Each year close to 600,000 women undergo a
hysterectomy in the United States. Although the number of these
procedures increased through most of the 1960s and 1970s, and peaked
in 1981 at 668,922, they have continued to decrease into the late 1990s.
Nonetheless, hysterectomies remain second in number only to cesarean
births in terms of major surgical procedures performed in women of
reproductive age.[1-3] The rate of hysterectomies per 1,000 women
over age 14 years in this country has also decreased since 1981,
dropping from 7.2 to a relatively stable rate of 4.4 in 1997. These
decreases notwithstanding, the Centers for Disease Control and
Prevention report that, given the latest surveillance data, more than
one-quarter of all women in the United States will have a
hysterectomy by the age of 60 years.
With increasing numbers of women reaching middle age (when most
hysterectomies are performed) and with an estimated annual cost of
$5 billion for these procedures, hysterectomies continue to be
of great public health interest as well as increasing medical
The most common reasons for having a hysterectomy are (1) to manage
symptomatic fibroids (leiomyomas), (2) to treat endometriosis, and
(3) to repair genital prolapse (Figure A).
Cancer remains the fourth most frequent diagnosis associated with
these surgeries, accounting for 12% to 15% of the hysterectomies
performed since the mid-1960s.[Popovic J, personal communication]
Traditionally, the surgery is executed either abdominally (by
laparotomy, removing the uterus through an abdominal incision), or
vaginally, with the uterus removed via an incision in the vaginal
canal.[5,6] The vaginal approach is more often used in women with a
small or prolapsing uterus, whereas the abdominal procedure (also
referred to as a laparotomy) is used when more extensive surgery is
required, if the uterus is larger, or if other pelvic conditions
exist.[6,7] Abdominal hysterectomies continue to account for the
majority of these surgeriestwo-thirds of the procedures were
laparotomies in 1997 (Figure B).
In 1983, the laparoscope was introduced as an aid in performing the
more conventional hysterectomies. Later modifications led to its use
as an alternative to the traditional hysterectomies and allowed for
the removal of the uterus completely through the laparoscope.
Currently, laparoscopically assisted vaginal hysterectomy (LAVH) is
usefully substituted for total abdominal hysterectomies in some
cases while not recommended as a substitute for a vaginal
hysterectomy.[8-11] Although the LAVH techniques are evolving
rapidly, the procedure remains controversial despite the fact that it
is less invasive and usually has a shorter length of hospital stay.
The LAVH is technically more difficult and costly, principally
because it requires additional training, specialized instruments,
more hospital resources, and more time in the operating room.[3,8]
Nonetheless, LAVHs are increasingly performed, their efficacy
monitored, and ways to reduce their costs investigated. Although the
three procedures continue to be refined and their techniques
improved, vaginal hysterectomies remain the procedure of choice
when hysterectomy is required.
The Metropolitan Life Study
The latest average hospital and physician charges associated with
claims paid during 1998 for a hysterectomy are presented in Table
1. The data are drawn from the 1998 claims experiences of more
than 8 million group health insured lives. Average charges were
calculated from data merged and edited by Corporate Health
Strategies, an Ingenix Company. Almost three-quarters of a million
hospital claims records were reviewed, the majority (58.3%) of which
were for women. Study patients were selected from these 416,944
records and restricted to women in major diagnostic category 13
(designating diseases and disorders of the female reproductive
system) who had undergone a hysterectomy and were over 30 years old.
After eliminating inaccurate and incomplete records, the study group
totaled 14,184 women, of whom 6% had undergone an abdominal
hysterectomy; 26%, a vaginal procedure; and 10%, an LAVH (Table
1). In line with national data, there was significant regional
variation in the rates of these surgeries, as well as their charges.
Proportionately more of the surgeries were performed in the southern
states and fewer in the northeastern area. The diagnoses
associated with the various procedures varied as well, ie, two of
every five laparotomies were performed because of fibroids; 43% of
the vaginal hysterectomies were for genital prolapse, whereas 29% and
19% of the LAVHs were performed for fibroids and endometriosis, respectively.
The women undergoing LAVH were the youngest of the three patient
groups and the modal and median ages were either identical or very
similar to each other for the laparotomy and vaginal hysterectomy
patients. In agreement with other studies and reports, the LAVH
procedures were the most expensive and associated with the shortest
Analysis of the charge data revealed considerable regional variation
in the type of and charges for these three surgeries. The data are
presented for all states but are highlighted and discussed for those
in which 150 or more laparotomies, 75 or more vaginal hysterectomies,
and at least 25 LAVH procedures were performed.
Average Total Charges
The average total charge for an LAVH was $14,540, 16% higher than for
the laparotomies ($12,500), and 40% higher than the vaginal
hysterectomies ($10,380). Although there was extensive variation in
cost between regions and states for the procedures, charges were
highest in the Pacific area of the country and lowest in the West
North Central for each surgery (Tables 2,
These area charges averaged around 20% above and 20% below the norm,
respectively, for each of the surgeries.
While the relative position varied somewhat by procedure, the
Mountain, West South Central, and Middle Atlantic areas recorded
total charges above the norm for each of the surgeries. With the
exception of the New England area, where charges were just above the
average for abdominal hysterectomies (1%) but below for vaginal
(9%) and for LAVHs (18%), the geographic areas were
consistently higher or lower than the norm for each type of
hysterectomy. The differences between the high- and low-area charges
varied from 35% for laparotomies to 31% for vaginal hysterectomies.
Interstate variation in charges was more pronounced, however. The
California charges were consistently the highest38%, 40%, and
43% above the norm for the abdominal, vaginal, and LAVH procedures,
respectively, and more than double the lowest charges in Iowa and
Kansas. Of the study states, California, New Jersey, Illinois, and
New York each registered total charges over 20% higher than the
average for an abdominal hysterectomy, whereas Indiana, Delaware,
Kansas, and Iowa had charges at least 20% lower. For the other two
hysterectomies, California was the only study state with charges more
than 20% higher than the average, while Missouri, Washington, and
Nebraska joined Kansas with LAVH charges averaging at least 20% below
the US norm; Oklahoma and Nebraska along with Iowa reported average
vaginal hysterectomy charges 20% or more below the average for the
rest of the country.
Average Physician Charges
Average physicians fees ranged from 33% to 39% of the average
total inpatient charges for the various hysterectomy surgeries (Tables
2, 3, 4).
Of the three procedures, doctors fees for LAVHs were the
highest ($4,770), while accounting for the smallest proportion (33%)
of the total hospital charges. By geographic area, the
physicians fees in the Pacific states made up the smallest
percentage of total charges for the abdominal and vaginal procedures,
while the average doctors fees in the West North Central area
were the smallest proportion of the total LAVH charges. The physician
portion of the total charge was the highest in the Middle Atlantic
area for each of the three surgeries.
Among the study states, the New York doctors fees were the
highest for all three procedures and were almost three times higher
than the fees charged for an abdominal hysterectomy in Iowa ($7,360
and $2,460, respectively). Although the differences were not so large
for the other two surgeries, these fees were at least two times
higher in New York than in Iowa for vaginal hysterectomies and in
Minnesota for LAVHs.
Hospital charges, including room and board and ancillary fees, also
varied extensively across the country. The Pacific area registered
the highest average total hospital charge for each surgery, with
charges averaging around 30% higher than the US norm. The West North
Central area had the lowest hospital charges for laparotomies
($6,830, or 17% below the average), while in the New England area,
hospital charges were lowest for vaginal hysterectomies ($5,220, or
18% below the norm) and for LAVHs ($7,730, or 21% lower).
Among study states, California led in total hospital charges for each
procedure, with charges averaging more than 50% higher than the norm
for each. Iowa registered the lowest hospital total charges for
vaginal and abdominal hysterectomies, 35% and 41%, respectively,
below the average, while hospital charges in New York were the lowest
for LAVHs ($6,290, or 36% lower than the US norm). More than
two-thirds of the total hospital charge was attributed to ancillary
fees for the LAVH procedures; comparable proportions were 62% and
64%, respectively, for abdominal and vaginal hysterectomies.
The geographic difference was more pronounced among the LAVHs. That
is, ancillary fees accounted for 78% of the total hospital charges
for these procedures in the New England area, and for just 60% of the
total in the Middle Atlantic area. Ancillary fees ranged from 56% to
66% of the regional laparotomy hospital charges and from 56% to 68%
of the vaginal hysterectomy hospital charges.
Length of Stay
As noted earlier, the shortest hospital stayjust under 2
dayswas associated with LAVH procedures. Women undergoing an
abdominal hysterectomy remained in the hospital, on average, for 3.1
days, whereas those with a vaginal hysterectomy were discharged after
2.2 days. Length of stay was the longest in the Middle Atlantic
states for both the abdominal and vaginal procedures and in the West
North Central area for LAVHs. The shortest length of stay was
reported in the West South Central area for LAVHs and laparotomies
(both with stays around 7% shorter than the norm) and in the East
South Central for a vaginal hysterectomy (1.88 days, or 15% shorter
than the US average).
The largest variation in length of stay among study states was
apparent for abdominal surgeries, for which New York patients
remained hospitalized more than 4 days compared with 2.63 days in
Delaware. For a vaginal hysterectomy, 1.3 days separated the lengths
of stay for patients in New York and Tennessee. The difference
between confinements for LAVH in Minnesota and those in Louisiana and
Washington was less than 1 day (0.93 days).
The noted variations in rates and charges for the three types of
hysterectomy procedures are in accord with those noted nationally and
continue to be investigated. Whether LAVHs will achieve wider
acceptance and application will be of interest to the public as well
as surveillance professionals. It remains to be seen whether they
will gain in frequency as the charges associated with their
performance are controlled, more surgeons are trained and become more
skillful in the procedure, more of these surgeries are performed in
ambulatory care settings, and their efficacy is demonstrated.
The reasons for the continued high rates in the southern states will
be watched with interest as the geographic variations in charges and
race-specific rates of uterine fibroids are further explored through
increased surveillance programs.
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