Relative costs of gynecologic endoscopy vs traditional surgery for treatment of abnormal uterine bleeding.

BACKGROUND: The traditional treatment for abnormal uterine bleeding when medical therapy fails has been abdominal or vaginal hysterectomy. More recently, operative gynecologic endoscopy (laparoscopy and hysteroscopy) has partially replaced this traditional approach. The cost and healthcare utilization of endoscopy compared with traditional surgical methods are poorly understood. OBJECTIVE: To compare the cost and healthcare utilization associated with different gynecologic endoscopic therapies vs traditional methods for the treatment of abnormal uterine bleeding. STUDY DESIGN: Review of the available medical literature. RESULTS: Vaginal hysterectomy is the least costly of all hysterectomy techniques. The direct costs of laparoscopically assisted vaginal hysterectomy are higher than those of abdominal hysterectomy, but the indirect costs are significantly less. The direct and indirect costs of endometrial ablation/resection are significantly lower than those of hysterectomy even when the cost of treatment failures is included. CONCLUSION: Endometrial ablation/resection might be chosen over hysterectomy to treat abnormal uterine bleeding because it avoids major surgery, significantly shortens hospitalization, and allows rapid return to normal functioning.

Cost and quality-of-life issues associated with different surgical therapies for the treatment of abnormal uterine bleeding.

Abnormal uterine bleeding is a common problem among women of reproductive age and can be treated medically or surgically. When medical therapy fails to cure menorrhagia, many women undergo hysterectomy. Over the past 15 years, operative laparoscopy and hysteroscopy increasingly have replaced traditional surgery (i.e., abdominal and vaginal hysterectomy). An endoscopic approach such as LAVH has been added to the therapeutic choices of patient and physician. Additionally, hysterectomy alternatives such as endometrial resection and ablation and myomectomy have been offered to women with significant menorrhagia. This article reviewed the cost and quality-of-life issues of endoscopic treatment versus traditional surgical methods. Vaginal hysterectomy is the least costly of all hysterectomy techniques. Studies have shown that for LAVH, direct costs are higher that abdominal hysterectomy. However, this difference decreases with additional operator experience and with the use of nondisposable instrumentation. The indirect cost of LAVH is significantly less than abdominal hysterectomy because of the more rapid convalescence. With endometrial resection and ablation, direct and indirect costs are significantly less than those of hysterectomy even when high failure rates are factored. Women choose this procedure over hysterectomy because it avoids major surgery, allows for a fast return to normal functioning, and entails short hospitalization. Hysterectomy can lead to many psychologic and physical changes for a woman. It continues to provide a high satisfaction rate because it is a guaranteed cure for abnormal bleeding.

Cost of different types of surgical therapy for abnormal uterine bleeding. A review.

Treatment of abnormal uterine bleeding by abdominal or vaginal hysterectomy has been partially replaced by operative endoscopy. Operative endoscopy (laparoscopy and hysteroscopy), appropriately employed, might offer numerous advantages, such as decreased hospital stay, complications and discomfort. The cost and health care utilization of operative laparoscopy and hysteroscopy as compared to traditional surgical methods are less understood.

Long-term economic evaluation of resectoscopic endometrial ablation versus hysterectomy for the treatment of menorrhagia.

STUDY OBJECTIVE: To assess long-term costs of resectoscopic endometrial ablation versus hysterectomy in women with menorrhagia. DESIGN: Controlled cohort study (Canadian Task Force classification II-2). SETTING: Multispeciality group practice. PATIENTS: Sixty-four women who underwent endometrial ablation during 1992-1994 and 46 women who underwent hysterectomy during 1990-1992. To attain comparable controls, patients with uterine size exceeding 14 weeks or uterine weight greater than 300 g, ovarian pathology, endometriosis, or neoplasia were excluded. INTERVENTIONS: Endometrial ablation and hysterectomy, followed by economic evaluation. MEASUREMENTS AND MAIN RESULTS: Direct costs were hospitalization charges, professional fees, preoperative depot leuprolide, and gynecologic care during 3 years after primary surgery. Indirect costs were calculated based on known demographic data, recovery time, and lost productivity. Surgical outcomes, complications, repeat surgeries, menstrual outcomes, and overall patient satisfaction were assessed. Operating time (38 vs 107 min), hospital stay (0.7 vs 2.7 days), frequency of postoperative complications (6.3% vs 21.7%), and recuperation time (5 vs 32 days) were less with endometrial ablation than with hysterectomy. Mean follow-up was 48.5 months (range 36-68 mo), with rates of amenorrhea, hypomenorrhea, and eumenorrhea of 49%, 29%, and 8%, respectively. One patient was lost to follow-up. There were eight failures (12%): repeat endometrial ablations (2 women), abdominal hysterectomy (1), and laparoscopic-assisted hysterectomy (5). Most women (85%) remained satisfied with the operation. Total direct costs/case for endometrial ablation were $5434 versus $8417 for hysterectomy; respective indirect costs/case were $525 and $3360. Conclusion. Long-term direct and indirect costs of endometrial ablation were significantly less than those of hysterectomy ($5959 vs $11,777) for the treatment of menorrhagia.

Treating adnexal masses. Operative laparoscopy vs. laparotomy.

OBJECTIVE: To compare operative laparoscopy vs. laparotomy for the treatment of adnexal masses. STUDY DESIGN: A retrospective review of all surgical cases who underwent operative laparoscopy or laparotomy for an adnexal mass during 1988-1995 at one multispecialty group practice. Preoperative screening for women over 45 included a CA-125 and ultrasound. If a malignant mass was encountered, it was immediately staged by laparotomy with the assistance of a surgical oncologist. During the study period 121 patients underwent ovarian cystectomy and 284 patients, oophorectomy. RESULTS: Laparoscopy was successfully completed in 118 of 127 (93%) oophorectomy and 71 of 72 (98%) of ovarian cystectomy patients. The incidence of malignant lesions at operative laparoscopy was 2%. The hospital stay for ovarian cystectomy was significantly shorter for laparoscopy (0.8 vs. 3.1 days). Hospital stay for oophorectomy was significantly shorter for laparoscopy (0.8 vs. 4.1 days). Ovarian cystectomy by laparotomy resulted in slightly more total complications than did laparoscopy (8% vs. 1%). Oophorectomy by laparotomy resulted in significantly more total complications than did oophorectomy by laparoscopy (29% vs. 3%). The mean total charge for laparoscopic oophorectomy was $5,873 versus $7,007 for laparotomy. The mean total charge for laparoscopic ovarian cystectomy was $4,507 vs. $5,541 for laparotomy. CONCLUSION: Treatment of adnexal masses by operative laparoscopy can be performed safely, with reduced morbidity and patient disability, and at a reduced cost. By having an oncologist backup in house, we have been able to convert most procedures to the laparoscopic approach.

Cost of assisted reproductive technologies for a health maintenance organization.

OBJECTIVE: To calculate the cost of assisted reproductive technologies (ART) for a health maintenance organization (HMO), assess factors that contribute to the cost per delivery and to analyze how utilization rates can be controlled by the use of clinical criteria. STUDY DESIGN: Pregnancy outcome and a cost analysis of all ART cycles at an HMO in a state with mandated coverage for these procedures was performed. All patients (n = 148) undergoing ART cycles insured by the HMO performed at one in vitro fertilization (IVF) center during 1990-1995 were studied. RESULTS: ART cycle outcomes and a cost analysis, including global cycle and cancellation charges, medication costs, obstetric costs and neonatal care costs, were assessed. ART cycles (n = 375) included IVF (n = 278), gamete intrafallopian transfer (n = 46), cryopreserved embryo transfer (ET) (n = 42), zygote intrafallopian transfer/tubal embryo transfer (n = 7) and donor oocyte (n = 2). Pregnancy outcome with IVF was 18.3% deliveries per retrieval, for gamete intrafallopian transfer 27.8% deliveries per retrieval and for frozen ET 19% per procedure. Overall, 62/148 (41.9%) of the patients delivered. There were 35 singletons, 22 twin sets and 5 triplet sets. This resulted in an average cycle cost per delivery of $36,417. The mean obstetric and neonatal charges were $9,329 for a singleton delivery, $20,318 for twins and $153,335 for triplets. If these charges are expressed in terms of the number of infants born, a twin pregnancy would cost $10,159 per infant and a triplet pregnancy, $51,112. The ART cycle cost per HMO plan member was $2.49 per annum. Our IVF utilization was 295 cycles per million population. CONCLUSION: An HMO can control the cost of ART services by establishing preauthorization clinical criteria. Our utilization rates might be used as a benchmark for other insurers considering ART coverage. The cost of ART ($2.49 per annum) would be only a small fraction of the typical annual insurance premium.

Staging endometrioid adenocarcinoma. Clinical and financial comparison of laparoscopic and traditional approaches.

OBJECTIVE: To compare laparoscopically assisted surgical staging (LASS) of endometrioid adenocarcinoma with traditional surgical staging by laparotomy. STUDY DESIGN: A retrospective review of all cases of uterine cancer (n = 108) insured by one health maintenance organization during 1990-1995. During this period, 29 patients underwent successful LASS and were compared to 64 who underwent laparotomy for treatment of surgical stage I endometrioid adenocarcinoma. RESULTS: LASS was performed successfully in 29 of 32 attempted cases. All patients on whom LASS was attempted were found to have surgical stage I. Laparoscopic pelvic lymphadenectomy was highly successful, with no failures and a mean number of 14 nodes obtained. The overall complication rate was significantly higher for laparotomy than for LASS (28% vs. 7%, P < .001). The average length of stay for laparotomy was significantly higher than for LASS (5.1 vs. 2.3 days, P < .001). CONCLUSION: LASS for stage I endometrioid adenocarcinoma is an attractive alternative to traditional surgical staging. It causes fewer complications and shortens the hospital stay.

Clinical and financial analyses of ectopic pregnancy management at a large health plan.

STUDY OBJECTIVE: To compare three treatment options for ectopic pregnancy-laparotomy, laparoscopy, and methotrexate-including clinical aspects, costs, and reproductive outcomes. DESIGN: Retrospective review of outpatient and inpatient records of all patients with a diagnosis of ectopic pregnancy insured by Fallon Community Health from 1990 to 1995. SETTING: Multispecialty group practice and a university-affiliated private hospital. PATIENTS: One hundred seven women treated for ectopic pregnancy. INTERVENTIONS: Thirty-six women were treated by laparotomy, 58 by laparoscopy, and 13 by single-dose intramuscular methotrexate. Data from the chart review were analyzed to define differences among the three groups with respect to several predetermined outcome variables: initial symptoms, risk factors, human chorionic gonadotropin levels, size of ectopic gestation, procedure types, rupture rates, surgical outcomes and morbidity, failure rates, length of convalescence, reproductive outcomes, and costs. MEASUREMENTS AND MAIN RESULTS: The incidence of ectopic pregnancy was 8.6/1000 reported pregnancies. Initially, 38% of surgical patients had laparoscopic treatment, but by 1995 the figure reached 100%. From 1994 to 1995, 13 (29%) of 45 pregnancies were treated with single-dose methotrexate. Compared with laparoscopy, length of stay was significantly longer for laparotomy (3.1 vs 1.3 days), as was recuperation time (2.4 vs 4.6 wks). Laparotomy had similar rates of total complications as laparoscopy (13.9% vs 10.3%). The rate of treatment failures (persistent trophoblastic activity) were 2.7% and 3.4%, respectively. The rate of persistence for laparoscopic salpingostomy was 6.1%. Methotrexate therapy resulted in no tubal ruptures or treatment failures. Two of 13 women required a second injection. The only complication of methotrexate therapy was mild leukocytopenia in one patient. Total charges were similar for laparotomy and laparoscopy ($6720 vs $6840). Outpatient methotrexate therapy cost significantly less than the two surgical procedures (average $818/case, p < 0.001). Laparotomy resulted in similar intrauterine pregnancy rates as laparoscopy (66% vs 77%), and similar repeat tubal pregnancy rates (17% vs 7%). CONCLUSION: The results of this study support laparoscopy and methotrexate as efficacious, safe, and cost effective for the treatment of ectopic pregnancy compared with laparotomy. Reproductive outcomes were similar among the three groups.

A comparison of clinical outcomes and cost of office versus hospital hysteroscopy.

STUDY OBJECTIVE: To compare office hysteroscopy with suction biopsy versus the hospital procedure with respect to clinical outcomes, success rates, and cost. DESIGN: Retrospective review of outpatient and inpatient records for all attempted office hysteroscopies with suction biopsy from September 1991 to June 1995, and all hospital diagnostic hysteroscopies with dilatation curettage from January 1993 to June 1994. SETTING: Multispeciality office group practice and a university-affiliated private hospital. PATIENTS: Four hundred seventy-three women who had office hysteroscopy with suction biopsy and 95 who had hospital diagnostic hysteroscopy with dilatation curettage. INTERVENTIONS: The procedures were performed by 13 gynecologists who had no experience with office hysteroscopy. MEASUREMENTS AND MAIN RESULTS: A cost analysis was completed by obtaining hospital and anesthesia charges for the hospital procedures and comparing them with office, instrument repair, and capital equipment costs. Gynecologists' professional fees were excluded from the analysis since they were the same in both settings. The overall failure rates to complete office and hospital hysteroscopies were 7.2% and 3.1%, respectively. Abnormal uterine bleeding was the indication in 89% of office and 96% of hospital procedures. Office hysteroscopy in these women revealed an abnormality in 40.1% of office versus 38.5% of hospital procedures. Histology revealed insufficient tissue for diagnosis in 3.4% office and 22.1% hospital procedures. The minor complication rate for office hysteroscopy was 1.9% and for hospital hysteroscopy 4.2%. There were no major complications in either group. The mean charges, excluding professional fees, for the hospital were $1799 versus $62 for office hysteroscopy. CONCLUSIONS: Office hysteroscopy has a high success rate and a low complication rate even when performed by a group of gynecologists with limited experience in the procedure. Because of its lower cost and greater diagnostic accuracy, office hysteroscopy with suction biopsy should be the method of choice for evaluating gynecologic conditions such as abnormal bleeding.

Advances in gynecologic care: the effect on an HMO.

The introduction of four endoscopic surgical procedures into the gynecology department at Fallon Community Health Plan (FCHP) is discussed. The use of these endoscopic procedures reduced average length of stay (ALOS), hospital days/1OOO members, and rate of postoperative complications compared to the open (laparotomy) method. These minimally invasive procedures are popular with patients and physicians, and their use has the potential to decrease an HMO's overall operational costs.

A health maintenance organization's initial experience with laparoscopic-assisted vaginal hysterectomy and endometrial ablation.

STUDY OBJECTIVE: To determine how the integration of laparoscopic-assisted hysterectomy (LAVH) and endometrial ablation into a health maintenance organization's (HMO) gynecologic practice affected quality of care and operating costs. DESIGN: A clinical study reviewing charts of HMO patients having a hysterectomy or endometrial ablation during 1990-1993. SETTING: A group practice in Worcester, Massachusetts. PATIENTS: Female members of the Fallon Community Health Plan, classic program. INTERVENTIONS: Total hysterectomies and endometrial ablations for 1990 through 1993; the numbers were 126, 105, 152, and 185, respectively. Hysterectomy was subdivided as total abdominal hysterectomy (TAH), vaginal hysterectomy (VH), vaginal hysterectomy with anterior or posterior colporrhaphy (VHC), and LAVH. All records of patients undergoing endometrial ablation (33), LAVH (59), and VH (44) were reviewed. Also reviewed were a random sample of the records of 60 patients (1990-1992) having TAH for benign conditions and 40 patients (1990-1993) having VHC. MEASUREMENTS AND MAIN RESULTS: We analyzed indications, uterine weights, endometriosis and adhesion classification, complications, surgical outcomes, total charges, trends in hysterectomy type, and annual hysterectomy rates. The annual hysterectomy rate did not change significantly over the study years, varying 1.83 to 2.71 per 1000 women. Menorrhagia as an indication for vaginal hysterectomy dropped from 58% in 1990-1991 to 17% in 1992-1993 after endometrial ablation was initiated. Postoperative complications were highest for TAH (45%) and lowest for LAVH (9%) and endometrial ablation (3%). The mean total charges were greatest for LAVH ($9739) and the least for endometrial ablation ($3580). The group reduced the rate of TAH from 78% (1990) to 47% (1993) of total procedures. For all procedures the number of weeks before return to work dropped from 5.57 to 4.45 during the study years. The mean cost per procedure did not change significantly, varying from $6634 to $7180. CONCLUSIONS: The integration of LAVH and endometrial ablation into an HMO's gynecologic practice improved quality of care by a marked reduction in surgical complications and more rapid return to work, but has not reduced operating costs due to the high total charges for LAVH. Continued study over the next few years may reveal further reduction in operating costs with an increased rate of endometrial ablation versus hysterectomy for menorrhagia.

The initial worcester experience with laparoscopic hysterectomy.

STUDY OBJECTIVE: To examine three community hospital's experience with the first 108 attempted laparoscopic hysterectomies. DESIGN: Retrospective analysis of hospital and office charts using a standardized data-collection sheet. SETTING: All procedures were performed at the Medical Center of Central Massachusetts, St. Vincent's Hospital, or the University of Massachusetts Medical School, Worcester, Massachusetts. PATIENTS: The first 108 patients to have a laparoscopic hysterectomy attempted. Ninety procedures were completed successfully. MEASUREMENTS AND MAIN RESULTS: Areas that were analyzed were indications for surgery, type of laparoscopic hysterectomy, surgeons' instrument preference, failure to complete the operation, complications, and relative cost. Surgical indications, patient demographics, and complication rates were comparable with those unpublished papers. However, our data showed no improvement in estimated blood loss or operating room time with increased operator experience. Review of pathology reports indicated no cases in which an unsuspected malignancy was encountered. CONCLUSIONS: Laparoscopic hysterectomy can be performed safely and successfully by generalists in obstetrics and gynecology. Additional study is required to know whether variables such as operating room time and expense will improve as this procedure is increasingly performed by generalists rather than specialists.

Laparoscopic Hysterectomy, The Worcester Experience

Despite the enthusiasm in the gynecologic community and the lay press for laparoscopic hysterectomy, there remain few articles to date in the literature supporting this new surgical technique. Those papers that have been published review the laparoscopic hysterectomy experience of the most advanced pelviscopic surgeons. However, the majority of patients inquiring about this surgery are presenting to generalists in obstetrics and gynecology. This paper differs from those previously published in that it examines a community's experience with the first 108 attempted laparoscopic hysterectomies. Areas that were analyzed included indications for surgery, type of laparoscopic hysterectomy, instrument preference, failure to complete operation, complications and relative cost. A retrospective analysis was performed of hospital and office charts using a standardized collection sheet. Laparoscopic-assisted vaginal hysterectomy in which the uterine vessels are controlled vaginally was the most common operative technique used in the Worcester community from August 1991 to December 1992. Surgical indications, patient demographics, and complication rates were comparable with previously published papers. However, our data showed no improvement in estimated blood loss or operating room time with increased operator experience. Pathology reports were reviewed and there were no cases in which an unsuspected malignancy was encountered. This data is presented to evaluate a new surgical procedure and its introduction into the community. In order to reach a consensus on the validity of laparoscopic hysterectomy, continued evaluation will be necessary.

Clinical and financial analyses of laparoscopically assisted vaginal hysterectomy versus abdominal hysterectomy.

STUDY OBJECTIVE: To perform clinical and financial analyses of laparoscopically assisted vaginal hysterectomy (LAVH) and total abdominal hysterectomy (TAH). DESIGN: During the 16 months between August 1991 and December 1992, 34 women who underwent LAVH were compared with 60 women having TAH during 1990. Indications, surgical outcomes, complications, time to return to work, and hospital charges for each group were analyzed. SETTING: A multispecialty group practice. PATIENTS: The LAVH group included the first 34 cases by the senior author and were the only such procedures at this hospital. The TAH group included all patients having this procedure for benign conditions from the same group practice for 1990. Interventions. Either LAVH or TAH. MEASUREMENTS AND MAIN RESULTS: The most common primary indication in both groups was fibroids. Only one LAVH failed and was converted to a TAH. Postoperative complications were significantly greater for TAH than for LAVH (45% vs 9%). The length of stay and time to return to work were significantly less after LAVH. Total hospital charges increased for LAVH over TAH ($7623 vs $4550) despite a significantly shorter length of stay after LAVH. CONCLUSIONS: Although LAVH has a significantly lower complication rate than TAH, it is more costly to perform. This higher cost, despite a shorter hospital stay, is attributed to high operating room charges. Employers and patients benefit from early return to work with LAVH.

Salpingo-oophorectomy: clinical and financial analyses of laparoscopic and open techniques.

OBJECTIVE: To analyze clinical results and financial costs of salpingo-oophorectomy performed by laparoscopy versus laparotomy. STUDY DESIGN: Comparison of laparoscopic salpingo-oophorectomy with procedures performed by laparotomy. SETTING: St. Vincent's Hospital and Fallon Clinic in Worcester, Massachusetts. PATIENTS: Twenty women in both groups. INTERVENTIONS: Salpingo-oophorectomies performed by laparoscopy and laparotomy. MEASUREMENTS AND MAIN RESULTS: Women undergoing laparotomy had a 25% rate of postoperative complications compared with 0% of those having laparoscopy. The duration of the procedures and hospital charges were similar for both groups. Length of hospital stay and time to return to work were significantly less after laparoscopy than laparotomy. CONCLUSIONS: Laparoscopic salpingo-oophorectomy was associated with significantly fewer complications than the operations performed by laparotomy. Although women in the laparoscopy group had a shorter hospital stay, their higher charges were attributed to costly disposable instruments. Patients benefit from early return to work and other activities after laparoscopy.