Timing of inguinal hernia repair affects long-term costs

Last Updated: 2016-01-28

By Will Boggs MD

NEW YORK (Reuters Health) - Early operative repair of minimally symptomatic inguinal hernia in men provides the greatest long-term savings from the perspective of the third-party payer, according to a mathematical model that compares expectant management, early operative repair, and laparoscopic repair.

"Making decisions that are cost-conscious, but not cost-driven, requires an understanding of cost over the entire cycle of care," Dr. David I. Soybel from Pennsylvania State University College of Medicine, Hershey, told Reuters Health by email.

"In the case of inguinal hernia, expectant management means a cycle of care that can last up to 10 years. A long cycle of care means other factors may alter costs that might never have entered into our thinking, such as the present value of money," he said.

For asymptomatic hernias that are not enlarging, it remains unclear whether and when repair should be offered, but most patients managed expectantly will eventually develop indications for surgery.

Dr. Soybel's team developed a mathematical model from a third-party payer's perspective to compare the costs of early operative repair (OR) via open tension-free-repair versus expectant management (EM) in a simulated cohort of patients with inguinal hernia based on recently reported long-term outcomes from prospective randomized trials.

Expected crossover from EM to OR differed with age and approached 62% at 10 years for younger men and 79% at 10 years for older men.

Besides age, the duration of follow-up and the cost of money (reflected in the discount rate used for the net present value analysis) significantly influenced the outcome.

Over a realistic range of discount rates, early open operation results in lower costs to third-party payers over the 10-year window, according to the January 13 online report in the American Journal of Surgery.

For all discount rates, early OR remained less costly than EM in older and younger patients, and laparoscopic repair was more costly than either OR or EM.

At a 3% discount rate, EM became more expensive than OR at 5.32 years following the initial diagnosis. For patients older than 65, the costs of EM eclipsed those of OR even earlier (4.38 years) than for younger patients (5.77 years).

With only one surveillance annually (instead of the four visits in the randomized trials) early OR was less costly than EM for younger patients at 0% discount rates and for patients older than 65 at both 0% and 3% discount rates, but once the rate reaches 3% and 5%, respectively, payers would pay more for OR (and laparoscopic repair) than for EM.

"Along the lines argued by the Business Professor Michael Porter, we would like to think this sort of analysis can help payers, patients, and providers recognize that the concept of improving 'value' in health care applies not just to big-ticket technologies, major procedures, or critical illness," Dr. Soybel explained.

"We think our report shows how small changes in cost or savings could be significant when applied to seemingly mundane but very common problems such as the minimally symptomatic inguinal hernia," he said.

These findings may not apply to women with inguinal hernia.

"Subtle variables include the anatomy and natural history of a hernia in women and the higher likelihood of a femoral hernia in women -- both of which could alter the rate at which hernias become symptomatic, the likelihood of emergency operation, and even the likelihood of recurrence; thus, the influence on the costs associated with operation or expectant management," Dr. Soybel said.

"Another issue for the young woman is pregnancy, which could influence decisions based on worries about needing urgent surgery during the pregnancy. I have not seen a study that was able to reliably show asymptomatic hernia incidence in women or that easily teases out its natural history," he added.

"With respect to patients in other countries, we think the results are applicable for populations similar to the U.S. and U.K. (where the natural history studies were done)," Dr. Soybel said. "Our study provides some insight into how the natural history of the hernia -- once you know it for a specific patient group -- would influence the analysis."

The authors reported no funding or disclosures.

SOURCE: http://bit.ly/1PlP9eo

Am J Surg 2016.