Determinants of Cost for Outpatient Hysterectomy for Benign Indications in a Nationwide Sample.

OBJECTIVE: To identify surgeon-level variation in cost to produce an outpatient hysterectomy for benign indications in the United States. METHODS: A sample of patients undergoing outpatient hysterectomy in October 2015 to December 2021, excluding those with a diagnosis of gynecologic malignancy, was obtained from the Vizient Clinical Database. The primary outcome was total direct hysterectomy cost, which is a modeled cost to produce care. Patient, hospital, and surgeon covariates were analyzed with mixed-effects regression, which included surgeon-level random effects to capture unobserved differences influencing cost variation. RESULTS: The final sample included 264,717 cases performed by 5,153 surgeons. The median total direct cost of hysterectomy was $4,705 (interquartile range $3,522-6,234). Cost was highest for robotic hysterectomy ($5,412) and lowest for vaginal hysterectomy ($4,147). After all variables were included in the regression model, approach was the strongest of the observed predictors, but 60.5% of the variance in costs was attributable to unexplained surgeon-level differences, implying a difference in costs between the 10th and 90th percentiles of surgeons of $4,063. CONCLUSION: The largest observed determinant of cost to produce an outpatient hysterectomy for benign indications in the United States is approach, but differences in cost are attributable primarily to unexplained differences among surgeons. Standardization of surgical approach and technique and surgeon awareness of surgical supply costs could address these unexplained cost variations.

Topical Hemostatic Agents in Gynecologic Surgery for Benign Indications.

Since a variety of procoagulant products, collectively called hemostatic agents, became available to surgeons in the mid-20th century, their use has increased across multiple specialties, including gynecology. Congruent with past research on the causes of regional variation in the practice of medicine, available evidence suggests that a central predictor for use of these products is physician preference rather than documented clinical necessity. Use of these products adds risks and avoidable cost. This article seeks to highlight specific gynecologic circumstances in which evidence and surgical judgment supports hemostatic agent use and other settings in which use should be reconsidered.

Asymptomatic microscopic hematuria in women.

PURPOSE OF REVIEW: The purpose of this review is to summarize the problem of asymptomatic microscopic hematuria (AMH) in women and the most recent publications on the topic. RECENT FINDINGS: Urologic malignancy is rarely associated with AMH in low-risk women. Screening for urologic malignancy includes upper urinary tract imaging and cystoscopy. Renal ultrasound is a cost-effective first-line imaging modality in patients with AMH. Multiphasic computed tomography (CT) urography increases healthcare costs, the risk of secondary malignancy due to cumulative radiation exposure, and the discovery of incidental benign findings resulting in additional work-up. Cystoscopy is universally recommended as a diagnostic test in the evaluation of AMH but it is not without harm. Reliable risk factors for urologic malignancy in women are age, smoking, and possibly the presence of visible blood in the urine. Given the infrequency of these cancers and the performance characteristics of diagnostic testing in this context there is a need for better diagnostic strategies incorporating these risk factors in estimating the woman's risk. SUMMARY: There is a need for sex-specific guidelines to risk stratify diagnostic evaluation for urologic malignancy in women with AMH. The low prevalence of these malignancies in women render diagnostic testing (e.g., cystoscopy and multiphasic CT urography) less impactful and pose unwarranted risk and significant healthcare costs.

Nationwide salpingectomy rates for an indication of permanent contraception before and after published practice guidelines.

OBJECTIVE: To identify the nationwide rate of salpingectomy for permanent contraception before and after the January 2015 American College of Obstetricians and Gynecologists (ACOG) Committee Opinion, Salpingectomy for Ovarian Cancer Prevention. STUDY DESIGN: Using ICD-9/10 diagnosis and procedure codes within the Vizient database, we identify permanent contraception procedures with and without salpingectomy, among females 18-50 years old between January 2013 and January 2017. Subject, hospital characteristics and costs information were recorded. To determine the changes in salpingectomy rates over time analysis was conducted using the Cochran-Armitage trend test and logistic regression models. RESULTS: A total of 211,312 women across 303 Vizient-member hospitals underwent a permanent contraception procedure over the study period. Of these, 174,930 subjects were selected from 160 hospitals that contributed data over the full 49-month period. Overall, 25,882 (14.8%) subjects underwent a salpingectomy for an indication of permanent contraception. Higher salpingectomy rates were identified among larger (p<.0001), teaching (p<.0001) hospitals versus smaller, non-teaching hospitals and in subjects with commercial/private payers (p<.0001). A lower salpingectomy rate was observed in Northeast hospitals (p<.0001). Median total hospital costs differed by $25 between permanent contraceptions performed with and without salpingectomy. The proportion of salpingectomies was <1% in January 2013 slowly rising to 20.6% in October 2015 and then 61.5% by January 2017 (p<.0001). During the pre-opinion period (Jan 2013-Dec 2014) the monthly increase in the odds of salpingectomy was 6% (OR 1.06, 95% CI 1.05, 1.06) compared to a monthly increase of 18% (OR 1.18, 95% CI 1.18, 1.18) during the post-opinion period (Jan 2015-Jan 2017). CONCLUSIONS: The nationwide rate of salpingectomies for permanent contraception has steadily increased among Vizient-member hospitals since the ACOG committee opinion. IMPLICATIONS: Salpingectomy as an approach to permanent contraception in the United States is increasing since the ACOG Committee Opinion with differing utilization rates by hospital type, region, size, and patient payer types. Physician behavior may be influenced by practice guidelines but other factors mitigate the effect.

Achieving high value in the surgical approach to hysterectomy.

Value-based care, best clinical outcome relative to cost, is a priority in correcting the high costs for average clinical outcomes of health care delivery in the United States. Hysterectomy represents the most common and identifiable nonobstetric major surgical procedure among women. Surgical approaches to hysterectomy in the United States have changed in recent decades. For benign indications, clinical evidence identifies the superiority of vaginal hysterectomy over all other routes. These conclusions rest on clinical outcomes; however, cost differentials also exist across hysterectomy approaches, with the vaginal approach consistently incurring the lowest overall costs. Taken together, vaginal hysterectomy has the highest value, whereas the robotic (given high costs) and abdominal approaches (given less favorable clinical outcomes) have less value. Traditional laparoscopic hysterectomy holds an intermediate value. Increasing the use of high-value hysterectomy approaches can be achieved by adopting multimodal strategies, with changes in the payment models being the most important.

Interobserver reliability of microscopic assessment of saline-prepared vaginal fluid.

OBJECTIVE: To determine the interobserver reliability of microscopic assessment of saline-prepared vaginal fluid. MATERIALS AND METHODS: Blind-paired microscopic assessments of saline-prepared vaginal fluid collected from women presenting for gynecologic care were compared using concordance and weighted chance-corrected agreement statistics (κ). RESULTS: Vaginal fluid from 105 women was collected and examined by 65 distinct observer pairs. The mean age of participants was 39 years, with vaginal itch (29%) followed by discharge (21%) as the most common presenting complaints. The κ value for microscopic findings ranged from 0.28 (normal flora) to 0.50 (clue cells >20%). The κ value for vaginitis diagnoses ranged from 0.25 (atrophic vaginitis) to 0.45 (bacterial vaginosis). CONCLUSIONS: Interobserver agreement in the microscopic assessment of vaginal fluid is at best moderate. The value of microscopy in the diagnosis of vaginitis is uncertain, and effort should be directed to improve the precision of this tool.