- Contents lists available at sciencedirect.com Journal homepage: www.elsevier.com/locate/vhri Economic Evaluation Cost-Effectiveness Analysis of Inguinal Hernia Repair With Mesh Performed by Surgeons and Medical Doctors in Ghana Jessica H. Beard, MD, Zin Min Thet Lwin, MBBS, Shilpa Agarwal, MD, Michael Ohene-Yeboah, MBChB, Stephen Tabiri, MD, Joachim K.A. Amoako, MBChB, Zoë Maher, MD, Carrie A. Sims, MD, Hobart W. Harris, MD, Jenny Löfgren, MD 2212-10 A B S T R A C T Objectives: Task-sharing is the pragmatic sharing of tasks between providers with different levels of training. To our knowledge, no study has examined the cost-effectiveness of surgical task-sharing of hernia repair in a low-resource setting. This study has aimed to evaluate and compare the cost-effectiveness of mesh repair performed by Ghanaian surgeons and medical doctors (MDs) following a standardized training program. Methods: This cost-effectiveness analysis included data for 223 operations on adult men with primary reducible inguinal hernia. Cost per surgery was calculated from the healthcare system perspective. Disability weights were calculated using pre- and postoperative pain scores and benchmarks from the Global Burden of Disease Study 2017. Results: The mean cost/disability-adjusted life-year (DALY) averted in the surgeon group was 444.9 United States dollars (USD) (95% confidence interval [CI] 221.2-668.5) and 278.9 USD (95% CI 199.3-358.5) in the MD group (P = .168), indicating that the operation is very cost-effective when performed by both providers. The incremental cost/DALY averted showed that task-sharing with MDs is also very cost-effective (95% bootstrap CI 2436.7 to 454.9). The analysis found that increasing provider salaries is cost-effective if productivity remains high. When only symptomatic cases were analyzed, the mean cost/DALY averted reduced to 232.0 USD (95% CI 17.1-446.8) for the surgeon group and 129.7 USD (95% CI 79.6- 179.8) for the MD group (P = .348), and the incremental cost/DALY averted increased by 45% but remained robust. Conclusions: Elective inguinal hernia repair with mesh performed by Ghanaian surgeons and MDs is a low-cost procedure and very cost-effective in the context of the study. To maximize cost-effectiveness, symptomatic patients should be prioritized over asymptomatic patients and a high level of productivity should be maintained. Keywords: cost-effectiveness analysis, global surgery, hernia repair, task-sharing. VALUE HEALTH REG ISSUES. 2022; 32:31–38 Introduction The provision of effective care for essential surgical conditions is now recognized as a crucial component of global healthcare delivery.1,2 Once thought to be too expensive in resource- constrained settings, essential surgical care has been shown to be cost-effective in low- and middle-income countries (LMICs).3-14 Using varying methodologies, studies have demonstrated cost- effectiveness of surgery for many conditions in LMICs, including inguinal hernia, obstetric emergencies, cataracts, and cardiac disease.6-9,11,12,15 We estimate that inguinal hernia affects 547 million people globally, including nearly 1 million people in Ghana.5,16 Limited access to inguinal hernia repair in LMICs leads to negative ef- fects on well-being and productivity.5 In 1 Ghanaian cohort study, 16% of hernia patients reported an inability to work, whereas 64% reported limitations in daily activities.17 Increased capacity for high-quality, cost-effective elective inguinal hernia 99/$36.00 - see front matter ª 2022 International Society for Health Econo repair is urgently needed in low-resource settings to alleviate the suffering of hernia patients and prevent potentially life- threatening complications.18 Advocated by the World Health Organization (WHO) to in- crease access to healthcare, task-sharing is the pragmatic sharing of tasks between providers with different levels of training.19,20 Task-sharing of surgical procedures with nonsurgeons is com- mon, especially in settings with limited human resources.21,22 Multiple studies have demonstrated that nonsurgeons can perform surgical procedures, including cesarean section, laparot- omy, and inguinal hernia repair with similar results compared with surgical specialists.23-28 In Ghana, task-sharing of surgical procedures between surgeons and medical doctors (MDs), who are doctors with limited formal training in surgery, is widely practiced.29-31 In fact, most inguinal hernia repairs in Ghana are performed by MDs.30,31 Our previous research indicates that both surgeons and MDs can perform elective mesh inguinal hernia repair in Ghana with excellent outcomes, nevertheless, to our mics and Outcomes Research. Published by Elsevier Inc. www.sciencedirect.com http://www.elsevier.com/locate/vhri Delta:1_given name Delta:1_surname Delta:1_given name Delta:1_surname Delta:1_given name Delta:1_surname Delta:1_given name Delta:1_surname Delta:1_given name Delta:1_surname http://crossmark.crossref.org/dialog/?doi=10.1016/j.vhri.2022.07.004&domain=pdf 32 VALUE IN HEALTH REGIONAL ISSUES NOVEMBER 2022 knowledge, the effect of task-sharing on cost-effectiveness of inguinal hernia repair has not been studied before.15 The purpose of this study was to compare the cost- effectiveness of inguinal hernia repair with mesh performed by Ghanaian surgeons and MDs following a standardized training program. The results of this study will add to understanding of the impact of task-sharing on mesh hernia repair cost-effectiveness and serve to inform policy makers on the cost-effectiveness of providing elective mesh inguinal hernia repair in healthcare set- tings with human resource constraints. Methods Training Course and Materials Developed in 2017, the Ghana Hernia Society’s mesh repair training program utilizes Ghana’s existing system of task-sharing to train both surgeons and MDs through lectures and supervised operations.15 Following completion of the inaugural course, trainees (2 surgeons and 3 MDs) performed 242 open inguinal hernia repairs under local anesthesia on adult men with primary reducible hernias. Hernias were repaired according to the Lich- tenstein technique using commercial polypropylene mesh pur- chased in Ghana. The MDs had completed medical school followed by a 2-year general internship but had no formal training in sur- gery. The surgeons had completed 6 years of postgraduate training in general surgery. Only trainees currently performing open tissue inguinal hernia repair were trained, and 1 surgeon trainee re- ported experience with mesh inguinal hernia repair. A previously published investigation found that MD trainees were noninferior to surgeons in terms of 1-year hernia recurrence (0.9% vs 2.8%, respectively) with equivalent rates of postoperative complications, chronic pain, and patient satisfaction.15 Study Setting and Procedures This study was conducted in Ghana, which is a lower-middle income country in West Africa. Although Ghana’s economy has been growing rapidly, an estimated 11.2% of people live on 1.90 United States dollars (USD) per day, the incidence of multidi- mensional poverty is 45.6%, and Ghana ranks 140 out of the 189 countries and territories on the Human Development Index.32-34 In 2003, Ghana became one of the first countries in the sub- Saharan African region to propose a government sponsored so- cial health insurance system, the national health insurance scheme (NHIS).35 Although Ghana’s NHIS was designed to be equitable and progressive, studies have found that individuals enrolled often make out-of-pocket payments at the point of care, and up to 18% of NHIS-insured Ghanaians make catastrophic healthcare payments.35 The study site was in Ho, Ghana at the Volta Regional Hospital, a 306-bed referral hospital for the Volta region under the man- agement of the Ghana Health Service. The hospital Finance, Pro- curement, and Human Resource Departments provided information about hospital budget, supplies, and payroll for 2017. Individual participants gave written informed consent to partici- pate in the initial cohort study.15 Of the 242 patients in the original study, 223 (92.1%) were available for follow-up at 1 year.15 Because this cost analysis relies on postoperative pain scores at 1 year, only the patients who completed 1 year follow-up (n = 223) were included. We used deidentified clinical information for these 223 patients, including patient age, operative time, and pre- and postoperative pain scores.15 The overall rate of severe post- operative pain at 1-year follow-up was 2.2%, with no difference between patients in the MD or surgeon groups. Further information about pre- and postoperative pain scores may be found in the results of the previously published outcomes study.15 The Temple University Institutional Review Board and the Ghana Health Service Ethical Review Committee approved this study. Cost and Cost-effectiveness Analysis This study is a cost-effectiveness analysis (CEA) of inguinal hernia repair with mesh performed by MDs and surgeons following the mesh hernia repair training program described above. First, we assessed generalized cost-effectiveness of the hernia operation performed by either provider, compared with no treatment. This analysis is most applicable to settings where there are limited or no specialist surgeons in Ghana. Then, we analyzed relative cost-effectiveness of the operation performed by MDs compared with surgeons. This analysis serves to further inform the allocative efficiencies of surgical task-sharing in contexts where human resources are less scarce. We designed our analysis using the recommendations fromWHO guide to CEA (2003)36 and from Drummond and Sculpher (2005).37 Costs from the healthcare system and providers’ perspective were used, including staff time, medicine and material costs, overhead costs, capital costs, and equipment costs (see Table 1). Because medicines and materials were standard for each opera- tion, a standard consumption was used for cost calculations. The cost for the commercially available mesh purchased for use in this study was 11 USD, and the mesh was paid for from the original training course budget. Operating room staff costs were calculated based on daily salary divided by 5, which was the standard number of hernia repairs performed by each provider and team per day. Salaries for ancillary staff were added to the hospital stay calculation. Per hospital policy, patients paid a standard out-of- pocket operation cost, which we included in our analysis. Because we did not collect cost data from patients, no indirect patient costs were included. Overhead costs were estimated based on space per square foot in the operating rooms and surgical wards along with the use of ancillary services (Table 1). Capital costs were calculated for the area used in the operating rooms and surgical wards along with any equipment used, accounting for depreciation. Costs were converted from Ghanaian cedis to USD using the 2017 exchange rate.38 No discounts were applied to costs as there were minimal expected needs for additional healthcare for limited long-term complications after elective inguinal hernia repair. Disability-adjusted life-year (DALY) is defined as the sum of the measure of years of life lived with a disability (YLD) and years of life lost (YLL). A value of 1 represents full health, whereas a value of 0 represents death. Following methods from previous global surgery CEAs, costs and DALYs averted were calculated for each individual patient.11,12,14 To determine YLD, we used patient re- sponses to the Inguinal Pain Questionnaire (IPQ) preoperatively and 1-year postoperatively.39 The IPQ is a 7-level scale in which a score of 1 represents no pain, 2 to 3 indicates mild pain that does not interfere with daily activities, 4 to 5 indicates pain that is moderate and debilitating, and 6 to 7 represents severe pain, which prevents daily activities completely.39 Disability weights (DWs) were determined by matching the IPQ score for each pa- tient with DWs used for inguinal hernia in the Global Burden of Disease Study 2017 (Table 221,22).40 Patients with no pain preop- eratively were assigned a DW of 0.011 as we considered the presence of the hernia a disability. Then, YLD was calculated by multiplying the DW by the remaining life expectancy at the time of surgery based on WHO Ghana Life Tables for each patient.41 To determine YLL, the estimated risk of early death was calculated to be 0.00112 per patient-year based on the risk of hernia Table 1. Items included in the cost analysis. Definition Source of information Cost calculation method Medicines and materials Medicines Intraoperative medicines used - Pharmacy price list Number of items per standard operation 3 price per item Materials Materials used in surgery - Procurement and supply departments Number of items per standard operation 3 price per item Staff costs Operating room Mean cost for MD or surgeon and one operating room nurse - Operative time and hospital payroll Mean operative time in minutes 3 salaries per minute Overhead costs Operating room Overhead costs proportional to operating room space vs hospital size - Measurement of building size - Hospital budget reports for Volta region Operating room size proportion 3 average annual expenditure/average number of operations per day Patient ward Overhead costs proportional to ward size vs hospital size - Measurement of building size - Average hospital budget in Volta region Ward size proportion 3 average annual expenditure/number of patients in ward per day Capital costs Operating room Potential cost if space had been rented as office space in Ho - Measurement of building size - Average price of leasing office space in Ho Operating room space in ft2 3 yearly cost per ft2 of office space in Ho town/365 days/mean number of operations per day Patient ward Potential cost if space had been rented as office space in Ho - Measurement of building size - Average price of leasing office space in Ho Patient ward space in ft2 3 yearly cost per ft2 of office space in Ho town/365 days/mean number of operations per day Equipment Cost of equipment per operation if all equipment had been bought new - Procurement and supply department - Electrical equipment office Equipment cost divided by number of operations equipment (depreciation calculated as cost/365 days 3 number of years item is depreciated over) Note. All hospital data were obtained from the Volta Regional Hospital in Ho, Ghana. MD indicates medical doctor. ECONOMIC EVALUATION 33 complication of 0.0056 and the assumption that the overall risk of death in a groin hernia emergency is 20%.4,5,14 This number was multiplied by the remaining life expectancy at the time of sur- gery.23 Of note, we assumed that the risk of early death after hernia repair was removed based on previous global surgery CEA methodology and hernia surgery literature.5,14,42 A discount rate of Table 2. Translation from IPQ score to disability weights using the G IPQ score GBD 1- No pain Not a 2- Pain present but could easily be ignored Mild; 3- Pain present could not be ignored, but did not interfere with everyday activities Mild; 4- Pain present could not be ignored, but interferes with concentration on chores and daily activities Mode 5- Pain present, could not be ignored, interferes with most activities Mode 6- Pain present could not be ignored, necessitated bed rest Sever 7- Pain present could not be ignored, prompt medical advice sought Sever GBD indicates Global Burden of Disease Study; IPQ, Inguinal Pain Questionnaire. 0.03 was applied in calculating DALYs. The following equations were used for analysis: DALY = YLD 1 YLL YLD = DW 3 remaining life expectancy at time of surgery YLL = risk of early death without surgery 3 remaining life expectancy at time of surgery BD 2017.21,22 severity category GBD disability weight pplicable 0.011 before surgery 0 after surgery does not interfere with daily activities 0.011 does not interfere with daily activities 0.011 rate; difficulties with daily activities 0.114 rate; difficulties with daily activities 0.114 e; unable to carry out daily activities 0.324 e; unable to carry out daily activities 0.324 Table 3. Patient characteristics, costs, and cost-effectiveness of inguinal hernia repair with mesh performed by surgeons and MDs. Characteristic Surgeon, n = 109 MD, n = 114 P value* Mean (SD) 95% CI Mean (SD) 95% CI Age, years 52.5 (17.4) 49.2-55.8 51.3 (16.1) 48.3-54.3 .587 Remaining life expectancy, years 23.3 (13.1) 20.8-25.8 26.2 (25.6) 21.4-30.9 .290 Operative time, minutes 56.1 (24.8) 51.4-60.9 59.1 (17.9) 55.8-62.4 .304 IPQ score preoperative 3.5 (1.9) 3.1-3.9 3.4 (1.8) 3.0-3.7 .615 IPQ score postoperative 1.0 (0.2) 1.0-1.1 1.1 (0.3) 1.0-1.1 .654 DW preoperative 0.14 (0.124) 0.12-0.16 0.12 (0.105) 0.10-0.14 .272 DW postoperative 0.0012 (0.011) 20.0008 to 0.0033 0.0022 (0.015) 20.0006 to 0.005 .595 Change in DW preoperative vs postoperative 20.13 (0.118) 20.15 to 20.11 20.12 (0.115) 20.14 to 20.1 .489 DALYs Averted (discounted) 2.03 (2.06) 1.64-2.43 2.08 (2.27) 1.65-2.50 .890 Cost/DALY averted, USD (discounted) 444.9 (1177.9) 221.2-668.5 278.9 (429.1) 199.3-358.5 .168 CI indicates confidence interval; DALY, disability-adjusted life-year; DW, disability weight; IPQ, Inguinal Pain Questionnaire; MDs, medical doctors; USD, United States dollars. *P values are presented for independent sample two-sided Student’s t test of means. 34 VALUE IN HEALTH REGIONAL ISSUES NOVEMBER 2022 Incremental cost-effectiveness ratio (ICER) was calculated to measure the economic value of inguinal hernia repair performed by MDs compared with that by surgeons. It is defined by the difference in cost between the 2 interventions, divided by the difference in their effect, which was incremental cost per incre- mental DALY averted in this analysis. We defined “very cost-effective” according to the approach suggested by the WHO as costing less than the per capita gross domestic product (GDP) of Ghana per DALY averted and “cost- effective” as , 3 times the per capita GDP of Ghana per DALY averted.43 For reference, the GDP per capita for Ghana in 2017 was 2074.291 USD.44 Sensitivity Analysis We performed a deterministic sensitivity analysis from the pro- vider’s perspective, including halved productivity, doubled and tripled salaries (for surgeons,MDs, and staff), 95%confidence interval (CI) of DWs,1/2 20% variations of standard cost per procedure, and risk of early death.We also analyzed the cost-effectiveness of hernia repair performed for symptomatic cases only (preoperative IPQ score $ 2). A probabilistic sensitivity analysis was also conducted by running 1000 simulations through a bootstrapping technique. Based on the results, 95% CI of the ICER was calculated. Statistical Analysis Data were analyzed using Microsoft Excel 2016 (Microsoft Corportation) and SPSS (IBM, version 27). Descriptive outcomes are expressed as means with SD and 95% CIs. Independent sample Table 4. Incremental cost-effectiveness of inguinal hernia repair wit Costs Surgeon, n = 10 Standard cost per procedure, USD 110.6 Incremental cost, USD DALYs averted (discounted) 2.03 Incremental DALY averted (discounted) ICER, USD (discounted) CI indicates confidence interval; DALY, disability-adjusted life-year; ICER, incremental two-sided Student’s t tests of means were used for cost- effectiveness comparisons between the 2 study groups. P , .05 was considered statistically significant. Results For the 223 male patients included in the study, the mean age at the time of surgery was 51.8 (SD 16.8) years, and the mean remaining life expectancy was 24.8 (SD 20.5) years (Table 3). There were no statistically significant differences in age or remaining life expectancy between the surgeon and MD groups. The surgeon mean operative time was slightly shorter (56.1, SD 24.8 minutes) than the mean operative time for MDs (59.1, SD 17.9 minutes), but this was not statistically significant (P = .304). The standard cost per procedure was 110.6 USD in the surgeon group and 102.8 USD in the MD group. As shown in Table 3, there was no significant difference in the mean number of DALYs averted or the mean cost per DALY averted between the provider groups. The mean DALYs averted per procedure were 2.03 (95% CI 1.64-2.43) in the surgeon group and 2.08 in the MD group (95% CI 1.65-2.50) (P = .0890). The mean cost per DALY averted was 444.9 USD (95% CI 221.2-668.5) in the surgeons group and 278.9 USD (95% CI 199.3-358.5) in the MD group (P = .168). The incremental cost of the operation performed by an MD when compared with a surgeon was 27.8 USD for 0.05 incre- mental DALY averted (95% bootstrap CI 20.51 to 0.57) (Table 4). The incremental cost per DALY averted (ie, ICER) showed that the MD group dominated the surgeon group (95% bootstrap CI2436.7 h mesh performed by MDs compared with surgeons. 9 MD, n = 114 95% bootstrap CI 102.8 27.80 2.08 0.05 20.51 to 0.57 Dominates 2436.7 to 454.9 cost-effectiveness ratio; MD, medical doctors; USD, United States dollars. Table 5. Sensitivity analysis on cost-effectiveness of inguinal hernia repair with mesh performed by surgeons and MDs. Cost/DALY averted, USD Surgeon, n = 109 MD, n = 114 P value* Mean (SD) 95% CI Mean (SD) 95% CI Baseline 444.9 (1177.9) 221.2-668.5 278.9 (429.1) 199.3-358.5 .168 Doubled salaries 545.8 (1445.2) 271.4-820.2 325.9 (501.4) 232.8-418.9 .135 Tripled salaries 646.8 (1712.5) 321.6-971.9 372.9 (573.8) 266.4-479.4 .115 Halved productivity 655.1 (1734.7) 325.8-984.5 420.6 (647.2) 300.5-540.7 .179 Standard cost per procedure (1 20%) 533.81 (1413.4) 265.5-802.2 334.6 (514.9) 239.1-430.2 .168 Standard cost per procedure (2 20%) 355.9 (942.3) 177.0-534.8 223.1 (343.3) 159.4-286.8 .168 Mortality (1 20%) 415.1 (997.1) 225.8-604.4 275.2 (421.9) 196.9-353.5 .171 Mortality (2 20%) 487.7 (1453.4) 221.8-763.7 282.6 (436.5) 201.6-363.6 .160 DW for IPQ 6-7 (upper limit) 443.2 (1178.5) 219.4-666.9 277.8 (429.7) 198.1-357.5 .170 DW for IPQ 6-7 (lower limit) 447.8 (1176.8) 224.4-671.3 280.8 (427.9) 201.4-360.2 .165 DW for IPQ 4-5 (upper limit) 435.3 (1180.6) 211.2-659.5 271.0 (432.6) 190.7-351.3 .174 DW for IPQ 4-5 (lower limit) 459.1 (1174.1) 236.2-682.0 290.6 (424.5) 211.8-369.4 .160 DW for IPQ 2-3 (upper limit) 331.4 (1145.1) 114.0-548.8 166.0 (228.2) 123.7-208.3 .141 DW for IPQ 2.3 (lower limit) 698.4 (1345.5) 442.9-953.8 531.1 (875.1) 368.7-693.4 .270 Discount rate (0) 272.2 (451.4) 186.5-357.9 218.9 (380.8) 148.2-289.5 .340 Symptomatic hernia patients (IPQ 2 and above)† 232.0 (984.0) 17.1-446.8 129.7 (234.9) 79.6-179.8 .348 CI indicates confidence interval; DALY, disability-adjusted life-year; DW, disability weight; IPQ, Inguinal Pain Questionnaire; MD, medical doctor; SD, standard deviation; USD, United States dollars. *P values are presented for independent sample two-sided Student’s t test of means. †There were 87 symptomatic patients in the MD group and 83 symptomatic patients in the surgeon group. ECONOMIC EVALUATION 35 to 454.9) in conducting mesh hernia repair for the study participants. Table 5 presents the results from the sensitivity analysis of the cost per DALY averted for the operation in each provider group to variations of key parameters. Halved productivity, from a standard of 5 cases per day to 2.5 cases per day, increased the cost per DALY averted by approximately 50%, or to a similar level to the scenario where all salaries were tripled. A significant impact on cost- effectiveness of the operation was seen when asymptomatic patients were excluded from the analysis. For patients with symptomatic hernias, the mean cost per DALY averted was 232.0 (95% CI 17.1-446.8) in the surgeon group and 127.9 (95% CI 79.6- 179.8) in the MD group (P = .348). For all scenarios, inguinal hernia repair with mesh remained very cost-effective when performed by either provider level in Ghana. Figure 1 illustrates the sensitivity of the incremental cost per DALY averted (ICER) of the operation performed by MDs compared with surgeons to variations of key parameters. The most signifi- cant change was caused by the salary increase, which propor- tionately lowered the ICER. No discounting and prioritizing patients with symptomatic hernias, on the other hand, raised the ICER by 78% and 45%, respectively. Adjustments of other param- eters, such as DWs, standard cost per procedure, risk of early death, and half productivity led to relatively subtle changes to the value. The ICER remained robust in all tested scenarios. Discussion We found that elective inguinal hernia repair with commercial mesh performed by Ghanaian surgical care providers on male patients with primary reducible hernias is very cost-effective. Our findings echo the results of previous hernia repair cost- effectiveness analyses conducted in Western Ghana, Uganda, and Ecuador, adding further evidence to support the prioritization of inguinal hernia repair with mesh in the delivery of primary healthcare in LMICs.11,12,14,45 Our study adds new knowledge to the global health and global surgery cost-effectiveness literature and is the first of its kind to explore the effect of task-sharing on hernia surgery cost- effectiveness. Previous economic evaluations of surgical task- sharing have shown mixed results. A study from Mozambique found that employing a nonphysician clinician or técnico de cir- urgia to perform obstetric surgical care costs one-third as much as the cost involved in employing a specialist in Obstetrics.46,47 Conversely, a modeling study investigating task-sharing for sur- gical care in rural Ethiopia conducted by Shrime and colleagues4 found that, although surgical task-sharing has a significant posi- tive health impact, it does so by increasing costs for already impoverished people. In our study, we found that open mesh re- pairs performed by both surgeons and MDs were very cost- effective compared with the threshold value of Ghana’s GDP per capita. Although the ICER inferred the likely cost-effectiveness of MDs compared with surgeons, the difference in cost per operation between surgeons and MDs was just 7.8 USD, and there were no statistically, financially, or clinically significant differences in effectiveness of the operation between the 2 provider groups. Therefore, task-sharing of inguinal hernia repair with MDs did not result in significant cost saving. There are several possible explanations for the finding of no significant difference in cost-effectiveness between the 2 provider groups. First, although there was a difference between the salaries of surgeons and MDs, salary represents a relatively small pro- portion of the total costs of hernia surgery for both types of Figure 1. Sensitivity analysis on incremental cost-effectiveness of inguinal hernia repair with mesh performed MDs compared with surgeons. Tripled salaries Doubled salaries Disability weight for IPQ 6-7 (+20%) Disability weight for IPQ 4-5 (+20%) Disability weight for IPQ 2-3 (+20%) Disability weight for IPQ 2-3 (-20%) Risk of early death (+20%) Risk of early death (-20%) Disability weight for IPQ 4-5 (-20%) Disability weight for IPQ 6-7 (-20%) Halved productivity -200% -150% -100% -50% 0% Change in ICERa value 50% 100% 150% 200% Percent increase in ICER valuePercent decrease in ICER value aICER indicates incremental cost-effectiveness ratio; MD, medical doctors. 36 VALUE IN HEALTH REGIONAL ISSUES NOVEMBER 2022 providers in this study. Because both surgeons and MDs can perform multiple hernia operations per day, the differences in salaries were divided among multiple patients. This study did not include costs relating to the training of healthcare providers. Including training costs would have increased the costs for both cadres, most likely more so for the surgeons compared with the MDs. Although cost is an important element in the delivery of essential surgery, access to care is also necessary in a functioning surgical system. In Ghana, a nationwide study found that most first-level hospitals did not have a surgeon despite performing a significant number of district-level hernia surgeries.30,31 Based on the results of the present study, the main benefit of task-sharing between surgeons and MDs is not cost saving. Instead, task- sharing with MDs serves to expand the pool of skilled surgical providers able to provide hernia surgery for the many millions of people living with hernia in Ghana and sub-Saharan Africa. Well- trained MDs are vital members of the Ghanaian surgical work- force, ensuring essential surgical care in district hospitals, especially in rural areas.30,31 Our sensitivity analysis shows that productivity appears to be key to maintaining high levels of cost-effectiveness, although it does not seem to have an impact on the ICER between the 2 provider groups. In the context of the study, if high productivity can be ensured, salaries for all surgical providers could be increased while maintaining cost-effectiveness. Increased salaries could motivate surgeons, MDs, and staff to perform the significant volume of hernia surgeries needed to have a public health impact on the burden of disease from hernia in Ghana. In addition, increasing salaries could address challenges with hiring and retaining providers in rural or underserved areas. From the health economics and equity perspectives, patients with symptomatic inguinal hernia should be prioritized over those with asymp- tomatic hernia in the design of future public health interventions. To place our study in context, we reviewed the existing liter- ature on inguinal hernia repair cost-effectiveness globally. We found 8 studies conducted in 7 countries, including 3 high-income countries and 4 LMICs.11,12,14,45,48-51 Several methods of hernia repair were studied, including tissue repair, open mesh repair (mosquito-net and commercial mesh), and laparoscopic repair. Varying measures of cost and cost-effectiveness were used, including cost, DALYs averted, and quality-adjusted life-years gained. Our review of these studies indicates that inguinal hernia repair is cost-effective across a variety of surgical methods and contexts and in countries of all income levels.11,12,14,45,48-51 Our study overcomes some limitations found in previous research. Of the 8 studies we reviewed, 2 were analyses of cost data from international surgical missions, which may not accu- rately reflect the day-to-day delivery of surgical care in LMICs.11,12 In Shillcutt and colleagues’11 CEA of an Operation Hernia mission in Ghana, the hernia repair cost-effectiveness was greater than the cost-effectiveness found in our study. Shillcutt’s higher cost- effectiveness could be because salary, transportation, and costs of lost wages for the high-income surgeons who participated were not included. In addition, an extremely low-cost mosquito-net mesh was used for hernia repair, which is no longer recom- mended.52 In contrast, our study analyzed the cost and cost- effectiveness of hernia repair performed by local providers using locally available materials, including standard commercial mesh, and is therefore more likely to accurately reflect the delivery of surgical care in Ghana. In addition, we used pre- and post- operative pain scores at 1-year to estimate DWs, which would be unlikely to overestimate benefits of inguinal hernia repair.12 Our study has limitations, which we present within the context of previously defined guidelines for economic evaluations.37,53 Similar to other CEAs in LMICs, we used DALYs as our health outcome metric, which can create skewed results for older pa- tients and underestimate treatment benefit. This is particularly important to consider for inguinal hernia, as the incidence of disease increases with age and discounting disability in older patients may be seen as age discrimination.54 Any patient with symptomatic hernia who is a surgical candidate should be offered repair, regardless of age. Because of our study design, we did not include patients’ direct nonmedical costs or indirect costs, and we did not account for possible long-term complications. Although including these data would be unlikely to change our ultimate findings, exploring these costs and long-term complications will be an important area for future research. Although some of our ECONOMIC EVALUATION 37 findings are broadly transferrable to other contexts, including patient health states before and after hernia surgery, costs of materials and medicines and provider salaries are likely more narrowly transferrable to hospitals Ghana’s public health system and other similarly resourced settings.55 Our sensitivity analysis has attempted to account for variations in productivity, hospital costs, and staff salaries, nevertheless there are likely factors we could not account for that would reduce transferability. Finally, our CEA results may not be generalizable to all patients with inguinal hernia, including women, children, and patients with incarcerated or strangulated hernias or to patients undergoing inguinal hernia repair in other settings, including first-level or rural hospitals. Conclusions In this CEA, we found that elective inguinal hernia repair with mesh performed by Ghanaian providers on men with primary reducible hernias using locally available materials is very cost- effective, regardless of surgical provider training level. These re- sults combined with our previous task-sharing outcomes study indicate that with adequate training, local surgical care providers, including surgeons and MDs, can perform high-quality elective inguinal hernia repair using mesh with excellent outcomes and high cost-effectiveness in the context of the study in this lower- middle income country.15 To maximize cost-effectiveness, symp- tomatic patients should be prioritized over asymptomatic patients and a high level of productivity should be maintained. Policy makers in similarly resourced countries could consider utilizing task-sharing to expand access to inguinal hernia surgery with the caveat that robust training opportunities, oversight, and outcomes monitoring are necessary to ensure patient safety. Going forward, barriers to widespread availability of mesh inguinal hernia repair in LMICs beyond workforce limitations must be addressed, including access to commercial mesh, infra- structure development, and capacity building for surgical training in mesh technique. As a next step, we are implementing our training program for MDs in first-level hospitals around Ghana and evaluating outcomes. Through this program, we will continue to develop and support supply chains for low-cost commercial mesh and develop resources for essential surgical capacity in Ghana. Article and Author Information Accepted for Publication: July 13, 2022 Published Online: August 29, 2022 doi: https://doi.org/10.1016/j.vhri.2022.07.004 Author Affiliations: Department of Surgery, Division of Trauma and Surgical Critical Care, Lewis Katz School of Medicine at Temple University, Philadelphia, PA, USA (Beard, Agarwal, Maher); Swedish Institute for Health Economics, Stockholm, Sweden (Lwin); Department of Surgery, School of Medicine and Dentistry, University of Ghana, Accra, Ghana (Ohene-Yeboah, Amoako); Department of Surgery, School of Medicine and Health Sciences, University for Development Studies and Tamale Teaching Hospital, Tamale, Ghana (Tabiri); Department of Surgery, Division of Trauma, Critical Care, and Burn Surgery, Ohio State University, Columbus, OH, USA (Sims); Department of Surgery, University of California-San Francisco, San Francisco, CA, USA (Harris); Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden (Löfgren). Correspondence: Jessica H. Beard, MD, Lewis Katz School of Medicine Temple University, 3401 N. Broad St., 4th Floor, Zone C, Philadelphia, PA 19140, USA. Email: jbeard08@gmail.com Author Contributions: Concept and design: Beard, Lwin, Agarwal, Ohene-Yeboah, Tabiri, Amoako, Maher, Sims, Harris, Löfgren Acquisition of data: Beard, Agarwal, Ohene-Yeboah, Tabiri, Amoako Analysis and interpretation of data: Beard, Lwin, Agarwal, Löfgren Drafting of the manuscript: Beard, Lwin, Agarwal, Löfgren Critical revision of the paper for important intellectual content: Beard, Lwin, Agarwal, Ohene-Yeboah, Tabiri, Maher, Sims, Harris, Löfgren Statistical analysis: Beard, Lwin, Agarwal, Amoako, Löfgren Provision of study materials or patients: Beard, Agarwal, Ohene-Yeboah, Tabiri, Amoako Obtaining funding: Beard, Ohene-Yeboah, Sims, Harris, Löfgren Administrative, technical, or logistic support: Ohene-Yeboah, Tabiri, Amoako, Maher, Sims, Harris, Löfgren Supervision: Sims, Harris, Löfgren Conflict of Interest Disclosures: Drs Beard, Ohene-Yeboah, Tabiri, Amoako, and Löfgren reported receiving grants from the Americas Hernia Society, the Swedish Research Council, and the Swedish Association for Innovative Surgical Technology during the conduct of the study. Dr Beard also reported receiving grants from the Temple University Office of International Affairs during the conduct of the study. No other disclosures were reported. Funding/Support: This work was supported by grants from the Temple University Office of International Affairs, the Americas Hernia Society, the Swedish Research Council, and the Swedish Association for Innovative Surgical Technology. Role of the Funder/Sponsor: The funder had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication. Acknowledgment: The authors acknowledge the administration, staff, and surgical team at Volta Regional Hospital, the Ghana Health Service, and the Ghana Hernia Society. REFERENCES 1. Mock CN, Donkor P, Gawande A, et al. Essential surgery: key messages of this volume. In: Debas HT, Donkor P, Gawande A, et al., eds. 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http://refhub.elsevier.com/S2212-1099(22)00135-2/sref55 Cost-Effectiveness Analysis of Inguinal Hernia Repair With Mesh Performed by Surgeons and Medical Doctors in Ghana Introduction Methods Training Course and Materials Study Setting and Procedures Cost and Cost-effectiveness Analysis Sensitivity Analysis Statistical Analysis Results Discussion Conclusions References