Open Abdominal versus Laparoscopic and Vaginal Hysterectomy: Analysis of a Large United States Payer Measuring Quality and Cost of Care

Objective: To compare minimally invasive procedures (MIP)-laparoscopic and vaginal hysterectomy with the traditional open abdominal hysterectomy method by evaluating clinical and economic outcomes and use. Methods: A retrospective analysis was performed with deidentified claims data and enrollment information from a large U.S. managed care plan. Data were collected on intraoperative and postoperative complications, length of stay, rates of readmission, and insurer and patient payment totals for inpatient and outpatient procedures. Bivariate comparisons between MIP and open abdominal procedures used t-tests for continuous variables and χ² tests for proportions. The predicted generalized linear modeling regression equation evaluated the effect of procedures on expenditures. Results: Of 15 404 patients, MIP was performed in 43% of subjects, with 23% (3520) undergoing laparoscopic hysterectomy, and 20% (3130) a vaginal hysterectomy. Postoperative infection rates were higher for patients undergoing open abdominal hysterectomy: 18% as compared with 15% of laparoscopic and 14% of patients undergoing vaginal hysterectomy (P < .05). With open abdominal hysterectomy, length of stay (mean [SD]) was 3.7 (1.83) days versus 1.6 (1.5) and 2.2 (1.5) for patients undergoing MIP laparoscopic and MIP vaginal hysterectomy, respectively (P < .001 for both). Unadjusted expenditures (SD) for patients undergoing open abdominal hysterectomy averaged $12 086 ($12673), whereas MIP (laparoscopic and vaginal) patients accrued costs (SD) of $10 868 ($13 465) and $9544 ($8644), respectively (P < .05). When expenditures were adjusted for differences in patient mix, there was no difference for open abdominal hysterectomy versus MIP laparoscopic; however, there were significantly (P <.05) lower expenditures for MIP vaginal versus open abdominal hysterectomy with a mean difference of $1270 (CI $850-$1691). Adjusted expenditures associated with outpatient MIP were markedly lower than expenditures for inpatient open abdominal hysterectomy. Conclusion: These clinical and economic outcomes should encourage clinicians to consider greater use of minimally invasive hysterectomy procedures in patients who have no contraindications for laparoscopic or vaginal approach to hysterectomy. Significant savings are realized when appropriate candidates receive minimally invasive procedures and are thus able to migrate from the inpatient to outpatient setting.