Regional variation and rising costs of groin hernia repairs in Australia: is there an urgent need for clinical consensus guidelines?

摘要

There has been a slow but steady rise in Australia over the past 20 years in the proportion of groin hernias repaired using a minimally invasive surgery (MIS) approach. In 2011/12, the absolute number of MIS operations performed for inguinal and femoral hernias overtook the number of open operations.1 The reasons for this are multifactorial and not necessarily based on strong clinical evidence or economics. When considering fixed costs such as operating room time and the use of disposables, in 2011/12 laparoscopic inguinal hernia repair in a Victorian metropolitan public hospital was AUS$1268 extra per procedure than open repair.2 In a private hospital in NSW in 2016, laparoscopic hernia repair performed as an overnight stay was AUD$2000 extra per procedure than an open repair done as a short stay operation.3 In the United States, the number of robotic-assisted inguinal hernia repairs rose an average of 2% per year from 2012 to 2018 across 73 Michigan hospitals,4 and cost an additional AUS$3260 (US$2200) per procedure compared with laparoscopic repair.5 The rising trends in MIS for groin hernia repair and increased access to robotics in Australia suggest that healthcare costs in relation to this surgical condition are set to increase. However, the potential impact of changing surgeon preferences on Medicare Benefits Schedule (MBS) expenditure for groin hernia repairs is unknown. In July 2021, Medicare introduced changes to the classification of abdominal wall hernias including a new MBS item number (30748) to replace the two previous numbers for laparoscopic or open repairs (30 609 or 30 614, respectively); raising the MBS fee slightly from $479.05 to $483.35 regardless of technique.6 This change effectively removed classifications for the surgeon's chosen repair method. The rationale behind this decision is unclear but has the potential to increase hospital and patient out of pocket costs if the repair method involves the use of significant disposable equipment or is followed by complications. The current report analysed Medicare statistical data for groin hernia repair procedures from July 2000 to June 2021—prior to the introduction of the new MBS item number. These data describe the Medicare reimbursement for hernia repair during this period, although this does not necessarily represent the cost of the operation or what the hospitals or surgeons charge. Over the period July 2000 to June 2021, data for MBS benefit per capita (i.e., per 100 000 population) were extracted for item numbers 30 609: ‘Femoral or inguinal hernia, laparoscopic repair of, other than a service associated with a service to which item 30614 applies’ and 30 614: ‘Femoral or inguinal hernia or infantile hydrocele, repair of, on a person 10 years of age or over, other than a service to which item 30503 or 30615 applies.’ For each financial year, data were disaggregated by state. Descriptive analysis and the proportions of expenditure were calculated using Microsoft Excel Version 16. The study was considered negligible risk and granted exemption from review by The University of Sydney Human Research Ethics Committee. During the study period, the national annual benefit increased by 2.7% per year from $4.7 million to $7.9 million. Total expenditure for laparoscopic repair rose from 22.6% in 2000/2001 to 61.0% in 2020/2021, exceeding open repair in 2014/2015 (Fig. 1). The average per capita spending for laparoscopic repairs increased by 6.5% per year ($5288 to $18556) and decreased for open repair by 2.1% per year ($18 103 to $11880). There were marked regional variations in spending across Australia (Table 1). In 2000/2001, the highest and least funded regions varied by 86.3% (QLD versus NT: $26 383 versus $14156). In 2020/2021, this figure increased to 130.8% (TAS versus NT: $43 542 versus $18870). The average annual growth in spending ranged from 0.4% in VIC to 2.8% in TAS. There was a 10-year regional difference in the crossover in spending for laparoscop