Surgical technique advanced but costly It reduces the time a patient spends in the hospital; Older methods were cheaper; Hysterectomy study at GBMC poses question: Is benefit worth cost?


New medical technology that has become increasingly popular may get people out of the hospital sooner, but a study says that doesn't mean lower hospital bills.

According to the new study published today in the New England Journal of Medicine, hysterectomies performed with the help of high-tech laparoscopy cost as much as $1,900 more than traditional surgical techniques, even though the newer method allows shorter hospital stays.

The study was done at the Greater Baltimore Medical Center, which runs the state's largest gynecological surgery service.

Dr. James H. Dorsey, lead author and GBMC's chairman of gynecology, said expensive disposable equipment and longer operating room times account for the higher costs.

But Dorsey's work points to a larger issue affecting medicine: the increasing amount of sophisticated technology being rapidly introduced into patient care -- and whether these new, usually more expensive, techniques are any better than the old ways.

Experts say the GBMC study is the kind of rigorous analysis that must be done, not only on cost, but on quality issues such as pain, complications, and when a patient can return to work.

"We are living in an increasingly invasive, highly specialized and technical medical care culture, and we have to be very careful as providers not to use procedures that don't have demonstrated cost-effectiveness," said Dr. Chris Forrest, an instructor in health policy at the Johns Hopkins School of Public Health.

About 650,000 hysterectomies are performed in the United States each year, making the surgical removal of the uterus among the most common operations for women.

The procedure is needed for many reasons, including fibroid tumors, abnormal bleeding and endometriosis, a condition in which uterine tissue grows outside the uterus.

The best way to do a hysterectomy is vaginally, since that avoids a long incision and the woman suffers fewer complications and recovers faster. If the uterus is too large or there are other problems, surgeons make an abdominal incision.

In the third and newest technique, physicians use laparoscopy to get inside the abdomen and address any problems without having to make the long incision.

Surgeons thread miniature instruments -- including a fiber-optic camera -- through three small incisions. Afterward, the uterus can be removed vaginally. The technique is called laparoscopically-assisted vaginal hysterectomy, or LAVH.

Critics have said that doctors were using laparoscopy for hysterectomies even when they didn't need to, which is one reason Dorsey's group wanted to study it.

They analyzed 1,049 hysterectomies performed at GBMC in 1993 and 1994 by 96 surgeons. They found that LAVH cost about $1,000 more, on average, than abdominal hysterectomy, and about $1,900 more, on average, than vaginal hysterectomy.

According to the study, GBMC charged $6,116 for an LAVH, $5,084 for an abdominal and $4,221 for a vaginal.

Even though the LAVH costs more, hospital stays for the operation were on average 2.6 days -- compared with 3.9 days for the abdominal method and 2.9 for the vaginal technique.

A second study published yesterday confirmed GBMC's findings. Conducted by physicians at the Cleveland Clinic, it also found that LAVH cost more than the other surgical techniques. They determined that laparoscopy was most likely to be used when women were insured.

Over the past decade, laparoscopic procedures have revolutionized surgery across the country. The technology has been praised because, by reducing the invasiveness of an operation, pain, complications and recovery time should theoretically be reduced.

Even though this is the general consensus, small studies have produced conflicting results and large studies proving this are few, said Dr. Steven Palter, assistant professor and director of the Yale Office Laparoscopy Program.

That's partly because it's so difficult to compare, since the quality of the operation, the time required to do it, and therefore, the costs, depend on the surgeon's skills.

One weakness of the studies was not taking into account how much money is saved because women can return to work earlier.

One woman who underwent the LAVH praised it. As a recovery nurse in a Hopkins operating room, Paula Woodward, 38, said she routinely sees women who have undergone the abdominal surgery. "That's real traumatic, but my post-op pain was a piece of cake," said Woodward, who had the procedure at GBMC because of fibroids, or benign tumors.

Officials at Johnson & Johnson, one of the manufacturers of laparoscopic instruments, argue that this improvement in quality life should be considered. They cite a study that found reduced blood loss and an accelerated return to normal activities.

Dr. Timothy Hickman, an ob-gyn and reproductive endocrinologist at Hopkins, said the GBMC study reaffirms that vaginal hysterectomy is the best method, and that LAVH should be used only to avoid an abdominal hysterectomy.

In an editorial accompanying the studies, Dr. Thomas G. Stovall of the Bowman Gray School of Medicine and Dr. Robert L. Summitt Jr. of the University of Tennessee, warned that enthusiasm for the procedure should be tempered until more data are in.

The expensive disposable instruments used in LAVH would have to be eliminated if costs are to come down, they wrote. Just as crucial, clinical trials are needed to find out how women fare under the different methods.

Dorsey is working on that kind of study now. But even if research definitively proves the benefits, there is another factor.

"Is it worth it? I bet most people would say yes," said Hickman. "However, the question is, will insurance companies think it's worth it?"

Pub Date: 8/15/96

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