How To Bill For A Laparoscopic Bilateral Hernia Repair
JSLS. 2014 October-Dec; xviii(4): e2014.00217.
Hospital Costs Associated With Laparoscopic and Open up Inguinal Herniorrhaphy
Fernando Spencer Netto, Dr., PhD, 
Fayez Quereshy, MD, MBA, Bruna Grand. Camilotti, Kristen Pitzul, BScH, MSc, Josephine Kwong, BScH, MPA, Timothy Jackson, Doctor, MPH, Todd Penner, MD, and Allan Okrainec, Md, MHPE
Fernando Spencer Netto
Universidade do Oeste do Parana, Cascavel, Brazil
Fayez Quereshy
Segmentation of General Surgery, University Health Network, Toronto, Ontario, Canada
Department of Surgery, Academy of Toronto, Toronto, Ontario, Canada
Bruna G. Camilotti
Universidade Regional de Blumenau, Blumenau, Brazil.
Kristen Pitzul
Division of Full general Surgery, University Wellness Network, Toronto, Ontario, Canada
Josephine Kwong
Sectionalization of General Surgery, University Health Network, Toronto, Ontario, Canada
Timothy Jackson
Sectionalisation of General Surgery, University Wellness Network, Toronto, Ontario, Canada
Department of Surgery, University of Toronto, Toronto, Ontario, Canada
Todd Penner
Division of General Surgery, University Wellness Network, Toronto, Ontario, Canada
Department of Surgery, University of Toronto, Toronto, Ontario, Canada
Allan Okrainec
Division of General Surgery, Academy Health Network, Toronto, Ontario, Canada
Section of Surgery, University of Toronto, Toronto, Ontario, Canada
Abstract
Purpose:
The purpose of this study was to compare the full hospital costs associated with elective laparoscopic and open inguinal herniorrhaphy.
Methods:
A prospectively maintained database was used to identify patients who underwent constituent inguinal herniorrhaphy from April 2009 to March 2011. A retrospective review of electronic patient records was performed along with a standardized case-costing analysis using data from the Ontario Case Costing Initiative. The main outcomes were operating room (OR) and full hospital costs.
Results:
2 hundred eleven patients underwent elective unilateral inguinal herniorrhaphy (117 open and 94 laparoscopic), and 33 patients underwent constituent bilateral inguinal herniorrhaphy (9 open up and 24 laparoscopic). OR and total hospital costs for open up unilateral inguinal hernia repair were significantly lower than for the laparoscopic approach (median total cost, $3207.15 vs $3723.66; P < .001). OR and total infirmary costs for repair of constituent bilateral inguinal hernias were similar between the open and laparoscopic approaches (median total toll, $4574.02 vs $4662.89; P = .827).
Conclusions:
In the setting of a Canadian academic hospital, when considering the repair of an elective unilateral inguinal hernia, the OR and total infirmary costs of open surgery were significantly lower than for the laparoscopic techniques. There was no statistical difference between OR and full infirmary costs when comparison open surgery and laparoscopic techniques for the repair of bilateral inguinal hernias. Given the perioperative benefits of laparoscopy, further studies incorporating hernia-specific outcomes are necessary to make up one's mind the price-effectiveness of each approach and to define the optimal treatment strategy.
Keywords: Hospital costs, Inguinal herniorrhaphy, Laparoscopic inguinal herniorrhaphy, Open inguinal herniorrhaphy
INTRODUCTION
Inguinal herniorrhaphy is ane of the well-nigh common constituent procedures performed worldwide. In the United states of america, an estimated 800,000 inguinal hernia repairs are performed each year, accounting for 10% to 15% of all surgical procedures.ane However, there continues to remain controversy surrounding the optimal surgical management of this condition. Several studies have validated the clinical utility of laparoscopic inguinal herniorrhaphy and have demonstrated comparable brusque-term rubber and long-term efficacy relative to the open arroyo.2,3
Given increasing fiscal constraints, procedural cost-effectiveness has become an important metric in evaluating surgical procedures. Although several studies take demonstrated higher costs associated with laparoscopic inguinal herniorrhaphy,4,–6 others have successfully reported toll-containment strategies in laparoscopic surgery.7 Given that elective inguinal hernia repairs are most oft ambulatory procedures, the straight operating room (OR) expense predominates every bit the driving gene in the full price of care. Therefore, the objective of this study was to compare the OR and full hospital costs associated with laparoscopic versus open inguinal herniorrhaphy performed at a publicly funded, tertiary bookish institution.
MATERIALS AND METHODS
Using a prospectively maintained database, all patients undergoing elective open or laparoscopic inguinal hernia repair between April 2009 and March 2011 at the Toronto Western Hospital, University Health Network, were identified. Open up inguinal herniorrhaphy was performed using a standardized Lichtenstein repair with either a polypropylene or a polyester mesh. A retrospective review of electronic patient records was performed, along with a standardized instance-costing assay using data from the Ontario Instance Costing Initiative.
Laparoscopic mesh repair varied by surgeon preference between a standardized transabdominal preperitoneal (TAPP) and a total extraperitoneal (TEP) arroyo. As part of a local cost-sensation strategy, permanent trocars are preferentially used. Laparoscopic balloons to dissect the preperitoneal space were rarely used.
Principal outcome variables included OR and full hospital costs. Budgetary values are shown in Canadian dollars and were converted to 2012 values using Consumer Toll Alphabetize inflationary adjustments. Secondary outcomes included perioperative complications, 30-day hospital readmission, and thirty-day emergency section visits. Curt-term perioperative complications included early recurrence, surgical site infection, seroma and hematoma germination, and urinary retention.
Statistical analysis was conducted using SPSS version 21 (SPSS, Inc, Chicago, Illinois). Patient information were evaluated using an intention-to-treat arroyo. Continuous variables are expressed equally means or medians and were compared using t tests, analysis of variance, or Mann-Whitney U tests equally appropriate. Chiselled variables are expressed as proportions and were compared using either χii or Fisher exact tests. A 2-sided P value < .05 was considered statistically significant.
Costing Analysis
The University Health Network Case Costing Department (CCD) is responsible for capturing costs ascribed to each patient's hospital visit. The University Wellness Network afterwards reports this information at regular intervals to ensure financial responsibility and fiduciary control. The total toll of intendance is recorded under the patient's unique medical record number and a specific hospital visit number. The total cost per patient visit (from preadmission to discharge) is an aggregate of private departmental costs; for the purposes of this study, departmental costing centers were grouped as advisable and termed "infirmary departments."
Specific visit numbers relating to patients undergoing elective inguinal herniorrhaphy were used to recollect costing information from the CCD. The estimate of cost was performed using a "lesser-up" approach, which identifies all of the resources directly used for a given intervention.8 The CCD uses a microeconomic method of costing. As such, full straight cost is calculated on the basis of the consumption of resources, including supplies, medications, investigations, food, and lodging expense. Each OR has a computerized dispensing cabinet that itemizes supplies used during each case and allocates price to a specific patient procedure (Pyxis ProcedureStation System; Cardinal Health, Dublin, Ohio). All pharmaceuticals throughout the hospital are dispensed by a similar organisation (Pyxis MedStation System; Primal Wellness). These costs are detailed in the CCD reports as "direct costs."
Personnel cost information were based on budgetary statements provided by individual infirmary departments to the CCD. Personnel cost includes the wages (compensation and benefits) of the nursing, paramedical, and administrative staffs. These totals were calculated using a "top-down" approach by dividing full costs by the number of patients admitted on any given day.nine These costs are subsequently reported in the CCD figures equally the "indirect costs" associated with specific hospital visits. Additional overhead expenses, such every bit heating costs, are derived past dividing total costs by ward square footage and the number of admitted patients. Equipment (including maintenance), facilities, and other global expenses (including it infrastructure) were included in departmental budgets.
Doctor fees are separately reimbursed by the Ontario Ministry building of Health and were not recorded in this study. Furthermore, postdischarge intendance, follow-upwardly, readmission, and potential loss of income were not included in this analysis. All costs were adapted for inflation to 2012 Canadian dollars co-ordinate to the Banking company of Canada's inflation figurer.
RESULTS
During the study period, 244 patients underwent constituent inguinal hernia repair. One hundred twenty-six patients (51.6%) underwent open inguinal herniorrhaphy, while 118 (48.4%) underwent laparoscopic repair. Among the laparoscopic cases, 94 patients (79.7%) underwent TAPP repair, while 24 (twenty.iii%) were treated using the TEP technique.
The demographic profiles of the 2 study cohorts are shown in Table i . Patients undergoing laparoscopic hernia repair were younger (mean age, 55 vs 66 years; P < .001) and had lower American Gild of Anesthesiologists classes (P < .001). A significantly college proportion of patients undergoing open surgical repair had histories of abdominal surgery (67.v% vs 46.six%, P < .001). Bilateral inguinal hernia repair was preferentially performed using a laparoscopic arroyo (72.7% vs 27.3%, P = .002), and all hernias diagnosed as bilateral had both sides operated during the aforementioned procedure.
Table 1.
Patient Demographics
| Variable | Open | Laparoscopic | P |
|---|---|---|---|
| n = 126 (51.6) | n = 118 (48.iv) | ||
| Age, mean, y | 66 | 55 | <.001 |
| BMI, mean, kg/m2 | 27 | 27 | .992 |
| Men | 119 (94.4) | 111 (94.1) | .900 |
| ASA class | |||
| I | 11 (viii.seven) | 37 (31.four) | <.001 |
| Ii | 39 (31.0) | 52 (44.1) | |
| III | 68 (54.0) | 26 (22) | |
| Iv | 8 (6.3) | 3 (2.five) | |
| Previous abdominal surgery, No. (%) | 85 (67.five) | 55 (46.6) | .001 |
| Laterality, No. (%) | |||
| Unilateral | 117 (92.9) | 94 (79.7) | .002 |
| Bilateral | 9 (7.one) | 24 (20.3) | |
| Direct/indirect, No. (%) | |||
| Straight | 42 (33.three) | 50 (42.4) | .068 |
| Indirect | 64 (fifty.8) | 53 (44.nine) | |
| Pantaloon | 7 (5.six) | 10 (8.5) | |
| Not specified | 13 (10.3) | 5 (4.ii) | |
| Recurrent, No. (%) | 12 (9.5) | 8 (vi.8) | .186 |
The perioperative outcomes for the two groups are shown in Table ii . All laparoscopic inguinal herniorrhaphies were performed under general anesthesia, compared with 42.9% of open cases. Twenty-three patients undergoing open up inguinal herniorrhaphy required postoperative admission, compared with 2 patients in the laparoscopic accomplice (P = .025). There was no deviation in the incidence of early recurrence or early on postoperative complications. One case was converted from laparoscopic (TAPP technique) to open repair considering of meaning small bowel adhesions. During the study period, there were no deaths or major complications identified in either grouping. Patients in the laparoscopic group had a longer median OR time of 101 minutes compared with 84 minutes for open repairs (P < .001).
Table 2.
Intra- and Postoperative Outcomes
| Variable | Open | Laparoscopic | P (ANOVA) |
|---|---|---|---|
| northward = 126 (51.6%) | n = 118 (48.4%) | ||
| Anesthesia, No. (%) | |||
| Full general | 54 (42.9) | 118 (100) | .000 |
| Local/regional | lxx (55.6) | 0 (0) | |
| Spine | ii (one.six) | 0 (0) | |
| Blazon of mesh, No. (%) | |||
| Polypropylene | 116 (92.i) | 57 (48.3) | .833 |
| Polyester | vii (five.6) | 60 (50.8) | |
| No mesh | one (0.8) | 0 (0) | |
| Not specified | 2 (1.half-dozen) | i (0.8) | |
| Length of stay | |||
| No stay | 103 (81.7) | 113 (95.8) | .025 |
| ≥one d | 23(18.three) | two (4.2) | |
| Follow up, No. (%) | 121 (96) | 111 (94.1) | .480 |
| 30-d readmission, No. (%) | |||
| Yes | one (0.viii) | 1 (0.8) | .480 |
| No | 120 (95.2) | 110 (93.two) | |
| Not specified | v (4.0) | 7 (5.ix) | |
| xxx-day ER visit, No. (%) | |||
| Yes | 10 (7.ix) | 6 (5.ane) | .487 |
| No | 111 (88.i) | 105 (89) | |
| Not specified | 5 (4.0) | 7 (5.nine) | |
| Recurrence, No. (%) | 2 (ane.half-dozen) | two (1.7) | .934 |
| Early complication, No. (%) | |||
| Hematoma | 10 (7.9) | 2 (i.7) | .333 |
| Seroma | vi (4.8) | 9 (7.six) | |
| Cellulites/infection | two (1.half dozen) | 1 (0.8) | |
| Urine retention | 0 (0) | 4 (iii.4) | |
| Non specified | 9 (7.one) | 9 (vii.6) |
Total hospital costs (from preadmission to discharge) for open unilateral inguinal herniorrhaphy were significantly lower than for the laparoscopic approach (median total cost, $3207.fifteen and $3723.66, respectively; P < .001). This difference in total costs was driven primarily by the OR costs associated with the laparoscopic approach (median OR cost, $2399.49 and $3092.03, respectively; P < .001) (Tabular array 3). Yet, OR and total hospital costs for repair of elective bilateral inguinal hernias were similar between the open and laparoscopic approaches (median total hospital cost, $4574.02 vs $4662.89; P = .827) (Tabular array 4).
Table 3.
Cost for Unilateral Inguinal Herniorrhaphy
| Cost Center | Open, $ | Laparoscopic, $ | P | ||
|---|---|---|---|---|---|
| Median | IQR | Median | IQR | ||
| Preadmission | 0.00 | 0.00–349.00 | 0.00 | 0.00–192.06 | .008 |
| PACU | 243.93 | 198.68–292.27 | 259.02 | 234.38–283.99 | .082 |
| Twenty-four hours surgery | 260.84 | 141.45–337.26 | 323.21 | 257.40–373.33 | <.001 |
| Full OR | 2399.49 | 2015.54–2763.42 | 3092.03 | 2476.03–3509.21 | <.001 |
| Ward | 0.00 | 0.00–59.32 | 0.00 | 0.00–59.32 | .341 |
| Other costs | 467.03 | 429.34–511.10 | 520.57 | 470.21–558.28 | .002 |
| Total | 3270.15 | 2775.63–3819.23 | 3723.66 | 3162.l–4375.28 | <.001 |
Table 4.
Price for Bilateral Inguinal Herniorrhaphy
| Cost Eye | Open, $ | Laparoscopic, $ | P | ||
|---|---|---|---|---|---|
| Median | IQR | Median | IQR | ||
| Preadmission | 278.85 | 0.00–363.76 | 0.00 | 0.00–210.98 | .142 |
| PACU | 284.00 | 251.44–345.26 | 244.66 | 231.61–284.fifteen | .193 |
| Day surgery | 221.33 | 145.41–363.46 | 266.24 | 233.84–364.52 | .222 |
| Total OR | 3471.86 | 3117.94–3702.82 | 3940.54 | 3195.835–4316.00 | .145 |
| Ward | 66.02 | 32.98–296.86 | 0.00 | 0.00–62.67 | .012 |
| Other costs | 588.28 | 526.83–608.59 | 571.27 | 545.84–644.78 | .032 |
| Total | 4574.02 | 4214.81–6361.29 | 4662.89 | 4178.84–5228.31 | .827 |
When comparing unilateral and bilateral hernia repair within the laparoscopic accomplice, there was no statistical deviation in the cost (either OR or total episode of intendance) between the TAPP and TEP techniques. Further to the operative approach, the use of general anesthesia was associated with an increased price compared with other types of anesthesia (local or regional) (P < .0001).
DISCUSSION
In this study, we systematically reviewed the OR and total infirmary costs involved with the treatment of inguinal hernias and, specifically, compared the costs associated with an open versus a laparoscopic approach. Our results demonstrate that OR and full hospital costs for open up unilateral inguinal hernia repair were significantly lower than for the laparoscopic approach. However, OR and total hospital costs for repair of bilateral inguinal hernias were similar between the 2 groups.
The results of this analysis are comparable with those from other centers in the United States. Several authors have demonstrated that the primary departure in cost relates to OR expense. Khajanchee et al7 showed a $795 incremental cost associated with the TEP approach relative to an open up Lichtenstein repair. Similarly, Schneider et aliv constitute the total cost of laparoscopic herniorrhaphy to be college than for the open up approach ($2,861 vs $2,009). Combined with the current analysis, these studies advise that the total cost of each process may be contained of local economic factors and may be directly attributable to surgical technique.
Nonetheless, the perioperative benefits of laparoscopy are significant. Several studies have demonstrated enhanced recovery after surgery, shorter lengths of stay, and fewer perioperative complications associated with a minimally invasive approach. Equally such, the incremental value associated with laparoscopic repairs of unilateral hernias may justify the increased relative cost ($453.51). Further studies using hernia-specific outcomes are necessary to understand the economic utility and price-effectiveness of each arroyo.
This study has several important limitations. The inherent selection bias that accompanies a retrospective study design cannot be ignored. Differences in patient demographics and surgeon preference may accept influenced the technique used. In addition, the calculation of total hospital cost does not address the out-of-infirmary expenses incurred by the patients. Furthermore, the indirect and societal costs associated with patient suffering, loss of productivity, and caregiver expense are difficult to quantify. Farther studies are needed to evaluate the total societal cost associated with inguinal hernia repairs to decide the price-effectiveness of each strategy.
A methodological limitation in the cost analysis is related to the institutional sectionalisation of expenses. OR costs are amassed as an aggregate of all expenses incurred in the OR. As such, with the current accounting arrangement, it is hard to dribble the cloth contribution of operative time, general anesthesia, or equipment costs to the total expense. A refined case-costing system may provide additional insight into each component of patient care and highlight opportunities for efficiency.
CONCLUSIONS
In the setting of a Canadian 3rd academic hospital, the OR and total hospital costs of open inguinal herniorrhaphy were significantly lower than for the laparoscopic approach. All the same, in that location was no statistical difference between OR and total hospital costs when comparing open up surgical and laparoscopic techniques for repair of bilateral inguinal hernias. Given the perioperative benefits of laparoscopic surgery, further studies incorporating hernia-specific outcomes are necessary to make up one's mind the cost-effectiveness of each approach and to ascertain the optimal treatment strategy.
Contributor Information
Fernando Spencer Netto, Universidade exercise Oeste do Parana, Cascavel, Brazil.
Fayez Quereshy, Division of Full general Surgery, University Health Network, Toronto, Ontario, Canada. Department of Surgery, University of Toronto, Toronto, Ontario, Canada.
Bruna M. Camilotti, Universidade Regional de Blumenau, Blumenau, Brazil.
Kristen Pitzul, Division of General Surgery, University Health Network, Toronto, Ontario, Canada.
Josephine Kwong, Division of General Surgery, University Health Network, Toronto, Ontario, Canada.
Timothy Jackson, Partition of General Surgery, University Health Network, Toronto, Ontario, Canada. Section of Surgery, Academy of Toronto, Toronto, Ontario, Canada.
Todd Penner, Division of General Surgery, University Health Network, Toronto, Ontario, Canada. Section of Surgery, University of Toronto, Toronto, Ontario, Canada.
Allan Okrainec, Division of General Surgery, University Health Network, Toronto, Ontario, Canada. Department of Surgery, University of Toronto, Toronto, Ontario, Canada.
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Source: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4216173/
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