Open and Laparoscopic Inguinal Hernia Surgery: A Cost Analysis

Introduction

The surgical treatment of an inguinal hernia is one of the most common present-day surgical interventions practiced worldwide. ¹ Since the first reported laparoscopic inguinal hernia repair (LIHR) performed by Ger in 1988, ² the approach has gained increasing success and nowadays the techniques' clinical advantages are well documented.^3,4 Nevertheless, the widespread application of the laparoscopic approach is diminished by the financial burden compared with the standard open approach. ⁵ Several scientific articles have demonstrated higher in-hospital costs for the laparoscopic approach, whereas others reported that it is not necessarily associated with an increase in hospital resource consumption.^6–9

Clearly, this topic is still a matter of debate and some financial issues remain unclear. Despite costs being influenced by a huge number of factors, the available literature provides reliable results in terms of financial in-hospital burden. On the contrary, there is little hard evidence with regard to the economic reimbursement for hospitals based on the two operative groups in the current age of diagnosis-related group (DRG) reimbursement. Factors that affect whether a hospital or health system may earn or lose financially depending on laparoscopic or open inguinal hernia repair is still, as yet, underexplored.

The aim of this study was to provide a reliable analysis of hospital costs and reimbursement with regard to the inguinal hernia surgery.

Methods

This retrospective study analyzed the 1-year experience in inguinal hernia repair from January 2017 to December 2017 at our institution. Inpatient cases undergoing elective open Lichtenstein hernia repair (OL), ¹⁰ laparoscopic totally extraperitoneal unilateral (UTEP), or bilateral (BTEP) inguinal hernia repair were included. No cases of bilateral OL were recorded.

Demographics and clinical results were recorded in a database including age, sex, comorbidities (hypertension/cardiac, pulmonary, liver, or renal diseases, diabetes mellitus, antiplatelet, and anticoagulant therapy), type of approach (OL, UTEP, or BTEP), rate of conversion to OL, postoperative length of hospital stay, and in-hospital complications rate (bleeding, wound hematoma, infection, and urinary complications).

For all patients included we recorded the medical resource utilization (direct and indirect costs) and we compared it with the DRG-based reimbursement. In particular, direct costs are specifically associated with patients' care services and related to medications, sutures, prosthetic material, and single-use surgical instruments. Indirect costs, conversely, are the costs incurred during the clinical care, operative services, and care of the patient, such as operating theater, anesthesia, radiology and laboratory investigations, physician salaries, physiotherapy, nursing care, hospital stay, and administration. All financial data are expressed in EURO (Swiss Franc to EURO exchange rate = 0.8708).

Results

During the study period, 137 consecutive patients were identified. From this population, 39 (28.5%) patients underwent OL (all unilateral), 82 (59.9%) patients UTEP, and 16 (11.6%) patients BTEP. The analysis revealed statistically significant differences between groups in terms of age (P = .003), hypertension and cardiac disease (P = .004), renal disease (P < .001), anticoagulants (P < .001), antiplatelet therapy (P < .001), and recurrent hernia (P < .001), with all these factors more prevalent in the OL group. Among postoperative complications, no case of infection was recorded and we found no statistical differences between groups except for one case of postoperative hemorrhage (6.2% in BTEP group, P = .023). This case was successfully treated conservatively with two units of red blood cells. Demographic details, comorbidities, and clinical outcome are given in Table 1.

Mean direct costs were 321 EUR in the OL group, 831 EUR in the UTEP group, and 1156 EUR in the BTEP group (overall P < .001, no significant difference between UTEP and BTEP only). Indirect costs were 3805 EUR in the OL group, 4303 EUR in the UTEP group, and 5926 EUR in the BTEP group (P < .001). The average total cost amounted to 4126 EUR in the OL group, 5134 EUR in the UTEP group, and 7082 EUR in the BTEP group (P < .001). The hospital reimbursement amounted to 5486 EUR in the OL group, 5252 EUR in the UTEP group, and 6555 EUR in the BTEP group (overall P < .001, no significant difference between OL and UTEP only). Finally, the mean hospital earnings were 1360 EUR, 118 EUR, and −527 EUR for each patient in OL, UTEP, and BTEP groups, respectively (P < .001). Details on direct and indirect costs are given in Table 2 and Figures 1 and 2.

OPEN IN VIEWER

FIG. 1.

Costs differences between groups are represented by the histogram. Black column for open Lichtenstein, dark and light gray for unilateral and bilateral totally extraperitoneal repair, respectively.

OPEN IN VIEWER

FIG. 2.

Detailed repartition of direct and indirect costs between groups. Black column for open Lichtenstein, dark and light gray for unilateral and bilateral totally extraperitoneal repair, respectively.

After risk factors adjustment, the analysis of costs showed no substantial differences compared with results mentioned above.

The multiple R-squared line regression analysis showed no significant correlation between costs and age (P = .810), male gender (P = .151), pulmonary disease (P = .236), hypertension/cardiac disease (P = .804), diabetes mellitus (P = .382), renal disease (P = .113), or liver disease (P = .099), anticoagulant therapy (P = .351), antiplatelet therapy (P = .737), and recurrent hernia (P = .988). Among postoperative complications hematoma (P = .975) and urinary retention (P = .092) were not independently related to costs but was associated with an increased length of hospital stay (both P < .001). Conversely, factors such as bleeding (P = .002) and length of hospital stay (P < .001) were independently related to costs. Because of the increased cost weight calculation, the antiplatelet therapy (P = .022) and the length of hospital stay (P < .001) significantly increased the hospital reimbursement. Finally, antiplatelet (P = .006) and anticoagulant therapy (P = .031) were independent factors that increased the hospital earning, because of the increased cost weight in the DRG calculation. The length of hospital stay was significantly associated with financial loss (P < .001); in fact, costs related to a long hospital stay overcame the increased reimbursement.

Discussion

The clinical advantages of laparoscopic inguinal hernia repair are nowadays well documented^3,4 and the recommended repair technique should be in accordance with published guidelines. ³ In particular, LIHR is recommended for recurrent hernia after anterior approach, for bilateral hernias, and for patients of working age. In our series, we found a significant difference between groups in terms of age and comorbidities, with younger and healthier patients in the laparoscopic (UTEP and BTEP) groups. Our series adheres to these recommendations and clinical outcomes matching those of international standards. ¹¹

The DRG-based payments are today the principal form of hospitals reimbursement in high-income countries. Introduced first in the United States, its use has spread worldwide ¹² and in 2007 it was introduced in Switzerland. ¹³ In the DRG era, costs of OL and LIHR have already been evaluated. Several articles described higher costs for LIHR approach compared with OL.^5–7 Tadaki et al. ⁵ reported 4360 USD versus 5105 USD for OL and LIHR, respectively. Similar results were reported by Smart and Castles, ⁶ describing increased disposable costs for LIHR (343 USD vs. 1611 USD). Nevertheless the debate is still open, Wittenbecher et al. ⁹ reported 1857 EUR versus 1744 EUR for OL and LIHR, respectively.

In our experience, the in-hospital cost of OL was significantly lower than UTEP and BTEP (4126 EUR, 5134 EUR, and 7082 EUR, respectively, P < .001) both in direct and indirect costs. Nevertheless, despite the increased cost, the DRG-based reimbursement was raised only in the BTEP group, being OL and UTEP comparable since in the same DRG. Consequently, the OL group produced a mean hospital earning of 1360 EUR for every patient, whereas UTEP group had a mean gain of only 118 EUR. In the BTEP group the hospital had an overall median loss of 527 EUR for every patient, as the reimbursement was insufficient to overcome the increased costs.

The aforementioned data were compiled from noncomparable groups in terms of age and risk factors. It is pleasing to note that these differences were because of the adherence to hernia guidelines ³ ; yet, in terms of economic impact one could argue for a possible bias. For this reason, we generated a dataset that matched cases according to risk factors. For older patients and those with comorbidities it is expected to cost more and generally the hospital earning is worse despite the DRG cost-weight increase. ¹⁴ In our experience the antiplatelet therapy in OL group was higher than that in the UTEP and BTEP groups (33.3%, 7.3%, and 6.2%, respectively) and did not cause an increase in costs but produced a significant increase in the DRG-based reimbursement and ultimately in the hospital earning. Similar results were noted for the anticoagulant therapy. This aspect is part of the DRG itself, where comorbidities raise the cost weight to compensate the costs of an expected higher rate of complications in high-risk groups.

In our series, no cases of major complications in patients with antiplatelet or anticoagulant therapy occurred, but it could be expected that in a larger case series, these factors would not assist in the increase of hospital earnings. The different length of hospital stay differed among three groups (1.9 for OL, 1.6 for UTEP, and 2.3 for BTEP); it was associated with increased costs and a decrease in hospital profit. Moreover, postoperative bleeding (6.2% in the BTEP group) was significantly associated with increased costs (P = .002) in a patient not taking antiplatelet or anticoagulant therapy, as a result of the lack of DRG compensation, in a case that required more hospital resources. For these reasons, the matched dataset aided to eliminate the age, comorbidity, and complication-related bias and permitted the analysis of the financial impact, based only on the group of treatment. That being said, after cost correction for the length of hospital stay, there were no substantial differences compared with the “unmatched patients” analyzed.

Finally, costs, reimbursement, and hospital earning should be considered in the clinical context. The indication to perform an LIHR produced a lower hospital earning in the UTEP group and led to financial loss in the BTEP group. A separate analysis should be carried out with regard to the unilateral inguinal hernia repair. Compared with OL, despite the fact that the UTEP approach had higher in-hospital costs related to disposable materials, operating room, and anesthesia, the hospital reimbursement was the same. Both techniques had the same DRG regardless of the operative approach, so that, when it was decided to treat young healthy patients with UTEP, there is the problem of a nonignorable reduction in hospital earnings. Paradoxically, if we would had treated all unilateral inguinal hernias with OL, there would have been a profit of >100,000 EUR in 2017. Respecting international guidelines and moral and clinical standards, this view is evidently out of question, but it highlights the lack of an appropriate financial correlation to the routinely clinical practice.

Another issue is the comparison between UTEP and BTEP. Clearly, in the BTEP group a higher use of disposable material, operating room, and anesthetic resource is expected and accordingly confirmed in our series. In the case of bilateral hernias, however, the DRG-based reimbursement is corrected for, based upon the differences in therapeutic surgical indications. The increase is slight and not sufficient enough to cover the costs of the bilateral procedure, leading to an overall financial loss for the hospital and making it difficult to finance the BTEP approach; notwithstanding the fact that it may have a strong clinical indication, supported by high-level evidence demonstrating its beneficial aspects. Hence, surgeons should be aware that clinical advantages of the laparoscopic approach are nowadays not compensated by a merely economic point of view. The possibility to treat a patient with a two-step OL instead of BTEP is obviously out of question; however, it is our view that the financial aspects should be more representative and better reflect the clinical settings and the indications to surgery in the treatment of inguinal hernias.

Nonetheless, this study has several limitations. First, the lack of randomization and the retrospective design. Moreover, we found significant differences between groups in terms of age, comorbidities, and complications. To minimize this bias, a subset of analysis was conducted to evaluate costs in a case–control-matched population. Results were not considerably different from the “unmatched analysis,” indicating that in our case study age, comorbidities, and complications, even different between groups, did not significantly affect the overall costs.

Financial results in our analysis could not be applicable worldwide because costs and reimbursement vary among countries and our data were derived from a single Swiss institution. The base rate is the reference price for an average DRG and is assigned to individual hospitals or regional hospitals. However, we expect our results could predict costs and reimbursements in inguinal hernia surgery at other hospitals, given the fact that many countries around the world have adopted the DRG-based payment. The Swiss DRG is based on the German DRG, and is known to share many similarities with other European countries and remains comparable also with the U.S. DRG.^12,15–18

In addition, we should aim for an overall reduction of costs. Among other factors that contribute to increased costs, international guidelines ³ recommend to consider the use of nondisposable trocars and instruments as well as nonfixation techniques. In our study probably part of the increased cost in UTEP and BTEP was because of this nonadherence to guidelines, although the cost difference cannot be justified by this feature only. In addition, a reduction in the length of hospital stay should be considered to be of primary importance to optimize costs. This study considered only in-hospital costs, whereas societal costs should also be further evaluated.^4,19 Finally, only inpatients were considered in the analysis but it should be said that our results are expected to predict economic commitment in outpatients as well, because cost differences were primarily related to the group of treatment (direct costs, anesthesia, and operating room). Further analyses in the outpatient setting are also needed.

Conclusions

In our study, in-hospital costs were higher in UTEP and BTEP compared with OL. The DRG-based reimbursement provided adequate compensation for patients with unilateral inguinal hernia, whereas hospital earnings were profitable in OL group only, and led to an overall financial loss for every patient in the BTEP group. Surgeons should be conscious that clinical advantages of the laparoscopic approach are not adequately compensated for, from an economic point of view. Finally, financial aspects should be better tailored to clinical scenarios and surgical therapies, as in the case of the inguinal hernia treatment.