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.
Ann Surg. 2019 Feb;269(2):358-366. doi: 10.1097/SLA.0000000000002507.
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.
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.
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.
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.
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.
比较三种可复性腹疝的治疗策略（即诊断时修复[开放或腹腔镜]和观察等待）相关的长期临床和经济结局。
腹疝的治疗存在差异。最近的数据表明观察等待是安全的；然而，不同治疗策略的长期临床和经济结局仍不清楚。
我们构建了一个状态转移微观模拟模型，以预测可复性腹疝患者的结局，为每种策略模拟了 100 万人的队列。我们从全国住院患者样本（2003-2011 年）中获得了队列特征（平均年龄 58 岁，63%为女性）、医院费用和围手术期死亡率，以及来自文献的其他概率、成本和效用。结局包括任何修复、紧急修复和复发的发生率；终生成本；质量调整生命年（QALY）；以及增量成本效益比。我们使用 50000 美元/QALY 的意愿支付阈值进行随机和概率敏感性分析，以确定影响最佳管理的参数阈值。
观察等待后，39%的患者最终需要修复（14%为紧急修复），24%的患者复发。70%的诊断修复后复发。与诊断时的开放修复相比，诊断时的腹腔镜修复具有成本效益（增量成本效益比为 27700 美元/QALY）。手术策略（开放与腹腔镜）的选择取决于手术成本和术后生活质量。当围手术期死亡率超过 5.2%或每年复发超过 19.2%时，观察等待成为首选。
诊断时进行腹疝修复非常具有成本效益。开放和腹腔镜修复之间的选择取决于手术成本和术后生活质量。对于围手术期死亡率或复发风险较高的患者，观察等待是首选。
