Objective
The study objective was to compare total costs for hospital stay and postoperative recovery for 2 groups of women who underwent fast-track abdominal benign hysterectomy: 1 group under general anesthesia; 1 group under spinal anesthesia. Costs were evaluated in relation to health-related quality of life.
Study Design
Costs of treatment were analyzed retrospectively with data from a randomized multicenter study at 5 hospitals in Sweden. Of 180 women who were scheduled for benign abdominal hysterectomy, 162 women were assigned randomly for the study: 80 women allocated to general anesthesia and 82 women to spinal anesthesia.
Results
Total costs (hospital costs plus cost-reduced productivity costs) were lower for the spinal anesthesia group. Women who had spinal anesthesia had a faster recovery that was measured by health-related quality of life and quality adjusted life-years gained in postoperative month 1.
Conclusion
The use of spinal anesthesia for fast-track benign abdominal hysterectomy was more cost-effective than general anesthesia.
Hysterectomy is the most common major gynecologic operation in Europe and the United States and usually is performed through laparotomy as an in-hospital procedure. Various fast-track strategies have been developed to enhance postoperative recovery and shorten hospital stay after general surgery, but these strategies have hardly been studied for gynecologic surgery. Effective analgesia that allows early mobilization is essential for improved postoperative recovery. Perioperative regional anesthesia often is used in fast-track programs. Spinal anesthesia with intrathecally applied opioids (SA) may further optimize postoperative pain management after open hysterectomy.
Economic evaluations are needed in addition to the evaluation of clinical effects to make rational decisions regarding the acceptance of new treatments and the resulting consumption of health resources. Relating direct and indirect costs of different treatments to the perceived health-related quality of life (HRQoL) of the patients enables comparison of cost-effectiveness. Such analysis is essential to determine the most cost-effective treatment and to strengthen the possibility of acceptance and implementation of a new health technology. Multimodal evidence-based care within fast-track strategies in general surgery has been shown to enhance postoperative recovery, but no economic analyses of these strategies have been presented. Studies of fast-track hysterectomy report encouraging improvements in clinical outcomes but these studies also lack health economic evaluations.
We conducted an open, randomized, multicenter study that compared general anesthesia (GA) and SA in fast-track abdominal benign hysterectomy (the general anesthesia vs spinal anesthesia [GASPI] study). Results concerning clinical outcomes have been presented previously. SA was found to have substantial advantages for concerned perceived postoperative symptoms during recovery, HRQoL, and duration of sick leave.
One aim in the GASPI study was to investigate costs and HRQoL in relation to mode of anesthesia to evaluate the cost-effectiveness of SA compared with GA in fast-track hysterectomy. The purpose of this health economic analysis was to evaluate whether costs from a societal perspective differed between women who underwent fast-track abdominal benign hysterectomy with GA or with SA. The cost calculations were then evaluated in relation to the effects on HRQoL.
Materials and Methods
The Departments of Obstetrics and Gynecology at 5 hospitals in the southeast health region of Sweden participated in the GASPI study. The study was approved by the Regional Ethical Review Board in Linköping (Dnr M159-06, approval date Nov. 15, 2006) and registered in the Protocol Registration System ( NCT00527332 ; www.ClinicalTrial.gov ) with initial release Sept. 7, 2007. In the study, 2 different perioperative anesthetic techniques in a fast-track program were compared.
The inclusion and exclusion criteria, randomization process, perioperative care, postoperative follow-up period, and study flow chart have been described previously ; therefore, only a brief summary is presented here. Women who were admitted to the hospitals for elective abdominal hysterectomy between March 2007 and June 2009 were asked to participate. After they had given verbal and written informed consent, the enrolled women were assigned randomly to receive either GA or SA. Of the 180 women who were assigned randomly, 162 women completed the study. Both modes of anesthesia were standardized and given in conventional ways. Premedication, a summary of the modes of anesthesia, and the content of the fast-track program are presented in Figure 1 .
In Sweden, the anesthetic service in the operation theater routinely is provided by an anesthesiologist who is responsible for several concurrently ongoing operations. In addition, an anesthetic nurse is present in each single operation theater and has responsibility for supervising the single operation in that theater. The anesthesiologist, who participates in the induction of anesthesia, is present until the patient is stable, and supervises the anesthesia by making frequent visits to each patient. The anesthesiologist is continuously accountable and is available in each operating theater on request of the anesthetic nurse. SA is performed only by anesthesiologists. When the anesthetic level is found adequate and the patient’s vital signs are stable, an anesthetic nurse is primarily responsible for the patient as in GA. The hysterectomy is performed as a standard extrafascial abdominal hysterectomy, total or subtotal with the surgeon’s routine technique. All surgeons were accustomed to doing gynecologic and obstetric surgery performed with SA, but abdominal hysterectomy is usually carried out with GA.
Assessment of HRQoL
The assessment of HRQoL was based on results from the EuroQol instrument EQ-5D. Each woman completed the EQ-5D form preoperatively, then daily during the first week after surgery, and then once weekly until the 5-week postoperative visit. The EQ-5D is a validated generic measure of health status comprising 5 dimensions of health (mobility, self care, ability to undertake usual activities, pain/discomfort, and anxiety/depression). Each dimension comprises 3 levels (“no problems,” “moderate problems,” or “severe problems”). A unique EQ-5D health state is defined by combining 1 level from each of the 5 dimensions. This health state can be converted into utility with a weighted health state index by applying scores from EQ-5D value sets that were elicited from the general population samples to calculate HRQoL. The index ranges from 0–1. Zero indicates the state of death; 1 indicates full health.
To estimate the number of quality adjusted life-years (QALYs), we used the average differences in health state index scores between the SA group and the GA group. For the first week, the differences in measured QoL (weight range, 0–1) between the study groups were calculated for each day. For week 2-4, the average differences per week were calculated based on mean health state index scores on days 7, 14, 21, and 28. The day differences were summed together and divided by the number of days with a gain in QoL (1.86/29 = 0.064). We assume no effect after day 29. The gain in QoL (29 days/365 days = 0.08 of a whole year) is expressed in average gain that represents the QALY per patient.
Diary concerning informal care
At discharge, each woman was instructed to complete a diary once a day for 35 days after the operation and to report in this diary the kind and extent of postoperative support with informal care, if any, that was performed by a relative, friend, or neighbor. The time spent with informal care was reported by the patient in hours per week and subsequently added up for all weeks.
Direct costs
The most relevant direct costs that were related to hospital stay were calculated for the GA and SA groups with costs from 2010. The costs were calculated in Swedish kronor and converted into US dollars (US) according to the average exchange rate in 2010: $1 US = 7.20 Swedish kronor.
A standard unit cost for time spent in the operating theater was estimated on the basis of the cost accounting records from the University Hospital, Linköping, for the year 2010. The use of a standard unit cost was justified by the fact that there were no significant differences between the study groups concerning time of anesthesia, time of surgery, and costs of devices and material. Furthermore, the duration of hospital stay before anesthesia was similar in the 2 groups. The cost included a fixed once-for-all cost and a variable cost that depended on the duration of surgery. The costs for the anesthetic drugs and the time for the anesthesiologist to administer the anesthesia are presented separately.
The cost for the anesthesiologist was calculated as a mean of the yearly salary from all relevant categories of anesthesiologists in Sweden multiplied by 1.5 to include the social benefits that are regulated by law. A full-time anesthesiologist works approximately 200 days annually, and the time spent in the operating theater is approximately 8 hours per day. With a mean annual cost of $128,600, this yields a cost per minute of $1.34. The time for the anesthesiologist to administer the anesthesia was estimated to be 25 minutes for SA and 15 minutes for GA.
Time in the postanesthesia care unit was determined as time from arrival from operating theater until discharge to the gynecologic ward. A standard unit cost per minute was estimated from cost accounting records from the University Hospital, Linköping, for the year 2010. Duration of hospital stay in the gynecologic ward was determined as time from start of anesthesia to discharge. Costs for hospital stay in the ward were derived from cost accounting records of the Department of Obstetrics and Gynecology, University Hospital, Linköping, and included salaries for all types of personnel involved, analyses of blood samples, and the use of pharmaceuticals. Costs for facilities, heating, cleaning, and buildings were also included. Duration of hospital stay was calculated as time in hours from start of anesthesia until discharge from the gynecologic ward.
Costs in US dollars for all items are shown in Table 1 . There were no differences between study groups concerning rates of complications and outpatient visits; therefore, no separate calculations of these costs were done.
| Variable | Cost (US$) |
|---|---|
| Fixed cost for the operation a | 583.61 |
| Variable cost for time of surgery (per min) b | 9.38 |
| Anesthesiologist (per min) | 1.34 |
| Anesthetic drugs (general anesthesia) | 42.36 |
| Anesthetic drugs (spinal anesthesia with morphine) | 21.53 |
| Time in postanesthesia care unit (per min) | 0.93 |
| Hospital care in gynecology ward (per h) | 72.08 |
| Sick leave (per d) | 139.72 |
a Preparation and closing of theater, sterilization, basal equipment, staff in theater;
Indirect costs
At discharge from the hospital, each woman was granted sick leave for 14 days. On the basis of the woman’s demand, the sick leave was prolonged by at most 7 days at a time until the woman was able to return to work. The number of days of sick leave was registered and included adjustment for part-time sick leave. Duration of the sick leave was defined as the time from the day of surgery to the day of return to work to the same extent as the woman had before the surgery. Women who were on sick leave for other reasons than the hysterectomy, who were unemployed, or who had a disability pension were excluded from the analysis of sick leave.
Costs for productivity loss because of sick leave were estimated by the human capital approach, based on the average annual income for women in Sweden 2008, aged 20-64 years, multiplied by 1.5 to include social benefits. The annual income was divided by 365 to get the cost of productivity loss per day, weekends included ( Table 1 ).
Statistics
All analyses were performed according to intention-to-treat principles. In case of missing data, the number of participants for the specific item is noted. Univariate analyses were performed with the Student t test (2-sided) for continuous data and with Yates corrected χ 2 test or Fishers’ exact test, as appropriate, for nominal data. Analyses of data that were measured repeatedly were done by means of repeated-measures analysis of variance. Level of significance was set at a probability value of < .05. Stat View for Windows software (version 5.0.1; SAS Institute Inc, Cary, NC) was used for the statistical analyses.
Stay updated, free articles. Join our Telegram channel
Full access? Get Clinical Tree
