Surgical Outcome Research Cost-utility analysis of repair of reducible ventral hernia Anne M. Stey, MD, MSc, Matthew Danzig, BS, Sylvia Qiu, MS, Sujing Yin, BS, and Celia M. Divino, MD, FACS, New York, NY
Background. Patient-reported outcomes are an important metric of the effectiveness of care. Ventral hernia repair is a procedure where the effectiveness can best be quantified using health-related quality of life. This study sought to quantify quality of life with respect to costs of ventral hernia repair. Methods. This observational study of patients diagnosed with a ventral hernia between 2004–2011 in a single center identified 3 groups of patients: (1) Patients diagnosed with ventral hernias managed with observation, (2) patients diagnosed with ventral hernias who underwent operative repair only when incarceration occurred, and (3) patients with ventral hernias who underwent herniorraphy before incarceration. The Short Form (SF)12v2 was administered to measure quality of life. The direct costs of care were obtained from Financial Services. Patients were surveyed about direct, non-health costs to obtain a societal perspective. A cost-utility analysis was performed. Results. The SF-12v2 was administered to 243 patients; 80 were observed, 69 underwent repair of an incarcerated hernia, and 94 underwent repair of a nonincarcerated hernia. The response rates were similar among groups---59%, 55%, and 52%. Quality of life as measured by utility score was less at 0.68 (95% CI, 0.65–0.71) in patients who did not undergo repair compared with those after repair of a nonincarcerated hernia, 0.76 (95% CI, 0.73–0.79; P < .001). The elective repair of a nonincarcerated hernia was cost-effective with an incremental cost effectiveness ratio of $8,646 per quality-adjusted lifeyear. Conclusion. The prompt elective repair of ventral hernias is cost-effective. (Surgery 2014;155:1081-9.) From the Department of Surgery, Icahn School of Medicine at Mount Sinai Hospital, New York, NY
VENTRAL HERNIAS can compromise quality of life. Patients may suffer from obstruction and pain in up to 69% of cases,1,2 as well as experience limitations in their daily life owing to loss of important functions of the abdominal wall, such as protection of the viscera, stabilization of the core, spine support, and generation of Valsalva pressures. Nonetheless, many patients undergoing elective ventral hernia repair may be asymptomatic.3 In these cases, fear of incarceration and strangulation is cited as a reason for seeking operative repair1 although incidence is 3–10%.2,4,5 The effectiveness of elective Presented at the Academic Surgical Congress, February 2012, San Diego, California. Accepted for publication March 26, 2014. Reprint requests: Celia M. Divino, MD, FACS, 1 Gustave Levy Place, Box 1259, New York, NY 10029. E-mail: celia.divino@ mountsinai.org. 0039-6060/$ - see front matter Ó 2014 Mosby, Inc. All rights reserved. http://dx.doi.org/10.1016/j.surg.2014.03.041
ventral hernia repair across the full range of patients with these varied symptoms is unclear. The effectiveness of operative treatment is being measured increasingly using patient-reported outcomes. These outcomes may be particularly important in common, relatively low mortality operations such as hernia repairs.6 Several studies note improvement in quality of life after ventral hernia repair.7,8 Observing patients may not be a benign act, because not only is quality of life poorer for these patients, but the progressive loss of peritoneal domain may make delayed repair more difficult. Should patients be observed until the occurrence of incarceration or strangulation, the technical approaches may be very different. The technical steps of the operation may be fairly different if incarcerated viscera (any tissue within visceral peritoneum, including but not limited to omentum, bowel, and liver) are in the defect and require adhesiolysis, reduction, and possibly resection, depending on the viability of the tissues. Extra-manipulation of the viscera may increase SURGERY 1081
1082 Stey et al
the chances of intraoperative and postoperative adverse events if not done with delicacy and efficiency.9 For these reasons, incarcerated hernias may have more postoperative complications.10-12 The result may be a lesser quality of life for patients who underwent repair in the setting of incarceration. If so, operating while the hernia is still reducible, even if asymptomatic, is imperative. No study has measured quality of life in incarcerated patients exclusively. This study sought to measure the quality of life in patients being observed, patients who underwent nonincarcerated hernia repair, and patients who underwent incarcerated hernia repair. Not only is patient quality of life important to measure, their quality of life must be put into the context of the costs of care. Ventral hernia recurrence remains a relatively common occurrence, and quality of life may decrease as a result.13 If there is no sustained improvement in the quality of life, the procedure may not merit the cost of operative repair. To determine accurately the value of the procedure, the quality of life implications of common long-term complications, such as recurrence, must also be considered in the context of cost. The overarching aim of this study was to determine whether elective repair of a nonincarcerated hernia was cost-effective from a societal perspective compared with watchful waiting with repair only at the time of incarceration. The hypothesis was that ventral hernia repair would be cost-effective owing to the largest improvement in quality of life for patients who undergo prompt repair. METHODS Data source. This observational, retrospective study of 442 consecutive patients diagnosed with a ventral hernia between 2004 and 2011 at The Mount Sinai Medical Center identified patients using the Data Warehouse System with a diagnosis of ‘‘ventral hernia’’ anywhere in the electronic medical record. The Data Warehouse system integrates disparate electronic medical record systems and acts as a central repository for all electronic data. Performing a search of the Data Warehouse system searches for the words ventral hernia within all the different electronic medical record platforms operating within the various clinical settings, including but not limited to EPIC, TDS, Centricity PACS, and anesthesia data systems. Patients were excluded if they underwent a concurrent primary operation, were
Background. Patient-reported outcomes are an important metric of the effectiveness of care. Ventral hernia repair is a procedure where the effectiveness can best be quantified using health-related quality of life. This study sought to quantify quality of life with respect to costs of ventral hernia repair. Methods. This observational study of patients diagnosed with a ventral hernia between 2004–2011 in a single center identified 3 groups of patients: (1) Patients diagnosed with ventral hernias managed with observation, (2) patients diagnosed with ventral hernias who underwent operative repair only when incarceration occurred, and (3) patients with ventral hernias who underwent herniorraphy before incarceration. The Short Form (SF)12v2 was administered to measure quality of life. The direct costs of care were obtained from Financial Services. Patients were surveyed about direct, non-health costs to obtain a societal perspective. A cost-utility analysis was performed. Results. The SF-12v2 was administered to 243 patients; 80 were observed, 69 underwent repair of an incarcerated hernia, and 94 underwent repair of a nonincarcerated hernia. The response rates were similar among groups---59%, 55%, and 52%. Quality of life as measured by utility score was less at 0.68 (95% CI, 0.65–0.71) in patients who did not undergo repair compared with those after repair of a nonincarcerated hernia, 0.76 (95% CI, 0.73–0.79; P < .001). The elective repair of a nonincarcerated hernia was cost-effective with an incremental cost effectiveness ratio of $8,646 per quality-adjusted lifeyear. Conclusion. The prompt elective repair of ventral hernias is cost-effective. (Surgery 2014;155:1081-9.) From the Department of Surgery, Icahn School of Medicine at Mount Sinai Hospital, New York, NY
VENTRAL HERNIAS can compromise quality of life. Patients may suffer from obstruction and pain in up to 69% of cases,1,2 as well as experience limitations in their daily life owing to loss of important functions of the abdominal wall, such as protection of the viscera, stabilization of the core, spine support, and generation of Valsalva pressures. Nonetheless, many patients undergoing elective ventral hernia repair may be asymptomatic.3 In these cases, fear of incarceration and strangulation is cited as a reason for seeking operative repair1 although incidence is 3–10%.2,4,5 The effectiveness of elective Presented at the Academic Surgical Congress, February 2012, San Diego, California. Accepted for publication March 26, 2014. Reprint requests: Celia M. Divino, MD, FACS, 1 Gustave Levy Place, Box 1259, New York, NY 10029. E-mail: celia.divino@ mountsinai.org. 0039-6060/$ - see front matter Ó 2014 Mosby, Inc. All rights reserved. http://dx.doi.org/10.1016/j.surg.2014.03.041
ventral hernia repair across the full range of patients with these varied symptoms is unclear. The effectiveness of operative treatment is being measured increasingly using patient-reported outcomes. These outcomes may be particularly important in common, relatively low mortality operations such as hernia repairs.6 Several studies note improvement in quality of life after ventral hernia repair.7,8 Observing patients may not be a benign act, because not only is quality of life poorer for these patients, but the progressive loss of peritoneal domain may make delayed repair more difficult. Should patients be observed until the occurrence of incarceration or strangulation, the technical approaches may be very different. The technical steps of the operation may be fairly different if incarcerated viscera (any tissue within visceral peritoneum, including but not limited to omentum, bowel, and liver) are in the defect and require adhesiolysis, reduction, and possibly resection, depending on the viability of the tissues. Extra-manipulation of the viscera may increase SURGERY 1081
1082 Stey et al
the chances of intraoperative and postoperative adverse events if not done with delicacy and efficiency.9 For these reasons, incarcerated hernias may have more postoperative complications.10-12 The result may be a lesser quality of life for patients who underwent repair in the setting of incarceration. If so, operating while the hernia is still reducible, even if asymptomatic, is imperative. No study has measured quality of life in incarcerated patients exclusively. This study sought to measure the quality of life in patients being observed, patients who underwent nonincarcerated hernia repair, and patients who underwent incarcerated hernia repair. Not only is patient quality of life important to measure, their quality of life must be put into the context of the costs of care. Ventral hernia recurrence remains a relatively common occurrence, and quality of life may decrease as a result.13 If there is no sustained improvement in the quality of life, the procedure may not merit the cost of operative repair. To determine accurately the value of the procedure, the quality of life implications of common long-term complications, such as recurrence, must also be considered in the context of cost. The overarching aim of this study was to determine whether elective repair of a nonincarcerated hernia was cost-effective from a societal perspective compared with watchful waiting with repair only at the time of incarceration. The hypothesis was that ventral hernia repair would be cost-effective owing to the largest improvement in quality of life for patients who undergo prompt repair. METHODS Data source. This observational, retrospective study of 442 consecutive patients diagnosed with a ventral hernia between 2004 and 2011 at The Mount Sinai Medical Center identified patients using the Data Warehouse System with a diagnosis of ‘‘ventral hernia’’ anywhere in the electronic medical record. The Data Warehouse system integrates disparate electronic medical record systems and acts as a central repository for all electronic data. Performing a search of the Data Warehouse system searches for the words ventral hernia within all the different electronic medical record platforms operating within the various clinical settings, including but not limited to EPIC, TDS, Centricity PACS, and anesthesia data systems. Patients were excluded if they underwent a concurrent primary operation, were
