Inpatient Hospital Costs and Route of Hysterectomy for Management of Benign Uterine Disease in the 90-Day Global Billing Period.

OBJECTIVE: To compare inpatient hospital costs and complication rates within the 90-day global billing period among routes of hysterectomy. METHODS: The Premier Healthcare Database was used to identify patients who underwent hysterectomy between 2000 and 2020. Current Procedural Terminology codes were used to group patients based on route of hysterectomy. Comorbidities and complications were identified using International Classification of Diseases codes. Fixed, variable, and total costs for inpatient care were compared. Fixed costs consist of costs that are set for the case, such as operating room time or surgeon costs. Variable costs include disposable and reusable items that are billed additionally. Total costs equal fixed and variable costs combined. Data were analyzed using analysis of variance, t test, and χ 2 test, as appropriate. Factors independently associated with increased total costs were assessed using linear mixed effects models. Multivariate logistic regression was performed to evaluate associations between the route of surgery and complication rates. RESULTS: A cohort of 400,977 patients were identified and grouped by route of hysterectomy. Vaginal hysterectomy demonstrated the lowest inpatient total cost ($6,524.00 [interquartile range $4,831.60, $8,785.70]), and robotic-assisted laparoscopic hysterectomy had the highest total cost ($9,386.80 [interquartile range $6,912.40, $12,506.90]). These differences persisted with fixed and variable costs. High-volume laparoscopic and robotic surgeons (more than 50 cases per year) had a decrease in the cost difference when compared with costs of vaginal hysterectomy. Abdominal hysterectomy had a higher rate of complications relative to vaginal hysterectomy (adjusted odds ratio [aOR] 1.52, 95% CI, 1.39-1.67), whereas laparoscopic (aOR 0.85, 95% CI, 0.80-0.89) and robotic-assisted (aOR 0.92, 95% CI, 0.84-1.00) hysterectomy had lower rates of complications compared with vaginal hysterectomy. CONCLUSION: Robotic-assisted hysterectomy is associated with higher surgical costs compared with other approaches, even when accounting for surgeon volume. Complication rates are low for minimally invasive surgery, and it is unlikely that the robotic-assisted approach provides an appreciable improvement in perioperative outcomes.

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.

Cost evaluation, quality of life and pelvic organ function of three approaches to hysterectomy for benign uterine conditions: study protocol for a randomized controlled trial.

BACKGROUND: Hysterectomy is the commonest major gynaecological surgery. Although there are many approaches to hysterectomy, which depend on clinical criteria, certain patients may be eligible to be operated in any of the several available approaches. However, most comparative studies on hysterectomy are between two approaches. There is also a relative absence of data on long-term outcomes on quality of life and pelvic organ function. There is no single study which has considered quality of life, pelvic organ function and cost-effectiveness for the three main types of hysterectomy. Therefore, the objective of this study is to provide evidence on the optimal route of hysterectomy in terms of cost-effectiveness by way of a three-armed randomized control study between non-descent vaginal hysterectomy, total laparoscopic hysterectomy and total abdominal hysterectomy. METHODS: A multicentre three-armed randomized control trial is being conducted at the professorial gynaecology unit of the North Colombo Teaching Hospital, Ragama, Sri Lanka and gynaecology unit of the District General Hospital, Mannar, Sri Lanka. The study population is women needing hysterectomy for non-malignant uterine causes. Patients with a uterus > 14 weeks, previous pelvic surgery, those requiring incontinence surgery or pelvic floor surgery, any medical illness which caution/contraindicate laparoscopic surgery and who cannot read and write will be excluded. The main exposure variable is non-descent vaginal hysterectomy and total laparoscopic hysterectomy. The control group will be patients undergoing total abdominal hysterectomy. The primary outcome is time to recover following surgery, which is the earliest time to resume all of the usual activities done prior to surgery. In total, 147 patients (49 per arm) are needed to have 80% power at α-0.01 considering a loss to follow-up of 20% to detect a 7-day difference between the three routes; TLH versus TAH versus NDVH. The economic evaluation will take a societal perspective and will include direct costs in relation to allocation of healthcare resources and indirect costs which are borne by the patient. A micro-costing approach will be adopted to calculate direct costs from the time of presentation to the gynaecology clinic up to 6 months after surgery. Incremental cost-effectiveness ratios (ICER) will be obtained by calculating the incremental costs divided by the incremental effects (time to recover and QALYs gained) for the intervention groups (NDVH and TLH) over the standard care (TAH) group. DISCUSSION: The cost of the procedure, quality of life and pelvic organ function following the three main routes of hysterectomy are important to clinicians and healthcare providers, both in developed and developing countries. TRIAL REGISTRATION: The study was registered in the Sri Lanka clinical trials registry (SLCTR/2016/020) and the International Clinical Trials Registry Platform ( U1111-1194-8422 ) on 26 July 2016.

Postoperative outcomes and quality of life following hysterectomy by natural orifice transluminal endoscopic surgery (NOTES) compared to laparoscopy in women with a non-prolapsed uterus and benign gynaecological disease: a systematic review and meta-analysis.

OBJECTIVE: To critically appraise studies comparing benefits and harms in women with benign disease without prolapse undergoing hysterectomy by natural orifice transluminal endoscopic surgery (NOTES) versus laparoscopy. STUDY DESIGN: We followed the PRISMA guidelines. We searched MEDLINE, EMBASE and CENTRAL for randomised controlled trials (RCTs), controlled clinical trials (CCTs) and cohort studies comparing NOTES with laparoscopy assisted vaginal hysterectomy (LAVH) or total laparoscopic hysterectomy (TLH) in women bound to undergo removal of a non-prolapsed uterus for benign disease. Two authors searched and selected studies, extracted data and assessed the risk of bias independently. Any disagreement was resolved by discussion or arbitration. RESULTS: We did not find RCTs but retrieved two retrospective cohort studies comparing NOTES with LAVH. The study quality as assessed by the Newcastle-Ottawa scale was acceptable. Both studies reported no conversions. The operative time in women treated by NOTES was shorter compared to LAVH: the mean difference (MD) was -22.04min (95% CI -28.00min to -16.08min; 342 women; 2 studies). There were no differences for complications in women treated by NOTES compared to LAVH: the risk ratio (RR) was 0.57 (95% CI 0.17-1.91; 342 women; 2 studies). The length of stay was shorter in women treated by NOTES versus LAVH: the MD was -0.42days (95% CI -0.59days to -0.25days; 342 women; 2 studies). There were no differences for the median VAS scores at 12h between women treated by NOTES (median 2, range 0-6) or by LAVH (median 2, range 0-6) (48 women, 1 study). There were no differences in the median additional analgesic dose request in women treated by NOTES (median 0, range 0-6) or by LAVH (median 1, range 0-5) (48 women, 1 study). The hospital charges for treatment by NOTES were higher compared to LAVH: the mean difference was 137.00 € (95% CI 88.95-185.05 €; 294 women; 1 study). CONCLUSIONS: At the present NOTES should be considered as a technique under evaluation for use in gynaecological surgery. RCTs are needed to demonstrate its effectiveness.

Comparison of robotic and other minimally invasive routes of hysterectomy for benign indications.

BACKGROUND: Despite a lack of evidence showing improved clinical outcomes with robotic-assisted hysterectomy over other minimally invasive routes for benign indications, this route has increased in popularity over the last decade. OBJECTIVE: We sought to compare clinical outcomes and estimated cost of robotic-assisted vs other routes of minimally invasive hysterectomy for benign indications. STUDY DESIGN: A statewide database was used to analyze utilization and outcomes of minimally invasive hysterectomy performed for benign indications from Jan. 1, 2013, through July 1, 2014. A 1-to-1 propensity score-match analysis was performed between women who had a hysterectomy with robotic assistance vs other minimally invasive routes (laparoscopic and vaginal, with or without laparoscopy). Perioperative outcomes, intraoperative bowel and bladder injury, 30-day postoperative complications, readmissions, and reoperations were compared. Cost estimates of hysterectomy routes, surgical site infection, and postoperative blood transfusion were derived from published data. RESULTS: In all, 8313 hysterectomy cases were identified: 4527 performed using robotic assistance and 3786 performed using other minimally invasive routes. A total of 1338 women from each group were successfully matched using propensity score matching. Robotic-assisted hysterectomies had lower estimated blood loss (94.2 ± 124.3 vs 175.3 ± 198.9 mL, P < .001), longer surgical time (2.3 ± 1.0 vs 2.0 ± 1.0 hours, P < .001), larger specimen weights (178.9 ± 186.3 vs 160.5 ± 190 g, P = .007), and shorter length of stay (14.1% [189] vs 21.9% [293] ≥2 days, P < .001). Overall, the rate of any postoperative complication was lower with the robotic-assisted route (3.5% [47] vs 5.6% [75], P = .01) and driven by lower rates of superficial surgical site infection (0.07% [1] vs 0.7% [9], P = .01) and blood transfusion (0.8% [11] vs 1.9% [25], P = .02). Major postoperative complications, intraoperative bowel and bladder injury, readmissions, and reoperations were similar between groups. Using hospital cost estimates of hysterectomy routes and considering the incremental costs associated with surgical site infections and blood transfusions, nonrobotic minimally invasive routes had an average net savings of $3269 per case, or 24% lower cost, compared to robotic-assisted hysterectomy ($10,160 vs $13,429). CONCLUSION: Robotic-assisted laparoscopy does not decrease major morbidity following hysterectomy for benign indications when compared to other minimally invasive routes. While superficial surgical site infection and blood transfusion rates were statistically lower in the robotic-assisted group, in the absence of substantial reductions in clinically and financially burdensome complications, it will be challenging to find a scenario in which robotic-assisted hysterectomy is clinically superior and cost-effective.

Surgical outcome and cost comparison between total vaginal hysterectomy and laparoscopic hysterectomy for uteri weighing >500 g.

STUDY OBJECTIVE: To compare surgical outcomes and overall costs of less invasive methods of hysterectomy to treat benign disease including total vaginal hysterectomy (TVH) and total laparoscopic hysterectomy (TLH) in women with a uterus weighing >500 g. DESIGN: Retrospective review of medical records (Canadian Task Force classification III). SETTING: University-associated hospital. PATIENTS: One hundred three women with a uterus weighing >500 g who had undergone either total vaginal hysterectomy (TVH) (n = 52) or total laparoscopic hysterectomy (TLH) (n = 51). MEASUREMENTS AND MAIN RESULTS: Cost data were extracted from the hospital billing system. Patient characteristics, surgical outcomes, and hospital costs were compared between the 2 groups. Patient characteristics were similar in both groups except for a history of surgery (TVH 11.5%, and TLH 37.3%; p = .01). Insofar as surgical outcomes, mean (SD) operative time was shorter in the TVH group compared with the TLH group (110.00 [28.68] minutes vs 180.47 [51.32] minutes; p < .001), and hospital stay was longer (8.08 [0.68] days vs 7.45 [1.03] days; p < .001). Other surgical outcomes including estimated blood loss (p = .20) and decrease in hemoglobin (p = .12) did not differ between the 2 groups. Total hospital costs (converted from Korean won to US dollars) were significantly lower in the TVH group than in the TLH group ($2076.59 [$666.58] vs $2744.03 [$715.76]; p < .001). CONCLUSION: Our data suggest that TVH is a safe and economic procedure even in women with a uterus weighing >500 g. Skilled surgeons should preferentially consider TVH for treatment of benign uterine disease, regardless of uterine size.

Fibromyalgia and hysterectomy: the impact on health status and health care costs.

Women account for over 80 % of the fibromyalgia syndrome (FMS) population. Some researchers have noted that a large percentage of women with FMS have had hysterectomies. The purpose of this study was to examine the relationship between FMS and hysterectomies, and to examine the impact of having a hysterectomy on health status and health care costs. A sample of 573 American women, who were members of a health maintenance organization with a confirmed diagnosis of FMS, reported whether they had a hysterectomy. Participants completed the Quality of Well-Being Scale and their annual health care costs were calculated based on their medical records. Almost half of the sample (48.3 %) reported having had a hysterectomy, with 90.7 % reporting having had the surgery before their FMS diagnosis. Those who had a hysterectomy had significantly lower general health status and incurred higher health care costs than the women with FMS who did not have a hysterectomy. The percentage of women with FMS who had a hysterectomy was considerably higher than that found in the general population. In this study, having a hysterectomy and a diagnosis of FMS was related to poorer health status and higher health care costs.

The inSIGHT study: costs and effects of routine hysteroscopy prior to a first IVF treatment cycle. A randomised controlled trial.

BACKGROUND: In in vitro fertilization (IVF) and intracytoplasmatic sperm injection (ICSI) treatment a large drop is present between embryo transfer and occurrence of pregnancy. The implantation rate per embryo transferred is only 30%. Studies have shown that minor intrauterine abnormalities can be found in 11-45% of infertile women with a normal transvaginal sonography or hysterosalpingography. Two randomised controlled trials have indicated that detection and treatment of these abnormalities by office hysteroscopy after two failed IVF cycles leads to a 9-13% increase in pregnancy rate. Therefore, screening of all infertile women for intracavitary pathology prior to the start of IVF/ICSI is increasingly advocated. In absence of a scientific basis for such a policy, this study will assess the effects and costs of screening for and treatment of unsuspected intrauterine abnormalities by routine office hysteroscopy, with or without saline infusion sonography (SIS), prior to a first IVF/ICSI cycle. METHODS/DESIGN: Multicenter randomised controlled trial in asymptomatic subfertile women, indicated for a first IVF/ICSI treatment cycle, with normal findings at transvaginal sonography. Women with recurrent miscarriages, prior hysteroscopy treatment and intermenstrual blood loss will not be included. Participants will be randomised for a routine fertility work-up with additional (SIS and) hysteroscopy with on-the-spot-treatment of predefined intrauterine abnormalities versus the regular fertility work-up without additional diagnostic tests. The primary study outcome is the cumulative ongoing pregnancy rate resulting in live birth achieved within 18 months of IVF/ICSI treatment after randomisation. Secondary study outcome parameters are the cumulative implantation rate; cumulative miscarriage rate; patient preference and patient tolerance of a SIS and hysteroscopy procedure. All data will be analysed according to the intention-to-treat principle, using univariate and multivariate logistic regression and cox regression. Cost-effectiveness analysis will be performed to evaluate the costs of the additional tests as routine procedure. In total 700 patients will be included in this study. DISCUSSION: The results of this study will help to clarify the significance of hysteroscopy prior to IVF treatment. TRIAL REGISTRATION: NCT01242852.

Endometrial aspiration cytology by various techniques.

The demand for testing endometrium for detecting pathological as well as hormonal status is increasing and cytodiagnosis is extended very rapidly in malignant and non-malignant conditions. The gynaecologists have responded to this trend by providing cost effective care without compromising the quality. With this in mind, uterine aspiration curettage, ambulatory procedure, for endometrial sampling was studied. Dilatation and curettage (D&C) is probably most commonly performed gynaecological surgery. It accounts for large proportion of hospital bed use and operating room time, the cost is significant and patient also risks the complication of anaesthesia. Consequently various alternative procedures for endometrial sampling like endometrial brush, uterine lavage, jet wash vabra aspiration and endometrial biopsy have been reported.

[Economics analysis of endometriosis and adenomyosis surgeries].

OBJECTIVE: To explore the hospital expenses and hospital stay of surgical management for endometriosis and adenomyosis. METHODS: The average hospital expenses and average hospital stay were compared for a total of 12003 patients of endometriosis and adenomyosis confirmed operatively at our hospital from January 1994 to December 2008. And the relevant factors consisted of surgical phases, pathological types, surgical approaches, surgical routes, definite procedures and age groups. RESULTS: The average hospital expenses were significantly higher than average gynecologic surgical expenses (RMB 7073 vs RMB 6847, P < 0.01) while and the average hospital stays significantly shorter than the latter (6.8 vs 8.6 days, P < 0.01). The periods of 2006 - 2008 and 1994 - 1996 had significantly different average hospital expenses (RMB 7853 vs RMB 3382, P < 0.01) and average hospital stay (6.4 vs 9.5 days, P < 0.01). Multivariate analysis showed age was the most important correlated factor for the hospital expenses of endometriosis and adenomyosis surgeries (all P < 0.01). And surgical approach was one of the most important factors for hospital stay (all P < 0.01). CONCLUSION: Adenomyosis has the highest cost and younger endometriosis patients carry the lowest economic burden. Laparoscopy and conservative surgery may reduce the economic burden of endometriosis and adenomyosis operations.

Costs and health-related quality of life effects of hysterectomy in patients with benign uterine disorders.

OBJECTIVE: To gain knowledge about the utility of hysterectomy in a real-world setting and to relate the utility of the intervention to its costs. DESIGN: Prospective observational study. SETTING: University referral hospital in Helsinki. POPULATION: A total of 337 women entering for routine hysterectomy due to a benign disease (210 benign uterine or ovarian cause, 20 endometriosis, 51 uterovaginal prolapse, 56 menorrhagia). METHODS: Patients filled in the 15D health-related quality of life (HRQoL) questionnaire before and six months after the operation. Costs were examined from the perspective of secondary care provider. Benefits of surgery were extrapolated till the end of remaining statistical life expectancy of each woman in the prolapse group and until menopause in the other groups. MAIN OUTCOME MEASURES: HRQoL and cost per quality-adjusted life year (QALY) gained. RESULTS: Mean [standard deviation (SD)] HRQoL score (on a 0-1 scale) in the whole group improved from the preoperative of 0.905 (0.073) to 0.925 (0.077) six months after the operation (p < 0.001). The largest mean (SD) improvement was seen in patients with endometriosis [0.048 (0.067)] followed by those with menorrhagia [0.024 (0.054)], benign uterine or ovarian cause [0.018 (0.071)], and prolapse [0.017 (0.055)]. In the whole group, the intervention produced a mean (SD) of 0.222 (1.270) QALYs at mean (SD) direct hospital cost of euro3,138 (2,098). Consequently, the cost per QALY gained in the whole group was euro14,135 varying from euro3,720 to 31,570 in the disease groups. CONCLUSIONS: The cost per QALY gained for hysterectomy for benign uterine disorders is strongly dependent on the indication for surgery.

[Cost-utility analysis of surgical obstetrics in cattle with torsio uteri intra partum]. / Kosten und Nutzen der operativen Geburtshilfe bei der Torsio uteri intra partum des Rindes.

This study presents a cost-utility analysis concerning profitability of surgical obstetrics in bovines with torsio uteri intra partum. The calculations are based on 43 surgical treated cows and their postoperative outcome. Cows with torsio uteri intra partum which can not be treated conservatively are mostly, until the end of the follwing lactation period, a loss for the owner/farmer of the animal. The total loss of untreated - euthanized patients is almost 1000 euro (mainly expenses for the replacement of animals) whereas the loss of surgical treated animals, including calculated risks, is on an average 200 euro variing from -452 euro to +28 euro. The calculations presented in this study show, that the surgical treatment of conservatively incorrectable uterine torsion intra partum pays.

The cost of microwave endometrial ablation under different anaesthetic and clinical settings.

OBJECTIVE: To compare the costs of microwave endometrial ablation under local anaesthetic and general anaesthetic in an operating theatre and to estimate the cost of performing treatment under local anaesthetic in a dedicated clinic setting. DESIGN: The costing study was undertaken alongside a randomised controlled trial comparing the acceptability of microwave endometrial ablation using local versus general anaesthetic in a theatre setting. SETTING: Department of Gynaecology, Aberdeen Royal Infirmary, Scotland. SAMPLES: One hundred and twenty-seven women undergoing microwave endometrial ablation who had been randomly allocated to general or local anaesthetic. METHODS: Health and non-health service resource use was recorded prospectively. Data on resource use were combined with unit costs estimated using standardised methods to determine the cost per patient for microwave endometrial ablation under local or general anaesthetic in theatre. A model was developed to estimate the health service cost of microwave endometrial ablation under local anaesthetic in a clinic setting. MAIN OUTCOME MEASURES: Health and non-health service costs. RESULTS: There was little difference in cost when treatments were performed under local or general anaesthetic in theatre. The median health and non-health cost of microwave endometrial ablation was 440 pounds and 120 pounds, respectively, under general anaesthetic and 428 pounds and 125 pounds per women under local anaesthetic. The health service cost of microwave endometrial ablation using local anaesthetic in a clinic setting was estimated to be 432 pounds per treatment; however, this varied from 389 pounds to 491 pounds in the sensitivity analysis. CONCLUSION: There are minimal cost savings to the patient or health service from using local rather than general anaesthetic for microwave endometrial ablation in a theatre setting. Cost modelling suggests that in a clinic setting microwave endometrial ablation has a similar cost to theatre based treatment once re-admissions for treatment under general anaesthetic are considered. Sensitivity analysis indicated that these findings were sensitive to assumptions in the model.

The cost of juvenile-onset recurrent respiratory papillomatosis.

OBJECTIVE: To assess the medical costs and the number of quality-adjusted life years lost owing to juvenile-onset recurrent respiratory papillomatosis (JORRP). DESIGN: We examined hospital and physician charges for JORRP surgical procedures in Maryland in 1994 adjusting for inflation and the cost-charge ratio. Centers for Disease Control and Prevention data on treatment intensity for JORRP were augmented with a review of treatment records for 18 patients with JORRP. Sensitivity analyses were performed. To illustrate the application of our cost estimates, we compare the costs of JORRP to the costs of the surgical procedures that would be necessary to prevent it. RESULTS: We find that the present value at birth of the cost of a single case of JORRP is $201,724 (range, $61,822-$474,334). The annual cost for a single case of JORRP is $57,996 (range, $32,407-$94,114). The annual cost of JORRP in the United States is between $40 million and $123 million depending on the prevalence. Cesarean section (CS) for women with condyloma has been suggested as a potential strategy to prevent JORRP, but its efficacy remains to be determined. Our results suggest that if only 1% of the CSs actually prevented JORRP, this strategy would be a cost-effective means to prevent JORRP. CONCLUSIONS: Studies to reduce the uncertainty surrounding the efficacy of CS and the effect of both CS and JORRP on families need to precede consideration of a policy of CS for women with clinically evident genital condyloma. Patients should be kept thoroughly informed about the role of CS for the prevention of JORRP and the nature of the remaining uncertainties.

Quality of life, health care utilization, and costs among women undergoing hysterectomy in a managed-care setting.

OBJECTIVE: We compared quality of life, utilization, and costs for women undergoing elective abdominal, laparoscopically assisted vaginal, or vaginal hysterectomy within a managed-care organization. STUDY DESIGN: A prospective study of 287 women who underwent an elective hysterectomy was performed. RESULTS: Patients undergoing a vaginal hysterectomy reported returning to normal activity levels sooner and had more favorable quality-of-life scores than did those undergoing laparoscopically assisted vaginal hysterectomy or abdominal hysterectomy. Laparoscopically assisted vaginal hysterectomy was often nearly as favorable as vaginal hysterectomy, particularly at 28 days after the operation, whereas the abdominal hysterectomy group consistently reported the poorest postoperative quality-of-life scores. No significant differences were noted in utilization or costs in the 60-day preoperative period, whereas hospitalization and postoperative costs were highest among the abdominal hysterectomy group and lowest for those undergoing a vaginal hysterectomy. CONCLUSIONS: Vaginal hysterectomy resulted in better quality-of-life outcomes and lower utilization and costs compared with laparoscopically assisted vaginal or abdominal hysterectomy.