Rutstein Sarah E, Siedhoff Matthew T, Geller Elizabeth J, Doll Kemi M, Wu Jennifer M, Clarke-Pearson Daniel L, Wheeler Stephanie B
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.
Department of Obstetrics & Gynecology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina.
J Minim Invasive Gynecol. 2016 Feb 1;23(2):223-33. doi: 10.1016/j.jmig.2015.09.025. Epub 2015 Oct 22.
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.
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).
U.S. hospitals.
Adult premenopausal women undergoing LH or AH for presumed benign leiomyomata.
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.
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.
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.
在美国，因假定的平滑肌瘤而进行的子宫切除术是未怀孕女性中最常见的外科手术之一。采用肌瘤粉碎术的腹腔镜子宫切除术（LH）是腹式子宫切除术（AH）的一种有吸引力的替代方法，但在隐匿性平滑肌肉瘤（LMS）的情况下可能导致恶性细胞扩散并产生更差的结果。我们试图评估LH与AH的成本效益。
对美国100,000名女性进行决策分析模型，评估每获得一个质量调整生命年（QALY）所增加的成本效益比（ICER），以美元为单位（加拿大工作组III级分类）。
美国医院。
因假定的良性平滑肌瘤接受LH或AH的成年绝经前女性。
我们从提供者的角度开发了一个为期5年的决策分析模型，比较LH与AH在每获得一个QALY的成本效益（以2014年美元计）。该模型包括与手术、并发症和临床结果相关的平均总直接医疗成本和效用。成本和概率数据的基线估计及范围取自现有文献。
LH组的估计总死亡人数低于AH组（98例对103例）。LH组因LMS导致的死亡比AH组更常见（86例对71例）。基础病例假设估计，LH组的人均成本低于AH组，节省2193美元（24,181美元对26,374美元）。在5年期间，LH组女性经历了4.99个QALY，而AH组女性为4.91个QALY（增量收益为0.085个QALY）。在基础病例估计中，LH优于AH：LH既成本更低又能带来更大的QALY收益。ICER对LH和AH的手术成本敏感。AH手术成本的变化产生的ICER为每获得一个QALY 87,651美元（最小值），到AH被主导（最大值）。概率敏感性分析中，所有输入参数和成本同时变化，显示该模型相对稳健。AH方法在68.9%的时间内被主导；17.4%的模拟结果高于每获得一个QALY支付意愿阈值50,000美元。
在考虑医院总直接成本、并发症和发病率时，与AH相比，LH成本更低且获得的QALY更多。由于隐匿性LMS罕见以及术中和术后并发症发生率降低，采用肌瘤粉碎术的LH可能是一种更具成本效益且侵入性更小的AH替代方法，应仍然是因平滑肌瘤需要子宫切除术的女性的一个选择。
