Adhesions in abdomino-pelvic surgeries: A real economic impact?

Adhesions are one of the most common cause of complications after abdomino-pelvic surgery and cause short and long-term complications such as female infertility, chronic pelvic pain and small bowel obstruction (SBO) all lifelong [ 1 ]. Additionally, adhesions induce reoperations, hospital readmissions and consequently, a significant expenditure for the healthcare system and for society in terms of work lost, force capacity and impaired quality of life [ 2 ]. In North America and Europe, 40 to 70% of scheduled interventions for general surgery are re-operations [ 3 ]. Krielen et al. lastly found, in the SCAR update study, that laparoscopy directly reduces the risk of adhesion related rehospitalization by 32% and by 11% for possibly related rehospitalization [ 4 ]. Despite the progress in terms of variety of commercially available anti-adhesion barriers, both surgeons and healthcare administrators remain unconvinced that the current evidence for adhesion prevention products warrants routine use [ 5 ]. Moreover, even with the advances in surgical techniques in recent years, the burden of adhesions-related complications has not changed [ 6 ]. Adhesions generate major clinical, social and economic burden still. Although all costs related to adhesions are difficult to quantify, their costs are estimated being between 60 and 600 million € per year in France [ 1 ], showing the considerable contribution that adhesions make on the resources and health expenditure. Available economic data being rare on the cost of adhesions, we have decided to explore the PMSI (medicalized information system program) database to discuss the interest of anti-adhesion products and their use.

26.387 adhesiolysis procedures were listed in France in 2019 through 8 CCAM acts (HPPC001, HPPC002, HPPC003, HPPA001, HPPA002, HPPA003, HGPA004 and HGPC015) regrouping open surgeries and laparoscopic procedures ( Table 1 ). This adhesiolysis number is certainly minimized as surgeons can only code two procedures per patient in the PMSI. Therefore, adhesiolysis is rarely rated especially if it is part of a combined procedure. Regarding the HPPC001 and HPPC002 laparoscopic surgical acts grouping, adhesiolysis acts raise 34% and 27% in the 13C191 and 13C19J DRGs respectively, which are sterility procedures or grounds related to reproductive care either on an outpatient basis or level 1 ( Fig 1 ). We found also an important number of adhesiolysis acts in the 13C07J (Intervention on the uteroannexal system for non-malignant conditions, other than tubal interruptions, on an outpatient basis) and 13C071 (Intervention on the uteroannexal system for non-malignant conditions, other than tubal interruptions, level 1) DRGs, i.e 2008 and 2775 respectively what represent 13% and 12% coded acts in the general DRGs. Adhesiolysis acts by the open surgical procedures (HPPA001 and HPPA003) are less represented in the DRG, i.e found in 5% of 13C181 (Myomectomy of the uterus, level 1) and 13C182 (Myomectomy of the uterus, level 2) DRGs ( Fig 2 ). This analysis showed that presence of adhesions increased mean LoS by about one day for open procedures ( Table 2 ) while no LoS change has been observed compared to average LoS of the general DRG in the laparoscopy group ( Table 3 ) which might be related to the well-known benefits of laparoscopy. The rest of this study deals with the N736 main and associated diagnosis coding for pelvi-peritoneal adhesions in women. N736 has been coded 1551 times as main diagnosis in 2019 and much more number as associated diagnosis. Direct cost of adhesion-related re-operations reached almost €4 million even though this is a very conservative model since the analysis has been calculated on an effective of 1461 (instead of 1551 really records). Indeed, due to statistical secrecy putting place by ATIH, it is not possible to access to DRG when the number of main diagnosis is less than 11 cases ( Table 4 ). Study concerns 1461 DRG cases as it is not possible to access data when number is less than 11 cases due to statistical secrecy.

Our results demonstrate that the extra-cost directly related to post-operative adhesions is massive–even though this is a very conservative model since this analysis doesn’t include the additional non-surgical costs (social costs, drugs…). Various products available on the market have demonstrated their efficacy in reducing these adhesions and their complications. Therefore, it seems reasonable to make every effort in reducing post-operative adhesions, both for medical and medico-economic considerations. Our study is a local and retrospective analysis and under-estimates costs. It would be valuable to perform a larger medico-economic study to evaluate more precisely the accurate rapport between cost of adhesions complications and cost of adhesion reduction agents. But the significant cost of adhesions-related complications demonstrated in our analysis supports the cost-effectiveness properties of adhesions barriers, and advocates for a broader use of these products.

This retrospective descriptive study following by economic evaluation was conducted in France through PMSI database to evaluate adhesions epidemiology and their associated direct costs for hospitals and the social security (the French public health insurance). Through this analysis, we have only focused our researches on the rehospitalization rate and their induced costs. Other important costs related to adhesions consequences such as the analgesic costs, the induced infertility leading to in-vitro fertilization or the sick leaves cannot be found via this database. Therefore, this analysis shows only a part of costs directly related to abdomino-pelvic adhesions (synechia were excluded) and their consequences on a cohort of patients. PMSI provides a synthetic and standardized description of the medical activity of public and private health establishments, which is based on the recording of standardized medico-administrative data in a standard collection of information. All data for this study are public and have been extracted from Scan Santé website, which is managed by Agency for Information on Hospital Care (ATIH) from the native PMSI database. ATIH provides on this site information about public and private hospital medical activities, and especially information about the Diagnosis Related Groups which is made up medical acts and diagnosis. First, all adhesiolysis Common Classification of Medical Acts (CCAM) acts carried out in France in 2019 in public and private hospitals have been extracted. Then, for each act previously obtained, the 10 main DRG have been identified. From these DRG, information such as number and Length of Stay (LoS) were available. These different data have been put in perspective with those of general DRG. This comparison allowed to quantify the direct part of adhesiolysis in the French hospital system according to surgical procedures. We performed a sub-analysis to evaluate if the type of procedures (open surgeries vs laparoscopic approaches) had an impact on the presence of adhesions and patient’s LoS. For this part, the CCAM acts falling under the same type of procedures have been grouped in order to facilitate the analysis of data, i.e that all laparoscopy acts and all open surgeries acts were grouped together. Furthermore, we had a specific look at adhesiolysis as a main diagnosis (N736 PMSI Code). From that, we were able to obtain a DRG list providing adhesiolysis as the main reason of patient hospitalization. In order to give an idea on the direct costs of re-operation related to adhesions, we extracted the cost for each DRG from the 2018 costs national scale which is a scale providing a calculated real average cost for each DRG. In our data extraction, the origin of adhesion was not identifiable.

(XLSX) Click here for additional data file.