RESUMEN
Aim: We examine the impact of the new risk information about a surgical device on surgery and patient outcomes for hysterectomy in the inpatient setting. Methods: We utilize a difference-in-differences approach to assess the impact of new risk information on patient outcomes in the inpatient setting between 2009 and 2014. The inpatient data come from a nationally representative sample of hospitalizations in the USA. We use the likelihood of laparoscopic surgery, measures of resource use and surgical complications as outcome variables. Results: We estimate a three-percentage point decrease in the likelihood of receiving laparoscopic hysterectomy, a one-percentage point increase in the likelihood of experiencing a surgical complication and no impact on resource use, relative to pre-existing means. Conclusion: Our findings show that there was movement away from laparoscopic surgery in the months following the dissemination of new risk information. These changes had limited effect on patient outcomes.
Asunto(s)
Histerectomía/métodos , Leiomioma/cirugía , Morcelación/efectos adversos , Ovariectomía/métodos , Neoplasias Uterinas/cirugía , Femenino , Gastos en Salud , Humanos , Histerectomía/efectos adversos , Histerectomía/economía , Pacientes Internos , Laparoscopía/efectos adversos , Laparoscopía/métodos , Tiempo de Internación , Persona de Mediana Edad , Morcelación/economía , Morcelación/instrumentación , Ovariectomía/efectos adversos , Ovariectomía/economía , Complicaciones Posoperatorias/epidemiología , Medición de Riesgo , Estados Unidos , United States Food and Drug Administration , Miomectomía Uterina/efectos adversos , Miomectomía Uterina/métodosRESUMEN
PURPOSE OF REVIEW: As the Food and Drug Administration raised concern over the power morcellator in 2014, the field has seen significant change, with patients and physicians questioning which procedure is safest and most cost-effective. The economic impact of these decisions is poorly understood. RECENT FINDINGS: Multiple new technologies have been developed to allow surgeons to continue to afford patients the many benefits of minimally invasive surgery while minimizing the risks of power morcellation. At the same time, researchers have focused on the true benefits of the power morcellator from a safety and cost perspective, and consistently found that with careful patient selection, by preventing laparotomies, it can be a cost-effective tool. SUMMARY: Changes since 2014 have resulted in new techniques and technologies to allow these minimally invasive procedures to continue to be offered in a safe manner. With this rapid change, physicians are altering their practice and patients are attempting to educate themselves to decide what is best for them. This evolution has allowed us to refocus on the cost implications of new developments, allowing stakeholders the opportunity to maximize patient safety and surgical outcomes while minimizing cost.
Asunto(s)
Enfermedades de los Genitales Femeninos/cirugía , Costos de la Atención en Salud , Histerectomía/economía , Morcelación/economía , Miomectomía Uterina/economía , Actitud del Personal de Salud , Actitud Frente a la Salud , Contraindicaciones de los Procedimientos , Análisis Costo-Beneficio , Diagnóstico Tardío/efectos adversos , Diagnóstico Tardío/economía , Diagnóstico Tardío/tendencias , Femenino , Enfermedades de los Genitales Femeninos/economía , Neoplasias de los Genitales Femeninos/diagnóstico , Neoplasias de los Genitales Femeninos/economía , Neoplasias de los Genitales Femeninos/cirugía , Costos de la Atención en Salud/tendencias , Humanos , Histerectomía/efectos adversos , Histerectomía/instrumentación , Histerectomía/tendencias , Complicaciones Intraoperatorias/economía , Complicaciones Intraoperatorias/etiología , Complicaciones Intraoperatorias/mortalidad , Complicaciones Intraoperatorias/terapia , Laparoscopía/efectos adversos , Laparoscopía/economía , Laparoscopía/tendencias , Morcelación/efectos adversos , Morcelación/instrumentación , Morcelación/tendencias , Tempo Operativo , Seguridad del Paciente/economía , Estados Unidos , United States Food and Drug Administration , Miomectomía Uterina/efectos adversos , Miomectomía Uterina/instrumentación , Miomectomía Uterina/tendenciasRESUMEN
OBJECTIVE: To evaluate operating room (OR) costs associated with the 2 available morcellators in the United States in a matched cohort and to determine benign prostatic hyperplasia surgeon's morcellator preference. MATERIALS AND METHODS: Patients from 2013, the last year our institution exclusively used the VersaCut device, were matched 1:1 with the most recent patient cohort, utilizing the Wolf Piranha morcellator. Cost of morcellation including the expense of OR time and disposable instrument costs were calculated. A survey to the Endourological Society e-mail listserv was sent to determine morcellator preference. RESULTS: We identified 142 patients who underwent holmium laser enucleation of the prostate in 2013. When compared with the VersaCut group, morcellation efficiency (4.4 vs 7.0 g/min, P <.01) and expense of OR time ($1420.80 vs $992.21, P <.005) both favored the Piranha morcellator system even when the costs of disposable instruments were factored into the analysis ($1338.81 vs $1637.50, P <.05). A total of 126 urologists responded to the survey. Of these, 56 (44.5%) perform transurethral prostate enucleations, which included 48 (86%) holmium. More endourologists use the VersaCut (n = 33, 59%) than the Piranha (n = 24, 43%) morcellator. Qualities that impacted the preference of morcellator included the preferred device is safer, faster, easier to use, reusable, and less expensive. CONCLUSION: We identified a significant improved efficiency and improved cost savings utilizing the Piranha morcellator even when controlling for disposable costs. Of the endourologists who responded to the survey, less than half perform transurethral enucleation. Morcellator preference is largely based on safety, efficiency, and ease of use, whereas cost and reusablility were of lesser importance.
Asunto(s)
Costos y Análisis de Costo , Morcelación/economía , Morcelación/instrumentación , Pautas de la Práctica en Medicina , Hiperplasia Prostática/cirugía , Urología , Estudios de Cohortes , Diseño de Equipo , Humanos , Masculino , Persona de Mediana Edad , Estudios Retrospectivos , Estados Unidos , Procedimientos Quirúrgicos Urológicos Masculinos/economíaRESUMEN
STUDY OBJECTIVE: Hysterectomy for presumed leiomyomata is 1 of the most common surgical procedures performed in nonpregnant women in the United States. Laparoscopic hysterectomy (LH) with morcellation is an appealing alternative to abdominal hysterectomy (AH) but may result in dissemination of malignant cells and worse outcomes in the setting of an occult leiomyosarcoma (LMS). We sought to evaluate the cost-effectiveness of LH versus AH. DESIGN: Decision-analytic model of 100 000 women in the United States assessing the incremental cost-effectiveness ratio (ICER) in dollars per quality-adjusted life-year (QALY) gained (Canadian Task Force classification III). SETTING: U.S. hospitals. PATIENTS: Adult premenopausal women undergoing LH or AH for presumed benign leiomyomata. INTERVENTIONS: We developed a decision-analytic model from a provider perspective across 5 years, comparing the cost-effectiveness of LH to AH in terms of dollar (2014 US dollars) per QALY gained. The model included average total direct medical costs and utilities associated with the procedures, complications, and clinical outcomes. Baseline estimates and ranges for cost and probability data were drawn from the existing literature. MEASUREMENTS AND MAIN RESULTS: Estimated overall deaths were lower in LH versus AH (98 vs 103). Death due to LMS was more common in LH versus AH (86 vs 71). Base-case assumptions estimated that average per person costs were lower in LH versus AH, with a savings of $2193 ($24 181 vs $26 374). Over 5 years, women in the LH group experienced 4.99 QALY versus women in the AH group with 4.91 QALY (incremental gain of .085 QALYs). LH dominated AH in base-case estimates: LH was both less expensive and yielded greater QALY gains. The ICER was sensitive to operative costs for LH and AH. Varying operative costs of AH yielded an ICER of $87 651/QALY gained (minimum) to AH being dominated (maximum). Probabilistic sensitivity analyses, in which all input parameters and costs were varied simultaneously, demonstrated a relatively robust model. The AH approach was dominated 68.9% of the time; 17.4% of simulations fell above the willingness-to-pay threshold of $50 000/QALY gained. CONCLUSION: When considering total direct hospital costs, complications, and morbidity, LH was less costly and yielded more QALYs gained versus AH. Driven by the rarity of occult LMS and the reduced incidence of intra- and postoperative complications, LH with morcellation may be a more cost-effective and less invasive alternative to AH and should remain an option for women needing hysterectomy for leiomyomata.