Detailed Cost Analysis of Robotic Sacrocolpopexy Compared to Transvaginal Mesh Repair.

OBJECTIVE: To evaluate the hospital-realized cost difference between transvaginal mesh prolapse repair and robot-assisted sacrocolpopexy. METHODS: Consecutive transvaginal mesh prolapse surgery and robot-assisted sacrocolpopexy cases from January 2012 to December 2013 were evaluated. Patient clinical and operative data were recorded. The total institutional costs (direct and indirect) for each procedure were obtained and subcategorized by area. Independent sample t tests and chi-squared analysis were performed. RESULTS: One hundred twenty women underwent transvaginal mesh repair whereas 106 underwent robotic sacrocolpopexy. Body mass index was similar between groups (28.1 vs 27.5) as was midurethral sling placement (50% vs 59%). Robotic patients were younger (61 years vs 67 years., P < .001) and more likely to undergo concomitant hysterectomy (58.5% vs 26.7%). There were similar rates for additional compartment repairs. Amortized costs for robotic purchase and maintenance were included with all depreciated equipment and realized by all patients undergoing surgery. Overall mean robotic operative time was longer with and without hysterectomy (279 minutes vs 174 minutes, P < .001 and 201 minutes vs 91 minutes, P < .001). Mean total costs were higher with robotic technique ($9675 vs $6718, P < .001), primarily driven by anesthesia ($1141 vs $675, P < .001), and operative ($6883 vs $4487, P < .001) costs. No differences for total costs were seen in laboratory fees, recovery room, or inpatient nursing. CONCLUSION: Transvaginal prolapse repair is less costly than robotic sacrocolpopexy. Length of surgery and additional robotic supplies drive the majority of increased operative costs. Costs attributed to robot purchase and maintenance do not uniquely factor into the procedure costs.

Cost-utility of routine endometrial evaluation before le fort colpocleisis.

INTRODUCTION: Routine preoperative evaluation of the endometrium before Le Fort colpocleisis is often recommended. There are no data, however, to support this practice. In select patients, it may not be a necessary addition to the preoperative evaluation of Le Fort colpocleisis. METHODS: A decision analysis model was created to compare uterine evaluation, by either endometrial (EM) biopsy or transvaginal ultrasound, to no evaluation for a hypothetical cohort of women undergoing Le Fort colpocleisis. We assumed the absence of risk factors for EM cancer. Probabilities and health outcome utilities were obtained from literature review. Medicare charges were used to estimate cost in 2012 US dollars. Cost-utility analysis was performed using US recommendations from a health plan perspective. RESULTS: At willingness-to-pay thresholds of $50,000 and $100,000, no evaluation is superior to both biopsy and ultrasound. At a 64% probability of cancer, biopsy is more cost-effective than no evaluation and ultrasound. CONCLUSIONS: Compared to biopsy and ultrasound, in low-risk women, no EM evaluation before Le Fort colpocleisis demonstrates superior cost-utility.

Cost analysis of open versus robotic-assisted sacrocolpopexy.

OBJECTIVE: This study aimed to report on the costs, operative times, and length of stay for robotic and open sacrocolpopexy. STUDY DESIGN: This retrospective study compares consecutive open and robotic sacrocolpopexies that were performed beyond the surgical learning curve. Hospital direct costs, operative times, and length of stay were compared for the 2 groups. Robot cost and maintenance were included. Statistical significance was considered at P < 0.05. RESULTS: The study comprised 91 open and 73 robotic sacrocolpopexies. Both groups were similar clinically. Median operative times for open and robotic approaches were 166 and 212 minutes (P < 0.001), respectively, and length of stay was 3 versus 2 days (P < 0.001). Of the women in the robotic group, 48% had length of stay less than 24 hours versus 1% in the open group. Median robotic and open procedure direct costs were $6668 and $7804 (P = 0.002), respectively. Readmission rates at 30 days postoperatively were similar. CONCLUSIONS: Robotic sacrocolpopexy costs less but takes slightly longer to perform than the open procedure.

Cost minimization analysis of laparoscopic sacral colpopexy and total vaginal mesh.

OBJECTIVE: The objective of the study was a cost minimization analysis of the laparoscopic sacral colpopexy (LSC) and total vaginal mesh (TVM). STUDY DESIGN: Primary clinical costs were derived from our randomized control trial comparing LSC and TVM and were compared using prices from privately- and publicly-conducted procedures. Womens' opportunity cost of time were added to these estimates to produce estimates of the primary economic costs of the procedures. Reoperation costs were added to estimate the economic cost per subject. RESULTS: LSC has lower mean primary clinical cost as compared with the TVM in both the public (mean difference, $1102.96; 95% confidence interval [CI], 468.52-1737.385) and private models (mean difference, $1176.68; 95% CI, 1116.85-1236.51), respectively. Mean total economic costs were significantly lower in the LSC group as compared with the TVM ($4013.07; 95% CI, 3107.77-4918.37). Labor costs were significantly greater in the LSC but were offset by lower consumable, inpatient, opportunity, and reoperation costs as compared with the TVM. CONCLUSION: The LSC has lower economic cost than TVM.

Costs of ambulatory care related to female pelvic floor disorders in the United States.

OBJECTIVE: We sought to evaluate trends in costs of ambulatory care related to female pelvic floor disorders (PFD) in the United States. STUDY DESIGN: We used the National Ambulatory Medical Care Survey for national estimates of ambulatory visits in the United States. PFD-related visits were based on International Classification of Diseases, Ninth Revision, Clinical Modification codes. Visits were assigned an Evaluation and Management code, and costs were estimated using national average Medicare allowances for physician services. We converted costs to 2006 dollars using the physicians' services component of the Consumer Price Index and compared the average annual costs between 1996-1997 and 2005-2006. RESULTS: The average annual cost of ambulatory physician services related to PFDs was $190 million in 1996-1997 and $298 million in 2005-2006 (P=.05). Adjusting for deductibles and copayments, these estimates increased to $262 million in 1996-1997 and $412 million in 2005-2006. CONCLUSION: The cost of ambulatory care related to female PFDs is significant and is increasing.

Rate, type, and cost of pelvic organ prolapse surgery in Germany, France, and England.

OBJECTIVE: To estimate the rate, type and costs of surgical interventions for pelvic organ prolapse (POP) in Germany, France, and England. STUDY DESIGN: We identified the number, rate, and type of hospital admissions for pelvic floor surgery in 2005 from national hospital activity databases in each country: the German Hospital Episode, the French Medical Care Program Information System, and the National Health Service England Hospital Episode Statistics. Costs to the payer were estimated using the Diagnosis-Related Group reimbursement rates for each country. RESULTS: In 2005, the number (rate) of admissions for POP surgery was 36,854 (0.87 per 1000 women) in Germany, 36,679 (1.14 per 1000 women) in France, and 28,959 (1.13 per 1000 women) in England. Admissions for POP surgery constituted 10.4%, 16.7% and 16.9% of all admissions for female genital tract therapeutic interventions in Germany, France and England, respectively. At least 20% of hysterectomies were performed for the primary indication of POP. 57.4%, 45.0%, and 40.1% of all admissions for POP surgery included a hysterectomy. The costs to payers were 144,236,557 euro, 83,067,825 euro, and 81,030,907 euro in Germany, France, and England, respectively. CONCLUSION: Burden and costs associated with POP surgery are substantial in the three countries studied. Thus, programs aimed at reducing the burden of this disease are desirable.

A comparison of costs for abdominal, laparoscopic, and robot-assisted sacral colpopexy.

The aim of this study was to compare the short-term estimated hospital costs and charges for open, laparoscopic, and robot-assisted sacral colpopexy. The null hypothesis was that there would be no difference in costs and charges. Fifteen comparable cases were reviewed for demographics, surgical information, and estimated hospital charges and costs and then compared with analysis of variance. There were no differences in demographics and surgical variables among the three groups. For estimated hospital charges, minimally invasive sacral colpopexy was most expensive; open was the least expensive approach. The estimated direct costs were significantly higher for robot-assisted compared with open sacral colpopexy, but not different between robot-assisted and laparoscopic sacral colpopexy. Robot-assisted sacral colpopexy produces the highest estimated hospital charges and is more expensive than open sacral colpopexy. The least expensive surgical approach from the hospital costs perspective is open abdominal sacral colpopexy.

Pelvic organ prolapse in rural Ghana.

OBJECTIVE: To determine the prevalence of pelvic organ prolapse (POP) and its impact on the lives of women in Sekyidumasi, a rural Ghanaian community. METHODS: A cross-sectional study of 200 women was performed using a questionnaire and pelvic examination to detect symptoms and signs of prolapse. Main outcome measures were the presence of POP and its impact on quality of life. RESULTS: Out of 174 women included in the study, 21 women (12.07%) had POP. Seventeen of these women (81%) were symptomatic, of which only 6 women (35.3%) had sought treatment because of financial constraints. The odds of prolapse increased with increasing parity (P=0.02) and age (P<0.01). The main impacts of prolapse were on emotional well-being (52.4%), the women's relationship with their partner (46.2%), and sex life (25%). CONCLUSION: Only about one-third of women with symptomatic prolapse sought treatment because the cost of medical care outweighed the impact of the condition on their lives.

Cost of pelvic organ prolapse surgery in the United States.

OBJECTIVE: To estimate the annual direct cost to society of pelvic organ prolapse operations in the United States. METHODS: We multiplied the number of pelvic organ prolapse operations identified in the 1997 National Hospital Discharge Survey by national average Medicare reimbursement for physician services and hospitalizations. Although this reimbursement does not estimate the actual cost, it is a proxy for cost, which estimates what society pays for the procedures. RESULTS: In 1997, direct costs of pelvic organ prolapse surgery were 1012 million dollars (95% confidence interval [CI] 775 dollars, 1251 million), including 494 dollars million (49%) for vaginal hysterectomy, 279 million dollars (28%) for cystocele and rectocele repair, and 135 million dollars (13%) for abdominal hysterectomy. Physician services accounted for 29% (298 million dollars) of total costs, and hospitalization accounted for 71% (714 million dollars). Twenty-one percent of pelvic organ prolapse operations included urinary incontinence procedures (218 million dollars). If all operations were reimbursed by non-Medicare sources, the annual estimated cost would increase by 52% to 1543 million dollars. CONCLUSION: The annual direct costs of operations for pelvic organ prolapse are substantial.

[Analysis of subjective effect, acceptance and costs of conservative treatment of prolapse and incontinence in women]. / Analyse von subjektivem Effekt, Akzeptanz and Kosten der konservativen Behandlung weiblicher Deszensus- und Inkontinenzzustände.

A renaissance of conservative treatment for urinary incontinence and descensus is taking place presently in the German speaking area for pre-surgical improvement of tissue quality as well as for long-term-treatment replacing or postponing surgery. Modern pessaries (shape and material), a more intense and pathophysiological well-founded physiotherapy as well as the support of treatment by electrostimulation and its completion by adequate hormone substitution lead to a successful conservative treatment. "Gesundheitsstrukturreform" (reformatory measures of the German Public Health System), "Fallpauschalen" (flat-rate tariff of treatment by the case) and "Praxisbudgets" (budgets for out-clinic-treatment by the case, also a form of flat-rate tariff) lead to a restriction in prescribing necessary conservative treatment or preventive measures. Assigning the patient to surgical treatment is therefore in large parts favoured (treatment costs are then charged to clinic budgets). On the basis of the presented exemplary cost analysis completed by data on subjective effectiveness, acceptance and evaluation of efforts for patient and doctor we want to show that it is not either method that has to be considered in the treatment but both. Besides we have to treat the patient sequentially-conservative treatment in most cases first, especially in younger women. Conservative treatment thereby offers the possibility to delay or postpone surgery, a very meaningful option offered regarding the relatively poor results of surgery especially in cases of recurrent disease.