Predictors of the cost of hysterectomy for benign indications

Why not vaginal?-Nationwide trends and surgical outcomes in low-risk hysterectomies: A retrospective cohort study

INTRODUCTION

The rate of vaginal hysterectomies is declining globally. We investigated surgical techniques, outcomes, and costs in a large national cohort of benign hysterectomies with prerequisites for vaginal surgery.

MATERIAL AND METHODS

A retrospective register-based cohort study with benign hysterectomies in the Swedish GynOp registry 2014-2023 (n = 17 804). Inclusion criteria were non-prolapse, non-endometriosis with uterus weight <300 g. The cohort was divided into a low-risk and a standard group, with the low-risk group having optimal conditions for vaginal hysterectomy: no previous caesarian section (CS), no previous abdominal surgery, Body Mass Index (BMI) <30, and no nulliparous patients. Surgical outcomes were quantified using crude and adjusted risk ratios (RR, ARR). Costs were calculated and compared between abdominal (AH), laparoscopic (LH), robot-assisted (RH), and vaginal hysterectomies (VH).

RESULTS

The rate of AH and VH decreased during the period studied. RH increased and was the most common surgical technique 2021-2023 (33.2%). VH had the shortest surgical time and was the cheapest method. In the low-risk group, 25.2% of the patients were operated on vaginally. AH had more postoperative complications and longer hospitalization compared to VH in the low-risk group. LH had less severe intraoperative complications, ARR = 0.38 (95% CI 0.17-0.86) but more mild postoperative complications, ARR = 1.24 (95% CI 1.05-1.46) compared to VH in the low-risk group. LH had more conversions, ARR = 1.46 (95% CI 1.00-2.12), longer surgical time, ARR = 2.73 (95% CI 2.46-3.00) and longer hospital stay, ARR = 1.26 (95% CI 1.12-1.43) compared to VH. Mild (ARR = 0.33, 95% CI 0.16-0.66) and severe (ARR = 0.17, 95% CI 0.05-0.58) intraoperative complications and bleeding >500 mL (ARR = 0.12, 95% CI 0.04-0.34) were less common in RH versus VH in the low-risk group. There were no differences between RH and VH regarding postoperative complications and reoperations. Surgical time <45 min was less common in RH versus VH (ARR = 0.47, 95% CI 0.42-0.54) and RH had a significantly longer postoperative hospital stay (ARR = 1.16, 95% CI 1.02-1.33).

CONCLUSIONS

A decline of vaginal hysterectomies in Sweden 2014-2023 among patients with prerequisites for vaginal surgery was shown. VH was the cheapest method with few postoperative complications and short hospitalization. Our results support the vaginal route in low-risk hysterectomies.

Impact of Body Mass Index on Operative Time in Women Undergoing Benign Hysterectomy

Background

Optimization of surgical scheduling represents an opportunity to improve resource utilization and increase patient access. Increasing body mass index (BMI) has been associated with increased operating time and may provide an opportunity to more accurately predict operating time.

Objective

To investigate the relationship between BMI and operative time for benign hysterectomy and develop a predictive model for hysterectomy operating time based on patient BMI.

Methods

A secondary analysis of women undergoing benign laparoscopic, abdominal, or vaginal hysterectomy between 2014 and 2019 was performed using the American College of Surgeons National Surgical Quality Improvement Program database, N = 117,691. Our primary outcome was log10 transformation of operative time. Multivariable linear regression was used to analyze the relationship between operative time and BMI. A model to predict operating time was created using variables that could be reliably obtained preoperatively.

Results

From our cohort, 22% of benign hysterectomies were performed abdominally, 16% were vaginal, and 62% were laparoscopic, and mean operative times were 144, 133, and 158 minutes, respectively. For every 10-unit increase in BMI, estimated mean operation time (OT) increased by 12.8%, 8.1%, and 6.5% for abdominal, vaginal, and laparoscopic hysterectomy, respectively. Neither an expanded nor a concise model was able to account for the variability in log10(OT).

Conclusion

Increasing BMI differentially impacts the operative time in abdominal greater than laparoscopic and vaginal hysterectomy. However, operative time for hysterectomy is highly variable, and its estimation is difficult to reliably predict using common preoperative variables.

Variables impacting prolonged post-anesthesia care unit length of stay in gynecologic cancer patients in the era of same day minimally invasive hysterectomy

OBJECTIVES

Minimally invasive surgery for treatment of gynecologic malignancies is associated with decreased pain, fewer complications, earlier return to activity, lower cost, and shorter hospital stays. Patients are often discharged the day of surgery, but occasionally stay overnight due to prolonged post-anesthesia care unit (PACU) stays. The objective of this study was to identify risk factors for prolonged PACU length of stay (LOS).

METHODS

This is a single institution retrospective review of patients who underwent minimally invasive hysterectomy for gynecologic cancer from 2019 to 2022 and had a hospital stay <24-h. The primary outcome was PACU LOS. Demographics, pre-operative diagnoses, and surgical characteristics were recorded. After Box-Cox transformation, linear regression was used to determine significant predictors of PACU LOS.

RESULTS

For the 661 patients identified, median PACU LOS was 5.04 h (range 2.16-23.76 h). On univariate analysis, longer PACU LOS was associated with increased age (ρ = 0.106, p = 0.006), non-partnered status [mean difference (MD) = 0.019, p = 0.099], increased alcohol use (MD = 0.018, p = 0.102), increased Charlson Comorbidity Index (CCI) score (ρ = 0.065, p = 0.097), and ASA class ≥3 (MD = 0.033, p = 0.002). Using multivariate linear regression, increased age (R2 = 0.0011, p = 0.043), non-partnered status (R2 = 0.0389, p < 0.001), and ASA class ≥3 (R2 = 0.0250, p = 0.023) were associated with increased PACU LOS.

CONCLUSIONS

Identifying patients at risk for prolonged PACU LOS, including patients who are older, non-partnered, and have an ASA class ≥3, may allow for interventions to improve patient experience, better utilize hospital resources, decrease PACU overcrowding, and limit postoperative admissions and complications. The relationship between non-partnered status and PACU LOS is the most novel relationship identified in this study.

Personalized Predictive Hemodynamic Management for Gynecologic Oncologic Surgery: Feasibility of Cost-Benefit Derivatives of Digital Medical Devices

BACKGROUND

Intraoperative hypotension is associated with increased perioperative complications, hospital length of stay (LOS) and healthcare expenditure in gynecologic surgery. We tested the hypothesis that the adoption of a machine learning-based warning algorithm (hypotension prediction index-HPI) might yield an economic advantage, with a reduction in adverse outcomes that outweighs the costs for its implementation as a medical device.

METHODS

A retrospective-matched cohort cost-benefit Italian study in gynecologic surgery was conducted. Sixty-six female patients treated with standard goal-directed therapy (GDT) were matched in a 2:1 ratio with thirty-three patients treated with HPI based on ASA status, diagnosis, procedure, surgical duration and age.

RESULTS

The most relevant contributor to medical costs was operating room occupation (46%), followed by hospital stay (30%) and medical devices (15%). Patients in the HPI group had EURO 300 greater outlay for medical devices without major differences in total costs (GDT 5425 (3505, 8127), HPI 5227 (4201, 7023) p = 0.697). A pre-specified subgroup analysis of 50% of patients undergoing laparotomic surgery showed similar medical device costs and total costs, with a non-significant saving of EUR 1000 in the HPI group (GDT 8005 (5961, 9679), HPI 7023 (5227, 11,438), p = 0.945). The hospital LOS and intensive care unit stay were similar in the cohorts and subgroups.

CONCLUSIONS

Implementation of HPI is associated with a scenario of cost neutrality, with possible economic advantage in high-risk settings.

Cost drivers for benign hysterectomy within a health care system: Influence of patient, perioperative, and hospital factors

OBJECTIVE

To identify patient, perioperative, and hospital factors that drive total hospital charges for benign hysterectomy.

METHODS

The authors conducted a retrospective cohort study between July 2014 and February 2019 at five academic and community hospitals within an integrated healthcare system in the state of Maryland with a Global Budget Revenue methodology for hospital charges. Predictor variables included patient, perioperative and hospital characteristics. One-way analysis of variance was used to compare charges among approaches. A multiple linear regression model was built to account for the interaction between covariates.

RESULTS

A total of 2592 patients underwent hysterectomy via laparoscopic (61%), abdominal (16%), robotic (14%), or vaginal (9%) approaches. Before adjusting for covariates, laparoscopic and vaginal approaches had similar charges ($11 637 and $12 229, respectively), while robotic and open approaches had higher charges ($17 535 and $19 099, respectively). After adjusting, charges for open, laparoscopic, and robotic approaches were higher than the vaginal approach ($692, $712, and $1279, respectively). Each operating room minute resulted in an increased cost of $46. Length of stay >23 h was associated with an increase of $865. Year, uterine size, body mass index, additional procedures, and transfusion influenced charges.

CONCLUSION

Perioperative and hospital characteristics significantly influence hospital charges for benign hysterectomy, more so than nonmodifiable patient characteristics. This provides opportunities to reduce healthcare expenditures, such as improving operating room efficiency and reducing length of stay.

Determinants of Cost for Outpatient Hysterectomy for Benign Indications in a Nationwide Sample

OBJECTIVE

To identify surgeon-level variation in cost to produce an outpatient hysterectomy for benign indications in the United States.

METHODS

A sample of patients undergoing outpatient hysterectomy in October 2015 to December 2021, excluding those with a diagnosis of gynecologic malignancy, was obtained from the Vizient Clinical Database. The primary outcome was total direct hysterectomy cost, which is a modeled cost to produce care. Patient, hospital, and surgeon covariates were analyzed with mixed-effects regression, which included surgeon-level random effects to capture unobserved differences influencing cost variation.

RESULTS

The final sample included 264,717 cases performed by 5,153 surgeons. The median total direct cost of hysterectomy was $4,705 (interquartile range $3,522-6,234). Cost was highest for robotic hysterectomy ($5,412) and lowest for vaginal hysterectomy ($4,147). After all variables were included in the regression model, approach was the strongest of the observed predictors, but 60.5% of the variance in costs was attributable to unexplained surgeon-level differences, implying a difference in costs between the 10th and 90th percentiles of surgeons of $4,063.

CONCLUSION

The largest observed determinant of cost to produce an outpatient hysterectomy for benign indications in the United States is approach, but differences in cost are attributable primarily to unexplained differences among surgeons. Standardization of surgical approach and technique and surgeon awareness of surgical supply costs could address these unexplained cost variations.

Association of Surgical Start Time with Outcomes of Benign Hysterectomy

STUDY OBJECTIVE

To evaluate whether surgical start time is associated with clinical and financial outcomes of hysterectomies performed for benign indications.

DESIGN

Retrospective cohort study.

SETTING

University 5-hospital healthcare system.

PATIENTS

Women who underwent benign hysterectomy between 2014 and 2019.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

We analyzed demographic, operative, and financial data to evaluate the relationships between surgical start time and perioperative outcomes including operating room time, estimated blood loss, length of stay, same-day discharge, and adverse perioperative events. Additionally, we evaluated the impact of surgical start time on total hysterectomy charges. Descriptive statistics and multivariate logistic and linear regressions were performed adjusting for confounders. Our study identified 2894 women who underwent benign hysterectomy, with 1910 hysterectomies starting prior to 12 pm (am group) and 984 hysterectomies starting after 12 pm (pm group). A pm start time was associated with higher estimated blood loss (Median 100, interquartile range 50, 200 in the am group vs Median 125, interquartile range 75, 250), increased length of stay, and decreased likelihood of same-day discharge. No significant differences were noted in the rates of adverse perioperative events between the 2 groups. Surprisingly, an afternoon start time was associated with decreased total hospital charges (median am $14 055.30 versus median pm $11 724.80). These cost differences persisted after multivariate linear regression, and when stratified by hysterectomy surgical approach, remained significant in the open and laparoscopic cohorts.

CONCLUSION

Afternoon hysterectomy start time is associated with increased blood loss and length of stay with decreased rates of same-day discharge; however, there was no associated increase in perioperative adverse events or mortality. Awareness regarding surgical start time and outcomes can guide surgical scheduling and optimize same-day discharge.

Impact of Obesity on Clinical and Financial Outcomes of Minimally Invasive Hysterectomy for Benign Conditions

OBJECTIVE

To evaluate the effect of obesity on clinical and financial outcomes of minimally invasive hysterectomy METHODS: This was a retrospective cohort study of 5 affiliated hospitals. We obtained demographic, operative, and financial characteristics to analyze the effects of obesity on outcomes, including operating room (OR) time, estimated blood loss (EBL), length of stay (LOS), adverse perioperative events, and hospital charges. Obesity was stratified by the following classes: no obesity (BMI <30 kg/m2), class I (BMI 30-34 kg/m2), class II (BMI 35-39 kg/m2), and class III (BMI >40 kg/m2). Descriptive statistics and multivariate logistic and linear regressions were performed.

RESULTS

A total of 2483 women underwent benign, minimally invasive hysterectomy. Laparoscopic was the most common approach (79.8%), followed by robotic (12.2%), and vaginal (8.0%). Mean BMI was 30.13 ± 6.99 kg/m2, and total charges were US $13 928 ± $5954. Each additional minute in the OR increased costs by US $47.89 (P < 0.001). Compared with patients without obesity, OR time and EBL were significantly higher among patients with class I or II obesity and highest among patients with class III obesity (P < 0.001). Obesity did not affect LOS or occurrence of adverse perioperative events. Although obesity appeared to be a significant predictor of hysterectomy charges, after adjusting for covariates, charges for laparoscopic and robotic hysterectomy did not differ significantly by BMI.

CONCLUSION

Obesity appears to have a significant effect on clinical outcomes of benign hysterectomy that is approach-dependent and most notable among patients with class III obesity. BMI was not, however, a predictor of financial outcomes.

Predictors of same-day discharge after minimally invasive hysterectomy for benign indications

OBJECTIVE

To identify predictors of same-day discharge after benign minimally invasive hysterectomy.

METHODS

In this retrospective cohort study, we identified women (n = 1084) undergoing benign minimally invasive hysterectomy from 2009 to 2016. Multivariate logistic regression was used to examine demographic, operative, and surgeon factors associated with discharge on postoperative day 0.

RESULTS

In our study population, 238 women (22%) were discharged on the same day. Robotic hysterectomy (risk ratio [RR] 2.24; 95% confidence interval [CI] 1.13-4.44), shorter operative time (lowest quartile; RR 5.28; 95% CI 2.66-10.46), and minimal blood loss (lowest quartile; RR 3.01; 95% CI 1.68-6.23) were associated with higher same-day discharge likelihood whereas later procedure start time (2-5 pm; RR 0.38; 95% CI 0.17-0.85) and postoperative complications (RR 0.19; 95% CI 0.06-0.55) significantly decreased its likelihood. The strongest predictor was surgeon's number of years in practice, with recently graduated surgeons more likely to discharge their patients on the same day (RR 3.15; 95% CI 2.09-4.77).

CONCLUSION

Same-day discharge after minimally invasive hysterectomy is determined by several patient, operative, and surgeon factors that can be incorporated into an implementation plan to promote earlier discharge. Most especially, scheduling patients based on perceived case complexity and targeted surgeon education can qualify a larger cohort for same-day discharge.