The economic burden of incisional ventral hernia repair: a … · hernias can reflect the...
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ORIGINAL ARTICLE
The economic burden of incisional ventral hernia repair:a multicentric cost analysis
J-F Gillion1 • D. Sanders2 • M. Miserez3 • F. Muysoms4
Received: 27 September 2015 / Accepted: 17 February 2016 / Published online: 1 March 2016
� Springer-Verlag France 2016
Abstract
Purpose A systematic review of literature led us to take
note that little was known about the costs of incisional
ventral hernia repair (IVHR).
Methods Therefore we wanted to assess the actual costs
of IVHR. The total costs are the sum of direct (hospital
costs) and indirect (sick leave) costs. The direct costs were
retrieved from a multi-centric cost analysis done among a
large panel of 51 French public hospitals, involving 3239
IVHR. One hundred and thirty-two unitary expenditure
items were thoroughly evaluated by the accountants of a
specialized public agency (ATIH) dedicated to investigate
the costs of the French Health Care system. The indirect
costs (costs of the post-operative inability to work and loss
of profit due to the disruption in the ongoing work) were
estimated from the data the Hernia Club registry, involving
790 patients, and over a large panel of different Collective
Agreements.
Results The mean total cost for an IVHR in France in
2011 was estimated to be 6451€, ranging from 4731€ for
unemployed patients to 10,107€ for employed patients
whose indirect costs (5376€) were slightly higher than the
direct costs.
Conclusion Reducing the incidence of incisional hernia
after abdominal surgery with 5 % for instance by imple-
mentation of the European Hernia Society Guidelines on
closure of abdominal wall incisions, or maybe even by use
of prophylactic mesh augmentation in high risk patients
could result in a national cost savings of 4 million Euros.
Keywords Incisional hernia � Prevention � Cost analysis �Health economics � Mesh augmentation
Introduction
Incisional hernias are a frequent complication of abdominal
surgery and some patient variables including obesity,
postoperative surgical site infections and the presence of
abdominal aortic aneurysm have been identified as risk
factors [1–3]. The surgical technique and material to close
abdominal wall incisions are also of utmost importance to
avoid a high frequency of incisional hernias [4, 5]. The
European Hernia Society has recently developed and
published guidelines on the closure of abdominal wall
incisions [6]. As part of this initiative, the Guidelines
Development Group ‘‘The Bonham Group’’ has tried to
determine the economic burden related to the treatment of
an incisional hernia according to previously published
recommendations [7]. Apart from the known negative
impact of an incisional hernia on the patients’ quality of
life and body image, patients with an incisional hernia are
at risk of potential serious complications [8]. The repair of
incisional hernia has direct costs and indirect costs. Esti-
mation of the costs related to the treatment of incisional
hernias can reflect the socio-economic gain to be made by
The data of the present study were presented by J-F Gillion during the
36th Annual Congress of the European Hernia Society in Edinburgh
on 31 May 2014.
& J-F Gillion
1 Unite de Chirurgie Viscerale et Digestive, Hopital Prive
d’Antony, Antony, France
2 Department of Surgery, Derriford Hospital, Plymouth, UK
3 Department of Abdominal Surgery, University Hospitals,
KU Leuven, Leuven, Belgium
4 Department of Abdominal Surgery, AZ Maria Middelares,
Ghent, Belgium
123
Hernia (2016) 20:819–830
DOI 10.1007/s10029-016-1480-z
optimizing abdominal wall closure technique and reduction
of the incidence of incisional ventral hernia.
The magnitude on a national level of the costs related to
incisional hernias has been reported for Sweden, where
about 2000 incisional hernias are repaired annually with a
direct cost approximately 170 million Swedish Krona
(SEK) (±18 million Euro). The direct and indirect costs for
an incisional hernia have been calculated to be 86,257 SEK
(±9112€) [9]. In a nationwide study for the United State
(US) an estimated 348,000 ventral hernia repairs were
performed in 2006 with a direct cost for inpatient proce-
dures of 15,899 US dollar (±13,000€) and for outpatient
procedures 3873 US dollar (±3168€) [10]. This amounts to
a total cost of ventral hernia repair for the US in 2006 of
3.2 billion US dollar (±2.6 billion Euro).
The objective of this study was to perform a review of
the literature on the costs related to incisional hernia repair
and to make an estimate of the direct and indirect costs for
incisional hernia repair in France using nationwide data.
Materials and methods
A systematic review of the literature was performed on 25
February 2014 in Pubmed, Medline and EmBase, limited to
Human data with the search terms: ‘‘Incisional hernia OR
ventral hernia AND health planning/economics/cost and
cost analysis/vital statistics/demography/population char-
acteristics/quality adjusted life years/health burden’’. The
Prisma flow diagram of the records found is shown in
Fig. 1. The results [9–16] are displayed in Table 1.
The cost of an incisional hernia repair is the sum of
direct costs and indirect costs [10]. The direct costs com-
prise all consumption of resources resulting from the
treatment. The indirect costs are those related to the out-
patient care during the sick leave, but mainly related to the
inability to work, such as the costs of a substitute, the loss
of productivity, and the costs of the daily allowance.
Direct costs
Analysis of the ATIH data
In our study the direct costs were estimated from a cost
analysis [17] performed in 2011 among 51 public French
hospitals by the Agence Technique de l’ Information sur l’
Hospitalisation (ATIH). The ATIH (www.atih.sante.fr) is a
public agency dedicated to investigate the costs of the
French Health Care system, especially the intra-hospital
costs of various diseases, classified in more than 3000
GHM (Groupes Homogenes de Malades = Homogeneous
groups of patients), the French version of the DRG (Di-
agnosis-Related Groups). The actual costs, observed in
such cost analysis serve as a basis to determine the amount
of money to be reimbursed to the hospitals for each GHM.
The reimbursement of every GHM is not calculated for
every patient, it is a package, annually updated. It has to be
noted that the reimbursed prices may be different from the
actual costs, especially if the National Health Policy targets
to promote certain healthcare priorities and therefore
adjusts the tariff to make the procedure more attractive to
healthcare providers.
The ATIH data are actual observed costs, written in the
general ledger. Among these ATIH data, we extracted
those concerning Incisional Ventral Hernia Repair in
adults, gathered in five GHM (Table 2). One of them is
dedicated to day-care surgery (06C24J), the four others
concern the inpatients, classified into four levels of severity
(06C241, 06C242, 06C243, 06C244).
Patients are grouped into four levels to determine the
complexity of their care and hence the costs involved.
Levels 1–4 are calculated using a National Health Care
System (National Security Fund) software named ‘group-
eur’, taking into account the severity of the co-morbidities,
the associated intra-hospital events (such as pulmonary
embolism, cardiac failure), the length of stay out of the
target. Not many surgical items are taken into account,
such as: complications related to a previous mesh, bowel
necrosis, or a bacteriologically proven deep infection. For
instance, this financial classification does not take into
account whether the procedure is done laparoscopically or
through an open approach, even though it probably carries
some financial implications. The list of the relevant items is
annually updated. Clinical conditions, which do not have
any impact on finance, are removed from the list at the
annual review.
In the ATIH multi-centric study, every observed unitary
piece of expenditure was detailed by specialized accoun-
tants, classified into 132 sub-groups of expenditure, and 6
chapters (medical expenses, technical-medical expenses,
management, direct charges, structural expenses) registered
and averaged for each GHM (Table 3).
Calculations based on the ATIH data
We wanted to calculate the average direct cost regardless
of the level of severity:
The average cost for each GHM was then weighted
according to the prevalence of the corresponding GHM
(Table 3) resulting in a ‘‘weighted average of the direct
cost for an average incisional hernia repair’’.
Indirect costs
The sick leave and the inability to work (including the
hospital stay) were estimated using data extracted from the
820 Hernia (2016) 20:819–830
123
prospective registry on abdominal wall hernias from the
‘‘Club Hernie’’. This is a collaborative registry of nearly 50
French surgeons with a specific interest in abdominal wall
surgery. Each participant accepts and signs the charter of
quality stating that ‘‘all input must be registered consecu-
tive, unselected, exhaustive and in real time’’. The partic-
ipants allow peer review control of the original medical
chart of randomly selected patients. Follow-up is obtained
by a clinical research assistant, independent from the
individual participants and blinded for the surgical proce-
dure. Consecutive patients with an IVH operated between
September 30th, 2011 and August 31st, 2014, were used
for the estimation of the indirect cost. Data on hospital stay
and postoperative absence from work were extracted from
the database to determine the estimated average duration of
inability to work (Table 4).
The average cost of inability to work and loss of pro-
ductivity, were estimated, firstly from the mean wages in
France in 2011 (Table 5), published by the National
Institute of Statistics (INSEE), and secondly using a
table taking into account the most frequent Collective
Agreement among the myriad of the different French social
public and private contracts (Table 6).
Results
Systematic review
The results of our systematic review are shown in the
Prisma flow diagram in Fig. 1. Initially 402 records were
identified, after removal of duplicates and non-relevant
Fig. 1 Prisma flow diagram
Hernia (2016) 20:819–830 821
123
Table
1Summaryoffindingstable
Summaryofevidence
table
for‘‘thecost
ofincisional
hernia
repair’’
Reference
citation
Studytype
Level
of
evidence
GRADE
Number
of
patients
Patientcharacteristics
Intervention
Comparison
Length
of
follow-up
Outcomemeasure
(currency)
Sourceof
funding
[9]
Economic
evaluation
from
RCT
Moderate
691
Matched
Smallstitch
closure
(n=
321)
Largestitch
closure
(n=
370)
5years
Costdirectandindirect
(SEK
=Swedish
Krona)
University
Grant
Effectsize
1.Costreductionwithsm
allstitches
1339SEK
per
patient
2.Directcostsofincisional
hernia
repair59909SEK
andindirectcosts26348SEK
[11]
Economic
evaluation
Low
44
Consecutivepatients
Meshrepair
Suture
repair
[1year
Costdirectandindirect
(SEK
=Swedish
Krona)
Notstated
Effectsize
Costsavingof6034SEK
withmeshrepair
[10]
Economic
evaluation
Verylow
N/A
Patientsfrom
healthcare
cost
and
utilizationproject
Inpatientventral
hernia
repair
None
5years
1.Totalnumber
of
repairs
Notstated
2.Meancosts(U
S$=
USDollar)
Effectsize
1.154,278ventral
hernia
repairs
inUSin
2006
2.Costper
operationUS$15,899
3.TotalcostUS$3.2billion
4.US$32milliondollar
reductionin
costforevery1%
decreasein
incisional
hernias
[12]
Economic
evaluation
Moderate
861
Consecutivepatients1988-1992having
midlinelaparotomy
Suture
length
towoundlength
ratioC4
Suture
length
towoundlength
ratio\4
1year
1.Incisional
hernia
rate
None
2.Costs
(SEK
=Swedish
Krona)
Effectsize
1.Relativerisk
reduction0.016withS:W
C4
2.CostreductionSEK
686
3.Savingper
patientofSEK116
4.Estim
ated
nationwidesavingofSEK2,107,140(2000)per
year
[13]
Economic
evaluation
Low
884
Consecutivepatients
undergoing
incisional
hernia
repairs
Laparoscopic
incisional
hernia
repair
Open
incisional
hernia
repair
30days
1.Operativetime
Notstated
2.Cost(U
S$=
US
Dollar)
3.Length
ofstay
4.30dayspostoperative
hospital
encounters
Effectsize
1.Shorter
stay
withlap
2.Longer
optimewithlap
3.Higher
supply
costswithlap(U
S$6396vsUS$664)
4.Higher
30dayshospital
encounters
withlap(15vs13%)
[14]
Economic
evaluation
Low
N/A
Theoreticalpatientswithincisional
hernia.Placedinto
decisionanalysis
model
Open
meshrepair
Open
suture
repair
N/A
1.Costs(U
S$=
US
Dollar)
Educational
Grant
Olympus
2.Costeffectiveness
822 Hernia (2016) 20:819–830
123
records, eight records remained for qualitative evaluation.
The Summary of Findings of the systematic review is
shown in Table 1. Significant heterogeneity in time periods
and the different currencies of the studies make it impos-
sible to perform quantitative evaluation.
Direct cost of IVHR in our study
In this multi-centric study the direct costs were studied
among 3239 patients treated in 51 French public hospitals.
The average direct costs for incisional hernia repair are
shown in Table 3. They were, respectively, 3497€, 4652€,8402€, 16,367€ for the level 1, level 2, level 3 and level 4
GHM and 2041€ for day-case incisional hernia repair. Eachof these five average costs was then weighted according to
the prevalence of the related GHM resulting in the
weighted average direct cost of a mean incisional hernia
repair, which is 4731€.
Indirect cost of incisional hernia repair in our study
From 30 September 2011 till 31 August 2014, 10,529
patients were registered in the Hernia Club Registries,
including 7851 patients operated on for groin hernias and
2678 patients for ventral hernias, including 991 patients
operated on for incisional ventral hernias. Sick leave,
hospital stay and nature of employment were properly
recorded in 790 of these 991 patients (Table 4). One-third
of our patients were employed. The hospital stay was
2.6 days for employed and 3.7 days when including
unemployed patients. The mean sick leave duration for
employed patients, including the hospital stay was 29.6
(range 0–90) days.
The mean monthly wages for employees in France in
2011, retrieved from the National Institute of Statistics are
reported Table 5. The average monthly wages were as
follows: Net wages: 2130€, Gross wages: 2830, Total
wages 4671€, corresponding to weekly Net wages of 492€,Gross wages of 654€ and Total wages of 1078€. The dif-
ferences between these different wages are explained in
Table 5.
The estimation of the value of one-week sick leave
among the most frequent French collective agreements for
this mean wages is reported in Table 6. The value of a
weekly sick leave for employed widely ranged across these
collective agreements from 359 to 1977€.The weighted mean value of a weekly sick leave for
employed was estimated at 1271€ (Table 6).
Therefore the average sick leave cost for our employed
patients was 5376€ (1271€ per week/7 9 29.6) while the
values ranged from 1518€ (359/7 9 29.6) to 8360€ (1977/
7 9 29.6) [Tables 4, 6].Table
1continued
Summaryofevidence
table
for‘‘thecostofincisional
hernia
repair’’
Reference
citation
Studytype
Level
of
evidence
GRADE
Number
of
patients
Patientcharacteristics
Intervention
Comparison
Length
of
follow-up
Outcomemeasure
(currency)
Sourceof
funding
Effectsize
1.Totalcostofsuture
repairUS$16,355
2.TotalcostofmeshrepairUS$16,947
3.Increm
entalcoststo
preventonerecurrence
withmeshUS$1878
[15]
Economic
evaluation
Moderate
1008
Allsurgical
patientsundergoingan
operation
N/A
N/A
Mean
1year
Costs(U
S$=
US
Dollar)
Notstated
Effectsize
1.Medianhospital
costsifnocomplication:US$4487
2.Medianhospital
costsifminorcomplicationsoccurred:US$14,094
3.Medianhospital
costifmajorcomplicationsoccurred:US$28,536
[16]
Review
Verylow
N/A
Incisional
hernias
N/A
N/A
N/A
N/A
None
Effectsize
Meshincisional
hernia
ismore
costeffectivethan
suture
repair
Hernia (2016) 20:819–830 823
123
Total cost of incisional hernia repair in our study
(Table 7)
For employed persons the global average cost (di-
rect ? indirect costs) in 2011 of an incisional hernia repair
in France was estimated at 10,107€. For these employed
patients, the indirect costs were higher than the direct costs.
Some of our patients, mainly unemployed and/or
elderly, probably spent their recovery in convalescent
home, but we could not evaluate these costs due to the lack
of indication concerning the rate, the duration, and the
prices.
For unemployed we took into account the direct costs,
because of the difficulty to evaluate in Euros the impact of
surgery on their daily life.
Finally the average total costs of IHR, regardless to the
employment was 4731 9 68 ? 10,107 9 32 % = 6451€.In other words: ‘‘the average total cost for an average
incisional hernia repair in an average patient’’ in France in
2011 was estimated to be 6451€.
Table 2 The five IVHR-GHM (Homogeneous groups of patients for Incisional Ventral Hernia repairs)
GHM Description Relevant comorbidities
or risk factors
Relevant associated
intra-hospital events
Hospital stay\ or[to the target
06C241 IVHR[ 17 years, level 1 0 0 0
06C242 IVHR[ 17 years, level 2 Level calculated using the French National Health Care computerized device ‘groupeur’ taking into
account severity and combinations of items annually updated according to their financial relevance06C243 IVHR[ 17 years, level 3
06C244 IVHR[ 17 years, level 4
06C24J IVHR[ 17 years, D case Low risk 0 0
Levels are calculated using the National Health Care computerized device (‘groupeur’) taking into account severity and combinations of the co-
morbidities, the associated intra-hospital events (such as pulmonary embolism, cardiac failure), the length of stay out of the target; Not many
surgical items are taken into account such as complications related to a previous mesh, bowel necrosis, or a bacteriologically proven deep
infection. For instance, this classification does not take into account whether the procedure is done laparoscopically or through an open approach
These items are annually updated. If one of these items does not have any financial relevance, it is withdrawn from the list
IVH incisional ventral hernia repair, y year, D case day case surgery
Table 3 Prevalence and observed direct costs of the five IVHR-GHM in the ATIH multicentric study, and calculation of the weighted average
direct cost of an average IVHR
GHM Description Prevalence Costsa Weightingb Weighted average
Cases % € € 9 %
06C241 IVHR[ 17 years, level 1 1.285 39.7 3497 1388
06C242 IVHR[ 17 years, level 2 1.516 46.8 4652 2177
06C243 IVHR[ 17 years, level 3 221 6.8 8402 571
06C244 IVHR[ 17 years, level 4 105 3.2 16,367 524
06C24J IVHR[ 17 years, D case 112 3.5 2041 71
3.239 100 4731€ Weighted average of the direct
cost of an average IVHR
a Observed costs per caseb Each cost was weighted according to the prevalence of the corresponding GHM
Table 4 Average sick leave duration, in IVHR registered in the Hernia Club registry
Occupation (item available for 790 patients) Average hospital stay (days, range) Average sick leave including
the hospital stay (days, range)
Employed Unemployed Employed Total Employed
251 539 2.6 3.7 29.6
32 % 68 % (0–11) (0–29) (0–90)
824 Hernia (2016) 20:819–830
123
Table 5 Wages in France in
2011 (INSEE)Net wagesa (€) Gross wagesb (€) Total wagesc Total wagesd
Monthly (€) Weekly (€)
Senior manager 3988 5385
Intermediate professions 2182 2910
Employees 1554 2049
Workers 1635 2137
Average 2130 2830 4671 1078€e
INSEE National Institute of Statistics and Economic Studies (www.insee.fr/)a Net wages: take home wages after payment of the compulsory social contributions (employer and
employee’s parts) and before payment of the direct taxesb Gross wages (Net 9 1.329): wages paid to the employee minus the compulsory employer’s part of social
contributionsc Total wages (Net 9 2.195 or Gross 9 1.65): net wages ? employee’s and employer’s compulsory social
contributions = the real employee’s wages = the actual cost of the employee for his employerd Weekly wages = Monthly wages/4.33e An average monthly gross wages of 2830€ is equivalent to weekly net wages of 492€, gross wages of654€, total wages of 1,078€
Table 6 Estimation of the value of 1 week sick leave among the most frequent French Collective Agreements for the average gross wages of
2830€
Collective
agreement (CA)
Sickness, benefita,
(SB) %
of wages
Waiting
periodb,
before SB
Income,
supplementc,
up to 100 %
Substituted Profit
loss (%)eValuef,
(€)Prevalence
(%)gWeighted,
valueh (€)
Private sector 80
Income supplement, not
included in CA
50 % 3 days No No 15 359 8 29
50 % 3 days No Yes 20 1196 8 96
Income supplement,
included in CA
50 % 3 days Yes No 15 947 16 152
50 % 3 days Yes Yes 20 1896 16 303
50 % Assumed, by
employer
Yes No 15 1028 16 164
50 % Assumed, by
employer
Yes Yes 20 1977 16 316
Public sector 20
100 % 0 day – No 15 505 10 51
100 % 0 day – Yes 20 1603 10 160
Weighted average value
of a weekly, sick leavei1271
Note it is almost the double of the gross wage and 2 times and a half more than the net wage
CA collective agreementa The Sickness Benefit, or Daily Allowance, is directly paid to the employee by the National Social Security Insurance (Securite Sociale),
usually after a waiting period of 3 days, except in Public sector, or if it is assumed by the employerb During their sickness, the public employers are given 100 % of their wages, the private employees are given 50 % of their wagesc Some private employees are given income supplement up to 100 % wages depending on their contractsd The cost of a substitute is comparable with the total wage of the substituted (1078€)e Due to the work disruption a profit loss of 15–20 % is generally estimatedf Value of a one-week sick leave taking into account the former itemsg Estimated prevalence of each collective agreementh Weighted value (value 9 prevalence)i Weighted average value of a weekly sick leave (1271€) for a weekly gross wage of 654€
Hernia (2016) 20:819–830 825
123
Key results
The mean total cost for an incisional hernia repair in France
in 2011 was estimated to be 6451€, ranging from 4731€ for
unemployed patients to 10,107€ for employed patients
whose indirect costs were slightly higher than the direct
costs. The average direct cost was 4731€, but direct costswidely ranged from 3497€ for level 1 to 16,367€ for level 4of severity (Tables 2, 3). The mean cost of a day-case IVHR
was 2041. The average indirect cost for employed patients
was 5376€ (Table 7), but the indirect costs spread across a
wide range of 1518€–8360€ (Tables 4, 6).
Discussion
Systematic review
The summary of findings of the systematic review is shown
in Table 1. Three records were from the Sundsvall Hospital
in Sweden [9, 11, 12]. In their most recent publication the
overall mean cost for an incisional hernia repair was
86,257 SEK (±9060€), with a direct cost of 59,909 SEK
(±6294€) and an indirect cost of 26,348 SEK (±2768€)[9]. They estimated that by adopting the technique of small
bites during closure of a midline laparotomy, the antici-
pated reduction of incisional hernias results in a cost
reduction for each patient of 1339 SEK (±141€).Four other studies reported data from the United States
and one record is a recent review on the topic [10, 13–16].
Dimick et al. showed that the incidence of postoperative
complications in surgical procedures, including hernia
surgery, increases the costs related to the procedure sig-
nificantly [15]: after adjusting for differences in patient
characteristics, major complications were associated with
an increase of $11,626 (95 % CI $9419 to $13,832;
p\ 0.001).
Bower et al. concluded that mesh repair of incisional
hernias is more cost effective than suture repair, because of
the significant higher need for subsequent repair of recur-
rent incisional hernia [16]. In the most recent study by
Poulouse et al. reporting on the cost of ventral hernia repair
(including both primary ventral and incisional hernias), the
direct cost for inpatient procedures was 15,899 US dollar
(±13,000€) and for outpatient procedures 3873 US dollar
(±3168€) [10]. Overall we can conclude that most authors
see an important cost saving in the prevention of incisional
hernias.
Significant heterogeneity in time periods and the dif-
ferent currencies of the studies, made it is not possible to
perform quantitative evaluation. Therefore we wanted to
assess the actual costs of IVHR.
Financial study
In this multi-centric cost analysis, the mean total cost for an
incisional hernia repair in France in 2011 was estimated to
be 6451€, ranging from 4731€ for unemployed patients
(68 % of patients) to 10,107€ for employed patients (32 %
of patients) whose indirect costs were slightly higher than
the direct costs. The average direct cost was 4731€, butdirect costs widely ranged from 3497€ for level 1 to
16,367€ for level 4 of severity (Tables 2, 3). The mean cost
of a day-case IVHR was 2041. The average indirect cost
for employed patients was 5376€ (Table 7) but the indirect
costs spread across a wide range of 1518€ to 8360€(Tables 4, 6).
Around 13.000 incisional hernia repairs are performed
in France each year. The global yearly cost for incisional
hernia repair in France can be estimated to be almost 84
million Euros, with a direct cost of 62 million Euros. In this
study the costs were calculated for public hospitals. In
France, 50–55 % of surgery is performed in private hos-
pitals. From data of the ATIH we know that the direct costs
are 25–50 % lower in private hospitals [17] even after
reintegration of the medical fees, not included in the pri-
vate hospital costs. Therefore the direct overall cost in
France (private and public) are probably closer to 45 mil-
lion Euros.
Nevertheless, reducing the incidence of incisional hernia
repair after abdominal surgery by 5 % (13.000 9 5 % =
650) would result in a yearly national cost savings (direct
Table 7 Total (direct and indirect) costs of IVHR for employed and unemployed patients
Employment % Average direct,
costs (€)Average indirect, costs (€) Average,
total cost
Average sick leave
Cost per week Cost Per day Duration (days) Total cost
Unemployed 68 4731 – – 4731€
Employed 32 4731 1271 182 29.6 5376a 10,107€
Irrespective,
of employment
(0.68 9 4731) ?
(0.32 9 10,107) =
6451€
a (1271/7) 9 29.6
826 Hernia (2016) 20:819–830
123
and indirect cost) of approximately 4 million Euros
(6451 9 650 = 4193,150€).Implementation of the recently published European
Hernia Society guidelines on the closure of abdominal wall
incisions [6], thus hold a good potential not only to avoid
postoperative morbidity related to incisional hernias, but
also to a significant cost saving from avoiding subsequent
incisional hernia repair operations. Prevention of incisional
hernias in patients at high risk for this complication with a
primary mesh augmentation is currently being studied in
several studies and the evidence on the efficacy and the
safety of this approach is increasing rapidly [6, 18, 19]. The
resulting decrease in incisional hernias will undoubtedly
compensate for the additional cost for a primary mesh
augmentation in mesh material and operative time in high-
risk patients.
Strengths of this study
This study is the first published multi-centric cost analysis
of both direct and indirect costs of IVHR. It was done
among a large panel of 51 French public hospitals,
including 3239 patients for the direct costs evaluation and
790 patients for the indirect costs evaluation. The hospital
costs were retrieved from a thorough analysis of 132 uni-
tary expenditure items done by the accountants of a spe-
cialized public agency (ATIH) dedicated to investigate the
costs of the French Health Care system. Moreover, the
ATIH data consist in observed costs (written in the general
ledger) and not reimbursed prices, which may differ from
actual costs especially if the national health policy targets
to promote some priorities and changes in the sanitary
behaviours.
The pathology studied (IVHR) is homogeneous and did
not include primary ventral hernias, which are very dif-
ferent in terms of pathology, hospital stay, postoperative
complications, recurrence rate [20] and finally in terms of
costs.
Furthermore this study estimates the costs of the post-
operative inability to work and loss of profit due to the
disruption in the on-going work over a large panel of dif-
ferent Collective Agreements.
Limitations
The ATIH cost analysis dates back from 2011. Such a wide
cost analysis is not organized each year. Fortunately, due to
a very low inflation rate over this period these costs are still
valid today.
The ATIH analysis does not address the indirect costs,
which were evaluated from the patients registered in the
Hernia Club Registry. These two populations may slightly
differ. For instance more laparoscopic repairs could have
been performed in the CH cohort, and more level 4 cases
could be treated in the ATIH cohort. The difference, if it
exists, may have a slight impact because the relative
financial weight of the level 4 is not prominent (Table 3).
The indirect costs, mainly for unemployed patients, are
probably slightly underestimated:
Unemployed and elderly patients may have spent some
of their recovery in convalescent homes, for which costs
could not be evaluated. Furthermore the Quality of Life is
not a financial variable, so we could not evaluate in
unemployed patients the cost of the daily life impairment
during the sick leave. The costs of a redo surgery in case of
recurrent IVHR, the costs of further medical care and work
gaps in case of complications such as chronic pain were
also not taken into account.
It would have been helpful to split the cost analysis
between open and laparoscopic repairs. Unfortunately due
to the lack of specific GHM (DRG) in this financial and not
medical ATIH study we could not assess the specific costs
of the laparoscopic repairs. This becomes more relevant as
laparoscopic techniques continue to improve and more
complex cases are being done in this fashion. This will
have a direct effect on the direct cost of the procedure as
laparoscopic consumables are more costly and the length of
the procedure may be longer. This may be offset by the fact
that laparoscopic procedures generally have a shorter
length of stay and a quicker return to work.
Moreover it is really difficult to briefly explain what the
four levels of hernia repair are and how they differ. Levels
are calculated using the National Health Care computerized
device (groupeur) taking into account severity and com-
binations of the co-morbidities, the associated intra-hos-
pital events (such as pulmonary embolism, cardiac failure),
the length of stay out of the target; Not many surgical items
are taken into account such as complications related to a
previous mesh, bowel necrosis, or a bacteriologically pro-
ven deep infection. These items are annually updated and
move: If one of these items has not got any financial rel-
evance, it is withdrawn from the list. Therefore it is really
difficult to briefly explain what these four levels are.
We have used the best available data at our disposal to
estimate the different components of the direct and indirect
costs. Although we think the samples are representative
they might not reflect the overall population of French
patients undergoing incisional hernia repair, such as inde-
pendent professionals, farmers, artisans, liberal professions
whose social systems are different from those of
employees.
The economic evaluations are, a priori, difficult to
extrapolate to other countries, because of variations in
healthcare systems and financing, the changes in currencies
and the inflation over time. Nevertheless the costs identi-
fied in the current study are very similar to those found in
Hernia (2016) 20:819–830 827
123
Sweden (9, 11–12). Therefore these costs seem represen-
tative for the cost of IVHR in Europe. In the United States
direct costs (16), are significantly higher than those
reported in this study.
Conclusion
Our study shows that next to a considerable direct cost, also
the indirect costs of incisional hernia repair have to be
accounted for when calculating the potential benefit of
preventive measures to decrease the rate of incisional
hernias after abdominal wall incisions. Upcoming evidence
on the efficacy and safety of mesh augmentation during
closure of abdominal wall incisions in the prevention of
incisional hernias shows an important potential to decrease
the costs related to subsequent incisional hernia repair.
Acknowledgments The authors would like to acknowledge the
Bonham Group and Hernia Club members (see appendix) and Guy
Gravet (GG), a specialized accountant, for helping them in the esti-
mation of the indirect costs.
Compliance with ethical standards
Conflict of interests None for this work: As President of the Her-
nia-Club and Organiser of the Mesh Congress, JFG has financial
partnerships with a number of companies. However, he received no
personal funding for this study.
The Hernia-Club is an independent scientific institution whose
objective is to assess the use of different procedures and prostheses
for hernia repair. It therefore has relationships with a number of
companies with an interest in independent evaluation of their
products.
Appendix A: Members of the Bonham Group
* F.E. Muysoms
Head of the Department of Abdominal Surgery, AZ
Maria Middelares, Ghent, Belgium
* J-F. Gillion
Unite de Chirurgie Viscerale et Digestive, Hopital Prive
d’Antony, France
* D.L. Sanders
Department of Surgery, Derriford Hospital, Plymouth,
United Kingdom
* M. Miserez
Department of Abdominal Surgery, University Hospi-
tals, KU Leuven, Belgium
* S.A. Antoniou 1,2
1Center for Minimally Invasive Surgery, Neuwerk
Hospital, Monchengladbach, Germany2Department of General Surgery, University Hospital of
Heraklion, University of Crete, Greece
* K. Bury
Department of Cardiac and Vascular Surgery, Medical
University of Gdansk, Poland
* G. Campanelli
University of Insubria, General and day surgery, Center
of research and high specialization for abdominal wall
pathology and hernia repair, Istituto Clinico Sant’
Ambrogio, Milano, Italy
* J. Conze
UM Herniacentre, Munich and Department of General,
Visceral and Transplantation Surgery, University Hospital
of the RWTH Aachen, Aachen, Germany
* D. Cuccurullo
Department of General and Laparoscopic Surgery,
Monaldi Hospital, Azienda Ospedaliera dei Colli, Naples,
Italy
*A.C. de Beaux
Department of General Surgery, The Royal Infirmary of
Edinburgh, Edinburgh, United Kingdom
* E.B. Deerenberg
Department of Sugery, Erasmus MC University Medical
Center Rotterdam, Rotterdam, the Netherlands
* B. East
Department of Surgery, Second Faculty of Medicine,
Charles University in Prague, Czech Republic
* R.H. Fortelny
Chief of the Hernia Center, Department of General,
Visceral and Oncological Surgery, Wilhelminenspital,
Vienna, Austria
* N.A. Henriksen
Digestive Disease Center, Bispebjerg Hospital and
Department of Gastroenterology, Hvidovre Hospital,
Copenhagen, Denmark
* L. Israelsson
Department of Surgery and Perioperative science, Umea
University, Umea, Sweden
* A. Jairam
Department of Sugery, Erasmus MC University Medical
Center Rotterdam, Rotterdam, the Netherlands
* A. Janes
Head of Upper GI and Trauma Surgery, Department of
Surgery, Sundsvall Hospital, Sundsvall, Sweden
* J. Jeekel
Department of Neurosciences, Erasmus MC University
Medical Center Rotterdam, Rotterdam, the Netherlands
* M. Lopez-Cano
Abdominal Wall Surgery Unit, Hospital Universitario
Vall d’Hebron. Universidad Autonoma de Barcelona,
Barcelona, Spain
* S. Morales-Conde
Chief of the Unit of Innovation in Minimally Invasive
Surgery, University Hospital Virgen del Rocıo,
Seville, Spain
* M.P. Simons
828 Hernia (2016) 20:819–830
123
Department of Surgery, Onze Lieve Vrouw Gasthuis,
Amsterdam, The Netherlands
* M. Smietanski
Department of General and Vascular Surgery, Ceynowa
Hospital in Wejherowo, Poland
* L. Venclauskas
Lithuanian University of Health Sciences, Department
of Surgery, Kaunas, Lithuania
* F. Berrevoet
Department of General and Hepatobiliary Surgery and
Liver Transplantation Service, University Hospital Ghent,
Belgium
Appendix B: Members of the Hernia Club
Ain J-F: Polyclinique Val de Saone, Macon, France
Beck M: Clinique Ambroise Pare, Thionville, France
Barrat C: Hopital Universitaire Jean Verdier, Bondy,
France
Berney C: Bankstown-Lidcombe Hospital, Sydney,
Australia
Berrot J-L: Groupe Hospitalier Paris St Joseph, Paris,
France
Binot D: MCO Cote d’Opale, Boulogne sur Mer, France
Blazquez D: Clinique Jeanne d’Arc, Paris, France
Bonan A: Hopital Prive d’Antony, Antony, France
Cas O: Centre Medico Chirurgical–Fondation WAL-
LERSTEIN, Ares, France
Dabrowski A: Clinique de Saint Omer, Saint Omer,
France
Champault-Fezais A: Groupe Hospitalier Paris St
Joseph, Paris, France
Chastan P: Bordeaux, France
Cardin J-L: Polyclinique du Maine, Laval, France
Chollet J-M: Hopital Prive d’Antony, Antony, France
Cossa J-P: CMC Bizet, Paris, France
Durou J: Clinique de Villeneuve d’Ascq, Villeneuve
d’Ascq, France
Dugue T: Clinique de Saint Omer, Saint Omer, France
Faure J-P: CHRU Poitiers, Poitiers, France
Framery D: CMC de la Baie de Morlaix, Morlaix,
France
Fromont G: Clinique de Bois Bernard, Bois Bernard,
France
Gainant A: CHRU Limoges, Limoges, France
Gauduchon L: CHRU Amiens, France
Gillion J-F: Hopital Prive d’Antony, Antony, France
Jacquin C: CH du Prado, Marseille, France
Jurczak F: Clinique Mutualiste, Saint Nazaire, France
Khalil H: CHRU Rouen, Rouen, France
Lacroix A: CH de Auch, Auch, France
Ledaguenel P: Clinique Tivoli, Bordeaux, France
Lepere M: Clinique Saint Charles, La Roche-sur-Yon,
France
Letoux N: Clinique Jeanne d’Arc, Paris, France
Loriau J: Groupe Hospitalier Paris St Joseph, Paris
Magne E: Clinique Tivoli, Bordeaux, France
Ngo P: Hopital Americain, Neuilly, France
Paterne D: Clinique Tivoli, Bordeaux, France
Pavis d’Escurac X: Strasbourg, France
Renard Y: CHRU Reims, Reims, France
Soler M: Polyclinique Saint Jean, Cagnes-sur-Mer,
France
Rignier P: Polyclinique des Bleuets. Reims
Roos S: Clinique Claude Bernard, Albi, France
Thillois J-M: Hopital Prive d’Antony, Antony, France
Tiry P: Clinique de Saint Omer, Saint Omer, France
Zaranis C: Clinique de la Rochelle, La Rochelle, France
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