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Abstract

MJA 1997; 166: 205-207  

Introduction

Hysterectomy is one of the commonest major operations performed in Australia.⁴ Traditionally, it has been performed by either the abdominal or the vaginal method.⁵ Vaginal hysterectomy is typically quicker, has less post-operative discomfort and has fewer complications than abdominal hysterectomy.⁵ However, over 75% of women in two recent reports relating to trends in the United States and the United Kingdom had had abdominal hysterectomies.^6,7

The first laparoscopic (vaginal) hysterectomy was reported by Reich and De Caprio in 1989,⁸ and since then the procedure has been widely reported.^6,9-14 Laparoscopic hysterectomy appears to offer advantages over abdominal hysterectomy in reduced postoperative discomfort, hospital stay and recovery time.¹⁵ This operation is becoming an acceptable alternative to abdominal hysterectomy where vaginal hysterectomy is considered difficult or in ap propriate (e.g., if there is significant endometriosis or no uterine descent).^12,14,16,17 What is not known is whether laparoscopic hysterectomy is cheaper than conventional hysterectomy in an Australian hospital setting.

In this study, we compare the hospital costs, including operating time and days in hospital, of abdominal hysterectomy with those of laparoscopic hysterectomy for benign disease in a casemix setting.  

Methods

The TAHs were performed by registrars under the supervision of a specialist gynaecologist in the general gynaecology units. All LAVHs were performed by a specialist gynaecologist in the Operative Laparoscopy Unit.

The laparoscopic procedure included ureteric dissection, followed by ligation and transection of the uterine vessels. In each case in this series, one to two premium 5-12 mm surgiports (Auto Suture Ltd, Connecticut, USA) were inserted, and one Endo GIA multifire gun and three Endo GIA reloads (Auto Suture Ltd, Connecticut, USA) were used.

We recorded the age of the patient, the indication for surgery, the operating time, the total inpatient stay, histological diagnosis and a detailed costing of each procedure. Operating time was calculated from the time the patient was taken into theatre until she was moved from the operating table.

We used Monash Medical Centre's clinical costing system (Transition 1) to obtain an individual costing for each patient. Computerised systems in the hospital departments record patients' resource use against their unique medical record number for purposes such as workload scheduling in laboratories, drug labelling in pharmacy, as well as patient tracking in the Admission, Transfer and Discharge system.

From these records, Transition 1 captures records of the actual resources consumed by individual patients during their stay in hospital, and during related outpatient treatments. These resources comprise days of care by nurses and doctors, theatre time, laboratory tests, radiological examination, pharmaceutical products, and allied health services. For each patient, the costing system applies the average actual cost of producing each resource used. The average costs are calculated over a period of time by applying the concept of relative values to the departmental operating costs, which are routinely recorded in the financial general ledger system.

Costs applied in this study were the average costs of the full financial years 1994 or 1995, depending on the discharge date of the patient. The indirect costs of administration, utilities and infrastructure are included in the costs presented, and represent approximately one-third of the total cost per patient. These indirect costs are distributed to patients in a two-step process: all the indirect department costs are allocated, firstly, to the departments (wards, theatre, laboratories, etc.) and, secondly, to the products of the departments (e.g., chest x-ray or bed-day). A series of accounting rules applies surrogates of indirect department use by the patient to the departments. For example, departmental salaries determine the share of Personnel Department cost allocated to each department and become an indirect cost in patient care. The rules applied are commonly found in Victorian hospitals. Each individual product attracts indirect cost in proportion to its total direct cost.

Theatre Department costs of salaries, consumables, prostheses, anaesthetics, and instruments are calculated according to the minutes of tabletop time recorded for each patient. We acknowledge that this crude method cannot accurately reflect the relevant cost of procedures requiring unique instruments or prostheses. Hence, we adjusted the dollar cost of each disposable instrument used in each LAVH to overcome this deficiency.  

Statistical analysis

Results

The main indications for surgery in the LAVH group were menorrhagia, fibroids, pelvic pain, endometriosis and adenomyosis. One patient had had an LAVH and bilateral salpingo-oophorectomy for persistent postmenopausal bleeding, with a normal hysteroscopy and normal ovaries on ultrasound. In the TAH group, the indications for surgery were fibroids, adenomyosis, pelvic pain and endometriosis. One patient had had a haematometra after an endometrial ablation. Histological examination of uterine tissue from each patient in both groups showed no malignant disease.

Box 1 also shows that the mean operating time in the TAH group was significantly shorter than that in the LAVH group. Conversely, the mean length of stay for the TAH group was significantly longer than for the LAVH group.

Finally, the mean cost of having a TAH as an inpatient was $3081, compared with $3148 for having an LAVH, which was not a significant difference.

Discussion

We found that the cost of LAVH and TAH was equal, despite the use of disposables in the laparoscopic procedure, which greatly increases its cost. However, early discharge from hospital has major cost implications -- if our LAVH patients had stayed in hospital for the same time as our TAH patients, laparoscopic hysterectomy would have proved far more expensive than the open procedure. It should be noted that there is no difference in the admission and discharge policies between the general gynaecology units and the laparoscopic units at our hospital; all patients are admitted on the day of surgery and discharged as soon as they are fit. We therefore infer that the cost of the increased operating time and the use of disposables was offset by the much shorter hospital stay. This was also found in a study by Raju and Auld. ¹¹

Patients are strongly in favour of laparoscopic hysterectomy because of its smaller incisions, diminished postoperative pain, shorter hospital stay and quicker return to normal activity. ^10,20 Although we found significantly longer operating times for LAVH than for TAH, we also found (as have other units ¹⁰ ) that operating time is shortened with more experience of both the surgeon and nursing staff. ¹¹ We believe the longer operating time is acceptable given the other benefits of this surgery, and that laparoscopic hysterectomy should be offered as a first-line procedure to women undergoing hysterectomy for benign disease and for whom a vaginal hysterectomy is contraindicated.

Further, in this casemix era, if hospitals are reimbursed on the basis of an output-based funding scheme, and the costs of LAVH and TAH are the same with a given number of beds, more patients can be treated by LAVH than by TAH. Hospitals with higher output levels will attract more revenue, which can be used for theatre-based resources rather than bed resources. Data such as these are essential in planning a hospital's financial management strategy.  

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