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Complex Ventral Hernia Repair Using Components Separation With or Without Biologic Mesh: A Cost Effectiveness Analysis
Abhishek Chatterjee, MD/MBA1, Naveen M. Krishnan, BS, MPhil2, Joseph M. Rosen, MD1.
1Dartmouth Hitchock Medical Center, Lebanon, NH, USA, 2Dartmouth Medical School, Hanover, NH, USA.
A complex ventral hernia requiring abdominal wall reconstruction presents a challenging scenario to the surgeon. Components separation provides a useful musculofascial advancement flap option in the armamentarium of closure choices. The use of biologic mesh in addition to performing components separation is an area of greater controversy. A technology that provides clinical benefit yet incurs a cost is ideally suited for cost effectiveness analysis, and such an analysis has not been previously undertaken. Our goal was to perform a cost effectiveness (utility) analysis on the use of biologic mesh in addition to performing components separation for the repair of complex ventral hernias.
A literature review was conducted to identify and pool published short and long term complications and recurrence rates for complex ventral hernia repairs requiring components separation with or without acellular dermal matrix. The average probabilities of the most common complications were combined with Medicare Current Procedural Terminology (CPT) reimbursement codes, Diagnosis Related Groups (DRG) reimbursement codes, and expert utility estimates to fit into a decision model to evaluate the cost effectiveness of components separation with or without biologic mesh in reconstructing complex ventral hernias. A third-party payer perspective was used. One-way sensitivity analysis was performed using hernia recurrence and the cost of mesh (assuming mesh size of 250cm2) as variables to verify the robustness of the results.
Our literature review resulted in 14 papers describing components separation alone and 10 papers describing components separation with biologic mesh. The pooled outcome rates for each ventral hernia treatment option are shown in Table 1 with using mesh resulting in more complications but less recurrence. Eleven expert derived utilities for various health states were obtained. Utilities, costs, and the average probability of clinically relevant outcomes were entered into a decision tree analysis shown in Figure 1. The use of biologic mesh in complex ventral hernia repair resulted in an incremental cost utility ratio of $15,002.90 per quality-adjusted life year (QALY) indicating cost effectiveness based on a previously published cost effectiveness threshold of $50,000 per QALY. Cost effectiveness favoring mesh was largely swayed by its decreased recurrence rate and related utility benefit. Assuming pooled complication and recurrence rates shown in Table 1, biologic mesh is cost effective when it costs less than $1,814. When using Medicare reimbursement for the cost of mesh ($268.22), the hernia recurrence rate (in the components separation only arm) must be at least 16% for the addition of mesh to be cost effective.
The addition of biologic mesh when performing components separation in repairing complex ventral hernias is cost effective from the perspective of a third party payer. Biologic mesh remains cost effective as long as its cost is less than $1,814.
Complex ventral hernia repair using components separation with or without biologic mesh
|Early Complications (wound dehiscence, infection, seroma, hematoma) (%)||Late Complications (abdominal bulging/laxity, small bowel obstruction, enterocutaneous fistula) (%)||Hernia Recurrence (%)|
|Components Separation Alone||20.6||0.88||17.3|
|Components Separation with Biologic Mesh||25.4||6.67||14.7|
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