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 economic concern.[1,4,5]
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 hospital stay.[1,3]
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, 3, 4). 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.