The economic impact of rostering junior doctors to triage to assist nursing staff in the early part of the patient journey through the emergency department.

OBJECTIVE: This study aims to determine whether redeploying junior doctors to assist at triage represents good value for money and a good use of finite staffing resources. METHODS: We undertook a cost-minimisation analysis to produce new evidence, from an economic perspective, about the costs associated with reallocating junior doctors in the emergency department. We built a decision-analytic model, using a mix of prospectively collected data, routinely collected administrative databases and hospital costings to furnish the model. To measure the impact of uncertainty on the model's inputs and outputs, probabilistic sensitivity analysis was undertaken, using Monte Carlo simulation. RESULTS: The mean costs for usual care were $27,035 (95% CI $27,016 to $27,054), while the mean costs for the new model of care were $25,474, (95% CI $25,453 to $25,494). As a result, the mean difference was -$1,561 (95% CI -$1,533 to -$1,588), with the new model of care being a less costly approach to managing staffing allocations, in comparison to the usual approach. CONCLUSION: Our study shows that redeploying a junior doctor from the fast-track area of the department to assist at triage provides a modest reduction in cost. Our findings give decision-makers who seek to maximise benefit from their finite budget, support to reallocate personnel within the ED.

Three months in a high-volume tertiary orthopaedic trauma unit: What is a registrar worth?

BACKGROUND: South Africa has a high burden of traumatic injuries that is predominantly managed in the public healthcare system, despite the relative disparity in human resources between the public and private sectors. Because of budget and theatre time constraints, the trauma waiting list often exceeds 50 - 60 patients who need urgent and emergent surgery in high-volume orthopaedic trauma centres. This situation is exacerbated by other surgical disciplines using orthopaedic theatre time for life-threatening injuries because of lack of own theatre availability. One of the proposed solutions to this problem is outsourcing of some of the cases to private medical facilities. OBJECTIVES: To establish the volume of work done by an orthopaedic registrar during a 3-month trauma rotation, and to calculate the implant and theatre costs, as well as compare the salary of a registrar with the theoretical private surgeon fees for procedures performed by the registrar in the 3-month period. METHODS: In a retrospective study, the surgical logbook of a single registrar during a 3-month rotation, from 14 January to 14 April 2019, was reviewed. Surgeon fees were calculated for these procedures, according to current medical aid rates, without additional modifier codes being added. RESULTS: During the 3-month study period, a total of 157 surgical procedures was performed, ranging from total hip arthroplasty to debridement of septic hands. Surgeon fees amounted to ZAR186 565.10 per month ‒ double the gross salary of a registrar. Total implant costs amounted to ZAR1 272 667. Theatre costs were ZAR1 301 976 for the 3-month period. CONCLUSIONS: Although this analysis was conducted over a short period, it highlights the significant amount of trauma work done by a single individual at a high-volume tertiary orthopaedic trauma unit. With increasing budget constraints, pressure on theatre time and a growing population, cost-effective expansion of resources is needed. From this study, it appears that increasing capacity in the state sector could be cheaper than private outsourcing, although a more in-depth analysis needs to be conducted.

Efficiency of Increasing Prospective Resident Entrustment in the Operating Room.

BACKGROUND: Prospective resident entrustment (i.e., trust an attending surgeon intends to give to a resident in the near future) in the operating room (OR) closely associates with granted future autonomy. However, the process of determining resident entrustment takes time and effort. Thus, this study aimed to assess the efficiency of granting incremental resident entrustment for upcoming surgical cases. METHODS: We analyzed prospective resident entrustment of 6 chief residents in 76 cases of laparoscopic cholecystectomy, laparoscopic colectomy, ventral hernia, and inguinal hernia scored by attending surgeon, resident, and a surgeon observer. Matched direct costs and operative time were extracted from hospital billing. We assessed the efficiency of granting incremental prospective resident entrustment with direct cost per minute incurred in the evaluated case. Effect size was computed to assess the differences between groups. RESULTS: Sixty-three cases (82.9%) were matched; 47.6% (30/63) of matched cases received prospective resident entrustment score ≥ 4. The direct cost per minute increased in three procedures (laparoscopic cholecystectomy, laparoscopic colectomy, and ventral hernia) with increased intention of granting incremental resident entrustment. Inguinal hernia was the only procedure in which chiefs were entrusted with future independence while the direct cost per minute decreased. CONCLUSIONS: Our findings demonstrate more time and effort are required (except for inguinal hernia) for residents to be entrusted with increased independence in the future. Faculty and resident development programs are recommended to improve the efficiency of the process of granting incremental operative entrustment to optimize resident training quality and cost of care delivery.

Cost-Consequences Analysis of Increased Utilization of Triple-Chamber-Bag Parenteral Nutrition in Preterm Neonates in Seven European Countries.

The safety of parenteral nutrition (PN) remains a concern in preterm neonates, impacting clinical outcomes and health-care-resource use and costs. This cost-consequence analysis assessed national-level impacts of a 10-percentage point increase in use of industry-prepared three-chamber bags (3CBs) on clinical outcomes, healthcare resources, and hospital budgets across seven European countries. A ten-percentage-point 3CB use-increase model was developed for Belgium, France, Germany, Italy, Portugal, Spain, and the UK. The cost-consequence analysis estimated the impact on compounding error harm and bloodstream infection (BSI) rates, staff time, and annual hospital budget. Of 265,000 (52%) preterm neonates, 133,000 (52%) were estimated to require PN. Baseline compounding methods were estimated as 43% pharmacy manual, 16% pharmacy automated, 22% ward, 9% outsourced, 3% industry provided non-3CBs, and 7% 3CBs. A modeled increased 3CB use would change these values to 39%, 15%, 18%, 9%, 3%, and 17%, respectively. Modeled consequences included -11.6% for harm due to compounding errors and -2.7% for BSIs. Labor time saved would equate to 41 specialized nurses, 29 senior pharmacists, 26 pharmacy assistants, and 22 senior pediatricians working full time. Budget impact would be a €8,960,601 (3.4%) fall from €260,329,814 to €251,369,212. Even a small increase in the use of 3CBs in preterm neonates could substantially improve neonatal clinical outcomes, and provide notable resource and cost savings to hospitals.

The Cost to Attending Surgeons of Resident Involvement in Academic Hand Surgery.

PURPOSE: For many types of surgical cases, there is an increase in length with the participation of a resident physician. The lost operative time productivity is not necessarily mitigated in any fashion other than to benefit the experience of the trainee. Moreover, increasing pressures to maximize productivity, coupled with diminishing reimbursements serve to disincentive resident involvement. The aim of this study was to examine the opportunity cost in the academic setting for intraoperative resident participation during specific hand surgery cases. METHODS: Retrospective analysis was performed on the American College of Surgeons National Surgical Quality Improvement Project (NSQIP) database from 2006 to 2015. Cases were identified by Current Procedural Terminology code to isolate distal radius fracture repairs, carpal tunnel releases, scaphoid fractures repairs, and metacarpal fracture repairs. Variables collected included operation time, presence or absence of resident physician, and postgraduate year level. Statistical analysis was performed using the statistical computing software R 3.4.2 (R Foundation for Statistical Computing, Vienna, Austria). Cost analysis was performed to quantify the effect of operative times in terms of relative value units (RVUs) lost. RESULTS: A total of 3727 cases were identified. Of those, 1264 cases were performed with a resident present. Residents participated in cases with higher total RVU (14.91 vs 13.16, P < 0.001). There was a statistically significant increase of 24.3 minutes (P < 0.001) in the mean operation time with a resident present as compared with those without. Moreover, RVU per hour in resident cases was significantly lower by 2.97 RVU per hour or 21% (P < 0.001). Using the late 2018 Medicare physician conversion factor of US $33.9996, the opportunity cost to attending physicians is US $159.20 per case. CONCLUSIONS: Resident participation in surgical cases is paramount to the education of future trainees, particularly in the era of trainee duty hour reform. Because residents are participating in higher total RVU cases, this selection bias may be playing a role in explaining our result. Nonetheless, resident involvement for certain procedures comes at an opportunity cost to faculty surgeons. How to balance the cost to train residents in the emerging value-based health systems will prove to be challenging but requires consideration.

Presenteeism exposures and outcomes amongst hospital doctors and nurses: a systematic review.

BACKGROUND: Presenteeism is a behavior in which an employee is physically present at work with reduced performance due to illness or other reasons. Hospital doctors and nurses are more inclined to exhibit presenteeism than other professional groups, resulting in diminished staff health, reduced team productivity and potentially higher indirect presenteeism-related medical costs than absenteeism. Robust presenteeism intervention programs and productivity costing studies are available in the manufacturing and business sectors but not the healthcare sector. This systematic review aims to 1) identify instruments measuring presenteeism and its exposures and outcomes; 2) appraise the related workplace theoretical frameworks; and 3) evaluate the association between presenteeism, its exposures and outcomes, and the financial costs of presenteeism as well as interventions designed to alleviate presenteeism amongst hospital doctors and nurses. METHODS: A systematic search was carried out in ten electronic databases from 1998 to 2017 and screened by two reviewers. Quality assessment was carried out using the Critical Appraisal Skills Program (CASP) tool. Publications meeting predefined assessment criteria were selected for data extraction. RESULTS: A total of 275 unique English publications were identified, 38 were selected for quality assessment, and 24 were retained for data extraction. Seventeen publications reported on presenteeism exposures and outcomes, four on financial costing, one on intervention program and two on economic evaluations. Eight (39%) utilized a theoretical framework, where the Job-Demands Resources (JD-R) framework was the most commonly used model. Most assessed work stressors and resources were positively and negatively associated with presenteeism respectively. Contradictory and limited comparability on findings across studies may be attributed to variability of selected scales for measuring both presenteeism and its exposures/outcomes constructs. CONCLUSION: The heterogeneity of published research and limited quality of measurement tools yielded no conclusive evidence on the association of presenteeism with hypothesized exposures, economic costs, or interventions amongst hospital healthcare workers. This review will aid researchers in developing a standardized multi-dimensional presenteeism exposures and productivity instrument to facilitate future cohort studies in search of potential cost-effective work-place intervention targets to reduce healthcare worker presenteeism and maintain a sustainable workforce.

Is 24/7 In-House Intensivist Staffing Necessary in the Intensive Care Unit?

Over the past few decades, an increasing number of studies have shown that intensivist-staffed intensive care units (ICUs) lead to overall economic benefits and improved patient outcomes, including shorter length of stay and lower rates of complications and mortality. This body of evidence has convinced advocacy groups to adopt this staffing model as a standard of care in the ICU so that more hospitals are offering around-the-clock intensivist coverage. Even so, opponents have pointed to high ICU staffing costs and a shortage of physicians trained in critical care as barriers to implementing this model. While these arguments may hold true in low-acuity, low-volume ICUs, evidence has shown that in high-acuity, high-volume centers such as teaching hospitals and tertiary care centers, the benefits outweigh the costs. This article explores the history of intensivists and critical care, the arguments for 24/7 ICU staffing, and outcomes in various ICU settings but is not intended to be a comprehensive review of all controversies surrounding continuous ICU staffing.

The Growing Executive-Physician Wage Gap in Major US Nonprofit Hospitals and Burden of Nonclinical Workers on the US Healthcare System.

BACKGROUND: In an era of increasing healthcare costs, the number and value of nonclinical workers, especially hospital management, has come under increased study. Compensation of hospital executives, especially at major nonprofit medical centers, and the "wage gap" with physicians and clinical staff has been highlighted in the national news. To our knowledge, a systematic analysis of this wage gap and its importance has not been investigated. QUESTIONS/PURPOSES: (1) How do wage trends compare between physicians and executives at major nonprofit medical centers? (2) What are the national trends in the wages and the number of nonclinical workers in the healthcare industry? (3) What do nonclinical workers contribute to the growth in national cost of healthcare wages? (4) How much do wages contribute to the growth of national healthcare costs? (5) What are the trends in healthcare utilization? METHODS: We identified chief executive officer (CEO) compensation and chief financial officer (CFO) compensation at 22 major US nonprofit medical centers, which were selected from the US News & World Report 2016-2017 Hospital Honor Roll list and four health systems with notable orthopaedic departments, using publicly available Internal Revenue Service 990 forms for the years 2005, 2010, and 2015. Trends in executive compensation over time were assessed using Pearson product-moment correlation tests. As institution-specific compensation data is not available, national mean compensation of orthopaedic surgeons, pediatricians, and registered nurses was used as a surrogate. We chose orthopaedic surgeons and pediatricians for analysis because they represent the two ends of the physician-compensation spectrum. US healthcare industry worker numbers and wages from 2005 to 2015 were obtained from the Bureau of Labor Statistics and used to calculate the national cost of healthcare wages. Healthcare utilization trends were assessed using data from the Agency for Healthcare Quality and Research, the National Ambulatory Medical Care Survey, and the National Hospital Ambulatory Medical Care Survey. All data were adjusted for inflation based on 2015 Consumer Price Index. RESULTS: From 2005 to 2015, the mean major nonprofit medical center CEO compensation increased from USD 1.6 ± 0.9 million to USD 3.1 ± 1.7 million, or a 93% increase (R = 0.112; p = 0.009). The wage gap increased from 3:1 to 5:1 with orthopaedic surgeons, from 7:1 to 12:1 with pediatricians, and from 23:1 to 44:1 with registered nurses. We saw a similar wage-gap trend in CFO compensation. From 2005 to 2015, mean healthcare worker wages increased 8%. Management worker wages increased 14%, nonclinical worker wages increased 7%, and physician salaries increased 10%. The number of healthcare workers rose 20%, from 13 million to 15 million. Management workers accounted for 3% of this growth, nonclinical workers accounted for 27%, and physicians accounted for 5% of the growth. From 2005 to 2015, the national cost-burden of healthcare worker wages grew from USD 663 billion to USD 865 billion (a 30% increase). Nonclinical workers accounted for 27% of this growth, management workers accounted for 7%, and physicians accounted for 18%. In 2015, there were 10 nonclinical workers for every one physician. The cost of healthcare worker wages accounted for 27% of the growth in national healthcare expenditures. From 2005 to 2015, the number of inpatient stays decreased from 38 million to 36 million (a 5% decrease), the number of physician office visits increased from 964 million to 991 million (a 3% increase), and the number of emergency department visits increased from 115 million to 137 million (a 19% increase). CONCLUSIONS: There is a fast-rising wage gap between the top executives of major nonprofit centers and physicians that reflects the substantial, and growing, cost of nonclinical worker wages to the US healthcare system. However, there does not appear to be a proportionate increase in healthcare utilization. These findings suggest a growing, substantial burden of nonclinical tasks in healthcare. Methods to reduce nonclinical work in healthcare may result in important cost-savings. LEVEL OF EVIDENCE LEVEL: IV, economic and decision analysis.

Evaluating physician awareness of common health care costs in the emergency department.

BACKGROUND: Health care costs are on the rise in Canada and the sustainability of our health care system is at risk. As gatekeepers to patient care, emergency department (ED) physicians have a direct impact on health care costs. We aimed to identify current levels of cost awareness among ED physicians. By understanding the current level of physician cost awareness, we hope to identify areas where cost education would provide the greatest benefit in reducing ordering costs. METHODS: We conducted a survey evaluating current awareness of common ordering costs among ED physicians from two tertiary teaching hospitals. Our study population was comprised of 124, certified emergency medicine staff physicians and emergency medicine resident physicians. Our survey asked ED physicians to estimate the costs of 41 items across four categories of day-to-day ordering: imaging investigations, materials, laboratory tests, and pharmaceuticals. Items were selected based on frequency of use, availability of cost-effective alternatives, and tests considered to be "low yield". The primary outcome was percentages of underestimates, correct estimates, and overestimates for ED costs among ED physicians. RESULTS: The average percentage of correct cost estimates among ED physicians was 14% across the four ordering categories. Where cost-effective alternatives exist, ED physicians overestimated the cost of the more cost-effective item. They also underestimated the cost of low-yield tests.InterpretationED physicians demonstrated limited cost awareness of common health care costs. Further studies that characterize utilization of hospital resources based on ED physician awareness of cost-effective alternatives and cost of "low yield" tests are needed.

Task shifting in the management of hypertension in Kinshasa, Democratic Republic of Congo: a cross-sectional study.

BACKGROUND: The Democratic Republic of the Congo (DRC) is characterized by a high prevalence of hypertension (HTN) and a high proportion of uncontrolled HTN, which is indicative of poor HTN management. Effective management of HTN in the African region is challenging due to limited resources, particularly human resources for health. To address the shortage of health workers, the World Health Organization (WHO) recommends task shifting for better disease management and treatment. Although task shifting from doctors to nurses is being implemented in the DRC, there are no studies, to the best of our knowledge, that document the association between task shifting and HTN control. The aim of this study was to investigate the association between task shifting and HTN control in Kinshasa, DRC. METHODS: We conducted a cross-sectional study in Kinshasa from December 2015 to January 2016 in five general referral hospitals (GRHs) and nine health centers (HCs). A total of 260 hypertensive patients participated in the study. Sociodemographic, clinical, health care costs and perceived health care quality assessment data were collected using a structured questionnaire. To examine the association between task shifting and HTN control, we assessed differences between GRH and HC patients using bivariate and multivariate analyses. RESULTS: Almost half the patients were female (53.1%), patients' mean age was 59.5 ± 11.4 years. Over three-fourths of patients had uncontrolled HTN. There was no significant difference in the proportion of GRH and HC patients with uncontrolled HTN (76.2% vs 77.7%, p = 0.771). Uncontrolled HTN was associated with co-morbidity (OR = 10.3; 95% CI: 3.8-28.3) and the type of antihypertensive drug used (OR = 4.6; 95% CI: 1.3-16.1). The mean healthcare costs in the GRHs were significantly higher than costs in the HCs (US$ 34.2 ± US$3.34 versus US$ 7.7 ± US$ 0.6, respectively). CONCLUSION: Uncontrolled HTN was not associated with the type of health facility. This finding suggests that the management of HTN at primary healthcare level might be just as effective as at secondary level. However, the high proportion of patients with uncontrolled HTN underscores the need for HTN management guidelines at all healthcare levels.

Migration intentions among Portuguese junior doctors: Results from a survey.

Migration of health personnel during periods of economic crisis represents a challenge for policymakers in origin and destination countries. Portugal is going through a period of economic hardship and much has been speculated about an increase in junior doctors' migration during this period. Using a questionnaire administered to a sample of Portuguese junior doctors who were still in the general residency (1st-year after medical school), we aim at determining the prevalence of migration intentions among Portuguese junior doctors and to identify the most important drivers of career choice for those who are considering emigrating in the near future. In our sample, 55% of Portuguese junior doctors are considering working abroad in the coming 10 years. Several variables were associated with an intention to work abroad: female sex (odds ratio [OR] 0.559; 95% confidence interval [CI] 0.488-0.640), the National Medical Exam score (OR 0.978; 95% CI 0.961-0.996;), having studied abroad (OR 1.756; 95% CI 1.086-2.867) and considering income and research opportunities as key factors for future specialty choice (OR 1.356; 95% CI 1.132-1.626; OR 2.626; 95% CI 1.228-4.172). Our study warns of the shortages the country may face due to doctors' migration and the main factors behind migration intentions in Portugal. Developing physician retention strategies is a priority to appropriately address these factors.

A time series analysis of the effects of financial incentives and mandatory clinical applications as interventions to improve spontaneous adverse drug reaction reporting by hospital medical staff in China.

RATIONALE, AIMS, AND OBJECTIVES: Spontaneous reporting of adverse drug reactions (ADRs) in hospitals is often under-reported, which may lead to problems in patient management. This study was aimed to assess the effectiveness of a financial intervention based on a fine and a bonus for improving spontaneous reporting of ADRs by physicians in a hospital setting. METHODS: This study was conducted at the First Affiliated Hospital of Zhengzhou University (China). Starting in 2009, a bonus of 20 RMB (Chinese currency) was given for each spontaneous ADR report, and a fine of 50 RMB was given for any withheld ADR report. A time series analysis using autoregressive integrated moving average models was performed to assess the changes in the total number of spontaneous ADR reports between the preintervention period (2006-2008) and during the first (2009-2011) and second (2012-2014) intervention periods. RESULTS: The median number of reported ADRs per year increased from 29 (range 27-72) in the preintervention period to 277 (range 199-284) in the first intervention period and to 666 in the second (range 644-691). The monthly number of reported ADRs was stable during the 3 periods: 3.56 ± 3.60/month (95% confidence interval (CI), 2.42-4.75) during the preintervention period, 21 ± 13/month (95% CI, 16.97-25.80) in the first intervention period, and 56 ± 20/month (95% CI, 48.81-62.17) in the second intervention period. CONCLUSION: A financial incentive and ADR management regulations had a significant effect on the increase of reported ADRs.

Results of the 2015 Scoliosis Research Society Survey on Single Versus Dual Attending Surgeon Approach for Adult Spinal Deformity Surgery.

STUDY DESIGN: An electronic survey administered to Scoliosis Research Society (SRS) membership. OBJECTIVE: To characterize surgeon practices and views regarding the use of two attending surgeons for adult spinal deformity (ASD) surgery. SUMMARY OF BACKGROUND DATA: The use of two experienced attending surgeons can decrease the operative time, estimated blood loss, and perioperative complication rates. However, the current practice patterns for the use of two attending surgeons remains unknown. METHODS: An electronic, 27-question survey regarding single/dual attending surgeons was administered to the SRS membership. Determinants included: surgeon/practice demographics, assistant type/level of training, and questions regarding use of two attending surgeons. Overall reporting and comparisons between groups were made: US versus international, academic versus private practice, and experience <15 years versus >15 years. RESULTS: A total of 199 surgeons responded from 27 different countries. Overall and between the groups, the respondents significantly reported believing that two attending spine surgeons improves safety, decreases complications, and improves outcomes (P < 0.01). Approximately, 67.3% reported using a second attending ≤25% of the time (33.2% do not), and 24.1% use one ≥51% of the time (similar between groups); 51.1% that have a second attending feel it's limited by reimbursement and access concerns and 71.9% have difficulty getting the second attending reimbursed. 72.3% use a second attending for ALL of the following reasons (no difference between groups): "it's safer/reduces complications," "it decreases operative time," "it decreases blood loss," "it results in improved outcomes," "it's less work and stress for me." If reimbursement was equal/assured for a second attending, 67.5% would use one "more often" or "always." CONCLUSION: The respondents feel that having a second attending surgeon improves patient care, however most do not use one often. Reasons include reimbursement/access concerns and the majority would use one if reimbursement was equal and assured. Based on the current literature and these results, there is a need for working with third party payers to improve dual surgeon reimbursement rates in complex cases. LEVEL OF EVIDENCE: 5.

Effectiveness of Resident Physicians as Triage Liaison Providers in an Academic Emergency Department.

INTRODUCTION: Emergency department (ED) crowding is associated with detrimental effects on ED quality of care. Triage liaison providers (TLP) have been used to mitigate the effects of crowding. Prior studies have evaluated attending physicians and advanced practice providers as TLPs, with limited data evaluating resident physicians as TLPs. This study compares operational performance outcomes between resident and attending physicians as TLPs. METHODS: This retrospective cohort study compared aggregate operational performance at an urban, academic ED during pre- and post-TLP periods. The primary outcome was defined as cost-effectiveness based upon return on investment (ROI). Secondary outcomes were defined as differences in median ED length of stay (LOS), median door-to-provider (DTP) time, proportion of left without being seen (LWBS), and proportion of "very good" overall patient satisfaction scores. RESULTS: Annual profit generated for physician-based collections through LWBS capture (after deducting respective salary costs) equated to a gain (ROI: 54%) for resident TLPs and a loss (ROI: -31%) for attending TLPs. Accounting for hospital-based collections made both profitable, with gains for resident TLPs (ROI: 317%) and for attending TLPs (ROI: 86%). Median DTP time for resident TLPs was significantly lower (p<0.0001) than attending or historical control. Proportion of "very good" patient satisfaction scores and LWBS was improved for both resident and attending TLPs over historical control. Overall median LOS was not significantly different. CONCLUSION: Resident and attending TLPs improved DTP time, patient satisfaction, and LWBS rates. Both resident and attending TLPs are cost effective, with residents having a more favorable financial profile.

Cost-effectiveness of groin hernia repair from a randomized clinical trial comparing commercial versus low-cost mesh in a low-income country.

BACKGROUND: Over 200 million people worldwide live with groin hernia and 20 million are operated on each year. In resource-scarce settings, the superior surgical technique using a synthetic mesh is not affordable. A low-cost alternative is needed. The objective of this study was to calculate and compare costs and cost-effectiveness of inguinal hernia mesh repair using a low-cost versus a commercial mesh in a rural setting in Uganda. METHODS: This is a cost-effectiveness analysis of a double-blinded RCT comparing outcomes from groin hernia mesh repair using a low-cost mesh and a commercially available mesh. Cost-effectiveness was expressed in US dollars (with euros in parentheses, exchange rate 30 December 2016) per disability-adjusted life-year (DALY) averted and quality-adjusted life-year (QALY) gained. RESULTS: The cost difference resulting from the choice of mesh was $124·7 (€118·1). In the low-cost mesh group, the cost per DALY averted and QALY gained were $16·8 (€15·9) and $7·6 (€7·2) respectively. The corresponding costs were $58·2 (€55·1) and $33·3 (€31·5) in the commercial mesh group. A sensitivity analysis was undertaken including cost variations and different health outcome scenarios. The maximum costs per DALY averted and QALY gained were $148·4 (€140·5) and $84·7 (€80·2) respectively. CONCLUSION: Repair using both meshes was highly cost-effective in the study setting. A potential cost reduction of over $120 (nearly €120) per operation with use of the low-cost mesh is important if the mesh technique is to be made available to the many millions of patients in countries with limited resources. TRIAL REGISTRATION NUMBER: ISRCTN20596933 (http://www.controlled-trials.com).