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Direct Cost of Hysterectomy When Performed by Different Routes
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Abstracts / Journal of Minimally Invasive Gynecology 24 (2017) S1–S201
Changes in heart rate, blood pressure, end tidal CO2, cerebral O2 saturation, systemic O2 saturation and autonomic variables during surgery. Phase 1 Phase 2 Phase 3a Phase 3b Phase 3c Phase 4
Phase 5
Body position Intra-abdominal pressure Low frequency power (log) (msec2/Hz) High frequency power (log) (msec2/Hz) Total power (log) (msec2/Hz) Heart rate (b.p.m) Systolic blood pressure (mmHg) Diastolic blood pressure (mm Hg) End tidal CO2 (mmHg) Cerebral O2 saturation (%) Systemic O2 saturation (%)
Supine 0 3.1 ± 1.0 3.2±1.0*† 4.1 ± 1.0 63 ± 12† 127 ± 21 78±12 34±4†‡ 75±9 99±0.9
Supine 0 2.8 ± 0.8* 2.5 ± 1.2* 3.8 ± 0.8 66 ± 10* 118 ± 20 73 ± 17 32±4* 73±9 99±0.7
Supine 14 3.1 ± 0.9 3.0 ± 1.0 4.0 ± 0.9 64 ± 11§ 125 ± 26 78 ± 17 36±4*† 72±8 99±0.8
Trendelenburg 10 3.3 ± 0.9* 3.2±0.9*† 4.3 ± 0.8 55 ± 6*†§ 130 ± 25 88 ± 12 36±4* 76±9 98±1
Trendelenburg 10 2.9 ± 0.9 2.9±1.0 3.9 ± 0.7 57 ± 7*‡ 126 ± 18 79 ± 8 35±2 75±10 99±0.9
Trendelenburg 10 2.9 ± 0.8 2.9±0.9 4.0 ± 0.7 61 ± 5 120 ± 18 75 ± 12 35±3 75±9 98±1.1
Trendelenburg 10 2.8 ± 0.7 2.8±0.7 3.8 ± 0.7 66 ± 13†‡ 126 ± 16 77±11 37±3*‡ 77±9 98±0.9
*p < 0.05. †p < 0.05. ‡p < 0.05. §p < 0.05.
identified with the following frequency: abdominal 17 (4.5%), laparoscopic 52 (14%), Vaginal 72 (19.5%), and Robotic 270 (62%). The average direct costs were: $3,822 abdominal, $3,821 laparoscopic, $ 3,110 vaginal, and $5,450 for the robotic. Once we broke down the direct costs per year, we found a significant decrease in the cost for the robotic route ($8,560 in 2014, $3,723 in 2015, $4,040 in 2016).
All these effects occurred without any significant shifts in systolic or diastolic blood pressure or in systemic oxygenation. Conclusion: This study supports the safety of robotic sacrocolpopexy performed with steep Trendelenburg positioning with pneumoperitoneum. Only minor alterations were observed in cerebral oxygenation and autonomic perturbations, which did not cause clinically significant alterations in heart rate and heart rate variability.
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Plenary 3 – Robotics (2:15 PM - 3:15 PM) 2:25 PM – GROUP A
Direct Cost of Hysterectomy When Performed by Different Routes Kaaki B. Unitypoint Health, Waterloo, Iowa Study Objective: We will be studying the direct cost of hysterectomy when performed by 4 different routes: abdominal, vaginal, laparoscopic and robotic. Design: Data of all patients who underwent hysterectomy from January 2014 until September 2016 were retrospectively collected and analyzed. Our primary outcome was the direct cost of hysterectomy. The secondary outcome was length of stay. Setting: Patients presented to a medium size teaching community hospital to have a hysterectomy. Patients: All patients presenting for a hysterectomy performed by any route from January 2014 until September 2016 were included. Measurements and Main Results: 371 patients underwent a hysterectomy from January 2014 until September 2016. Four routes of hysterectomy
The costs for the other routes were not significantly different throughout the years; (abdominal $3,333 in 2014, $3,823 in 2015, $4,169 in 2016), (laparoscopic $3,251 in 2014, $3,957 in 2015, $3,916 in 2016), (vaginal $3,465 in 2014, $2,725 in 2015, $2,884 in 2016). Breakdown by Years Route Volume
LOS (hrs)
Direct Cost ($)
Abdominal Vaginal Laparoscopic Robotic Abdominal Vaginal Laparoscopic Robotic Abdominal Vaginal Laparoscopic Robotic
2014
2015
2016
Total/Average
5 34 9 78 51 29 26 17 3,333 3,465 3,251 8,560
5 22 26 89 57 27 21 11 3,823 2,725 3,957 3,723
7 16 17 64 47 19 10 12 4,169 2,884 3,916 4,040
17 72 52 230 51 26 18 13 3,822 3,110 3,821 5,450
Table 1. The average length of stay was the shortest for robotics 13 hours, followed by laparoscopic 18 hours, then vaginal 26 hours and longest for abdominal 51 hours.
Abstracts / Journal of Minimally Invasive Gynecology 24 (2017) S1–S201 Conclusion: Vaginal hysterectomy continued to have the lowest direct cost. Robotic hysterectomy initially had the highest direct cost, and then dropped to become equivalent to the laparoscopic and abdominal route. Robotic hysterectomy had the shortest hospital stay, whereas the abdominal route had the longest. Multicenter study is recommended to confirm if this data can be replicated in other institutions.
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Plenary 3 – Robotics (2:15 PM - 3:15 PM) 2:35 PM – GROUP A
Use of Administrative Inpatient and Outpatient Databases to Determine Routes of Hysterectomy: the Different Stories They Tell in Florida Espinal M,1 Guha P,1 Dinh TA,1 Robertson MW,1 Spaulding AC,2 Colibaseanu DT,2 DeStephano CC1. 1Medical and Surgical Gynecology, Mayo Clinic Florida, Jacksonville, Florida; 2Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Jacksonville, Florida Study Objective: To determine whether differences exist in the routes of hysterectomy reported by two publicly available state databases. Design: Retrospective cross-sectional study (Canadian Task force classification II-3). Setting: Purchased data on routes of hysterectomy from Florida’s State Inpatient Database (SID) and State Ambulatory Surgery and Services Databases (SASD) were compared to data from HCUPnet (https://hcupnet.ahrq.gov). HCUPnet provides a free, on-line query system based on data from the Healthcare Cost and Utilization Project (HCUP). Patients: Adult females who underwent inpatient and outpatient hysterectomies in Florida in 2013-2014. Intervention: Using HCUPnet, identify the number of each type of inpatient hysterectomy in Florida using ICD-9-CM codes. Compare data from HCUPnet to SID and SASD to determine routes of hysterectomy when inpatient and outpatient data is analyzed together. Measurements and Main Results: HCUPnet provides health care data on inpatient procedures for 35 states for 2013-2014. The system does not allow the user to differentiate robotic-assisted hysterectomies with the robotic modifier code. Data for Florida from HCUPnet, SID, and SASD are demonstrated in Table 1 (2013) and Table 2 (2014). When only an inpatient database is used, open abdominal hysterectomies appear to be the most common route
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of hysterectomy in Florida in 2013-2014 (60.9% from HCUPnet and 57.3% from SID). However, 27,569 (69.8%) of 39,505 minimally invasive hysterectomies were performed as outpatient procedures in 2013-2014. Therefore, the majority (70.8%) of hysterectomies were actually performed in a minimally invasive fashion in 2013-2014 as demonstrated when both inpatient and outpatient data were used. Conclusion: To accurately determine routes of hysterectomy using administrative databases, it is essential to use databases that include both outpatient and inpatient procedures and allow combining the robotic modifier with hysterectomy procedural codes. HCUPnet and databases that only include inpatient data do not provide accurate representations of the hysterectomy route prevalence.
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Plenary 3 – Robotics (2:15 PM - 3:15 PM) 2:45 PM – GROUP B
Transversus Abdominis Plane Block Using Liposomal Bupivacaine during Robotic Hysterectomies for PostOperative Pain Control Chen Y,1 Labbad G,1 Pursell N,1 El-Neemany D,1 Dewan A,2 ElSahwi K1. 1 Ob/Gyn, Jersey Shore University Medical Center, Neptune, New Jersey; 2 Office of Clinical Research, Jersey Shore University Medical Center, Neptune, New Jersey Study Objective: Evaluate the efficacy of laparoscopy-guided TAP block using liposomal bupivacaine for post-operative pain control in patients undergoing robotic hysterectomies. Design: Retrospective cohort study. Setting: Academic affiliated community hospital. Patients: All robotic hysterectomies performed by the same surgeon in a four year period. Intervention: Injection of intra-operative dilute solution of liposomal bupivacaine into the Transversus Abdominis plane using a beveled needle under direct laparoscopic guidance. The solution constitutes 20 mL of liposomal bupivacaine/20 mL of 0.25% bupivacaine/20 mL of saline. We show a 90 second video of the procedure. Measurements and Main Results: A total of 115 patients were analyzed, 48 of whom received liposomal bupivacaine and 67 who did not. Average pain scores on post-op day 0 were comparable (4.8/10 in the liposomal bupivacaine group and 4.9/10 in the non-liposomal bupivacaine group,
Table 1. Number and percentage of each type of hysterectomy performed in Florida using HCUPnet, SID, and SASD in 2013 Hysterectomy route
HCUPnet inpatient database Number %
Florida SID Number
%
Florida SID and SASD Number %
Laparoscopic abdominal Laparoscopic vaginal Vaginal Robotic Open abdominal Total
3,131 1,806 1,939 Not available 9,373 16,249
1,078 1,133 1,872 2,555 7,685 14,323
7.53 7.91 13.07 17.84 53.65 100
4,438 3,316 3,047 11,200 7,820 29,821
19.27 11.12 11.93 Not available 57.68 100
14.88 11.12 10.22 37.56 26.22 100
Table 2. Number and percentage of each type of hysterectomy performed in Florida using HCUPnet, SID, and SASD in 2014 Hysterectomy route
HCUPnet inpatient database Number %
Florida SID Number
%
Florida SID and SASD Number %
Laparoscopic abdominal Laparoscopic vaginal Vaginal Robotic Open abdominal Total
2,594 1,391 1,581 Not available 10,036 15,602
849 910 1,487 2,052 8,323 13,621
6.23 6.68 10.92 15.06 61.11 100
3,596 3,261 2,490 8,157 8,481 25,985
16.63 8.92 10.13 Not available 64.32 100
13.84 12.55 9.58 31.39 32.64 100
Abstracts / Journal of Minimally Invasive Gynecology 24 (2017) S1–S201
Changes in heart rate, blood pressure, end tidal CO2, cerebral O2 saturation, systemic O2 saturation and autonomic variables during surgery. Phase 1 Phase 2 Phase 3a Phase 3b Phase 3c Phase 4
Phase 5
Body position Intra-abdominal pressure Low frequency power (log) (msec2/Hz) High frequency power (log) (msec2/Hz) Total power (log) (msec2/Hz) Heart rate (b.p.m) Systolic blood pressure (mmHg) Diastolic blood pressure (mm Hg) End tidal CO2 (mmHg) Cerebral O2 saturation (%) Systemic O2 saturation (%)
Supine 0 3.1 ± 1.0 3.2±1.0*† 4.1 ± 1.0 63 ± 12† 127 ± 21 78±12 34±4†‡ 75±9 99±0.9
Supine 0 2.8 ± 0.8* 2.5 ± 1.2* 3.8 ± 0.8 66 ± 10* 118 ± 20 73 ± 17 32±4* 73±9 99±0.7
Supine 14 3.1 ± 0.9 3.0 ± 1.0 4.0 ± 0.9 64 ± 11§ 125 ± 26 78 ± 17 36±4*† 72±8 99±0.8
Trendelenburg 10 3.3 ± 0.9* 3.2±0.9*† 4.3 ± 0.8 55 ± 6*†§ 130 ± 25 88 ± 12 36±4* 76±9 98±1
Trendelenburg 10 2.9 ± 0.9 2.9±1.0 3.9 ± 0.7 57 ± 7*‡ 126 ± 18 79 ± 8 35±2 75±10 99±0.9
Trendelenburg 10 2.9 ± 0.8 2.9±0.9 4.0 ± 0.7 61 ± 5 120 ± 18 75 ± 12 35±3 75±9 98±1.1
Trendelenburg 10 2.8 ± 0.7 2.8±0.7 3.8 ± 0.7 66 ± 13†‡ 126 ± 16 77±11 37±3*‡ 77±9 98±0.9
*p < 0.05. †p < 0.05. ‡p < 0.05. §p < 0.05.
identified with the following frequency: abdominal 17 (4.5%), laparoscopic 52 (14%), Vaginal 72 (19.5%), and Robotic 270 (62%). The average direct costs were: $3,822 abdominal, $3,821 laparoscopic, $ 3,110 vaginal, and $5,450 for the robotic. Once we broke down the direct costs per year, we found a significant decrease in the cost for the robotic route ($8,560 in 2014, $3,723 in 2015, $4,040 in 2016).
All these effects occurred without any significant shifts in systolic or diastolic blood pressure or in systemic oxygenation. Conclusion: This study supports the safety of robotic sacrocolpopexy performed with steep Trendelenburg positioning with pneumoperitoneum. Only minor alterations were observed in cerebral oxygenation and autonomic perturbations, which did not cause clinically significant alterations in heart rate and heart rate variability.
14
Plenary 3 – Robotics (2:15 PM - 3:15 PM) 2:25 PM – GROUP A
Direct Cost of Hysterectomy When Performed by Different Routes Kaaki B. Unitypoint Health, Waterloo, Iowa Study Objective: We will be studying the direct cost of hysterectomy when performed by 4 different routes: abdominal, vaginal, laparoscopic and robotic. Design: Data of all patients who underwent hysterectomy from January 2014 until September 2016 were retrospectively collected and analyzed. Our primary outcome was the direct cost of hysterectomy. The secondary outcome was length of stay. Setting: Patients presented to a medium size teaching community hospital to have a hysterectomy. Patients: All patients presenting for a hysterectomy performed by any route from January 2014 until September 2016 were included. Measurements and Main Results: 371 patients underwent a hysterectomy from January 2014 until September 2016. Four routes of hysterectomy
The costs for the other routes were not significantly different throughout the years; (abdominal $3,333 in 2014, $3,823 in 2015, $4,169 in 2016), (laparoscopic $3,251 in 2014, $3,957 in 2015, $3,916 in 2016), (vaginal $3,465 in 2014, $2,725 in 2015, $2,884 in 2016). Breakdown by Years Route Volume
LOS (hrs)
Direct Cost ($)
Abdominal Vaginal Laparoscopic Robotic Abdominal Vaginal Laparoscopic Robotic Abdominal Vaginal Laparoscopic Robotic
2014
2015
2016
Total/Average
5 34 9 78 51 29 26 17 3,333 3,465 3,251 8,560
5 22 26 89 57 27 21 11 3,823 2,725 3,957 3,723
7 16 17 64 47 19 10 12 4,169 2,884 3,916 4,040
17 72 52 230 51 26 18 13 3,822 3,110 3,821 5,450
Table 1. The average length of stay was the shortest for robotics 13 hours, followed by laparoscopic 18 hours, then vaginal 26 hours and longest for abdominal 51 hours.
Abstracts / Journal of Minimally Invasive Gynecology 24 (2017) S1–S201 Conclusion: Vaginal hysterectomy continued to have the lowest direct cost. Robotic hysterectomy initially had the highest direct cost, and then dropped to become equivalent to the laparoscopic and abdominal route. Robotic hysterectomy had the shortest hospital stay, whereas the abdominal route had the longest. Multicenter study is recommended to confirm if this data can be replicated in other institutions.
15
Plenary 3 – Robotics (2:15 PM - 3:15 PM) 2:35 PM – GROUP A
Use of Administrative Inpatient and Outpatient Databases to Determine Routes of Hysterectomy: the Different Stories They Tell in Florida Espinal M,1 Guha P,1 Dinh TA,1 Robertson MW,1 Spaulding AC,2 Colibaseanu DT,2 DeStephano CC1. 1Medical and Surgical Gynecology, Mayo Clinic Florida, Jacksonville, Florida; 2Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Jacksonville, Florida Study Objective: To determine whether differences exist in the routes of hysterectomy reported by two publicly available state databases. Design: Retrospective cross-sectional study (Canadian Task force classification II-3). Setting: Purchased data on routes of hysterectomy from Florida’s State Inpatient Database (SID) and State Ambulatory Surgery and Services Databases (SASD) were compared to data from HCUPnet (https://hcupnet.ahrq.gov). HCUPnet provides a free, on-line query system based on data from the Healthcare Cost and Utilization Project (HCUP). Patients: Adult females who underwent inpatient and outpatient hysterectomies in Florida in 2013-2014. Intervention: Using HCUPnet, identify the number of each type of inpatient hysterectomy in Florida using ICD-9-CM codes. Compare data from HCUPnet to SID and SASD to determine routes of hysterectomy when inpatient and outpatient data is analyzed together. Measurements and Main Results: HCUPnet provides health care data on inpatient procedures for 35 states for 2013-2014. The system does not allow the user to differentiate robotic-assisted hysterectomies with the robotic modifier code. Data for Florida from HCUPnet, SID, and SASD are demonstrated in Table 1 (2013) and Table 2 (2014). When only an inpatient database is used, open abdominal hysterectomies appear to be the most common route
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of hysterectomy in Florida in 2013-2014 (60.9% from HCUPnet and 57.3% from SID). However, 27,569 (69.8%) of 39,505 minimally invasive hysterectomies were performed as outpatient procedures in 2013-2014. Therefore, the majority (70.8%) of hysterectomies were actually performed in a minimally invasive fashion in 2013-2014 as demonstrated when both inpatient and outpatient data were used. Conclusion: To accurately determine routes of hysterectomy using administrative databases, it is essential to use databases that include both outpatient and inpatient procedures and allow combining the robotic modifier with hysterectomy procedural codes. HCUPnet and databases that only include inpatient data do not provide accurate representations of the hysterectomy route prevalence.
16
Plenary 3 – Robotics (2:15 PM - 3:15 PM) 2:45 PM – GROUP B
Transversus Abdominis Plane Block Using Liposomal Bupivacaine during Robotic Hysterectomies for PostOperative Pain Control Chen Y,1 Labbad G,1 Pursell N,1 El-Neemany D,1 Dewan A,2 ElSahwi K1. 1 Ob/Gyn, Jersey Shore University Medical Center, Neptune, New Jersey; 2 Office of Clinical Research, Jersey Shore University Medical Center, Neptune, New Jersey Study Objective: Evaluate the efficacy of laparoscopy-guided TAP block using liposomal bupivacaine for post-operative pain control in patients undergoing robotic hysterectomies. Design: Retrospective cohort study. Setting: Academic affiliated community hospital. Patients: All robotic hysterectomies performed by the same surgeon in a four year period. Intervention: Injection of intra-operative dilute solution of liposomal bupivacaine into the Transversus Abdominis plane using a beveled needle under direct laparoscopic guidance. The solution constitutes 20 mL of liposomal bupivacaine/20 mL of 0.25% bupivacaine/20 mL of saline. We show a 90 second video of the procedure. Measurements and Main Results: A total of 115 patients were analyzed, 48 of whom received liposomal bupivacaine and 67 who did not. Average pain scores on post-op day 0 were comparable (4.8/10 in the liposomal bupivacaine group and 4.9/10 in the non-liposomal bupivacaine group,
Table 1. Number and percentage of each type of hysterectomy performed in Florida using HCUPnet, SID, and SASD in 2013 Hysterectomy route
HCUPnet inpatient database Number %
Florida SID Number
%
Florida SID and SASD Number %
Laparoscopic abdominal Laparoscopic vaginal Vaginal Robotic Open abdominal Total
3,131 1,806 1,939 Not available 9,373 16,249
1,078 1,133 1,872 2,555 7,685 14,323
7.53 7.91 13.07 17.84 53.65 100
4,438 3,316 3,047 11,200 7,820 29,821
19.27 11.12 11.93 Not available 57.68 100
14.88 11.12 10.22 37.56 26.22 100
Table 2. Number and percentage of each type of hysterectomy performed in Florida using HCUPnet, SID, and SASD in 2014 Hysterectomy route
HCUPnet inpatient database Number %
Florida SID Number
%
Florida SID and SASD Number %
Laparoscopic abdominal Laparoscopic vaginal Vaginal Robotic Open abdominal Total
2,594 1,391 1,581 Not available 10,036 15,602
849 910 1,487 2,052 8,323 13,621
6.23 6.68 10.92 15.06 61.11 100
3,596 3,261 2,490 8,157 8,481 25,985
16.63 8.92 10.13 Not available 64.32 100
13.84 12.55 9.58 31.39 32.64 100