Patient satisfaction, chronic pain, and quality of life after elective incisional hernia repair: effects of recurrence and repair technique.

PURPOSE: To determine the effects of repair technique and hernia recurrence on patient-reported outcomes after incisional hernia repair. METHODS: This cohort study included patients from sixteen Veteran's Affairs Medical Centers across the United States who underwent elective incisional hernia repair between 1997 and 2002. Technical details and outcomes (repair type and recurrence status) were determined by physician chart review. Patient satisfaction, chronic pain (McGill pain scale and visual analogue scale), and health-related quality of life (Short Form 36) were evaluated with a mailed survey at a median of five years after repair. Multivariable regression modeling was performed to evaluate the effect of repair type and recurrence status on patient-reported outcomes. RESULTS: Of 854 patients alive at the time of survey mailing, 371 responded (43.4%). Patients with active recurrence were more likely to be dissatisfied with their results (odds ratio (OR) 6.2, P < 0.0001), to have chronic sensory hernia site pain (OR 3.2, P = 0.01), to report disturbance from pain (OR 2.1, P = 0.04), and to have significantly worse quality of life on the Physical Function, General Health, and Physical Component Score domains. Repair technique with permanent mesh versus suture had no independent effect on patient satisfaction, chronic pain, or QOL. CONCLUSIONS: Recurrence has a substantial negative effect on patient-reported outcomes after incisional hernia repair, whereas the repair technique has no independent effect.

Open suture versus mesh repair of primary incisional hernias: a cost-utility analysis.

BACKGROUND: Despite 100,000 ventral hernia repairs (VHR) being performed annually, no gold standard for the technique exists. Mesh has been shown to decrease recurrence rates, yet, concerns of increased complications and costs prevent its systematic use. We examined the cost-effectiveness of open suture (OS) versus open mesh (OM) in primary VHR. METHODS: A decision analysis model from the payer's perspective comparing OS to OM was constructed for calculating the total costs and cost-effectiveness. Probabilities for complications and outcomes were derived from the literature. The costs represented institutional fixed costs. The outcome measure of effectiveness was recurrence. One-way sensitivity analysis and a probabilistic analysis using Monte Carlo simulation were performed. RESULTS: OS was associated with a total cost of $16,355 (+/-6,041) per repair, while OM was $16,947 (+/-7,252). At 3-year follow-up, OM was the more effective treatment with 73.8% being recurrence-free, compared with 56.3% in the OS group. The incremental cost to prevent one recurrence by the placement of mesh was $1,878. OM became the less effective treatment strategy when the infection rate exceeded 35%. At a willingness to pay level of $5,500, OM was the more cost-effective treatment strategy. CONCLUSION: In subjects without contraindication to mesh placement, OM repair is the more effective surgical treatment for VHR, with a lower risk of recurrence at a small cost to the payer.

Cross-validation of prediction equations for resting energy expenditure in young, healthy children.

OBJECTIVE: To examine the accuracy of several prediction equations for resting energy expenditure (REE) in children. DESIGN: REE was measured in 113 prepubertal children (60 girls and 53 boys aged 3.9 to 7.8 years old, weighing 14.7 to 30.0 kg) using indirect calorimetry and compared with values estimated from the prediction equations of Altman and Dittmer, The Food and Agriculture Organization/World Health Organization/United Nations University (FAO/WHO/UNU), Maffeis et al, and Harris and Benedict. STATISTICAL ANALYSIS: Measured REE (MREE) was compared with predicted REE (PREE) by means of regression analysis. Prediction equations were considered accurate if the regression of MREE vs PREE was not significantly different from the line of identity (slope=1.0; intercept=0). Precision was assessed by the multiple correlation coefficient of the regression of MREE vs PREE. RESULTS: MREE was 938+/-119 kcal/day, and PREE was 1,057+/-224 kcal/day for the Altman and Dittmer equations, 956+/-84 kcal/day for the FAO/WHO/UNU equations, 948+/-64 kcal/day for the equations of Maffeis et al, and 954+/-102 kcal/day for the Harris-Benedict equations. The regression of MREE vs PREE was significantly different from the line of identity for all prediction equations except the FAO/WHO/UNU equations (slope=0.96, P=.735; intercept=-15 kcal/day, P=.885 for girls and slope=1.08, P=.635; intercept=-62 kcal/day, P=.635 for boys). None of the equations was precise for MREE vs PREE (for all, R2<.6). For the FAO/WHO/UNU equations, less than half of the predictions were within +/-50 kcal/day but 99% were within 200 kcal/day. CONCLUSION: Most prediction equations for REE in children do not accurately or precisely estimate REEs. The exception is the FAO/WHO/UNU equations, which are reasonably accurate and precise for practical purposes.