CASE STUDY

Hysterectomy
Introduction Approximately 600,000 hysterectomies are performed in the US each year, making hysterectomy the second most common major operation performed in women. Several methods can be used to perform this procedure. In 2009, a Cochrane Review concluded that vaginal hysterectomy should be performed in preference to abdominal hysterectomy, where possible. Where vaginal hysterectomy is not possible, a laparoscopic approach may avoid the need for an abdominal hysterectomy. Risks and benefits of different approaches may however be influenced by the surgeon's experience. More research is needed, particularly to examine the long-term effects of the different types of surgery. Methodology The 12 SCPMG Chiefs of Ob/Gyn wanted to increase the percentage of nonopen hysterectomies performed so that SCPMG would eventually be the national leader for the procedure. The Regional Chief of Ob/Gyn was given the mandate to create a teaching program to help reach this goal. Study Surgery to remove the uterus with a $1.5 million da Vinci robot doesn't reduce complications and may raise pneumonia risk compared with conventional, less-invasive techniques, according to the second big study to find no added benefit from the devices. Researchers examined data from about 16,000 women who had hysterectomies in 2009 and 2010 for benign conditions. The robot operations cost hospitals $2,489 more per procedure, with a similar complication rate as the standard practice. Analysis We used STATA (release 6.0, College Station TX) for statistical analyses. As a result of staggered entry into the trial, 182 women were not followed up for a full year. We therefore estimated mean costs and QALYs over one year by using methods to adjust for censored data. Given the short time horizon, costs and QALYs remain undiscounted. To account for the skewed nature of the data, we calculated 95% confidence intervals for differential costs and QALYs using the bias corrected and accelerated bootstrap method. Cost effectiveness analysis was undertaken to relate differential mean costs and QALYs associated with the alternative arms of the trial, with incremental cost effectiveness ratios (ICERs) calculated as appropriate. To account for uncertainty due to sampling variation in cost effectiveness, we plotted cost effectiveness acceptability curves, showing the probability of laparoscopic hysterectomy being more cost effective than conventional hysterectomy for

different maximum levels that the decision maker may be willing to pay for an additional QALY.