CostEffectiveness of Hernia Surgery: Implications for Practice

1
Cost-Effectiveness of Hernia Surgery
Implications for Practice

• Denise M Hynes, PhD, RN, Kevin T Stroupe, PhD,
  Ping, Luo, PhD, Anita Giobbie-Hurder, MS,
  Domenic Reda, PhD,
• Margaret Kraft, PhD, RN, Kamal Itani, MD, Robert
  Fitzgibbons, MD,
• Olga Jonasson, MD, and Leigh Neumayer, MD
• for the Veterans Affairs Cooperative Study Group
  on Hernia RepairBased on a manuscript In Press
  2006 at the
• Journal of the American College of Surgeons

2
(No Transcript)
3
Background

• Advent of minimal access surgical procedures,
  such as laparoscopy (LAP), offers potential for
  reduced healthcare use and improved outcomes
• Hernia repair is one of the most frequent
  surgical procedures
• UK 70,000 hernia repairs annually in UK, account
  for over 100,000 inpatient days
• US 700,000 annually in the VA hernia repairs
  account for 10 of all surgical procedures
• Lack of consensus on best hernia procedure

4
Technological Advances in Surgery Techniques

• 1980s OPEN w/mesh -- Tension Free Techniques
• 1982 Intro of LAP
• 1991 LAP w/ surgical mesh
• 1992 Advances in LAP reported (TEP)
• 1995 Tension-free (mesh) techniques most common
  in US

5
Study Objective

• To estimate costs, benefits, and cost
  effectiveness of laparoscopic (LAP) versus open
  (OPEN) inguinal hernia repair
• Focus on two year timeframe
• Subgroup Analysis unilateral and bilateral

6
Setting Population

• RCT at 14 VAMCs with two-year follow-up
• 2,164 men with inguinal hernia were randomized,
• 1,395 patients (708 open and 687 laparoscopic)
  were treated on an outpatient basis and data were
  available for the cost-effectiveness analysis

7
4769 Screened 3518 Eligible 2164 Randomized
1077 Assigned to LAP Repair
1087 Assigned to OPEN Repair
763 Completed Repair Procedures on Outpatient
Basis
788 Completed Repair Procedures on Outpatient
Basis
26 Not Identified in VA Databases 49
Incomplete 2 Yr Costs 1 Used Other Procedure
22 Not Identified in VA Databases 58
Incomplete 2Yr Costs
687 Included in Cost-effective Analysis for LAP
708 Included in Cost-effective Analysis for OPEN
8
MethodsHealthcare Use and Costs

• Day of Operation
• Inpatient stays
• Outpatients visits
• Medications

9
MethodsHealthcare Use Costs

• VA Inpatient and Outpatient Costs
• VA workload data
• VA Health Economics Resource Center (HERC)
  Average Costs Datasets
• Prescription Medication Costs
• VA Pharmacy Benefits Management

10
Methods Effectiveness - QALYs

• QALYs over two years were adjusted for baseline
  HUI2 scores by regression methods
• Calculated QALY 95 CI using the bias-corrected
  and accelerated bootstrap method based on 10,000
  replications.

11
MethodsAnalysis

• All costs were adjusted to 2003 US dollars using
  the Consumer Price Index
• Discounted both costs and QALYs at 3 per year
  starting with the date of randomization
• To account for the preference for current and
  benefits over and benefits in the future
• 95 CI used bias corrected accelerated
  bootstrapping to adjust for skewness

12
MethodsAnalysis

• Calculated incremental cost effectiveness ratio
  ICER
• ICER CostLAP CostOPEN
• QALYLAP QALYOPEN
• Precision estimates used boot strap with
  replacement

13
ResultsBaseline Characteristics-Demographics
14
ResultsBaseline Characteristics-SF36
15
ResultsTwo Year Follow-up Characteristics
16
ResultsIntraoperative Characteristics
17
ResultsOperative Postoperative Costs
18
ResultsQALYs
19
ResultsCost-Effectiveness Analysis
20
ICER Distribution Lap Versus Open Hernia Repair
Favor OPEN
Favor LAP
21
WTP Acceptability Curve Lap Versus Open Hernia
Repair
22
ICER Distribution Lap Versus Open Hernia
RepairUnilateral
Favor OPEN
Favor LAP
23
WTP Acceptability Curve Lap Versus Open
Bilateral and Unilateral Hernia
24
ResultsSummary

• LAP hernia repair is not cost effective compared
  to OPEN repair
• Recurrence rate higher
• Return to work sooner
• For patients with unilateral and recurrent
  hernias, LAP repair is cost effective option for
  some patients

25
Limitations

• Focus only on outpatient procedures at VA
• No valuation for days lost from normal activities
• LAP patients returned to normal activities 1.5
  days sooner than OPEN patients
• No separate accounting for cost differences due
  to the greater use of general anesthesia in LAP

26
Implications

• LAP repair has been recommended for recurrent or
  bilateral hernia
• Efficient
• Avoids previously operated field
• Facilitates simultaneous repair of bilateral
  hernias
• Our CE results
• Support LAP repair for recurrent unilateral
  hernia
• Favor OPEN repair of bilateral hernia

27
Conclusions

• LAP hernia repair is not cost effective compared
  to OPEN repair for all hernia patients
• For unilateral recurrent hernias, LAP was
  moderately more likely than OPEN to be cost
  effective
• Pace of adoption of LAP consistent with CE results

28
(No Transcript)
29
(No Transcript)
30
Additional Results
31
MethodsAnalysis

• We calculated the difference in
• mean costs CostLAP CostOPEN
• mean QALYs QALYLAP QALYOPEN
• 95 CI used bias corrected accelerated
  bootstrapping to adjust for skewness in the cost
  data

32
ResultsIntraoperative Characteristics
33
ResultsBaseline Characteristics-Comorbidities
34
ResultsBaseline Characteristics-ASA Class
35
ResultsBaseline Characteristics-Hernia Types
36
ResultsSurgical Costs
37
Results90-Day Post Operative Costs
38
Results90 day-2yr Postoperative Costs
39
League Table Selected Studies