year (Table 4). The one-way sensitivity analysis revealed that using synthetic mesh with components separation was cost-effective when the hernia recurrence using components separation alone was at least 19 percent (using average retail cost of mesh) (Fig. 3). Varying the utility estimates for each health state (across its standard deviation) did not change our conclusion. The maximum cost of synthetic mesh for it to be cost-effective (incremental cost-utility ratio = $50,000 per quality-adjusted ­life-year) is $2049.97 (regardless of size) (Table 4).

DISCUSSION Grade 1 and grade 2 ventral hernias may, by definition, be free of extensive contamination but are far from simple to treat. There is an abundance of literature describing the components separation

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Volume 133, Number 1 • Complex Ventral Hernia Repair method to assist in closure.2,12–27 There is a moderate amount of literature describing components separation with synthetic mesh to assist in closure.2,3,19,27–30 However, there is a scarcity of review literature that examines the cost of varying surgical technique,31 and in today’s health care system and economy, the justification for expensive adjunctive technology is important. Although components separation and synthetic mesh repair have both been separately shown to improve outcomes with regard to recurrence for complex ventral hernias,2,17,32–37 literature exists describing that when used together, a decreased rate of hernia recurrence is obtained but with a varying complication rate.13,14,18 This literature assumes that the ventral hernias can be approximated with components separation with mesh acting as an augmentation to the repair. Our results (Fig. 2) confirm decreased recurrence, short-term complication, and longterm complication rates when using synthetic mesh with components separation. Recurrence not only has a low utility, but patients also tend to suffer over a longer period (especially if they elect not to undergo surgical correction), thus decreasing the quality of life compared with other complications and increasing the relative importance of the recurrence rate in determining cost-effectiveness. Sensitivity Analysis When the complication rate (early and late) is varied when using components separation alone, synthetic mesh is cost-effective and should be adopted in any circumstance. Our univariate sensitivity analysis revealed that synthetic mesh should be adopted when the hernia recurrence rate without synthetic mesh (components separation alone) is 19 percent or higher. Published studies on complex ventral hernia repair using components separation alone report an average recurrence rate of 19.4 percent, which shows that our results are robust. Sensitivity analysis was performed to calculate the maximum price of biological mesh such that the incremental cost-utility ratio was at the upper limit of costeffectiveness ($50,000 per ­ quality-adjusted life-year) and was found to be $2049.97. This, in simple terms, provides the upper limit of cost for synthetic mesh that Fig. 1. Decision model used in our analysis for complex ventral hernia repair using components separation with or without synthetic mesh. Probabilities are displayed below terminal branches and cost and quality-adjusted ­life-years are displayed to the right of the terminal branches. Expected values were calculated for both cost and qualityadjusted life-years based on the probability of each health state and were summed across both arms for comparison.

makes its use cost-effective in ventral hernia repair with components separation. We made the assumption that society’s willingness to pay is $50,000 per year of perfect health gained (quality-adjusted life-years) to determine the upper limit of c­ost-effectiveness. We have now determined an individual’s maximum willingness to pay for synthetic mesh ($2049.97). This price is absolute and does not depend on the size of mesh used. Having this unique price point will allow hospitals and third-party payers to better negotiate with industry in providing cost-effective health interventions. The utility of each health state was based on an average of expert opinion and is subject to variability. To test the strength of our decision model, we varied utilities across their standard deviation for each health state (except successful surgery), and this did not change our conclusion, further proving that our findings are robust. Limitations One limitation inherent in cost-effectiveness analysis is its reliance on the reliability of the literature in the literature review.38–41 Clearly, inherent flaws are present when pooling data from a literature review, because patients and their clinical illness between studies can be different, as can operative results (abilities). We tried to address patient and clinical scenario variability by limiting our surgical population to grade 1 and grade 2 ventral hernias. Until further prospective, randomized, unbiased studies are performed, the decision analysis performed here provides a reasonable cost-effectiveness analysis that can aid in decision making when it comes to using or not using synthetic mesh with components separation for complex ventral hernia defects. A second limitation involves the grouping of synthetic mesh. This group has a variety of mesh ranging from permanent (polypropylene, polytetrafluoroethylene) to absorbable (BioA, Vicryl). Although differences exist, scarce evidence-based literature, if any, exists effectively and objectively comparing one synthetic mesh product against another. A synthetic, permanent mesh under a components separation closure allows improved distribution of forces across the repair line. A synthetic, temporary mesh potentially shields the abdominal closure from early pressure, preventing early suture line disruption. Empirically, past literature reviews about synthetic meshes have grouped these devices in a similar fashion as represented here.24 A third limitation is that both the fixation methods using components separation and the placement of mesh vary in the literature. Mesh placement varies depending on which plane the

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Fig. 2. Complication rates for specific health states with and without synthetic mesh. There is a decrease in hernia recurrence along with a decrease in wound infection, hematoma, and small bowel obstruction when using synthetic mesh in conjunction with components separation. All other complications are increased when using synthetic mesh with components separation for complex ventral hernia repair. CS, components separation; EC, enterocutaneous fistula; SBO, small bowel obstruction; Abd, Abdomen.

Fig. 3. One-way sensitivity analysis showing the incremental cost-utility ratio (ICUR) as the hernia recurrence rate in reconstructions without synthetic mesh is varied from 0.18 to 0.31 at 0.01 intervals. Using a maximum willingness to pay of $50,000 per quality-adjusted life year (QALY), use of synthetic mesh is cost-effective and should be adopted when the hernia recurrence rate without biological mesh is 18 percent or higher.

mesh is placed in (e.g., sublay versus onlay). The vast majority of patients included in our literature review had underlay mesh placements. Reliance on the literature review assumes that fixation styles

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are similar. Although this is definitely a limitation, past review articles have grouped components separation operations with varying mesh placement while acknowledging this weakness.12,13,15,17,42,43

Volume 133, Number 1 • Complex Ventral Hernia Repair The advantage of costing the synthetic mesh by using the average retail price provides the cost viewpoint of the provider/hospital. This is beneficial to those interested in influencing health care policy, as it provides the cost utility of synthetic mesh with a variety of price scenarios. In this case, third-party payers have theoretically more gain as they pay less for synthetic mesh, leading to a lower incremental cost-utility ratio. The hospital/physician, who pays a higher (retail) cost, has less gain based on the higher incremental cost-utility ratio but nevertheless would still incorporate a practice that is cost-effective if it sponsored the use of synthetic mesh with components separation. Potential future bargaining between third-party payers and the hospital would likely occur based on the two incremental cost-utility ratio results, leading to potential decreases in retail cost or improved third-party payments to further incentivize the use of synthetic mesh.

CONCLUSIONS The use of synthetic mesh in conjunction with components separation in the surgical treatment of complex ventral hernias is cost-effective from a hospital perspective. The threshold cost of synthetic mesh such that it is still cost-effective is $2049.97. Abhishek Chatterjee, M.D., M.B.A. Dartmouth Hitchcock Medical Center One Medical Center Drive Lebanon, N.H. 03756 [email protected]

Appendix. Checklist for a Cost-Utility Analysis Determine financial perspective Conduct literature review to obtain probabilities of clinically relevant complications Determine cost for successful procedure and for each complication Obtain utility estimates for each health state and convert into quality-adjusted life-years Run baseline decision tree analysis and sensitivity analyses

Hospital/provider 11 studies with 403 hernias repaired by components separation with synthetic mesh; six studies with 361 hernias repaired by components separation alone Done using average retail costs ($3/cm2) for synthetic mesh Obtained survey results from 11 expert plastic surgeons using visual analogue scale Done using TreeAge Pro software

ACKNOWLEDGMENTS

The authors thank the plastic and reconstructive surgeons and general surgeons who completed utility surveys for complex abdominal wall reconstruction.

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Complex ventral hernia repair using components separation with or without synthetic mesh: a cost-utility analysis.

Components separation provides a useful option among closure choices for complex ventral hernia repairs. The use of synthetic mesh in addition to perf...
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