Costs and Charges Associated with Three Alternative Techniques of Hysterectomy

Dorsey, James H.; Holtz, Patrice M.; Griffiths, Robert I.; McGrath, Margaret; Steinberg, Earl P.

doi:10.1056/nejm199608153350705

Cited by 184 publications

(42 citation statements)

References 11 publications

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“…While the average cost for laparoscopic and vaginal hysterectomy ranges from $7000-$8521 31 the risk-adjusted cost in our cohort doubled from $8700 to $18,900 for those patients who developed AKI only and quadrupled to $54,700 when AKI was further complicated with additional postoperative complication. The three-fold increase in median hospital length of stay of 11 days among patients with the least severe AKI (RIFLE-R) compared to the reported average length of stay between 2.6 and 3.9 days for patients undergoing abdominal and laparoscopic hysterectomies 32 is reflective of the strong association between higher cost and resource utilization once a complication develops, and reinforces the importance of early risk assessment and diagnosis. Any effort to intervene in the course of AKI prior to a severe and often irreversible stage will require preventive techniques that can be deployed after early risk stratification by frontline clinical providers.…”

Section: Discussionmentioning

confidence: 93%

Acute kidney injury in major gynaecological surgery: an observational study

Vaught

Ozrazgat‐Baslanti

Javed

et al. 2014

BJOG

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Objective To assess the prevalence, outcomes and cost associated with acute kidney injury (AKI) defined by consensus Risk, Injury, Failure, Loss, and End-stage kidney (RIFLE) criteria after gynecologic surgery. Design Retrospective single-center cohort study. Setting Academic medical center. Sample 2341 adult patients undergoing major inpatient gynecologic surgery between January 2000 and November 2010. Methods AKI was defined by RIFLE criteria as an increase in serum creatinine greater than or equal to 50% from the reference creatinine. We used multivariable regression analyses to determine the association between perioperative factors, AKI, mortality and cost. Main Outcome Measure(s) AKI, combined major adverse events (hospital mortality, sepsis or mechanical ventilation), 90-days mortality and hospital cost. Results Overall prevalence of AKI was 13%. The prevalence of AKI was associated with the primary diagnosis: 5% (43/801) of patients with benign tumor surgeries experienced AKI compared to 18% (211/1159) among patients with malignant disease (p<0.001). Only 1.3% of the whole cohort had evidence of urologic mechanical injury. In a multivariable logistic regression analysis AKI patients had nine times the odds of a major adverse event compared to patients without AKI (adjusted odds ratio 8.95, 95% confidence interval 5.27–15.22). We have identified several readily available perioperative factors that can be used to identify patients at high risk for AKI after in-hospital gynecologic surgery. Conclusion AKI is a common complication after major inpatient gynecologic surgery associated with an increase in resource utilization and hospital cost, morbidity and mortality.

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Section: Discussionmentioning

confidence: 93%

Acute kidney injury in major gynaecological surgery: an observational study

Vaught

Ozrazgat‐Baslanti

Javed

et al. 2014

BJOG

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“…We feel that differences in patient populations and surgical complexity make these distinct entities with a priori differences in the likelihood of benefit from robotic technique (11,13). Vaginal approach was excluded as a comparator due to consistent prior evidence of superiority on outcomes and cost (5,7,28). Another strength was our use of a modified Expanded Accordion Severity Grading System that allowed us to consider and analyze intraoperative and postoperative complications collectively and consistently across the four studies (Table 3) (19).…”

Section: Discussionmentioning

confidence: 99%

Robotic Versus Laparoscopic Hysterectomy for Benign Disease: A Systematic Review and Meta-Analysis of Randomized Trials

Albright

Witte

Tofte

et al. 2016

Journal of Minimally Invasive Gynecology

116

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We conducted a systematic review and meta-analysis to assess the safety and effectiveness of robotic versus laparoscopic hysterectomy in women with benign uterine disease, as determined by randomized studies. We searched MEDLINE, EMBASE, the Cochrane Library, ClinicalTrials.gov, and Controlled-Trials.com from inception to October 9th, 2014, using the intersection of the themes “robotic” and “hysterectomy.” We included only randomized and quasi-randomized controlled trials of robotic versus laparoscopic hysterectomy in women for benign disease. Four trials met inclusion criteria and were included in the analyses. Data was extracted and studies were assessed for methodological quality in duplicate. For meta-analysis, we used random effects to calculate pooled risk ratios (RR) and weighted mean differences. For our primary outcome, we used a modified version of the Expanded Accordion Severity Grading System to classify perioperative complications. We identified 41 total complications among 326 patients. When comparing robotic to laparoscopic hysterectomy, we found no statistically significant differences in the rate of class 1 and 2 complications (RR=0.66, 95% Confidence Interval (CI) 0.23–1.89) or in the rate of class 3 and 4 complications (RR=0.99, 95%CI 0.22–4.40). Analyses of secondary outcomes were limited due to heterogeneity, but showed no significant benefit of robotic compared to laparoscopic technique in terms of length of hospital stay (weighted mean difference= −0.39 days, 95%CI −0.92–0.14), total operating time (weighted mean difference=9.0 minutes, 95%CI −31.27–47.26), conversions to laparotomy, or blood loss. Outcomes of cost, pain, and quality of life were inconsistently reported and not amenable to pooling. Current evidence demonstrates neither statistically significant, nor clinically meaningful differences in surgical outcomes between robotic and laparoscopic hysterectomy for benign disease. The role of robotic surgery in benign gynecology remains unclear.

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“…Several publications have compared costs among the various surgical approaches, consistently favoring vaginal surgery (12,28,29). In January 2015, United HealthCare Services, Incorporated, released a network bulletin outlining changes in the company's requirements for preauthorization of hysterectomy procedures (30).…”

Section: Discussionmentioning

confidence: 99%

Determining Optimal Route of Hysterectomy for Benign Indications

Schmitt¹,

Leon²,

Occhino³

et al. 2017

Obstetrics &Amp; Gynecology

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Objective To evaluate practice change after initiation of a robotic surgery program using a clinical algorithm to determine the optimal surgical approach to benign hysterectomy. Methods A retrospective post-robot cohort of benign hysterectomies (2009-2013) was identified and the expected surgical route was determined from an algorithm using vaginal access and uterine size as decision tree branches. We excluded laparoscopic hysterectomy route. A pre-robot cohort (2004-2005) was used to evaluate a practice change after the addition of robotic technology (2007). Costs were estimated. Results Cohorts were similar in regard to uterine size, vaginal parity, and prior laparotomy history. In the pre-robot cohort (n=473), 320 hysterectomies (67.7%) were performed vaginally and 153 (32.3%) through laparotomy, with 15.1% (46/305) performed abdominally when the algorithm specified vaginal hysterectomy. In the post-robot cohort (n=1,198), 672 hysterectomies (56.1%) were vaginal; 390 (32.6%), robot-assisted; and 136 (11.4%), abdominal. Of 743 procedures, 38 (5.1%) involved laparotomy and 154 (20.7%) involved robotic technique when vaginal approach was expected. Robotic hysterectomies had longer operations (141 vs 59 minutes, P<.001) and higher rates of surgical site infection (4.7% vs 0.2%, P<.001) and urinary tract infection (8.1% vs 4.1%, P=.05) but no difference in major complications (P=.27) or readmissions (P=.27) compared with vaginal hysterectomy. Algorithm conformance would have saved an estimated $800,000 in hospital costs over 5 years. Conclusion When a decision tree algorithm indicated vaginal hysterectomy as the route of choice, vaginal hysterectomy was associated with shorter operative times, lower infection rate, and lower cost. Vaginal hysterectomy should be the route of choice when feasible.

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Costs and Charges Associated with Three Alternative Techniques of Hysterectomy

Abstract: Despite shorter hospital stays, in-hospital charges and costs for laparoscopically assisted vaginal hysterectomy are higher than for either alternative procedure, because of the disposable supplies that are typically used and the longer operating-room time.

Cited by 184 publications

References 11 publications

Acute kidney injury in major gynaecological surgery: an observational study

Acute kidney injury in major gynaecological surgery: an observational study

Robotic Versus Laparoscopic Hysterectomy for Benign Disease: A Systematic Review and Meta-Analysis of Randomized Trials

Determining Optimal Route of Hysterectomy for Benign Indications

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