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Cost-Effectiveness of Non-operative Management of Inguinal Hernias in the Elderly: a Markov Model
*Karina A Newhall1, *Maureen Hill1, *Philip P Goodney1,2, Timothy Counihan2,1
1Dartmouth Hitchcock Medical Center, Lebanon, NH;2White River Junction Veterans Administration Hospital, White River Junction, VT
Objective: Randomized trials of non-operative management of inguinal hernias have noted similar quality of life and very low rates of incarceration among patients with unrepaired hernias. However, most elderly patients within these trials developed pain, prompting eventual surgical repair. Given the higher risks of both elective and emergent surgery in older patients, we sought to evaluate whether non-operative management of asymptomatic inguinal hernias is a cost-effective strategy in older patients.
Design: Cost-utility analysis using a Markov model
Setting: Hypothetical cohort of men in United states
Patients: Men aged 65-90 with single asymptomatic inguinal hernia
Interventions: Non-operative management versus open elective repair
Main Outcome Measures: Cost/quality-adjusted-life-year (QALY)
Results: With our base case assumptions, including reimbursement of $1965 per elective hernia repair (current Medicare reimbursement for ambulatory surgical center), we found that watchful waiting is the preferred strategy for men aged 65-71, and those aged over 84 with an asymptomatic groin hernia. In this model, we noted that for a 65-year old male, watchful waiting cost $29/QALY versus $141/ QALY for elective repair. When the cost of elective repair exceeded $2500 (reimbursement for repair in an inpatient setting), it was no longer the preferred strategy for men of any age group. Likewise, if annual risk of developing pain from an asymptomatic hernia dropped below 3%, elective repair was not preferred for any age group. The model was sensitive to the risks of incarceration within the 65-70 year old age group, with annual risk of incarceration over 0.8% favoring primary elective repair.
Conclusions: Elective hernia repair for older men is a cost-effective strategy if the procedure is performed in an outpatient or ambulatory surgical clinic.
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