Management of Reducible Ventral Hernias Clinical Outcomes and Cost-effectiveness of Repair at Diagnosis Versus Watchful Waiting
Objective: To compare long-term clinical and economic outcomes associated with 3 management strategies for reducible ventral hernia: repair at diagnosis (open or laparoscopic) and watchful waiting. Background: There is variability in ventral hernia management. Recent data suggest watchful waiting is safe; however, long-term clinical and economic outcomes for different management strategies remain unknown. Methods: We built a state-transition microsimulation model to forecast outcomes for individuals with reducible ventral hernia, simulating a cohort of 1 million individuals for each strategy. We derived cohort characteristics (mean age 58 years, 63% female), hospital costs, and perioperative mortality from the Nationwide Inpatient Sample (2003–2011), and additional probabilities, costs, and utilities from the literature. Outcomes included prevalence of any repair, emergent repair, and recurrence; lifetime costs; quality-adjusted life years (QALYs); and incremental cost-effectiveness ratios. We performed stochastic and probabilistic sensitivity analyses to identify parameter thresholds that affect optimal management, using a willingness-to-pay threshold of $50,000/QALY. Results: With watchful waiting, 39% ultimately required repair (14% emergent) and 24% recurred. Seventy per cent recurred with repair at diagnosis. Laparoscopic repair at diagnosis was cost-effective compared with open repair at diagnosis (incremental cost-effectiveness ratio $27,700/QALY). The choice of operative strategy (open vs laparoscopic) was sensitive to cost and postoperative quality of life. When perioperative mortality exceeded 5.2% or yearly recurrence exceeded 19.2%, watchful waiting became preferred. Conclusions: Ventral hernia repair at diagnosis is very cost-effective. The choice between open and laparoscopic repair depends on surgical costs and postoperative quality of life. In patients with high risk of perioperative mortality or recurrence, watchful waiting is preferred.
|Keywords||cost-effectiveness, timing of repair, ventral hernia repair, watchful waiting|
|Persistent URL||dx.doi.org/10.1097/sla.0000000000002507, hdl.handle.net/1765/116818|
|Journal||Annals of Surgery|
Wolf, L.L., Ejiofor, J.I., Wang, Y, Hunink, M.G.M, Losina, E., Haider, A.H., & Smink, D.S. (2019). Management of Reducible Ventral Hernias Clinical Outcomes and Cost-effectiveness of Repair at Diagnosis Versus Watchful Waiting. Annals of Surgery, 269(2), 358–366. doi:10.1097/sla.0000000000002507