MESH DECISIONS The challenge when repairing hernias: how to patch abdominal defects without breaking the bank.

How much hernia mesh should you stock? If you have several surgeons performing hernia repair, you'll stock several different types of mesh — some of it quite expensive. Unlike other implants or medical devices, where research clearly supports one product over another, a mesh-implanted patient's outcome depends largely on the patient's characteristics and condition. Though many surgeons rely on conventional, permanent synthetic meshes (polypropylene is the most popular material) in light, mid and heavy weights, in some patients it may contribute to an adverse reaction, and we're still not 100% sure why. Often surgeons find a midweight synthetic is sufficient for their routine cases, but they may use a heavy- or lightweight option depending on the patient and the hernia. Though lightweight options are thought to help reduce chronic pain and inflammation, they may lack the tensile strength for some cases. For example, a lightweight mesh may work fine in inguinal hernia repairs, but it may not always be the best option for ventral hernia repair.

Should you stock conventional, synthetic mesh, or are biologic options better? Are the new bio-synthetic technologies worth the cost? And will your surgeons ever agree to using one type of mesh? Answering these questions is hard. There's no research that supports using one type of mesh over another. With new innovations promising better outcomes — as well as sky-high prices — how can you manage your mesh without breaking the bank?

First things first: You need to understand your mesh options and why your surgeons prefer a particular type of mesh before you can discuss paring down your inventory. There's a lot that's new.

New choices for complex cases
Biologic mesh options are receiving lots of recent attention. Biologics, made of human or animal tissue, are meant to facilitate growth of the patient's own healthy tissue into the biologic scaffold. The mesh helps reinforce the hernia repair, but is often designed to dissipate in time as the patient's own cells grow into the mesh. Because of these properties, biologic mesh is typically saved for cases where there's a high likelihood of infection. It costs a lot more — while standard synthetic options can be a few hundred dollars to up to $2,000, biologics range from $8,000 to $20,000.

Are these new technologies worth the price? That's hard to say. Because there's a lack of research demonstrating the value of any biologic mesh, there are other factors that determine mesh selection: surgeon comfort, the mesh's weight, cost and patient outcomes.

Here are thumbnail sketches of 3 newer, pricier technologies that tend to be used in complex abdominal cases. You likely won't find these on the shelves of smaller outpatient surgery centers performing routine cases. However, some surgeons use biologics primarily for outpatient inguinal hernia repairs. If that's the case in your center, I'd recommend asking them to track patient outcomes to see if the higher-priced mesh results in better care.

• Hybrid biosynthetic. Hybrid biosynthetic and long-term absorbable synthetic options are now being marketed as incorporating the best properties of synthetic and biologic options into a single style. The hybrid biosynthetic meshes on the market are made up of a permanent, synthetic mesh (polypropylene or PTFE) covered in a biologic or resorbable synthetic coating to help promote tissue ingrowth. There are also long-term synthetic absorbable meshes on the market that are completely resorbed over time. Since these are so new to the market, research on their effects is still limited, but they could be a promising option for cases where you're especially concerned about infection or contamination. Another bonus: These types of mesh are at a price point above conventional mesh, but much lower than traditional biologics, typically around $2,000 to $4,000.
• Coated. These meshes are coated with various substances to try to prevent complications. For example, several meshes are coated with omega-3 fatty acids or other non-stick coatings to prevent visceral ingrowth and minimize adhesions. More recently, some manufacturers are creating antibiotic or drug-eluting meshes, with the hope that the mesh will reduce the risk of infection. Again, there is limited evidence supporting or discouraging their use.
• Self-fixating. Self-fixating mesh avoids the need for fixation devices. This mesh requires no tacking or glue to fixate it to the abdominal wall. Instead, small Velcro-like hooks keep it in place. While it's a great idea, it can be difficult to manipulate and you run the risk of harming tissue if you need to rip it off and re-attach it during surgery.

SURGEONS' CHOICE Since research hasn't pointed to a single mesh's superiority, facilities largely base stock decisions on surgeon preferences.

Paring down your inventory
As you can see, harnessing your mesh supply isn't as easy as getting all of your surgeons to agree on using one type of mesh. You'll likely never get down to stocking a single type of mesh for all of your patients. Hernia cases are complex and require different weights and sizes depending on several factors, like the patient's weight, where the hernia is located, how contaminated the site is and the surgeon's preference. For example, in your standard inguinal repair, a surgeon may use a lightweight synthetic option. But for cases where there's contamination, a biologic may be the way to go, or maybe even the new hybrid bio-synthetic option.

You may not be able to limit your inventory to one mesh, but you could try to limit it to 1 or 2 manufacturers. Don't make this decision from the top and expect surgeons to comply. Ask your surgeons which meshes they use and why. Understand how the mesh impacts patient care — no surgeon is going to compromise on that just to save a few bucks. During this conversation you may find they use a mesh simply because that's what they used in their residency and that they are interested in trying other options. Brand names may vary, but types of mesh are often similar to one another, though their prices may vary by hundreds of dollars.

An effective way to get your surgeons on board is to show them cost data. They may not like the idea of abandoning their preferred brand, but once you show them an Excel spreadsheet that lays out how their box of synthetic, lightweight mesh is $500 more than one that is identical in appearance and quality, there's a good chance they'll change their minds.

If a surgeon is using a biologic simply because he feels it's the best, but doesn't have the data to back it up, it's fair to suggest testing a more affordable option and comparing outcomes. Weighing the cost of the device with patients' outcomes, whether you're talking about hernia mesh or surgical robots, is the only way to measure the true value of the product. Either ask your surgeons or work with your facility's staff to create a policy to follow-up with patients in the months, and even years, after surgery to check for complications such as chronic pain or recurrent hernias. It may seem overwhelming, but tracking this data will not only let you focus on streamlining your inventory, but also will potentially let you improve your patients' outcomes using the principles of clinical quality improvement (CQI).

Once you know what mesh you're looking for, then it's time to talk to your vendors. Don't be afraid to negotiate. Maybe you agree that you'll purchase 80% of your stock from them at a discounted price. Don't let the doctors' relationships with vendors dictate this process. Stay vendor-neutral and focus on quality, cost and patient outcomes.

If your surgeons agree to try a new mesh or new vendor, make sure you run a thorough trial before signing a contract. During this trial, you may not be able to measure long-term patient outcomes, but you can study the quality of care, re-admissions and complication rate, as well as seek out any research demonstrating the mesh's perceived benefits. OSM