Management of Reducible Ventral Hernias: Clinical Outcomes and Cost-effectiveness of Repair at Diagnosis Versus Watchful Waiting

OBJECTIVE: 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. BACKGROUND: 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. METHODS: 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 58y, 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 (ICERs). 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. RESULTS: With watchful waiting, 39% ultimately required repair (14% emergent) and 24% recurred. Seventy percent recurred with repair at diagnosis. Laparoscopic repair at diagnosis was cost-effective compared to open repair at diagnosis (ICER=$27,700/QALY). The choice of operative strategy (open versus laparoscopic) was sensitive to cost and post-operative quality of life. When perioperative mortality exceeded 5.2% or yearly recurrence exceeded 19.2%, watchful waiting became preferred. CONCLUSIONS: Ventral hernia repair at diagnosis is very cost-effective. The choice between open and laparoscopic repair depends on surgical costs and post-operative quality of life. In patients with high risk of perioperative mortality or recurrence, watchful waiting is preferred.