Long-Term Costs of Minimally Invasive Sacral Colpopexy Compared to Native Tissue Vaginal Repair With Concomitant Hysterectomy.

STUDY OBJECTIVE: To determine the long-term costs of hysterectomy with minimally invasive sacrocolpopexy (MISCP) versus uterosacral ligament suspension (USLS) for primary uterovaginal prolapse repair. DESIGN: A hospital-based decision analysis model was built using TreeAge Pro (TreeAge Software Inc, Williamstown, MA). Those with prolapse were modeled to undergo either vaginal hysterectomy with USLS or minimally invasive total hysterectomy with sacrocolpopexy (MISCP). We modeled the chance of complications of the index procedure, prolapse recurrence with the option for surgical retreatment, complications of the salvage procedure, and possible second prolapse recurrence. The primary outcome was cost of the surgical strategy. The proportion of patients living with prolapse after treatment was the secondary outcome. SETTING: Tertiary center for urogynecology. PATIENTS: Female patients undergoing surgical repair by the same team for primary uterovaginal prolapse. INTERVENTIONS: Comparison analysis of estimated long-term costs was performed. MEASUREMENTS AND MAIN RESULTS: Our primary outcome showed that a strategy of undergoing MISCP as the primary index procedure cost $19 935 and that undergoing USLS as the primary index procedure cost $15 457, a difference of $4478. Furthermore, 21.1% of women in the USLS group will be living with recurrent prolapse compared to 6.2% of MISCP patients. Switching from USLS to MISCP to minimize recurrence risk would cost $30 054 per case of prolapse prevented. Additionally, a surgeon would have to perform 6.7 cases by MISCP instead of USLS in order to prevent 1 patient from having recurrent prolapse. CONCLUSION: The higher initial costs of MISCP compared to USLS persist in the long term after factoring in recurrence and complication rates, though more patients who undergo USLS live with prolapse recurrence.

Excess use of surgical supplies in minimally invasive benign gynecology surgery: an observational study.

BACKGROUND: Single-use materials and equipment are regularly opened by the surgical team during procedures but left unused, potentially resulting in superfluous costs and excess environmental waste. OBJECTIVE: This study aimed to estimate the excess use of surgical supplies in minimally invasive benign gynecologic surgeries. STUDY DESIGN: This is a prospective observational study conducted at a university-affiliated single tertiary medical center. Designated study personnel were assigned to observe surgical procedures performed during July to September 2022. Surgical teams were observed while performing surgeries for benign indications. The teams were not informed of the purpose of the observation to avoid potential bias. Disposable materials and equipment opened during the procedure were documented. Excess supplies were defined as those opened but left unused before being discarded. Costs per item of the excess supplies were estimated on the basis of material and equipment costs provided by the hospital. RESULTS: A total of 99 surgeries were observed, including laparoscopic (32%), robotic (39%), hysteroscopic (14%), vaginal (11%), and laparotomy procedures (3%). Excess use of surgical supplies was documented in all but one procedure. The total cost across all surgeries reached $6357. The contained tissue extraction bag was the most expensive item not used (Applied Medical, Rancho Santa Margarita, CA; $390 per unit) in 4 procedures, contributing 25.54% to the total cost. Raytec was the most common surgical waste, with a total of n=583 opened but unused (average n=5.95 per surgery). A significant difference was found in the rate of excess supplies across the surgical approaches, with robotic surgery contributing 52.19% of the total cost (P=.01). CONCLUSION: Excess use of disposable materials and equipment is common in minimally invasive benign gynecologic surgeries and contributes to superfluous costs and excess environmental waste. It is predominantly attributed to the opening of inexpensive materials that are left unused during the procedure. Increased awareness of costs and generated waste may reduce excess use of surgical supplies and should be further explored in future research.

"Water or not water: That is the question." Analysis of costs and consumption of the operating theaters in a greener perspective.

OBJECTIVE: To compare the amounts of water and plastic used in surgical hand washing with medicated soaps and with alcohol-based products and to compare costs and consumption in a year, based on scheduled surgical activity. METHOD: This retrospective study was carried out at Udine's Gynecology Operating Block from October to November 2022. We estimated the average amount of water with a graduated cylinder and the total cost of water usage based on euros/m3 indicated by the supplier; for each antiseptic agent we collected the data relevant to wash time, amount of water and product used per scrub, number of handscrubs made with every 500 mL bottle and cost of a single bottle. We put data into two hypothetical contexts, namely WHO guidelines and manufacturers' recommendations. Data were subjected to statistical analysis. RESULTS: The daily amount of water using povidone-iodine, chlorhexidine-gluconate and alcohol-based antiseptic agents was 187.6, 140.7 and 0 L/day (P value = 0.001), respectively; A total of 69 000 L/year of water would be saved if alcohol-based products were routinely used. A single unit of an alcohol-based product allows three times as many handscrubs as any other product (P value = 0.001) with consequent reduction in plastic packaging. CONCLUSION: Despite the cost saving being negligible, choosing alcohol-based handrub over medicated soap handrub - on equal antiseptic efficacy grounds - could lead to a significant saving of water and plastic, thus making our operating theaters more environmentally friendly.

Is Preoperative Type and Screen High-value Care? A Cost-effectiveness Analysis of Performing Preoperative Type and Screen Prior to Urogynecological Surgery.

INTRODUCTION AND HYPOTHESIS: Routine preoperative type and screen (T&S) is often ordered prior to urogynecological surgery but is rarely used. We aimed to assess the cost effectiveness of routine preoperative T&S and determine transfusion and transfusion reaction rates that make universal preoperative T&S cost effective. METHODS: A decision tree model from the health care sector perspective compared costs (2020 US dollars) and effectiveness (quality-adjusted life-years, QALYs) of universal preoperative T&S (cross-matched blood) vs no T&S (O negative blood). Our primary outcome was the incremental cost-effectiveness ratio (ICER). Input parameters included transfusion rates, transfusion reaction incidence, transfusion reaction severity rates, and costs of management. The base case included a transfusion probability of 1.26%; a transfusion reaction probability of 0.0013% with or 0.4% without T&S; and with a transfusion reaction, a 50% probability of inpatient management and 0.0042 annual disutility. Costs were estimated from Medicare national reimbursement schedules. The time horizon was surgery/admission. We assumed a willingness-to-pay threshold of $150,000/QALY. One- and two-way sensitivity analyses were performed. RESULTS: The base case and one-way sensitivity analyses demonstrated that routine preoperative T&S is not cost effective, with an ICER of $63,721,632/QALY. The optimal strategy did not change when base case cost, transfusion probability, or transfusion reaction disutility were varied. Threshold analysis revealed that if transfusion reaction probability without T&S is >12%, routine T&S becomes cost effective. Scenarios identified as cost effective in the threshold and sensitivity analyses fell outside reported rates for urogynecological surgery. CONCLUSIONS: Within broad ranges, preoperative T&S is not cost effective, which supports re-evaluating routine T&S prior to urogynecological surgery.

Financial analysis of minimally invasive sacrocolpopexy compared with native tissue vaginal repair with concomitant hysterectomy.

INTRODUCTION: Minimally invasive sacrocolpopexy (MISCP) is increasingly used for uterovaginal prolapse, but comparative cost data of MISCP versus native tissue vaginal repair (NTR) are lacking. The objective was to determine the cost difference, from a hospital perspective, between MISCP and NTR performed with hysterectomy for uterovaginal prolapse. METHODS: This was a retrospective cohort study at a tertiary care center of women who underwent NTR or MISCP with concomitant hysterectomy in 2021. Hospital charges, direct and indirect costs, and operating margin (revenue minus costs) were obtained from Strata Jazz and compared using SPSS. RESULTS: A total of 82 women were included, 33 MISCP (25 robotic, 8 laparoscopic) versus 49 NTR. Demographic and surgical data were similar, except that MISCP had younger age (50.5 vs 61.1 years, p<0.01). Same-day discharge and estimated blood loss were similar, but operative time was longer for MISCP (204 vs 161 min, p<0.01). MISCP total costs were higher (US$17,422 vs US$13,001, p<0.01). MISCP had higher direct costs (US$12,354 vs US$9,305, p<0.01) and indirect costs (US$5,068 vs US$3,696, p<0.01). Consumable supply costs were higher with MISCP (US$4,429 vs US$2,089, p<0.01), but the cost of operating room time and staff was similar (US$7,926 vs US$7,216, p=0.07). Controlling for same-day discharge, anti-incontinence procedures and smoking, total costs were higher for MISCP (adjusted beta = US$4,262, p<0.01). Mean charges (US$102,060 vs US$97,185, p=0.379), revenue (US$22,214 vs US$22,491, p=0.929), and operating margin (US$8,719 vs US$3,966, p=0.134) were not statistically different. CONCLUSION: Minimally invasive sacrocolpopexy had higher costs than NTR; however, charges, reimbursement, and operating margins were not statistically significantly different between the groups.

Treatment patterns and economic burden among newly diagnosed cervical and endometrial cancer patients.

Aim: This study evaluated treatment patterns, healthcare resource use and healthcare costs among newly diagnosed US patients with cervical or endometrial cancer. Materials & methods: The authors identified patients diagnosed between 2015 and 2018, described them by line of therapy (LOT), then summarized all-cause per patient per month healthcare resource use and healthcare costs per LOT. Results: Among 1004 patients with cervical cancer and 2006 patients with endometrial cancer, 65.2 and 71.4%, respectively, received at least LOT1. Common treatment modalities in LOT1 were surgery (cervical, 58.0%; endometrial, 92.6%), radiation therapy (cervical, 49.8%; 24.7%) and systemic therapy (cervical, 53.3%; endometrial, 26.1%). Mean per patient per month costs per LOT were pre-treatment (cervical, US$17,210; endometrial, US$14,601), LOT1 (cervical, US$10,929; endometrial, US$6859), LOT2 (cervical, US$15,183; endometrial, US$10,649) and LOT3+ (cervical, US$19,681; endometrial, US$9206). Conclusion: Overall, newly diagnosed patients with cervical or endometrial cancer received guideline-recommended treatment. Outpatient visits mainly drove healthcare costs across LOTs.

Reimbursement for Female-Specific Compared With Male-Specific Procedures Over Time.

OBJECTIVE: To evaluate whether per-procedure work relative value units (RVUs) have changed over time and to compare time-based compensation for female-specific procedures compared with male-specific procedures. METHODS: Using the National Surgical Quality Improvement Program files for 2015-2018, we compared operative time and RVUs for 12 pairs of sex-specific procedures. Procedures were matched to be anatomically and technically similar. Procedure-assigned RVUs in 2015 were compared with 1997. Procedure compensation was determined using median dollars per RVU provided in SullivanCotter's 2018 Physician Compensation and Productivity Survey. This was compared with specialty-specific McGraw-Hill per-RVU data from 1994. Statistical analysis was performed with chi-square and Kruskal-Wallis tests. RESULTS: A total of 12,120 patients underwent 6,217 male-specific procedures and 5,903 female-specific procedures. Male-specific procedures had a median (interquartile range) RVU of 25.2 (21.4-25.2), compared with 7.5 (7.5-23.4) for female-specific procedures (P<.001). Male-specific procedures were 79 minutes longer (median [interquartile range] 136 minutes [98-186] vs 57 minutes [25-125], P<.001). Female-specific procedures were reimbursed at a higher hourly rate (10.6 RVU/hour [7.2-16.2] vs 9.7 RVU/hour [7.4-12.8], P<.001). However, male-specific procedures were better reimbursed ($599/h [$457-790] vs $555/h [$377-843], P<.001). Overall, per-procedure RVUs for male-specific surgeries have increased 13%, whereas, for female-specific surgeries, per-procedure RVUs have increased 26%. Reimbursement per RVU for male-specific procedures has decreased 8% ($67.30 to $61.65), whereas for female-specific procedures it has increased 14% ($44.50 to $52.02). CONCLUSION: Increases in RVUs and specialty-specific compensation have resulted in more equitable reimbursement for female-specific procedures. However, even with these changes, there is a lower relative value of work, driven by specialty-specific compensation rates, for procedures performed for women-only compared with equivalent men-only procedures.

Stepwise Approach to the Management of Endometriosis-Related Dysmenorrhea: A Cost-Effectiveness Analysis.

OBJECTIVE: To evaluate the cost effectiveness of sequential medical and surgical therapy for the treatment of endometriosis-related dysmenorrhea. METHODS: A cost-effectiveness model was created to compare three stepwise medical and surgical treatment strategies compared with immediate surgical management for dysmenorrhea using a health care payor perspective. A theoretical study cohort was derived from the estimated number of reproductive age (18-45) women in the United States with endometriosis-related dysmenorrhea. The treatment strategies modeled were: strategy 1) nonsteroidal antiinflammatory drugs (NSAIDs) followed by surgery; strategy 2) NSAIDs, then short-acting reversible contraceptives or long-acting reversible contraceptives (LARCs) followed by surgery; strategy 3) NSAIDs, then a short-acting reversible contraceptive or LARC, then a LARC or gonadotropin-releasing hormone modulator followed by surgery; strategy 4) proceeding directly to surgery. Probabilities, utilities, and costs were derived from the literature. Outcomes included cost, quality-adjusted life years (QALYs), and incremental cost-effectiveness ratios. Univariate, bivariate, and multivariate sensitivity analyses were performed. RESULTS: In this theoretical cohort of 4,817,894 women with endometriosis-related dysmenorrhea, all medical and surgical treatment strategies were cost effective at a standard willingness-to-pay threshold of $100,000 per QALY gained when compared with surgery alone. Strategy 2 was associated with the lowest cost per QALY gained ($1,155). Requiring a trial of a third medication before surgery would cost an additional $257 million, compared with proceeding to surgery after failing two medical treatments. The probability of improvement with surgery would need to exceed 83% for this to be the preferred first-line approach. CONCLUSION: All sequential medical and surgical management strategies for endometriosis-related dysmenorrhea were cost effective when compared with surgery alone. A trial of hormonal management after NSAIDs, before proceeding to surgery, may provide cost savings. Delaying surgical management in an individual with pain refractory to more than three medications may decrease quality of life and increase cost.

Disparity in Medicare payments by gender and training track in female pelvic medicine and reconstructive surgery.

BACKGROUND: Gender disparities in medicine have been demonstrated in the past, including differences in the attainment of roles in administration and in physician income. OBJECTIVE: Our objective was to determine the differences in Medicare payments based on the provider gender and training track among female pelvic medicine and reconstructive surgeons. STUDY DESIGN: Medicare payments from the Provider Utilization Aggregate Files were used to determine the payments made by Medicare to urogynecologists. This database was merged with the National Provider Identifier registry with information on subspecialty training, years since graduation, and the geographic pricing cost index used for Medicare payment adjustments. Physicians with <90% female patients and those who graduated medical school <7 years ago in obstetrics and gynecology or <8 years ago in urology were excluded. The effects of gender, specialty of training, number of services provided, years of practice, and geographic pricing cost index on physician reimbursement were evaluated using linear mixed modeling. RESULTS: A total of 578 surgeons with female pelvic medicine and reconstructive surgery subspecialty training met the inclusion criteria. Of those, 517 (89%) were trained as gynecologists, whereas 61 (11%) were trained as urologists. Furthermore, 265 (51%) of the gynecology-trained surgeons and 39 (80%) of the urology-trained surgeons were women. Among the urology-trained surgeons, the median female surgeon was paid $85,962 and their male counterparts were paid $121,531 (41% payment difference). In addition, urology-trained female pelvic medicine and reconstructive surgery surgeons performed a median of 1135 services and their male counterparts performed a median of 1793 services (57% volume difference). Similarly, among gynecology-trained surgeons, the median female payment was $59,277 with 880 services performed, whereas male gynecology-trained surgeons received a median of $66,880 with 791 services performed, representing a difference of 12% in payments and 11% in services. With linear mixed modeling, male physicians were paid more than female physicians while controlling for specialty training, number of services performed, years of practice, and geographic pricing cost index (P<.001). CONCLUSION: Although Medicare payments are based on an equation, differences in reimbursement by physician gender exist in female pelvic medicine and reconstructive surgery with female surgeons receiving lower payments from Medicare. The differences in reimbursement could not be solely explained by differences in patient volume, area of practice, or years of experience alone, suggesting that, similar to other fields in medicine, female surgeons in female pelvic medicine and reconstructive surgery are not paid as much as their male counterparts.

Short-term general, gynecologic, orthopedic, and pediatric surgical mission trips in Nicaragua: A cost-effectiveness analysis.

BACKGROUND: Short-term surgical missions facilitated by non-governmental organizations (NGOs) may be a possible platform for cost-effective international global surgical efforts. The objective of this study is to determine if short-term surgical mission trips provided by the non-governmental organization (NGO) Esperança to Nicaragua from 2016 to 2020 are cost-effective. METHODS: Using a provider perspective, the costs of implementing the surgical trips were collected via Esperança's previous trip reports. The reports and patient data were analyzed to determine disability-adjusted life years averted from each surgical procedure provided in Nicaragua from 2016-2020. Average cost-effectiveness ratios for each surgical trip specialty were calculated to determine the average cost of averting one disability-adjusted life year. RESULTS: Esperança's surgical missions' program in Nicaragua from 2016 to 2020 was found to be cost-effective, with pediatric and gynecology surgical specialties being highly cost-effective and general and orthopedic surgical specialties being moderately cost-effective. These results were echoed in both scenarios of the sensitivity analysis, except for the orthopedic specialty which was found to not be cost-effective when testing an increased discount rate. CONCLUSIONS: The cost-effectiveness of short-term surgical missions provided by NGOs can be cost-effective, but limitations include inconsistent data from a societal perspective and lack of an appropriate counterfactual. Future studies should examine the capacity for NGOs to collect adequate data and conduct rigorous economic evaluations.

Discrepancies Created by Surgeon Self-Reported Operative Time and the Effects on Procedural Relative Value Units and Reimbursement.

OBJECTIVE: To demonstrate discrepancies between operative times in the ACS NSQIP (American College of Surgeons National Surgical Quality Improvement Project) and self-reported operative time from the American Medical Association's Relative Value Scale Update Committee (RUC) and their effect on relative value units (RVU) determination. METHODS: This is a cross-sectional review of registry data using the ACS NSQIP 2016 Participant User File and the Centers for Medicare & Medicaid Services physician procedure time file for 2018. We analyzed total RVUs for surgeries by operative time to calculate RVU per hour and stratified by specialty. Multivariate regression analysis adjusted for patient comorbidities, age, length of stay, and ACS NSQIP mortality and morbidity probabilities. The surgeon self-reported operative times from the Centers for Medicare & Medicaid Services physician were compared with operative times recorded in the ACS NSQIP, with excess time from RUC estimates termed "overreported time." RESULTS: Analysis of 901,917 surgeries revealed a wide variation in median RVU per hour between specialties. Orthopedics (14.3), neurosurgery (12.9), and general surgery (12.1) had the highest RVU per hour, whereas gynecology (10.2), plastic surgery (9.5), and otolaryngology (9) had the lowest (P<.001 for all comparisons). These results remained unchanged on multivariate regression analysis. General surgery had the highest median overreported operative time (+26 minutes) followed by neurosurgery (+23.5 minutes) and urology (+20 minutes). Overreporting of the operative time strongly correlated to higher RVU per hour (r=0.87, P=.002). CONCLUSION: Despite reliable electronic records, the AMA-RUC continues to use inaccurate self-reported RUC surveys for operative times. This results in discrepancies in RVU per hour (and subsequent reimbursement) across specialties and a persistent disparity for women-specific procedures in gynecology. Relative value unit levels should be based on the available objective data to eliminate these disparities.

Double Discrimination, the Pay Gap in Gynecologic Surgery, and Its Association With Quality of Care.

In this commentary, we describe historical and other influences that drive "double discrimination" in gynecologic surgery-lower pay in the area of surgery that boasts the largest proportion of female surgeons and is focused on female patients and explore how it results in potentially lower quality care. Insurers reimburse procedures for women at a lower rate than similar procedures for men, although there is no medically justifiable reason for this disparity. The wage gap created by lower reimbursement rates disproportionately affects female surgeons, who are disproportionately represented among gynecologic surgeons. This contributes to a large wage gap in surgery for women. Finally, poor reimbursement for gynecologic surgery pushes many obstetrics and gynecology surgeons to preferentially perform obstetric services, resulting in a high prevalence of low-volume gynecologic surgeons, a metric that is closely tied to higher complication rates. Creating equity in reimbursement for gynecologic surgery is one important and ethically required step forward to gender equity in medicine for patients and surgeons.

Cost-effectiveness of Surgical Treatment Pathways for Prolapse.

OBJECTIVE: To evaluate the cost-effectiveness of surgical treatment pathways for apical prolapse. STUDY DESIGN: We constructed a stochastic Markov model to assess the cost-effectiveness of vaginal apical suspension, laparoscopic sacrocolpopexy, and robotic sacrocolpopexy. We modeled over 5 and 10 years, with 9 pathways accounting for up to 2 separate surgical repairs, recurrence of symptomatic apical prolapse, reoperation, and complications, including mesh excision. We calculated costs from the health care system's perspective. RESULTS: Over 5 years, compared with expectant management, all surgical treatment pathways cost less than the willingness-to-pay threshold of US $50,000 per quality adjusted life-years. However, among surgical treatments, all but 2 pathways were dominated. Of the remaining 2, laparoscopic sacrocolpopexy followed by vaginal repair for apical recurrence was not cost-effective compared with the vaginal-only approach (incremental cost-effectiveness ratio [ICER], >$500,000). Over 10 years, all but the same 2 pathways were dominated. However, starting with the laparoscopic approach in this case was more cost-effective with an ICER of US $6,176. If the laparoscopic approach was not available, starting with the robotic approach similarly became more cost-effective at 10 years (ICER, US $35,479). CONCLUSIONS: All minimally invasive surgical approaches for apical prolapse repair are cost-effective when compared with expectant management. Among surgical treatments, the vaginal-only approach is the only cost-effective option over 5 years. However, over a longer period, starting with a laparoscopic (or robotic) approach becomes cost-effective. These results help inform discussions regarding the surgical approach for prolapse.

Current Trends in Compensation for Fellowship in Minimally Invasive Gynecologic Surgery Graduates: A 6-Year Follow-Up.

STUDY OBJECTIVE: To present updated information regarding compensation patterns for Fellowship in Minimally Invasive Gynecologic Surgery (FMIGS)-graduated physicians in the United States beginning practice during the last 10 years, focusing on the variables that have an impact on differences in salary, including gender, fellowship duration, geographic region, practice setting, and practice mix. DESIGN: An online survey was sent to FMIGS graduates between March 15, 2019 and April 12, 2019. Information on physicians' demographics, compensation (on the basis of location, practice model, productivity benchmarks, academic rank, and years in practice), and attitudes toward fairness in compensation was collected. SETTING: Online survey. PARTICIPANTS: FMIGS graduates practicing in the United States. INTERVENTION: E-mail survey. MEASUREMENTS AND MAIN RESULTS: We surveyed 298 US FMIGS surgeons who had graduated during the last 10 years (2009-2018). The response rate was 48.7%. Most of the respondents were women (69%). Most of the graduates (84.8%) completed 2- or 3-year fellowship programs. After adjustment for inflation, the median starting salary for the first postfellowship job was $252 074 ($223 986-$279 983) (Table 1). The median time spent in the first job was 2.6 years, and the median total salary at the current year rose to $278 379.4 ($241 437-$350 976). The median salary for respondents entering a second postfellowship job started at $280 945 ($261 409-$329 603). Significantly lower compensation was reported for female FMIGS graduates in their initial postfellowship jobs and was consistently lower than for that of men over time. Most FMIGS graduates (59.7%) reported feeling inadequately compensated for their level of specialization. CONCLUSION: A trend toward higher self-reported salaries is noted for FMIGS graduates in recent years, with significant differences in compensation between men and women. Among obstetrics and gynecology subspecialists, FMIGS graduates earn significantly less than other fellowship-trained physicians, with median salaries that are lower than those of generalist obstetrics and gynecology physicians.

Variations in Volume and Costs of Inpatient Admissions for Female Pelvic Reconstructive Procedures Across the United States.

OBJECTIVES: We aim to describe the volume and cost of female pelvic reconstructive surgeries across the United States and evaluate the relationship between volume and cost of inpatient care for these surgeries. METHODS: Medicare Severity Diagnosis Related Group was used to identify admissions for female pelvic reconstructive procedures and aggregated at the state and census region levels using the 2016 Inpatient Medicare Provider Utilization and Payment Data. Total hospital charges were converted to cost using the cost-to-charge ratios for each state. For context and comparison with another benign gynecologic procedure, we replicated the analysis for benign uterine and adnexal surgeries. RESULTS: We identified 2133 patients admitted for female pelvic reconstructive procedures. Across all states, the average cost was US $11,857, and the average number of procedures per 100,000 Medicare beneficiaries was 4.4. The Northeast had the lowest cost, and the West had the highest. The regression model showed that, for each additional admission per 100,000 Medicare beneficiaries, the cost of inpatient care decreased (US $549, P = 0.04). In comparison, we identified 8340 admissions for benign uterine and adnexal surgeries and found a minimal, nonsignificant decrease in cost for each additional admission. CONCLUSIONS: There are variations in the volume and cost of admissions for female pelvic reconstructive surgeries across the United States. We identified that an inverse association between volume and cost for female pelvic reconstructive surgery was not seen in benign uterine and adnexal surgeries.

Outpatient uterine assessment and treatment unit in patients with abnormal uterine bleeding: an economic modelling study.

BACKGROUND: Most often in Canada, the evaluation and management of abnormal uterine bleeding occurs under general anesthesia in the operating room. We aimed to assess the potential cost-effectiveness of an outpatient uterine assessment and treatment unit (UATU) compared with the current standard of care when diagnosing and treating abnormal uterine bleeding in women. METHODS: We performed a cost-effectiveness analysis and developed a probabilistic decision tree model to simulate the total costs and outcomes of women receiving outpatient UATU or usual care over a 1-year time horizon (Apr. 1, 2014, to Mar. 31, 2017) at a tertiary care hospital in Ontario, Canada. Probabilities, resource use and time to diagnosis and treatment were obtained from a retrospective chart review of 200 randomly selected women who presented with abnormal uterine bleeding. Results were expressed as overall cost and time savings per patient. Costs are reported in 2018 Canadian dollars. RESULTS: Compared with usual care, care in the UATU was associated with a decrease in overall cost ($1332, 95% confidence interval [CI] -$1742 to -$1008) and a decrease in overall time to treatment (-75, 95% CI -89 to -63, d). The point at which the UATU would no longer be cost saving is if the additional cost to operate and maintain the UATU is greater than $1600 per patient. INTERPRETATION: From the perspective of Canada's health care system, an outpatient UATU is more cost effective than usual care and saves time. Future studies should focus on the relative efficacy of a UATU and the total budget required to operate and maintain a UATU.

Factors associated with high-cost hospitalizations in elderly ovarian cancer patients.

OBJECTIVE: To characterize factors associated with high-cost inpatient admissions for ovarian cancer. METHODS: Operative hospitalizations for ovarian cancer patients ≥65 years of age were identified using the 2010-2017 National Inpatient Sample. Admissions with high-cost were defined as those incurring ≥90th percentile of hospitalization costs each year, while the remainder were considered low-cost. Multivariable logistic regression models were developed to assess independent predictors of being in the high-cost cohort. RESULTS: During the study period, an estimated 58,454 patients met inclusion criteria. 5827 patient admissions (9.98%) were classified as high-cost. Median hospitalization cost for this high-cost group was $55,447 (interquartile range (IQR) $46,744-$74,015) compared to $16,464 (IQR $11,845-$23,286, p < 0.001) for the low-cost group. Patients with high-cost admissions were more likely to have received open (adjusted odds ratio (AOR) 2.23, 1.31-3.79) or extended (AOR 5.64, 4.79-6.66) procedures and be admitted non-electively (AOR 3.32, 2.74-4.02). Being in the top income quartile (AOR 1.77, 1.39-2.27) was also associated with high-cost. Age and hospital factors, including bed size and volume of gynecologic oncology surgery, did not affect cost group. CONCLUSION: High-cost ovarian cancer admissions were three times more expensive than low-cost admissions. Fewer open and extended procedures with subsequently shorter lengths of stay may have contributed to decreasing inpatient costs over the study period. In this cohort of patients largely covered by Medicare, clinical factors outweigh socioeconomic factors as cost drivers. Understanding the relationship of disease-specific and social factors to cost will be important in informing future value-based quality improvement efforts in gynecologic cancer care.

Clinical implications and economic effects of the Coronavirus pandemic on gynecology, obstetrics and reproductive medicine in Germany: learning from Italy.

The infection with the novel SARS Cov-2 Coronavirus, the cause of severe acute respiratory distress syndrome, possessing its origin in the Chinese province Hubei, has reached the extent of a global pandemic within a few months. After aerosol infection, most people experience mild respiratory infection with cold symptoms such as cough and fever, and healing within two weeks. In about 5% of those infected, however, a severe course develops with the occurrence of multiple subpleural bronchopulmonary infiltrates and even death as a result of respiratory failure. The Coronavirus pandemic has multiple impacts on social life that have not been seen before. For example, the government adopted measures to curb the exponential spread of the virus, which included a significant reduction in social contacts. Furthermore, the specialist societies recommended that no elective treatments be carried out during the pandemic period. This review article considers epidemiological aspects of novel Coronavirus infection and presents both the clinical as well the possible economic effects of the pandemic on gynecology, obstetrics and reproductive medicine in Germany in the past, present and future. In addition, useful preventive measures for daily clinical work and the previously known scientific findings dealing with the impact of Coronavirus on pregnancy and birth are discussed.