Table 5 demonstrates the multiple logistic regression model of variables contributing to cost of hysterectomy. After adjusting for the following confounders: age, race, length of stay, concomitant procedure, primary diagnosis, mode of hysterectomy, population density, median household income, and primary insurer, compared with the mid-Atlantic region, the Pacific region was still associated with the highest probability that hysterectomy costs would be above the median (adjusted odds ratio [OR] 10.43, 95% confidence interval [CI] 9.44–11.45). New England was not associated with a statistically significant increase in cost (adjusted OR 1.05, 95% CI 0.91–1.18). All other regions were associated with an increased probability of costs above the median with the South Atlantic (adjusted OR 5.39, 95% CI 4.95–5.86) and South Central (adjusted OR 2.40, 95% CI 2.21–2.62) regions having the highest risk.
Compared with vaginal hysterectomy, both laparoscopic (adjusted OR 2.86, 95% CI 2.61–3.15) and robotic hysterectomy (adjusted OR 5.66, 95% CI 5.11–6.26) were associated with an increased probability of costs being greater than the median. Interestingly, abdominal hysterectomy was not associated with a statistically significant increase in cost (adjusted OR 1.01, 95% CI 0.91–1.09). Compared with leiomyoma, which was the most common indication for hysterectomy, all other primary indications for hysterectomy that were evaluated were associated with a statistically significant decrease in cost below the median.
Compared with micropolitan counties with populations between 10,000 and 50,000 people, central metropolitan counties, with populations exceeding 1 million, were associated with increased odds of higher cost (adjusted OR 2.09, 95% CI 1.93–2.27). Outlying counties surrounding urban centers and counties with populations between 250,000 and 1 million people had similar odds of increased costs compared with medium-sized metropolitan (adjusted OR 1.48, 95% CI 1.36–1.61 and adjusted OR 1.58, 95% CI1.46–1.72, respectively). Small metropolitan counties had a low but significant association with increased costs (adjusted OR 1.14, 95% CI 1.04–1.26). Compared with patients who self-pay, patients with Medicare or private insurance were associated with a risk of increased costs (adjusted OR 1.17, 95% CI 1.05–1.32 and adjusted OR 1.18, 95% CI 1.05–1.31, respectively), whereas patients with Medicaid were not statistically more likely to have higher costs (adjusted OR 1.02, 95% CI 0.92–1.13).
Compared with white women, black (adjusted OR 1.04, 95% CI 1.01–1.16) and Hispanic women– (adjusted OR 1.36, 95% CI 1.26–1.49) were slightly more likely to have higher costs of hysterectomy. Other minority groups did not have an increased risk of above median costs (adjusted OR 1.09, 95% CI 0.98–1.20). Compared with women with an annual median household income of less than $38,000, women with higher annual median household incomes were not associated with higher costs. For every 10-year increase in age, there was a 0.3% increase in probability of having a higher than median cost. Similarly, there was an 88% incrementally increased risk of higher costs for every day of hospitalization.
Most concomitant procedures at the time of hysterectomy were associated with an increased cost, with anti-incontinence procedures (adjusted OR 2.03, 95% CI 1.83–2.24) and blood transfusion (adjusted OR 1.91, 95% CI 1.72–2.14) having the highest risk of costs above the median. Bilateral salpingectomy was not associated with an increased risk of higher cost (adjusted OR 1.03, 95% CI 0.95–1.12).
Our findings demonstrate that significant regional variation in cost, which have previously been described in nongynecologic literature, also exist for hysterectomy.14–17
In our analysis, there was a 233% difference in cost between the lowest cost mid-Atlantic region, which includes New York, New Jersey, and Pennsylvania, and the highest cost Pacific region, which includes California, Oregon, Washington, Alaska, and Hawaii. The South Atlantic, South Central, and Midwest regions were also associated with higher costs compared with the mid-Atlantic, but the differences were smaller, whereas the costs in New England were not significantly different. The probability of higher costs in these regions persisted after adjusting for confounding variables. This is consistent with previous studies that have reported the higher cost of inpatient care and surgical procedures in these regions.13,15,18
Regional cost variation can in part be explained by differences in practice patterns; however, these variables are not accurately captured within the National Inpatient Sample database. For instance, some surgeons may choose to use disposable devices, uterine manipulators, and hemostatic agents during hysterectomy, which have all been shown to lead to substantial differences in cost.19 Additionally, duration of surgery, which varies significantly with surgeon volume and experience as well as use of postoperative services such as laboratory testing and imaging can markedly affect the cost of a surgery. However, practice variations cannot fully account for the marked price differences seen in this and other studies.
The reported costs in this study reflect what hospitals are reimbursed by insurance companies. These costs are negotiated annually for individual hospitals, physicians, and health systems. The same insurance company may negotiate different reimbursements for the same diagnosis or procedure with individual hospitals.20 The Blue Cross and Blue Shield Association recently released an analysis regarding variations in the reimbursement of angioplasty and total knee and hip replacements. The most extreme variations were 512% for angioplasty and 313% for knee replacement with significant price differences noted in the same city.21,22 The regions with higher costs in these analyses were similar to what was found in this study.
Our findings reaffirm that vaginal hysterectomy remains the least costly method of hysterectomy and robotic-assisted hysterectomy, the most costly, with no significant difference between vaginal and abdominal hysterectomy.23,24 The contemporary view is that as a result of shorter hospital stays hospital stays compared with abdominal hysterectomy, hysterectomy using minimally invasive techniques actually leads to lower costs. However, after adjusting for length of stay, it is likely that shorter surgical times and use of nondisposable instruments used in abdominal hysterectomy actually result in lower surgical costs compared with minimally invasive modes of hysterectomy.
We also found that compared with leiomyoma, all other primary diagnoses were associated with decreased risk of higher costs. This may be attributable to the fact that women undergoing surgery for leiomyomas typically have larger uteri, which are associated with longer surgical times. In contrast, all concomitant procedures were associated with increased costs with the exception of bilateral salpingectomy. This may be the result of the fact that of all the other procedures evaluated, salpingectomy is the technically simplest and shortest and does not require the use of additional instruments or implants. However, these results should be viewed critically, because some of the diagnostic and procedure codes involved relatively small total or regional populations such as blood transfusion and cervical dysplasia. Additionally, although both unilateral salpingo-oophorectomy and bilateral salpingo-oophorectomy were significantly associated with higher costs, the adjusted ORs were close to 1.0, suggesting that these may not associations may not be clinically significant.
In our cohort, black and Hispanic women were slightly more likely to have higher associated costs compared with white women, with Hispanic women having a stronger association. Race has previously been reported as associated with higher costs for other surgical procedures, but it has not been specifically evaluated for hysterectomy. These studies have found that women belonging to these minority groups are more likely to have complications and longer hospital stays, both of which are associated with increased costs, compared with white women.25,26 Even after adjusting for length of stay, the increased risk of higher costs persisted for this population. Interestingly, women who were on Medicaid or were listed as “self-pay” were less likely to incur higher hysterectomy costs. This is likely a reflection of what the hospital was able to collect from these patients rather than what was charged.
Similar to other studies, private insurance and Medicare were associated with higher costs compared with self-pay patients. Conversely, Medicaid patients were not significantly more likely to have higher costs relative to this group. This is, again, likely the result of what hospitals and various payers have negotiated for reimbursement. Additionally, studies have shown that patients with private or Medicare insurance are likely to use more health care services than patients without insurance or those with Medicaid and self-pay patients, leading to increased costs in these groups.27,28
Increasing population density was associated with increasing probability of higher hysterectomy costs. Specifically, patients in core urban areas were more likely to be subject to higher hysterectomy costs compared with those in outlying, rural counties and smaller metropolitan areas. Previous studies have shown that patients in these areas are more likely to be self-pay, have Medicaid, and have less access to care, all of which are associated with lower cost.29
The main strength of this study is the use of the National Inpatient Sample, which allows for the analysis of a large cohort of patients undergoing hysterectomy. Given that these women represent a cross-section of the entire United States, these results are applicable to the entire population.
The retrospective design and the fact that the National Inpatient Sample relies on ICD-9-CM and Current Procedural Terminology codes, which could lead to erroneous inclusion or omission of clinical information, are limitations of this study. Another limitation is that, although the cost information within the National Inpatient Sample includes factors such as medications, ancillary services, and supplies used during hysterectomy and postoperative hospitalization, it does not provide a breakdown of all of these elements. Furthermore, the database does not include the physician professional fees, which would further affect cost.
As previously mentioned, the results of this study must be interpreted carefully, because some of the variables assessed such as cervical dysplasia and pelvic pain have small sample sizes leading to possible overestimation of statistical significance. Conversely, variables with larger sample sizes such as unilateral salpingo-oophorectomy and bilateral salpingo-oophorectomy showed relatively low adjusted ORs, and although they may be statistically significant, they may not hold clinical relevance. The results of this analysis suggest that there is significant geographic variation for costs related to inpatient hospitalization after hysterectomy that persist after controlling for confounders. Additional studies evaluating practice patterns of surgeons and use of postoperative services as well as what factors play a role in how hospitals and insurance companies negotiate reimbursements may help further delineate these differences in cost.
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© 2017 by The American College of Obstetricians and Gynecologists. Published by Wolters Kluwer Health, Inc. All rights reserved.
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