title: Cost-Effectiveness of Laparoscopic Hysterectomy With Morcellation Compared With Abdominal Hysterectomy for Presumed Myomas.
abstract: OBJECTIVE
  Hysterectomy for presumed leiomyomata is 1 of the most common surgical procedures performed in nonpregnant women in the United States. Laparoscopic hysterectomy (LH) with morcellation is an appealing alternative to abdominal hysterectomy (AH) but may result in dissemination of malignant cells and worse outcomes in the setting of an occult leiomyosarcoma (LMS). We sought to evaluate the cost-effectiveness of LH versus AH.
  
  
  METHODS
  Decision-analytic model of 100 000 women in the United States assessing the incremental cost-effectiveness ratio (ICER) in dollars per quality-adjusted life-year (QALY) gained (Canadian Task Force classification III).
  
  
  METHODS
  U.S. hospitals.
  
  
  METHODS
  Adult premenopausal women undergoing LH or AH for presumed benign leiomyomata.
  
  
  METHODS
  We developed a decision-analytic model from a provider perspective across 5 years, comparing the cost-effectiveness of LH to AH in terms of dollar (2014 US dollars) per QALY gained. The model included average total direct medical costs and utilities associated with the procedures, complications, and clinical outcomes. Baseline estimates and ranges for cost and probability data were drawn from the existing literature.
  
  
  RESULTS
  Estimated overall deaths were lower in LH versus AH (98 vs 103). Death due to LMS was more common in LH versus AH (86 vs 71). Base-case assumptions estimated that average per person costs were lower in LH versus AH, with a savings of $2193 ($24 181 vs $26 374). Over 5 years, women in the LH group experienced 4.99 QALY versus women in the AH group with 4.91 QALY (incremental gain of .085 QALYs). LH dominated AH in base-case estimates: LH was both less expensive and yielded greater QALY gains. The ICER was sensitive to operative costs for LH and AH. Varying operative costs of AH yielded an ICER of $87 651/QALY gained (minimum) to AH being dominated (maximum). Probabilistic sensitivity analyses, in which all input parameters and costs were varied simultaneously, demonstrated a relatively robust model. The AH approach was dominated 68.9% of the time; 17.4% of simulations fell above the willingness-to-pay threshold of $50 000/QALY gained.
  
  
  CONCLUSIONS
  When considering total direct hospital costs, complications, and morbidity, LH was less costly and yielded more QALYs gained versus AH. Driven by the rarity of occult LMS and the reduced incidence of intra- and postoperative complications, LH with morcellation may be a more cost-effective and less invasive alternative to AH and should remain an option for women needing hysterectomy for leiomyomata.
authors.affiliation: Department of Health Policy and Management, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina; Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina. Electronic address: sarah_rutstein@med.unc.edu.
authors.forename: Sarah E
authors.initials: SE
authors.lastname: Rutstein
authors.affiliation: Department of Obstetrics & Gynecology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina.
authors.forename: Matthew T
authors.initials: MT
authors.lastname: Siedhoff
authors.affiliation: Department of Obstetrics & Gynecology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina.
authors.forename: Elizabeth J
authors.initials: EJ
authors.lastname: Geller
authors.affiliation: Department of Obstetrics & Gynecology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina.
authors.forename: Kemi M
authors.initials: KM
authors.lastname: Doll
authors.affiliation: Department of Obstetrics & Gynecology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina.
authors.forename: Jennifer M
authors.initials: JM
authors.lastname: Wu
authors.affiliation: Department of Obstetrics & Gynecology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina.
authors.forename: Daniel L
authors.initials: DL
authors.lastname: Clarke-Pearson
authors.affiliation: Department of Health Policy and Management, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina.
authors.forename: Stephanie B
authors.initials: SB
authors.lastname: Wheeler
mesh_terms: D000328:Adult; D003362:Cost-Benefit Analysis; D003663:Decision Trees; D005260:Female; D017721:Hospital Costs; D006801:Humans; D007044:Hysterectomy / Q000191:economics* / Q000379:methods; D007889:Leiomyoma / Q000191:economics / Q000473:pathology / Q000601:surgery*; D008297:Male; D008875:Middle Aged; D000069577:Morcellation / Q000191:economics*; D019057:Quality-Adjusted Life Years; D014481:United States / Q000453:epidemiology; D055815:Young Adult
keywords: Abdominal hysterectomy; Cost-effectiveness; Laparoscopic hysterectomy; Morcellation; Uterine myomas