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Management of Reducible Ventral Hernias

Clinical Outcomes and Cost-effectiveness of Repair at Diagnosis Versus Watchful Waiting

Wolf, Lindsey L., MD, MPH*,†,‡; Ejiofor, Julius I., MD, MPH*,†,‡; Wang, Ye, PhD*; Hunink, Myriam G., MD, PhD§,¶; Losina, Elena, PhD||; Haider, Adil H., MD, MPH*,†; Smink, Douglas S., MD, MPH*,‡

doi: 10.1097/SLA.0000000000002507
ORIGINAL ARTICLES

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.

*Center for Surgery and Public Health, a joint venture of the Brigham and Women's Hospital, Harvard Medical School, and Harvard T.H. Chan School of Public Health, Boston, MA

The Division of Trauma, Burns, and Surgical Critical Care, Department of Surgery, Brigham and Women's Hospital, Boston, MA

The Division of Gastrointestinal and General Surgery, Department of Surgery, Brigham and Women's Hospital, Boston, MA

§Center for Health Decision Sciences, Harvard T.H. Chan School of Public Health, Boston, MA

Erasmus University Medical Center, Rotterdam, the Netherlands

||the Orthopaedic and Arthritis Center for Outcomes Research (OrACORe) and Policy, Innovation eValuation in Orthopedic Treatments (PIVOT) Research Center, Department of Orthopedic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA.

Reprints: Lindsey L. Wolf, MD, MPH, Center for Surgery and Public Health, Department of Surgery, Brigham and Women's Hospital, 1620 Tremont Street, 4th Floor, Suite 4-020, Boston, MA 02120. E-mail: llwolf@bwh.harvard.edu.

Meeting Presentation: This work was presented as an oral presentation at the American College of Surgeons Clinical Congress in Washington, D.C., October 16–20, 2016.

Financial disclosures: This work was supported by the American College of Surgeons Resident Research Scholarship to LLW and the U.S. National Institute of Health/National Institute of Arthritis and Musculoskeletal and Skin Diseases (K24AR057827-02) to EL. Not related to this work, AHH is the PI of a contract (AD-1306-03980) with the Patient-centered Outcomes Research Institute entitled “Patient-Centered Approaches to Collect Sexual Orientation/Gender Identity in the ED” and a Harvard Surgery Affinity Research Collaborative (ARC) Program Grant entitled “Mitigating Disparities Through Enhancing Surgeons’ Ability To Provide Culturally Relevant Care.” For the remaining authors, none was declared.

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