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ORIGINAL RESEARCH |
From the Boston Scientific Corporation, Natick, Massachusetts; and Massachusetts General Hospital, Boston, Massachusetts.
Address reprint requests to: Mary Ann Clark, MHA, Boston Scientific Corporation, One Boston Scientific Place, Natick, MA 01760; E-mail: maryann.clark{at}bsci.com.
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ABSTRACT |
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 ABSTRACT MATERIALS AND METHODSRESULTSDISCUSSIONREFERENCES |
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METHODS: The study was performed using a retrospective database of private insurance claims from 1995 to 1997. Records were selected for analysis based on the presence of ICD-9-CM procedure and/or CPT-4 codes associated with myomectomy. In addition, diagnosis of uterine leiomyoma and related symptoms for these patients were confirmed through ICD-9-CM diagnosis codes. Inpatient, outpatient, and physician costs were estimated. All cost data were converted into 1997 dollars.
RESULTS: A total of 4394 women, between the ages of 14 and 70, were available for analysis. Of these, 3305 were classified by type of myomectomy procedure, and complete data were available on 820 at 1 year and 236 at 2 years. Abdominal myomectomies were the most common procedures, followed by hysteroscopic and laparoscopic myomectomies. Conversion to a more invasive procedure occurred in 5.4% of the patients. The rate of additional surgeries was 8.3% in 6 months, 10.6% in 1 year, and 16.5% in 2 years. Overall cost increased from an initial $6,737 per patient to $7,575 in 1 year and to $8,001 in 2 years.
CONCLUSION: The repeat procedures required after the initial myomectomy add significantly to total cost and highlight the importance of assessing post-procedure health care use. This comprehensive analysis facilitates the systematic evaluation of myomectomy with current and emerging alternative treatments for uterine leiomyomas.
A systematic search of the literature (MEDLINE, Cochrane Reviews) from 1985 to 2000, using the terms "myomectomy cost," "myomectomy charges," and "myomectomy length of stay" only identified two studies that have attempted to estimate the cost of myomectomy. The study by Brumsted et al,1 analyzed the cost of hysteroscopic myomectomy and ablation for abnormal uterine bleeding in 14 patients. A mean charge of $5,525 was calculated, and this included the cost of those requiring repeat procedures. This estimate is not very reliable because it is based on an extremely small sample size and on charge data, which do not accurately reflect cost.2 The second study by Stringer et al3 compared the cost of 49 laparoscopic myomectomies with 49 open myomectomies. An average procedure cost of $14,461 for open myomectomy and $13,814 for laparoscopic myomectomy was estimated. It is not clear whether these estimates were derived from cost or charge data, and the costs associated with repeat procedures were not included. To compare the different types of myomectomies and alternative treatments (eg, hysterectomies), more reliable and thorough myomectomy cost estimates are required.
A comprehensive analysis of myomectomy cost must include all costs related to the initial procedure, whether by hysteroscopy, laparoscopy, or laparotomy, and any additional interventions that may be required. Intraoperative conversion from a laparoscopic or hysteroscopic myomectomy to an abdominal myomectomy or conversion from a myomectomy to a hysterectomy needs to be accounted for. Hysteroscopic and laparoscopic myomectomies are converted to open myomectomies in 1.75% to 8.60% of patients.4,5 An open myomectomy may have to be converted to a hysterectomy, and it is estimated to occur in about 2% of the procedures.6 After the initial myomectomy, the leiomyomas could recur, and this often requires repeat interventions. The rate of additional procedures (both hysterectomies and myomectomies) after myomectomies has been estimated to be as high as 9.6% in 1 year,7 13.1% in 2 years,7 and 20.5% in 5 years.8 In a large series involving 622 myomectomy cases with 10-year follow-up, a cumulative recurrence rate of 27% was reported.9
Given the lack of comprehensive analysis on myomectomy cost, the objective of this study is to estimate the outcomes and costs associated with hysteroscopic, laparoscopic, and open myomectomy procedures over a 2-year period. Such a systematic assessment of resource use is critical for evaluating alternate procedures to treat uterine leiomyomas.
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MATERIALS AND METHODS |
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ABSTRACTMATERIALS AND METHODSRESULTSDISCUSSIONREFERENCES |
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We identified women for inclusion in the study by searching for inpatient and outpatient claims containing Current Procedural Terminology, 4th edition (CPT-4) codes for hysteroscopic (56354, 58145), laparoscopic (56309), or abdominal (58140) myomectomies or the International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) procedure code for all types of myomectomies (68.29). In addition, diagnosis of uterine leiomyomas and related symptoms for these patients were confirmed through ICD-9-CM diagnosis codes (218.x).
We determined conversions from a hysteroscopic or laparoscopic myomectomy to an abdominal myomectomy when CPT-4 codes for these procedures were reported during the same admission. Myomectomy to hysterectomy conversions were determined in a similar manner. To study the rate of repeat myomectomy procedures and/or subsequent hysterectomies, women who were enrolled continuously in the health plan for at least 1 year from the date of their first (index) myomectomy event were selected. Women who had a hysterectomy conversion during their index event were excluded from our analysis of subsequent procedure rates. We reviewed the number of women who had an additional procedure(s) within 6 months, 1 year, and 2 years from the date of the index procedure.
We defined procedure cost as the total payment received by providers for the procedure, that is, the amount reimbursed to the hospital and physicians for the care provided. This amount includes the payment made by the private insurer and the patient. Defining costs in this way helps to eliminate the variation in health insurance plan benefits across many different payers and is a more appropriate approximation of costs than billed charge amounts. We did not have complete data on outpatient prescription drug costs (this was available for only a very small subset of the patients analyzed), so these costs were not included in the analysis. Patients with costs greater than or less than three standard deviations from the mean costs were considered outliers and were dropped from the analysis. This was done to eliminate incomplete claims and those with extremely high cost, which was usually because of other expensive procedures performed during the same admission.
Costs were computed separately by type of myomectomy and place of service. Hysterectomy costs were computed in a similar manner to estimate cost of additional procedures. We calculated total inpatient costs for a hospitalization by summing the costs of services rendered by all providers during the inpatient stay. Total outpatient procedure costs were computed by summing the costs associated with services rendered by all providers on the day of the procedure and within two days after the procedure. We used this window of time to allow for discrepancies in the dates of service submitted on different provider claims. As expected, those who underwent additional procedures, such as conversions to hysterectomies and abdominal myomectomies, had higher procedure costs than those who had only a single procedure; we estimated their cost separately.
Total procedure costs were defined as the mean cost per patient associated with the index myomectomy procedure. We calculated these procedure costs by incorporating the incremental cost associated with conversions. We modeled the costs for 1 and 2 years by multiplying the proportion of repeats by the procedure cost estimated from the database. That is, the cost of a hysterectomy/myomectomy was multiplied by the rate of hysterectomy/myomectomy and added to the initial procedure cost to arrive at a follow-up cost. To align the costs contained in our 3 years of data on a common scale, we inflated costs to 1997 dollars. We standardized all costs to 1997 dollars by applying the hospital and related services component of the consumer price index (CPI) to the costs in 1995 (8%) and 1996 (3.3%).
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RESULTS |
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ABSTRACTMATERIALS AND METHODSRESULTSDISCUSSIONREFERENCES |
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We could not identify the type of myomectomy procedure for one-fourth (1089) of the women because of the use of a general ICD-9 procedure code (68.29) that does not distinguish among procedure types. The remaining 3305 women were classified by type of myomectomy procedure according to specific CPT-4 procedure code. The number of patients by myomectomy type and place of service are indicated in Table 1
. Patients whose initial procedure was an inpatient abdominal myomectomy comprised the largest proportion of our sample at 45% (1959 cases of 4394). A total of 398 and 948 patients with laparoscopic and hysteroscopic procedures, respectively, were identified. Abdominal myomectomies were always performed with an inpatient admission, whereas a large proportion of the other myomectomies were performed on an outpatient basis.
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. Women who had abdominal myomectomies were on average 37 years old, whereas those who had a hysteroscopic myomectomy were 43 years old, a difference that is statistically significant. Average age was 39 and 37 for those who underwent laparoscopies in the inpatient and outpatient setting, respectively.
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Analysis performed on the subset of women with follow-up data revealed that there were many repeat and additional procedures. Figure 1 provides the rate of subsequent procedures at 6 months, 1 year, and 2 years. In the initial 6-month post-procedure period, 3.3% had a repeat myomectomy, and 5.0% had a hysterectomy. At the end of 2 years, 5.4% of all women had at least one additional myomectomy procedure, and 11.1% had a subsequent hysterectomy. The subsequent procedure rate was therefore 8.3% in 6 months, 10.6% in 1 year, and 16.5% in 2 years. Stratifying by type of myomectomy procedure reveals that the rate of repeat procedures at 1 year was 7.2%, 12.3%, and 14.0% for the open, laparoscopic, and hysteroscopic myomectomy groups, respectively.
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. These costs exclude procedures that converted to another type of myomectomy procedure within the same hospitalization or outpatient episode. Abdominal myomectomy was the most expensive ($8,860) and had the highest length of stay (2.91 days). Laparoscopic myomectomy cost $8,018 in the inpatient setting and $7,357 on an outpatient basis. Hysteroscopic myomectomy was $7,704 and $4,291 when performed in the inpatient and outpatient setting, respectively. On average, the cost of a myomectomy procedure was $6,540 (including all procedures). Facility costs accounted for about 60% of the total cost, whereas professional costs comprised the remaining 40%.
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Given the need for repeat and additional procedures, the overall cost increases from $6,737 per patient to $7,575 in 1 year and to $8,001 in 2 years. As indicated in Figure 2, the average cost increases by 12.5% at the end of 1 year and 18.7% in 2 years. About 61% of the increase over 2 years is due to subsequent inpatient procedures and 39% is due to subsequent outpatient procedures.
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DISCUSSION |
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ABSTRACTMATERIALS AND METHODSRESULTSDISCUSSIONREFERENCES |
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Repeat procedures required after the initial myomectomy procedure adds significantly to the total cost. An additional cost of $1,264 per person can be expected in the first 2 years after a myomectomy. Because additional procedures will be required in subsequent years8,9 (beyond the 2 years), higher per patient costs can be expected in future years. This analysis clearly highlights the importance of assessing long-term health care use.
There are several limitations to the analysis. First, we relied on the CPT-4 and ICD-9 codes available in the data to identify patients with different types of myomectomy procedures. These codes are only as accurate as their interpretation by those who use them to bill for these procedures. Second, claims databases do not contain actual procedure cost information. We used payer-allowed charges as proxies for cost. True procedure costs could be more or less than our estimates. Third, the cost estimates were calculated for all resources consumed during the initial inpatient hospitalization or outpatient procedure and for subsequent surgeries. We did not identify other resources and costs that could have been associated with treating uterine leiomyomas. For instance, our total cost estimates exclude drug costs. Drug therapy can be expensive and could be a significant cost driver of total cost. In addition, we did not include any indirect cost, such as those associated with work loss. We also assumed some high-cost estimates to be outliers and dropped them from the analysis. This elimination could result in an underestimation of the true cost of the myomectomy procedures. Therefore, the total cost associated with myomectomy procedures could be higher than the estimates reported in this study.
Despite these limitations, the results provided in this study quantify the 2-year cost associated with myomectomy procedures. This comprehensive analysis facilitates the systematic evaluation of myomectomy with current and emerging alternative treatments for uterine leiomyomas. Any such assessment should include long-term evaluation of outcomes and costs.
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Footnotes |
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Received December 27, 2000. Received in revised form May 10, 2001. Accepted May 31, 2001.
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REFERENCES |
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2. Finkler SA. The distinction between cost and charges. Ann Intern Med 1982;96:102–9.
3. Stringer NH, Walker JC, Muir S. Comparison of 49 laparoscopic myomectomies with 49 open myomectomies. J Am Assoc Gynecol Laparosc 1997;4:457–64.[Medline]
4. Nezhat FR, Roemisch M, Nezhat CH, Seidman DS, Nezhat CR. Recurrence rate after laparoscopic myomectomy. J Am Assoc Gynecol Laparosc 1998;5:237–40.[Medline]
5. Davies A, Hart R, Magos AL. The excision of uterine fibroids by vaginal myomectomy: A prospective study. Fertil Steril 1999;71:961–4.[Medline]
6. Iverson RE Jr, Chelmow D, Strohbehn K, Waldman L, Evantash EG. Relative morbidity of abdominal hysterectomy and myomectomy for management of uterine leiomyomas. Obstet Gynecol 1996;88:415–9.[Abstract]
7. Derman SG, Rehnstrom J, Neuwirth RS. The long-term effectiveness of hysteroscopic treatment of menorrhagia and leiomyomas. Obstet Gynecol 1991;77:591–4.
8. Emanuel MH, Wamsteker K, Hart AA, Metz G, Lammes FB. Long-term results of hysteroscopic myomectomy for abnormal uterine bleeding. Obstet Gynecol 1999;93: 743–8.
9. Candiani G, Fedele L, Parazzini F, Villa L. Risk of recurrence after myomectomy. Br J Obstet Gynaecol 1991;98: 385–9.[Medline]
10. Kuntz K, Steege J. Alternatives to abdominal hysterectomy: A review of clinical and economic outcomes. Am J Man Care 1996;2:399–406.
11. Smith DC, Donohue LR, Waszak SJ. A hospital review of advanced gynecologic endoscopic procedures. Am J Obstet Gynecol 1994;170:1635–42.[Medline]
12. Cameron I, Millison J, Pinion S, Atherton-Naji A, Buckingham K, Torgerson D. A cost comparison of hysterectomy and hysteroscopic surgery for the treatment of menorrhagia. Eur J Obstet Gynecol Reprod Biol 1996;70: 87–92.[Medline]
13. Sculpher M, Bryan S, Dwyer N, Hutton J, Stirrat G. An economic evaluation of transcervical endometrial resection versus abdominal hysterectomy for the treatment of menorrhagia. Br J Obstet Gynaecol 1993;100:244–52.[Medline]
14. Dorsey J, Holtz P, Griffiths R, McGrath M, Steinberd E. Cost and charges associated with three alternative techniques of hysterectomy. N Engl J Med 1996;335:476–82.
15. Vilos G, Pispidikis J, Botz C. Economic evaluation of hysteroscopic endometrial ablation versus vaginal hysterectomy for menorrhagia. Obstet Gynecol 1996;88:241–5.[Abstract]
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