{"paper_id":"494bb6b2-d0d4-41a6-9502-9a1f7cd53f82","body_text":"Vol.:(0123456789)\nArchives of Gynecology and Obstetrics (2025) 312:515–523 \nhttps://doi.org/10.1007/s00404-025-08035-1\nRESEARCH\nCost analysis of nurse‑lead telephone follow‑ups after benign \nhysterectomy: a randomized, single‑blinded, four‑arm, controlled \nmulticenter trial\nGulnara Kassymova1  · Thomas Davidson2  · Gunilla Sydsjö1  · Ninnie Borendal Wodlin1  · Lena Nilsson3  · \nPreben Kjølhede1 \nReceived: 26 December 2024 / Accepted: 12 April 2025 / Published online: 2 May 2025 \n© The Author(s) 2025\nAbstract\nPurpose The aim of the study was to evaluate the health economics of nurse-led telephone follow-up contacts (TFUs) within \nsix weeks after benign hysterectomy in a societal perspective, using a cost minimization analysis model. \nMethods A randomized, single-blinded, controlled, Swedish multicenter study comprising 487 women undergoing benign \nhysterectomy. The women were allocated 1:1:1:1 to either Group A (no TFUs), Group B (one clinically structured TFU \nthe day after discharge), Group C (as B, but with additional TFUs once weekly for six weeks, in total six TFUs), or Group \nD (as C, but by applying a coaching technique). Time consumption for planned TFUs, informal care, and the number of \nunplanned telephone contacts and visits were recorded. Costs were assessed using a cost-per-patient price list for Linköping \nUniversity Hospital.\nResults The total cost per patient more than doubled in the groups with repeated TFUs (Groups C and D) compared with no \nTFUs (Group A). Group D demonstrated fewer unplanned telephone contacts and lower informal care costs. Group B, with \nonly one TFU, exhibited the highest time consumption for TFU. The additional costs of six TFUs, with or without coaching, \nsubstantially increased the costs. The coaching TFU group (Group D) had the lowest cost for informal care.\nConclusion TFUs appeared to be costly and an inefficient way of using healthcare resources after benign hysterectomy. The \ncoaching TFU seemed to reduce unplanned telephone contacts and lower informal care costs. Careful consideration of the \ncosts and the impact on clinical outcomes is important before implementing TFU after surgery.\nTrial registration This study is registered retrospectively in ClinicalTrial.gov: NCT01526668 on January 27, 2012. Date of \nenrollment of first patient: October 11; 2011.\nKeywords Hysterectomy · Telephone follow-up · Cost minimization analysis · Healthcare · Patient-centered care\nAbbreviations\nCMA  Cost minimization analysis\nCPP  Cost per patient\nERAS  Enhanced recovery after surgery\nHRQoL  Health-related quality of life\nTFU  Telephone follow-up\nuTC  Unplanned telephone contact\nuV  Unplanned visit\nWhat does this study add to the clinical work \nAlthough coaching TFUs seemed to reduce \nunplanned telephone contacts and lower informal \ncare costs, TFUs appeared to be a costly and \ninefficient way of using healthcare resources after \nbenign hysterectomy. Careful consideration of \nthe costs and the impact on clinical outcomes is \nimportant before implementing TFU after surgery.\n * Gulnara Kassymova \n Gulnara@vackerman.se\n1 Department of Obstetrics and Gynecology in Linköping, \nand Department of Biomedical and Clinical Sciences, \nLinköping University, 58245 Linköping, Sweden\n2 Department of Health, Medicine and Caring Sciences, \nLinköping University, Linköping, Sweden\n3 Department of Anesthesiology and Intensive Care \nin Linköping and Department of Biomedical and Clinical \nSciences, Linköping University, Linköping, Sweden\n\n516 Archives of Gynecology and Obstetrics (2025) 312:515–523\nIntroduction\nHealthcare in Sweden is tax-funded and consequently has \nlimited resources. Thus, the financial resources need to be \nmanaged wisely to achieve a high intervention efficiency \nwhile minimizing the costs, without compromising the \nquality and safety of care.\nHealth economic evaluations are, among other things, \nused to help decision-makers deal with resource allocation \nand healthcare planning. By comparing the costs and effects \nof different interventions, policymakers and healthcare \nproviders can make more informed decisions on how to \nallocate resources and improve health outcomes for patients \nand society [1].\nHysterectomy is one of the most common major \ngynecological procedures performed worldwide. \nHysterectomy on benign indications is generally considered \ncost effective as it improves health-related quality of life at \nan acceptable cost. However, it is difficult to draw overall \nconclusions on the cost-effectiveness of benign hysterectomy \ndue to heterogeneity and methodological differences in \nstudies addressing this topic [2].\nAn important issue to take into consideration concerning \ncost-effectiveness in surgery is the impact of postoperative \nrecovery. The Enhanced Recovery After Surgery (ERAS) \npathways are approaches to optimizing the pre- and \nperioperative care [3 , 4]. In ERAS settings, the overall \nhospital costs decreased after hysterectomy due to shorter \nhospitalization without increasing complication or \nreadmission rates [5 ]. The patients’ experience of ERAS \nprograms in qualitative studies indicates a desire to extend \nthe program with contact from professional or experienced \npatient volunteers following hospital discharge, to offer \nsupport and guidance [6, 7]. Shortening of hospital stay can \ntherefore also be an incentive to enhance the post-discharge \nsupport to speed up recovery. However, the literature is \nsparse on information of this issue, and there are no validated \nfollow-up programs, guidelines, or treatment models \nto handle postoperative recovery. Based on healthcare \ntraditions and the women’s preferences, different methods of \nfollow-up contact are applied after benign hysterectomy. One \nof these methods is nurse-led telephone follow-up (TFU) \ncontact after discharge from the hospital.\nThe current evidence on the costs and cost-effectiveness \nof TFU after benign hysterectomy is scanty and \nheterogeneous [8 ]. Thus, it remains to be seen if TFU is \ncost effective. However, telephone-based health coaching for \nchronic diseases seemed to be a cost-effective intervention \nfrom a one-year perspective but with a substantial variation \nacross patient groups [9 ]. Thus, applying a coaching \nmodel to the TFU may perhaps increase the possibility of \nachieving a cost-effective result of recovery also after benign \nhysterectomy.\nThe implementation of TFUs after hysterectomy in \nSweden has been debated. We have recently shown that \nTFUs, also including coaching, did not improve recovery \nafter benign hysterectomy concerning health-related \nquality of life (HRQoL), duration of sick leave, intensity \nof postoperative symptoms, or analgesics consumption [10, \n11]. Since no effect was seen in the recovery of HRQoL \nbetween different TFU models, it seemed inappropriate \nto analyze the cost-effectiveness of TFUs. Instead, a cost \nminimization analysis (CMA) could be appropriate. A CMA \ndetermines the least costly intervention when the outcomes \nof the interventions are equal. It involves identification, \nquantification, and valuing of the costs in monetary terms \nof at least two alternative strategies [12].\nThis study presents a secondary outcome of a randomized, \nsingle-blinded, four-arm, controlled multicenter study, the \nPost-hysterectomy Recovery trial (POSTHYSTREC) [10, \n11]. The aim was to perform a CMA of four TFU models, \nfrom a societal perspective, of women undergoing benign \nhysterectomy, within six weeks after their discharge.\nMaterials and methods\nThe POSTHYSTREC, a randomized single-blinded, four-\narm, controlled multicenter intervention trial, was conducted \nat five departments of obstetrics and gynecology in five \npublic hospitals in the southeast health region of Sweden \nbetween October 2011 and May 2017. This study was \nperformed in line with the principles of the Declaration of \nHelsinki. Ethical approval was obtained from the Regional \nEthical Board at Linköping University (Dnr.2011/106-31, \napproval date 23 May; 2011).\nStudy population\nThe study population, flow chart, the inclusion/exclusion cri-\nteria, the randomization process, the interventions, and sur-\ngery have previously been described in detail [10]. Briefly, \nwomen admitted to the hospitals for benign hysterectomy \nwere eligible for this study. The main inclusion criteria \nwere age between 18 and 60 years, speaking fluent Swed-\nish, and having access to a private telephone or the internet. \nExclusion criteria were genital prolapse as an indication \nfor the hysterectomy, physical or mental disability, severe \npsychiatric disease, and current drug or alcohol abuse, pre-\nvious oophorectomy or the present operation would leave \nthe woman without ovaries. After receiving written and \noral information and having signed the consent document \napproximately one week before surgery, the participants \nwere randomized into the ratio 1:1:1:1 to one of four TFU \n\n517Archives of Gynecology and Obstetrics (2025) 312:515–523 \nmodels. The outcome of the allocation was kept secret from \nthe participant until the moment of discharge from hospital \nand only information about the TFU model that should be \nused for the specific participant was given. Thus, the women \nwere blinded to the other interventions.\nTFU intervention models\n• Group A—no planned follow-up contacts with the \nhealthcare services after discharge. The patient was \nrequested to contact the healthcare services, if necessary.\n• Group B—one planned, ordinary clinically structured \nTFU with the research nurse (RN) the day after discharge. \nThereafter, the patient was requested to contact the \nhealthcare services, if necessary.\n• Group C—planned, ordinary clinically structured TFU \nwith the RN the day after discharge and then once weekly \nfor six weeks.\n• Group D—planned, structured coaching TFU with the \nRN the day after discharge, and then once weekly for six \nweeks.\nThe content of the TFU models and the orientation of the \ncoaching model have previously been described in detail \n[10, 11].\nData collection\nDemographic and clinical data were collected \nprospectively. The participants filled in two generic \nHRQoL forms, the EQ-5D-3L [13, 14] and the SF-36 \n[15, 16], preoperatively and six weeks after the \nhysterectomy. The RN met all participants six weeks after \nthe hysterectomy at the end of the study for collection of \nthe study-specific forms and diaries, and for an interview. \nAll readmissions and reoperations were registered. The \nRN registered the time consumption of the planned TFUs \nand the number and time consumption of unplanned \ntelephone contacts (uTCs) along with the healthcare \nfacility of unplanned visits (uVs) (hospital outpatient \nfacility or primary healthcare) and the healthcare provider \n(gynecologist, physician, or nurse).\nThe participants were requested to report in a diary, week-\nby-week, if and how many hours per week they had informal \ncare from a family member, partner, friend, or neighbor after \ndischarge due to disability caused by the hysterectomy.\nDetermination of costs\nThe calculations of costs followed the structure of a cost \nanalysis [1 ] and the CHEERS 2022 requirements [17]. \nA societal perspective was used, capturing both direct \nhealthcare costs, productivity losses, and costs due to \ninformal care. The calculation of hospital costs was based \non the CPP principles [18]. CPP is a method to estimate \nhealthcare costs per care contact and patient. Thus, \nmedical data and costs are linked to an individual patient. \nIn this study, the 2022 CPP list from the University \nHospital in Linköping was used. The CPPs relevant to this \nstudy have been extracted from the list and are presented \nin Table  1 as € in rounded values. The average exchange \nrate for 2022 was 1 € = 1.0501 US$ = 10.6317 Swedish \nkronor [19].\nDirect cost covers all in-hospital costs and post-\ndischarge costs. The latter included all planned and \nunplanned contacts. The indirect costs, that is the societal \ncosts, as a measure of loss of production, were based on \nsick leave duration and information on the maximal level \nof compensation provided by the Social Insurance Agency \nfor 2021 along with the costs for informal care. The costs \nof informal care were estimated by multiplying the mean \nnumber of hours spent by the mean national hourly gross \nwage, including employer and social security contributions \n[20, 21]. Leisure time was valued at 35% of the gross wage \nrate. In 2022, this value was about 7.3 € per hour.\nStatistics\nThe software TIBCO  Statistica® v13.5.0 (TIBCO Software \nInc. 3307 Hillview Avenue, Palo Alto, CA 94304 USA) was \nused to process the data. Data are presented as mean and \nstandard deviation (SD), median and interquartile range \n(IQR), or number and percent, as appropriate. Nominal \ndata were analyzed by means of Pearson’s Chi-squared test. \nContinuous, normally distributed data were analyzed using \none-way analysis of variance (ANOVA), and not normally \ndistributed data were evaluated by means of Mann–Whitney \nTable 1  List for hospital costs \nper patient according to the \nCPP list, version 2022, from \nthe University Hospital in \nLinköping [13]\nAverage exchange rate 2022: 1 € = 1.0501 US$ = 10.6317 Swedish kronor\nEntity Basis of price Price in €\nTelephone contact or visit with nurse Standard price per contact or visit 76\nVisit to gynecologist in hospital Standard price per visit 133\nVisit to physician in outpatient care Standard price per visit 219\nInformal care cost Price per hour 7.3\n\n518 Archives of Gynecology and Obstetrics (2025) 312:515–523\nU-test or Kruskal–Wallis ANOVA, as appropriate. The \nsubsequent post hoc test between-group differences were \nconducted using multiple comparisons of mean ranks for \nall groups. The level of significance was set at p < 0.05 (two-\nsided testing).\nResults\nOut of 525 women enrolled in this study, 487 completed \nthis study. Baseline demographic and clinical outcomes \nincluding preoperative and six-week assessment of HRQoL \noutcomes in relation to intervention group are presented in \nTable  2.\nThe data of the TFUs, uTCs, uVs, and informal care are \nshown in Table  3. Group C and D had the same number of \nTFUs but differed in the content of the TFU. In Group C, the \nnurse applied a traditional clinically structured counseling \ntechnique, whereas a coaching technique was used in Group \nD. The numbers of uTCs, uVs, and the consumption of \ninformal care were similar in Groups A, B and C, whereas \nGroup D had a substantially lower number of uTCs and time \nconsumption of informal care.\nThe CPP for the nurse TFUs was set at a fixed average \nprice per session, independent of the de facto time \nconsumption. However, a significant difference was seen in \ntime consumption between the groups at the first and second \nTFU. The group with only one TFU (Group B) had the \nhighest time consumption on that occasion, but the coaching \nTFU (Group D) seemed to be more time consuming on \nthese two occasions compared with Group C, whereas no \ndifferences were seen later.\nThe cost analysis is presented in Table  4. Since the \nduration of sick leave, and consequently the costs for sick \nleave, did not differ between the intervention groups, the \nindirect costs were made up of the informal care costs only \nin the cost analysis. The highest total cost per patient was \nseen in Group C with a cost of 2.4 times the total cost per \npatient in the group without TFUs (Group A). This was \nmainly attributed to the obviously higher costs for the TFUs \nin Group C and the higher costs of uVs. Compared with no \nuse of TFU (Group A), the total cost per patient doubled \nwhen the TFUs included coaching (Group D). This was \nmainly caused by the higher costs for the TFUs in Group \nD, but the effect was counteracted by lower costs for fewer \nuTCs and lower costs for informal care in Group D.\nDiscussion\nThis study found that TFUs after benign hysterectomy \nseemed to be a cost-driving intervention without notable \nbenefits for the women or the healthcare services. Originally, \nthe study was planned to determine the cost-effectiveness \nof TFUs after benign hysterectomy but due to the absence \nof differences in recovery measures including HRQoL \nmeasurements between the four randomizations groups, \nwe conducted a cost analysis [ 10, 11]. CMA is a suitable \nmethod to provide a health economical evaluation of a “new” \nintervention. This study demonstrated that implementation \nof TFU after hysterectomy consumed societal resources \nwithout improvement of the quality of care or HRQoL.\nChoices between alternative interventions in healthcare \nare unavoidable. In contrast to everyday clinical decisions \nfocusing on the individual patient, policy guidelines need \nto analyze a patient population and society from a broader \nperspective. Although qualitative studies have shown that \nwomen preferred nurse-led follow-up after surgery [7 , 22], \na health economic evaluation can aid in identifying the \nmost advantageous option considering the limitations in the \navailable healthcare resources.\nThe success of ERAS programs is often assessed by \nthe duration of hospital stay. However, as emphasized \nby Kehlet and Joshi, this is only a surrogate marker of \nrecovery [23]. In the perspective of having achieved shorter \nhospitalization times using ERAS programs, the programs \ncould be extended to include factors that might influence \nthe recovery after discharge from the hospital. Tailored \nTFU programs in different contexts may result in different \noutcomes. For instance, TFU of elderly patients after major \ngastro-intestinal surgery was associated with reduced length \nof postsurgical recovery [24].\nWhen analyzing the different types of costs, it is obvious \nthat TFU using structured coaching (Group D) had the \nlowest costs for uTCs as well as for informal care. Especially \nin comparison with Group C, which had the same number \nof planned TFUs, these findings indicate that the coaching \ncontent of the TFU program was of value. This finding seems \nto support the conclusion of Kersley Rydmark et al. in their \nqualitative study that empowerment to take control of the \nrecovery process is a central theme in ERAS programs [25]. \nHowever, more studies are warranted to evaluate the impact \nof postoperative coaching follow-up models on recovery, \nespecially in selected groups of vulnerable individuals at \nhigh risk of delayed recovery, and the health economic cost-\neffectiveness of the models.\nA limitation of this study was the absence of qualitative \nquestions addressing whether the women were pleased with \ntheir follow-up program. Moreover, the RNs were not specif-\nically interviewed about their opinions on the TFU. A need \n\n519Archives of Gynecology and Obstetrics (2025) 312:515–523 \nto adapt the ERAS program to personal needs and individual \ngoals has been identified from interviews [25]. It is possible \nthat if sufficient information is provided to the women about \npostoperative recovery, in an ERAS setting, and the safety \nand assurance of contact possibility for questions and sup-\nport can be ensured; then planned TFUs may be redundant.\nCMA can be useful for healthcare decision-makers who \nneed to allocate resources and make decisions and prioritize. \nHowever, it is important to remember that CMA is an instru-\nment of economic evaluation, and other methods of analysis \nmay be more appropriate depending on the specific context \nand goals of the analysis. The CMA in this study was con-\nducted in a specific population and setting which may make \nit difficult to generalize the results. Another limitation of \nCMA is the sensitivity to changes in the price of interven-\ntions, which can have a significant impact on the results.\nTable 2  Demographic \nand clinical data of 487 \nwomen undergoing benign \nhysterectomy in relation to the \nintervention group\nFigures denote mean and (standard deviation) or number of women and (percent)\nEQ-5D-3L the EuroQol Group five dimensions with three level form; MCS mental component summary; \nPCS physical component summary; SF-36 Short-Form Health Survey\na One-way ANOVA; bPearson’s Chi-squared test; cKruskal–Wallis ANOVA; dComplications within six \nweeks postoperatively\nGroup A\n(n = 120)\nGroup B\n(n = 122)\nGroup C\n(n = 125)\nGroup D\n(n = 120)\np-value\nAge (years) 45.5 (5.3) 47.2 (5.6) 46.2 (5.3) 47.0 (5.8) 0.08a\nBMI (kg/m2) 26.8 (4.8) 27.0 (4.8) 26.7 (4.6) 26.5 (4.6) 0.85a\nSmoking 18 (15.5%) 9 (7.6%) 18 (14.4%) 11 (9.6%) 0.18b\nGainfully employment 107 (89.2%) 117 (95.9%) 111 (88.8%) 113 (94.2%) 0.10b\nComorbidity\n Mental illness 23 (19.2%) 8 (6.6%) 20 (16.0%) 14 (11.7%) 0.02b\n Chronic pain disorder 28 (23.3%) 30 (24.6%) 29 (23.2%) 31 (25.8%) 0.96b\nHysterectomy indication\n Myoma uteri 58 (48.3%) 65 (53.3%) 47 (37.6%) 53 (44.2%) 0.37b\n Bleeding disorder 32 (26.7%) 23 (18.8%) 35 (28.0%) 35 (29.2%)\n Myoma and bleeding 10 (8.3%) 14 (11.5%) 21 (16.8%) 13 (10.8%)\n Cervical dysplasia 14 (11.7%) 12 (9.8%) 14 (11.2%) 9 (7.5%)\n Pain 5 (4.2%) 8 (6.6%) 8 (6.4%) 9 (7.5%)\n Others 1 (0.8%) 0 (0.0%) 0 (0.0%) 1 (0.8%)\nASA classification\n Class 1 84 (70.0%) 78 (63.9%) 79 (63.2%) 79 (65.8%) 0.37b\n Class 2 35 (29.2%) 40 (32.8%) 39 (31.2%) 39 (32.5%)\n Class 3 1 (0.8%) 4 (3.3%) 7 (5.6%) 2 (1.7%)\nMode of hysterectomy\n Abdominal 97 (80.8%) 98 (80.3% 98 (78.4%) 90 (75.0%) 0.68b\n Vaginal 23 (19.2%) 24 (19.7%) 27 (21.6%) 30 (25.0%)\nClavien–Dindo complication  gradingd\n Grade 1 17 (14.2%) 15 (12.3%) 16 (12.8%) 9 (7.5%) 0.64b\n Grade 2 17 (14.2%) 19 (15.6%) 24 (19.2%) 16 (13.3%)\n Grade 3 3 (2.5%) 6 (4.9%) 4 (3.2%) 3 (2.5%)\nReadmission within six weeks \npostoperatively\n3 (2.5%) 7 (5.7%) 6 (4.8%) 8 (6.7%) 0.48b\nSick leave duration (days) 26.8 (10.4) 28.1 (10.7) 28.0 (10.0) 26.9 (10.8) 0.71c\nEQ-5D-3L health index\n Preoperatively 0.79 (0.22) 0.79 (0.21) 0.79 (0.22) 0.80 (0.18) 0.99c\n Six weeks postoperatively 0.91 (0.14) 0.89 (0.17) 0.89 (0.19) 0.89 (0.17) 0.90c\nSF-36\n PCS preoperatively 46.9 (10.6) 47.1 (9.9) 48.1 (9.1) 48.0 (8.5) 0.68c\n MCS preoperatively 47.2 (10.7) 46.4 (10.3) 47.0 (11.1) 48.0 (10.1) 0.70c\n PCS six weeks postoperatively 39.4 (7.8) 40.3 (9.3) 41.9 (8.3) 40.5 (8.8) 0.11c\n MCS six weeks postoperatively 47.6 (10.2) 47.8 (10.6) 46.9 (12.2 49.4 (11.4) 0.17c\n\n520 Archives of Gynecology and Obstetrics (2025) 312:515–523\nThe shortage of nurses is today a fact in Sweden and in \nsome other countries. It is necessary to use the nurses’ compe-\ntence and working time effectively for the most cost-effective \npatient care. The nurses´ expenditure of time for TFU after \nbenign hysterectomy can be replaced with time for other highly \nqualified tasks for nurses to improve the healthcare quality \nand the recovery of the patients. The unplanned contacts with \na healthcare provider by telephone with a subsequent visit, \nif necessary, would perhaps be a more cost-effective alterna-\ntive for women with complications after benign hysterectomy. \nHowever, to be successful such a strategy requires clear and \neasily accessible paths with instructions for the patient to make \nuse of.\nThe results of this study should also be viewed in the per-\nspective of advances in the application of patient-centered \ncare and through the use of telemedicine. The development of \ntelemedicine in healthcare over the past decade by introduc-\ntion of health apps, online patient records, and virtual consul-\ntations appears to have improved patient health and reduced \nhealthcare costs [26] and, possibly, indirectly to some extent \ncontributed to addressing the shortage of nurses in healthcare. \nHowever, patients’ concerns about data security when using \nTable 3  Summary report of TFUs, uTCs, uVs, and informal care in relation to the intervention group\nIQR interquartile range; SD standard deviation; TFU telephone follow-up; uTC unplanned telephone contact; uV unplanned visit\na Kruskal–Wallis ANOVA; bMann–Whitney U-test; cComparison between Group C and Group D; dPearson’s Chi-squared test; eMean (SD)/\nmedian (IQR) number of uTCs in the group; fMedian (IQR) of the women who had uTCs; guVs either in primary healthcare, or in a hospital \noutpatient facility, or in both\nGroup A\n(n = 120)\nGroup B\n(n = 122)\nGroup C\n(n = 125)\nGroup D\n(n = 120)\np-value\nTime consumption of TFU 1 (minutes), mean (SD) NA 9.8 (4.5) 8.3 (3.8) 8.7 (4.3) 0.02a\nTime consumption of TFU 2 (minutes), mean (SD) NA NA 7.4 (4.0) 8.5 (4.1)  < 0.01b\nTime consumption of TFU 3 (minutes), mean (SD) NA NA 7.5 (3.9) 7.7 (3.8) 0.82b\nTime consumption of TFU 4 (minutes), mean (SD) NA NA 6.7 (3.4) 7.0 (3.6) 0.97b\nTime consumption of TFU 5 (minutes), mean (SD) NA NA 6.3 (2.8) 6.3 (2.7) 0.81b\nTime consumption of TFU 6 (minutes), mean (SD) NA NA 5.5 (3.0) 5.6 (2.9) 0.66b\nSummary time consumption (minutes), mean (SD) NA 9.8 (4.5) 41.6 (15.5) 43.8 (16.3) 0.39b,c\nNumber of women with uTCs 57 (47.5%) 65 (53.3%) 62 (49.6%) 40 (33.3%) 0.01d\nNumber of uTCs\n Total number 110 135 109 73\n Mean (SD) e 0.9 (1.4) 1.1 (1.5) 0.9 (1.2) 0.6 (1.2) 0.01a\n Median (IQR) e 0.0 (0.0–1.0) 1.1 (0.0–2.0) 0.0 (0.0–1.0) 0.6 (0.0–1.0)\n Median (IQR) f 1.0 (1.0–2.0) 1.0 (1.0–3.0) 1.0 (1.0–2.0) 1.0 (1.0–2.0) 0.71a\nTime consumption uTCs (minutes)\n Mean (SD) 5.4 (9.1) 6.9 (11.0) 5.3 (7.8) 3.2 (7.3)  < 0.01a\n Median (IQR) 0.0 (0.0–7.0) 4.0 (0.0–10.0) 0.0 (0.0–8.0) 0.0 (0.0–5.0)\nNumber of women with  uVsg 57 (47.5%) 54 (44.3%) 62 (49.6%) 45 (37.5%) 0.25d\n In primary healthcare 21 (17.5%) 22 (18.0%) 23 (18.4%) 12 (10.0%) 0.23d\n In hospital outpatient facility 41 (34.2%) 43 (35.2%) 52 (41.6%) 38 (31.7%) 0.41d\nNumber of  uVsg\nTotal number/median (IQR) 97/0.0 (0.0–1.0) 143/0.0 (0.0–1.0) 153/1.0 (0.0–2.0) 113/0.0 (0.0–1.0) 0.34a\nIn primary healthcare\n Total number/median (IQR) 28/0.0 (0.0–0.0) 66/0.0 (0.0–0.0) 48/0.0 (0.0–0.0) 25/0.0 (0.0–0.0) 0.22a\nIn hospital outpatient facility\n Total number/median (IQR) 69/0.0 (0.0–1.0) 77/0.0 (0.0–1.0) 105/0.0 (0.0–1.0) 88/0.0 (0.0–1.0) 0.43a\nInformal care, week 1 (hours), median (IQR) 5.0 (0.0–14.3) 6.0 (0.5–14.0) 6.0 (0.0–12.0) 4.0 (0.3–9.5) 0.32a\nInformal care, week 2 (hours), median (IQR) 3.0 (0.0–9.5) 2.0 (0.0–8.0) 0.0 (0.0–4.0) 1.8 (0.0–5.0) 0.33a\nInformal care, week 3 (hours), median (IQR) 0.0 (0.0–4.3) 0.0 (0.0–5.0) 0.0 (0.0–4.0) 0.0 (0.0–2.0) 0.22a\nInformal care, week 4 (hours), median (IQR) 0.0 (0.0–2.0) 0.0 (0.0–2.0) 0.0 (0.0–0.0) 0.0 (0.0–0.0) 0.04a\nInformal care, week 5 (hours), median (IQR) 0.0 (0.0–0.0) 0.0 (0.0–0.0) 0.0 (0.0–0.0) 0.0 (0.0–0.0) 0.24a\nTotal time consumption for five weeks (hours), median \n(IQR)\n12.5 (0.0–31.5) 11.0 (0.5–32.0) 10.0 (0.0–26.0) 7.0 (0.5–17.5) 0.23a\nSummary of informal care in five weeks (hours) 2942.5 2878.0 3189.8 1780.5 –\n\n521Archives of Gynecology and Obstetrics (2025) 312:515–523 \ntelemedicine have recently been noticed and appear to be an \nimportant factor to consider when offering telemedicine [27]. \nThese factors should therefore be taken into consideration \nwhen offering telemedicine in a patient-centered healthcare \nsystem.\nConclusion\nThe TFU models after benign hysterectomy used in this \nstudy seemed to be a cost-driving and inefficient way of \nusing healthcare resources. However, the coaching TFU \nmodel appeared to both result in fewer uTCs and lower \ncosts for informal care. The cost evaluation of TFUs and \ntheir impact on clinical outcomes must be considered \nbefore implementation of planned TFUs after surgery or \nother medical follow-ups.\nAcknowledgements The authors thank all women who participated \nin this study. We are deeply grateful for the committed work con-\nducted by all in the POSTHYSTREC study group, in particular by \nthe research nurses for their meticulous work. The POSTHYSTREC \nStudy Group consisted of members from five hospitals in the South-\neast region of Sweden: Linköping University Hospital: Peter Lukas, \nMD, Petra Langström, RN, Pernilla Nilsson, RN, Linda Shosholli, \nRN, Sofia Bergström, RN, and Åsa Rydmark Kersley, RN, MSc. Vrin-\nnevi Hospital, Norrköping: Leif Hidmark, MD, Anders Bolling, MD, \nKristina Ekman, RNM, and Karin Granberg-Karlsson, RNM Ryhov \nHospital, Jönköping: Laila Falknäs, MD, Maria Häggström, MD, Ewa \nHermansson RNM Eksjö Highland Hospital: Tomaz Stypa, MD, PhD, \nLinda Myllimäki, MD, Iréne Johannesson, RNM, and Martina Ekeroth \nWikander, RNM. Värnamo Hospital: Christina Gunnervik, MD, Fatima \nJohansson, MD, Magnus Trofast, MD, Mari-Ann Andersson, RNM, \nand Carita Jacobsson, RN.\nAuthor contributions The POSTHYSTREC study was conceptualized \nby PK, GS, LN and NBW who also wrote the main research protocol. \nPK, GK, LN and NBW were responsible for the data collection. The \ninitiation and development of the research protocol of the current health \neconomic study was done by GK together with PK and TD. Analyses \nof data were performed by GK, PK and TD. The main author is GK. \nAll authors contributed to revising the manuscript, and all approved \nthe final version of the manuscript.\nFunding Open access funding provided by Linköping University. This \nstudy was supported by grants from the Medical Research Council of \nSoutheast Sweden (grant numbers FORSS-155141; FORSS-222211; \nFORSS-308441, and FORSS-387761), and Futurum—the Academy \nof Health and Care, Region Jönköping Council (grant numbers \nFUTURUM-487481, and FUTURUM 579171). Grant holder Preben \nKjølhede. The funding sources were not involved in study design, \ncollection, analysis and interpretation of data, or in writing, and \ndecision of submission of the article for publication.\nData availability No datasets were generated or analysed during the \ncurrent study.\nDeclarations \nConflict of interest The authors declare no competing interests.\nTable 4  Accounting of costs for TFUs, uTCs, uVs, and informal care in relation to the intervention group\nh hours; TFU telephone follow-up; uTC unplanned telephone contact; uV unplanned visit\na hospital outpatient care\nGroup A Group B Group C Group D\n(n = 120) (n = 122) (n = 125) (n = 120)\nNo. of \noccasions or \nhours\n€ No. of \noccasions or \nhours\n€ No. of \noccasions or \nhours\n€ No. of \noccasions or \nhours\n€\nTotal cost of TFUs 0 0 122 9272 750 57,000 720 54,700\nTotal cost of uTCs 110 8360 135 10,260 109 8284 73 5548\nTotal cost of uVs 97 12,509 143 14,632 153 18,305 113 13,579\nIn primary healthcare\n Nurse 14 1064 62 4712 32 2432 18 1368\n Physician 14 3066 4 876 16 3504 7 1533\nIn hospital  carea\n Nurse 14 1064 21 1596 28 2128 18 1368\n Gynecologist 55 7315 56 7448 77 10,241 70 9310\nCosts of informal care in five weeks 2942.5 h 21,408 2878 h 21,009 3190 h 23,285 1780.5 h 12,998\nTotal cost of post-discharge contacts 42,349 55,173 106,874 86,845\nTotal mean cost per patient 353 452 855 724\n\n522 Archives of Gynecology and Obstetrics (2025) 312:515–523\nOpen Access This article is licensed under a Creative Commons Attri-\nbution 4.0 International License, which permits use, sharing, adapta-\ntion, distribution and reproduction in any medium or format, as long \nas you give appropriate credit to the original author(s) and the source, \nprovide a link to the Creative Commons licence, and indicate if changes \nwere made. 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