LAS VEGAS – Vaginal hysterectomy was the least costly approach in one tertiary hospital’s experience with over a thousand cases.
Dr. Kelly N. Wright
Operative time was the greatest contributor to overall cost among 1,067 consecutive hysterectomy procedures performed in 2009 at Brigham and Women’s Hospital, an urban academic tertiary care center. The analysis examined operative and overall costs for abdominal, laparoscopic, vaginal, and robotic procedures, including about 150 performed for ovarian cancer, said Dr. Kelly N. Wright, a fellow at the hospital and Harvard Medical School, both in Boston.
Of the 1,067 total hysterectomies, 36% were abdominal, 13% vaginal, 45% laparoscopic, and 6% robotic. Operating time was the longest for robotic (267 minutes) and shortest for vaginal hysterectomy (155 minutes). Intraoperative complications were most common for abdominal (8.8%) and least common with robotic hysterectomy (just 0.4%). Complication rates did not vary significantly among the three minimally invasive methods, Dr. Wright said at the annual meeting of the AAGL.
Operative time was strongly correlated with operative cost, with robotic hysterectomy being the most expensive ($46,065) and vaginal the least ($26,619). In all, operative time accounted for 96% of the variation in operative costs, and charges based on operative time were up to 190-fold greater than were operative charges from equipment costs.
Other patient characteristics that significantly influenced operative time were body mass index, adhesions, and cancer indications, whereas uterine weight and age did not influence operative time.
A "cost minimization analysis" was done using cost to society, which included inpatient stay, lost wages, and time to recovery, in addition to the operative costs. This time, abdominal hysterectomy was the most costly ($58,959) because of the significantly greater length of stay (3.6 days vs. 1.2-1.3 days for the other methods). Vaginal hysterectomy was again the least expensive at $34,933.
But the cost of laparoscopic hysterectomy approached that of vaginal when it was performed in less than 140 minutes, and laparoscopic hysterectomy always was less costly than either abdominal or robotic, Dr. Wright pointed out.
Conversion of all the abdominal hysterectomies done at Brigham and Women’s Hospital in 2009 to laparoscopic would have saved over $7.8 billion, and conversion to robotic, over $1.9 billion. On the other hand, if all the laparoscopic procedures had been done robotically, $934 million would have been lost.
"There is room for savings in the health care system when we appropriately select the correct method of hysterectomy," she concluded.
Dr. Wright said that she had no financial disclosures.