A. N. Ehsan1, H. Thobani2, M. M. Shah3, S. M. Khan2, S. B. Chauhan3, S. Khan3 1Brigham and Women’s Hospital, Boston, MA, USA 2Aga Khan University Medical College, Karachi, Sindh, Pakistan 3Aga Khan University Medical College, Centre Of Global Surgical Care, Karachi, Sindh, Pakistan
Introduction: Current guidelines for the management of minimally symptomatic inguinal hernias recommend elective surgical repair or watchful waiting (with subsequent emergency surgical intervention in the case of disease progression). Both options have merits – the excellent outcomes of elective surgery favors the former, whereas the low risk of incarceration or strangulation warrants the latter. Therefore, cost often becomes a deciding factor when choosing between the two, especially in resource-limited settings such as Pakistan, where, due to inadequate health financing mechanisms, most medical care costs are borne by patients themselves. We conducted a cost-effectiveness analysis to compare elective versus emergency hernia repair in a low-and-middle-income country (LMIC) setting.
Methods: We conducted a cross-sectional study at a tertiary care hospital in Karachi, Pakistan. All patients above 18 years of age receiving surgery for an inguinal hernia from 2019-2021 were included. Patients were stratified based on whether they underwent elective or emergency surgery. For the cost analysis, aggregate and itemized out-of-pocket medical costs were collected, and a median cost per item was calculated and adjusted for a 2021 base price in US dollars (USD). Effectiveness was measured using disability-adjusted life years (DALYs) averted with Institute for Health Metrics and Evaluation disability weights (DW). Relative cost-effectiveness was reported as an incremental cost-effectiveness ratio (ICER).
Results: A total of 388 patients were included in this study. Elective procedures were carried out on 360 patients, while 28 patients required emergency surgery. The median age at operation was 61 in the elective procedures group and 52 years for the emergency surgery group. The median cost per patient for an elective repair was USD 879.38 and for emergency repair was USD 1881.28. On average, elective surgery averted 49.87 DALYs, whereas emergency procedures averted 207.87 DALYs. The ICER was 6.34 USD per DALY averted when taking elective repair as the standard of care, which fell in the north-eastern quadrant of the ICER plane. This demonstrated that emergency repairs are more costly but may also result in larger health gains.
Conclusion: Emergency surgery for inguinal hernia repair, while more costly, also results in more health gain. As the primary payment model in Pakistan (and of this study) is out-of-pocket, these findings reflect the direct financial burden on the patients themselves. Existing studies in LMIC settings have reported similar findings, indicating that resource-limited settings may inform policy based on the urgency of surgery from a patient economic perspective. Further research should focus on replicating these findings in similar settings, and for other essential surgical procedures outlined by the Disease Control Priorities initiative.