J. P. Fischer1, M. N. Basta1, N. Krishnan2, J. D. Wink1, S. J. Kovach1 1University Of Pennsylvania,Division Of Plastic Surgery,Philadelphia, PA, USA 2Georgetown University Medical Center,Plastic Surgery,Washington, DC, USA
Introduction
Although hernia repair with mesh can be successful, prophylactic mesh augmentation (PMA) represents a potentially useful preventative technique to mitigate incisional hernia (IH) risk select high-risk patients. The efficacy, cost-benefit, and societal value of such an intervention is not clear. The aim of this study is to determine the cost-utility of using prophylactic mesh to augment midline fascial incisions.
Methods
A systematic review was performed identifying articles containing comparative outcomes for PMA and suture closure of high-risk laparotomies. A web-based visual analog scale survey was administered to 300 nationally-representative community members to determine quality-adjusted life-years (QALYs) for several health states related to hernia repair (GfK Research). A decision tree model was employed to evaluate the cost-utility of using PMA relative to primary suture closure after elective laparotomy. Inputs included cost (DRG, CPT, and retail costs for mesh), quality of life, and health-outcome probability estimates. The cost effectiveness threshold was set at $50,000/year-of-life gained.The authors adopted the societal perspective for cost and utility estimates. The costs in this study included direct hospital costs and indirect costs to society, and utilities were obtained through a survey of 300 English-speaking members of the general public evaluating 14 health state scenarios relating to ventral hernia.
Results
Primary suture closure without mesh demonstrated an expected average cost of $17,182 (average QALY of 21.17) compared to $15,450 (expected QALY was 21.21) for PMA. Primary suture closure was associated with an ICER of -$42,444/QALY compared to prophylactic mesh, such that PMA was more effective and less costly. Monte-Carlo sensitivity analysis was performed demonstrating more simulations resulting in ICERs for primary suture closure above the willingness-to-pay threshold of $50,000/QALY supporting the finding that prophylactic mesh is superior in terms of cost-utility. Additionally, base rate analysis with an absolute reduction in hernia recurrence rate of 15% for prophylactic mesh demonstrated that mesh could cost a maximum of $3,700 and still be cost-effective.
Conclusions
Cost-utility analysis of suture repair compared to PMA of abdominal fascia incisions demonstrates PMA was more effective, less costly, and overall more cost-effective than primary suture closure. Sensitivity analysis demonstrates that PMA dominates at multiple levels of willingness-to-pay, and is a potentially valuable, cost-effective, low risk intervention to mitigate risk of IH.
