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.

Cost-effectiveness analysis of medical management versus conservative surgery for early tubal pregnancy.

STUDY QUESTION: Is conservative surgery (laparoscopic salpingotomy) cost-effective, using fertility as the endpoint compared with medical management (Methotrexate) in women with an early tubal pregnancy? SUMMARY ANSWER: Conservative surgery appeared slightly, but not statistically significantly, more effective than medical management but also more costly. WHAT IS KNOWN ALREADY: Women with an early tubal pregnancy treated with medical therapy (Methotrexate) or conservative surgery (laparoscopic salpingotomy) have comparable future intrauterine pregnancy rates by natural conception. Also, cost-minimisation studies have shown that medical therapy was less expensive than conservative surgery, but there is no cost-effectiveness study comparing these two treatments with fertility as the endpoint. STUDY DESIGN, SIZE, DURATION: A multicentre randomised controlled trial-based (DEMETER study) cost-effectiveness analysis of conservative surgery compared with medical therapy in women with an early tubal pregnancy was performed. PARTICIPANTS/MATERIALS, SETTINGS, METHODS: Included women had an ultrasound that confirmed an early tubal pregnancy. They were randomly allocated to conservative surgery or to medical therapy. The study clinical outcome was the intrauterine pregnancy rate. The payer's perspective was considered. Costs of conservative surgery and medical therapy were compared. The analysis was performed according to the intention-to-treat principle. Missing variables were imputed using the fully conditional method. To characterise uncertainty and to provide a summary of it, a non-parametric bootstrap resampling was executed and cost-effectiveness accessibility curves were constructed. MAIN RESULTS AND THE ROLE OF CHANCE: At baseline, costs per woman in the conservative surgery group and in the medical therapy group were 2627€ and 2463€, respectively, with a statistically significant difference of +164€. Conservative surgery resulted in a marginally, but non-significant (P = 0.46), higher future intrauterine pregnancy rate compared to medical therapy (0.700 vs. 0.649); leading, after bootstrap, to an incremental cost-effectiveness ratio of 1299€ (95% CI = -29 252; +29 919). Acceptability curves showed that conservative surgery could be considered a cost-effective treatment at a threshold of 3201€ for one additional future intrauterine pregnancy. LIMITATIONS, REASONS FOR CAUTION: A limitation was that monetary valuation was carried out using 2016 euros while the DEMETER study took place from 2005 to 2009. Anyway, the results would not have been very different given the marginal changes in the health insurance reimbursement tariffs during this period. WIDER IMPLICATIONS OF THE FINDINGS: Conservative surgery can be considered a cost-effective treatment, if the additional cost of 3201€ per additional future intrauterine pregnancy is an acceptable financial effort for the payer. STUDY FUNDING/COMPETING INTEREST(S): None. TRIAL REGISTRATION NUMBER: NCT 00137982.

Cost-effectiveness of robotic surgery in gynecologic oncology.

PURPOSE OF REVIEW: Robotically assisted surgeries have flourished in the United States, especially in gynecological procedures. Current robotic systems have high upfront and procedure costs that have led many in the medical community to question the new technology's cost-effectiveness. RECENT FINDINGS: Recent research continues to find that robotically assisted gynecological cancer treatments have comparable outcomes to traditional laparoscopy and similar or better outcomes than that of laparotomy in the cases studied. However, robotic surgery costs remain higher than that of traditional laparoscopy. SUMMARY: Under the current reimbursement climate, practicing physicians and hospitals should collaborate on identifying cost-effective uses of robotic systems and pushing manufacturers to lower purchase and procedure costs to a level that may be accepted by all stakeholders.

Specialist nurse supported discharge in gynaecology: a randomised comparison and economic evaluation.

AIM: To determine the effect on quality of life and cost effectiveness of specialist nurse early supported discharge for women undergoing major abdominal and/or pelvic surgery for benign gynaecological disease compared with routine care. STUDY DESIGN: Randomised controlled trial comparing specialist nurse supported discharge with routine hospital care in gynaecology. The SF-36, a generic health status questionnaire, was used to measure women's evaluation of their health state before surgery and at 6 weeks after surgery. A further questionnaire scoring patient symptoms, milestones of recovery, information given and satisfaction, was administered prior to discharge from hospital and at 6 weeks thereafter. SETTING: Gynaecology service at the Western Infirmary Glasgow, part of North Glasgow University, NHS Trust. PARTICIPANTS: One hundred and eleven women scheduled for major abdominal or pelvic surgery for benign gynaecological disease. MAIN OUTCOME MEASURES: SF-36 health survey questionnaire baseline scores were reported before surgery and at 6 weeks follow-up. Complications, length of hospital stay, readmission, information on discharge support and satisfaction of women were recorded at discharge from hospital and at 6 weeks follow-up. A cost consequence analysis was conducted based on the perspective of the NHS. RESULTS: The addition of a specialist nurse to routine hospital care in gynaecology significantly reduced the post-operative length of hospital stay p = 0.001, improved information delivery and satisfaction of women. The specialist nurse supported discharge group was associated with significantly lower total costs to the NHS than routine care resulting principally from the difference in the cost of the post-operative length of stay. CONCLUSIONS: Women undergoing major abdominal and pelvic surgery were discharged home earlier with provision of support from a specialist gynaecology nurse. The results of this study suggest that duration of hospital stay can be shortened by the introduction of a specialist nurse without introducing any adverse physical and psychological effects. This process of care is associated with receipt of information on health and lifestyle issues and maintenance of high levels of patient satisfaction and demonstrates the effectiveness of the specialist nurse role in the provision of health information for women. Earlier hospital discharge at 48 h after major abdominal and pelvic surgery is an acceptable, cost effective alternative to current routine practice in the absence of further randomised evidence.