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ORIGINAL RESEARCH |
From the Department of Obstetrics, Gynecology, and Reproductive Sciences and Department of Epidemiology and Biostatistics, University of California, San Francisco, California; General Internal Medicine Section, San Francisco Veterans Affairs Medical Center, San Francisco, California; Division of Research, Kaiser Permanente Medical Care Program, Oakland, California; and Division of Family and Community Medicine, Stanford University, Palo Alto, California.
Address reprint requests to: Leslee L. Subak, MD, Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California, San Francisco, Mount Zion Women’s Health, 2330 Post Street, Suite 200, San Francisco, CA 94143-1688; E-mail: subakl{at}obgyn.ucsf.edu.
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ABSTRACT |
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 ABSTRACT MATERIALS AND METHODSRESULTSDISCUSSIONREFERENCES |
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METHODS: We multiplied the number of pelvic organ prolapse operations identified in the 1997 National Hospital Discharge Survey by national average Medicare reimbursement for physician services and hospitalizations. Although this reimbursement does not estimate the actual cost, it is a proxy for cost, which estimates what society pays for the procedures.
RESULTS: In 1997, direct costs of pelvic organ prolapse surgery were $1012 million (95% confidence interval [CI] $775, 1251 million), including $494 million (49%) for vaginal hysterectomy, $279 million (28%) for cystocele and rectocele repair, and $135 million (13%) for abdominal hysterectomy. Physician services accounted for 29% ($298 million) of total costs, and hospitalization accounted for 71% ($714 million). Twenty-one percent of pelvic organ prolapse operations included urinary incontinence procedures ($218 million). If all operations were reimbursed by non-Medicare sources, the annual estimated cost would increase by 52% to $1543 million.
CONCLUSION: The annual direct costs of operations for pelvic organ prolapse are substantial.
Pelvic organ prolapse affects up to half of all women over 50 years of age1 and represents the most common indication for hysterectomy in this age group.2 In 1997, over 226,000 women underwent surgery for pelvic organ prolapse. This is similar to the frequency of other operations for women, including cholecystectomy, appendectomy, coronary artery bypass graft, and total knee replacement.3 Despite the high prevalence and frequency of surgery for pelvic organ prolapse, there is little information on costs of medical care for this condition. Our purpose was to estimate the annual direct cost of surgery for pelvic organ prolapse in the United States, using prevalence data from the 1997 National Hospital Discharge Summary and Medicare reimbursement allowances as a proxy for cost.
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MATERIALS AND METHODS |
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ABSTRACTMATERIALS AND METHODSRESULTSDISCUSSIONREFERENCES |
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Direct medical costs were approximated using Medicare’s national average allowance for physician services4 and national average Medicare payment for hospitalizations (Table 1
).5 We selected Medicare reimbursement as an estimate of what society pays for prolapse operations in the United States, and, therefore, we used cost and reimbursement as equivalent terms in this study. Surgical costs included reimbursement to surgeons,4 anesthesiologists,4 and hospitals (Table 1).5 Surgeon reimbursement was estimated using Medicare regulations and included 100% of the Medicare reimbursement for the primary surgical procedure, 50% of the second procedure, and 25% of any additional procedures. Surgeon reimbursement for combined procedures (ie, more than one procedure during the same operation) was estimated using Medicare regulations for bundling of procedures.6 Anesthesiologist reimbursement was calculated using the Medicare system of Basic Units plus average Time Units for anesthetic management, multiplied by the 1997 average national Medicare reimbursement per unit ($16).4,6 Costs of hospitalization were estimated as the average national reimbursement for each diagnosis-specific inpatient admission (female reproductive system reconstructive procedures [Diagnosis Related Group code 356], uterine and adnexa procedures for nonmalignancy with [358] and without complication or comorbidity [359]).4 Higher hospital costs for complications were not included because less than 1% exceeded the threshold length of stay (outlier threshold, 12, 19, and 10 days for Diagnosis Related Group codes 356, 358, and 359, respectively), which makes hospitals eligible for higher reimbursement.
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and 2). To estimate the upper limit of annual cost, we assumed physician reimbursement to be the national average of non-Medicare charges for physician services (surgeons and anesthesiologists) adjusted by a 50% reimbursement-to-charge ratio (personal communication, San Francisco Area average collection rate, 2000).4 Hospital reimbursement was assumed to be $1610 per day, consistent with the net inpatient revenue per day for patients with 3rd party insurance in California (personal communication, California Office of Statewide Health Planning and Development, 2000). All costs are in l997 US dollars. Discounting was not required because this analysis includes only one year of costs.
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Nationwide numbers of specific procedures were weighted by the reciprocals of estimated probability of selection, and adjusted for nonresponse and other factors.7 Constants provided in the National Hospital Discharge Survey documentation were used to compute relative standard errors and CI for total operations among all women. Data are presented as frequencies of operations, point estimates, and 95% CI.
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RESULTS |
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). Women had a mean age of 54.6 years (± standard deviation [SD] 15.2), and 31% were over 65 years. The most common procedure performed was hysterectomy (N = 130,731; 58% of total prolapse operations), with vaginal hysterectomy (N = 103,317; 79%) performed more often than abdominal hysterectomy (N = 27,414; 21%) (Table 2). Other common procedures included cystocele and rectocele repair (14%), cystocele repair (8%), and rectocele repair (8%). Nearly half of prolapse operations in 1997 included two or more procedures, with 40% including two procedures, 7% three procedures, and 1% four or more procedures. Additionally, 21% of prolapse operations included urinary incontinence procedures (Table 3).
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). This included physician fees of $298 million (29% total cost), with $242 million for surgeon’s fees (24%), and $56 million for anesthesiologist’s fees (5%), and hospital costs of $714 million (71%). The average length of hospital stay was 2.8 days (±SD 2.8). The number and types of operations done in each prolapse surgery did not increase the length of hospital stay. Overall, 15.5% of the women who underwent pelvic organ prolapse surgery had complications, with bleeding and infections accounting for more than half of complications. Serious complications including pulmonary embolism, brain infarction, and sepsis accounted for 1% of all complications. Very few operations resulted in lengths of hospitalization longer than the Medicare-defined outlier threshold, which would make them eligible for higher hospital reimbursement. Thus, complications had minimal impact on the total cost of prolapse surgery.
When the incidence of surgical procedures was varied over the range of the 95% CI observed in the National Hospital Discharge Survey, the baseline annual cost estimate was affected by 23.5% ($1012 million [95% CI $775, $1251 million]). Costs were also evaluated using adjusted non-Medicare charges resulting in an upper limit of annual costs for pelvic organ prolapse surgery of $1543 million, an increase of 52% compared with the basecase estimate.
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DISCUSSION |
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).8–12
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Medicare reimbursement is an accepted and generalizable "gross-costing" method to estimate medical care costs.13 The advantages of this approach are simplicity, practicality, and geographical generalizability. The primary disadvantage is the lack of detail of interventions to treat illness, which is diluted as procedure volume increases. In contrast, "microcosting" details individual resources used and the cost for each resource. Implicit in this method is that it is generalizable to the next application, setting, and location. Because this assumption rarely applies in healthcare in the United States, we elected to use a "gross-costing" method for this analysis. Many cost studies use a variation of these costing methodologies of local charges multiplied by a reimbursement-to-charge or cost-to-charge ratio. Although this provides a good local cost estimate, it rarely represents a nationally generalizable estimate of resource consumption. We have not included the broad category of indirect costs because we found no data quantifying these costs for prolapse or prolapse surgery. Both of these methodological assumptions probably result in an underestimation (ie, conservative) of the true cost of prolapse surgery.
Because only 30% of women were over 65 years of age, Medicare reimbursement is a conservative estimate of the cost of surgery. Women under 65 years are generally ineligible for Medicare and may have higher or lower reimbursement, based on the type of medical insurance. In our analysis, the estimated cost may be up to 50% higher if all women undergoing surgery had nonfederally funded health insurance.
Medicare reimbursement represents an accepted estimate of resource consumption. Although this reimbursement does not necessarily estimate the actual resource use or cost for each surgery, it represents what society pays for the surgery.
Peri-operative morbidity and mortality associated with pelvic organ prolapse surgery are low and their direct costs are negligible in the Medicare system. Medicare payment is based on the average length of stay for all patients with a specific principal diagnosis and resource needs of the average Medicare patient.
The National Hospital Discharge Survey3 has several limitations. Only procedures with pelvic organ prolapse listed as one of the seven discharge diagnoses recorded in the 1997 National Hospital Discharge Survey were included in this analysis. This may under- or overestimate the number of procedures for pelvic organ prolapse. International Classification of Diseases codes were used to identify procedures, introducing possible bias in the analysis because these codes are not very specific, and miscoding of diagnoses or procedures would lead to errors in surgical rates and cost estimates. However, the accuracy of hospital coding for diagnoses and procedures in the National Hospital Discharge Survey has been reported to exceed the standards of other data from the National Center for Health Statistics.14 The National Hospital Discharge Survey estimates coding errors to be approximately 0.9% for procedures and diagnoses and 0.2% for demographic data.15 In addition, the National Hospital Discharge Survey identifies only morbidity and mortality that occur within the same hospitalization. Therefore, complications that require readmission to the hospital or outpatient treatment were not included in this analysis but are expected to have minimal impact on the final estimates. Because only civilian hospitals are included in the National Hospital Discharge Survey (92% of all hospitalizations), our costs for prolapse surgery may be underestimated. Finally, the National Hospital Discharge Survey includes only hospital admissions, not outpatient procedures, likely resulting in an underestimation of the costs of prolapse surgery.
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Footnotes |
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Received December 13, 2000. Received in revised form May 10, 2001. Accepted May 24, 2001.
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REFERENCES |
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2. Wilcox LS, Koonin LM, Pokras R, Strauss LT, Xia Z, Peterson HB. Hysterectomy in the United States, 1988–1990. Obstet Gynecol 1994;83:549–55.[Abstract]
3. National hospital discharge survey: Annual summary, 1994. In: Statistics NCFH, ed. Vital and health statistics. Series 13, Data from the national health survey, no. 128. DHHS publication no. (PHS) 97-1789. Hyattsville, MD: US Department of Health and Human Services, Public Health Service, Centers for Disease Control and Prevention, Washington, DC, 1997.
4. 1997 Physicians fee and coding guide. In: Healthcare Consultants of America. Augusta, GA: HealthCare Consultants of America, 1997:ii–v, 64–6, 108–10, 387, 412–7, 444, 455.
5. DRG Guidebook. Reston, VA: St. Anthony Publishing, 1996.
6. 1998 Coding illustrated: Genitourinary. Salt Lake City, UT: Medicode Publications, 1997.
7. Kozak LJ. Underreporting of race in the National Hospital Discharge Survey. Advance Data 1995;265:1–12.
8. Information for disease and conditions. Appendix to: Disease-specific estimates of direct and indirect costs of illness and NIH support, September 1998 update. Table: Costs of illness and NIH support for selected diseases and conditions, Part 1A–2B, pp. 1–6. Bethesda, MD: Office of the Director, National Institutes of Health, Public Health Service, Department of Health and Human Services, 1998.
9. Rein DB, Kassler WJ, Irwin KL, Rabiee L. Direct medical cost of pelvic inflammatory disease and its sequelae: Decreasing, but still substantial. Obstet Gynecol 2000;95: 397–402.
10. Korn AP, Learman LA. Operations for stress urinary incontinence in the United States, 1988–1992. Urology 1996;48:609–12.[Medline]
11. Hoerger TJ, Downs KE, Lakshmanan MC, et al. Health-care use among U.S. women aged 45 and older: Total costs and costs for selected postmenopausal health risks. J Womens Health & Gender-Based Med 1999;8:1077–89.[Medline]
12. Consumer price index — all urban consumers, medical care. Bureau of Labor Statistics, 2000. Available via the Internet at: http://146.142.4.24/cgi-bin/surveymost?cu/. Accessed 2000 Mar 20.
13. Gold MR. Cost-effectiveness in health and medicine. New York: Oxford University Press, 1996.
14. Dennison C, Pokras R. Design and operation of the National Hospital Discharge Survey: 1988 redesign. Vital Health Stat 2000;39:1–42.
15. Kozak LJ, Lawrence L. National Hospital Discharge Survey: Annual summary, 1997. National Center for Health Statistics. Vital Health Stat 1999;144:13.
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