Cost analysis of nurse-lead telephone follow-ups after benign hysterectomy: a randomized, single-blinded, four-arm, controlled multicenter trial

Purpose The aim of the study was to evaluate the health economics of nurse-led telephone follow-up contacts (TFUs) within six weeks after benign hysterectomy in a societal perspective, using a cost minimization analysis model.

A randomized, single-blinded, controlled, Swedish multicenter study comprising 487 women undergoing benign hysterectomy. The women were allocated 1:1:1:1 to either Group A (no TFUs), Group B (one clinically structured TFU the day after discharge), Group C (as B, but with additional TFUs once weekly for six weeks, in total six TFUs), or Group D (as C, but by applying a coaching technique). Time consumption for planned TFUs, informal care, and the number of unplanned telephone contacts and visits were recorded. Costs were assessed using a cost-per-patient price list for Linköping University Hospital.

The total cost per patient more than doubled in the groups with repeated TFUs (Groups C and D) compared with no TFUs (Group A). Group D demonstrated fewer unplanned telephone contacts and lower informal care costs. Group B, with only one TFU, exhibited the highest time consumption for TFU. The additional costs of six TFUs, with or without coaching, substantially increased the costs. The coaching TFU group (Group D) had the lowest cost for informal care.

TFUs appeared to be costly and an inefficient way of using healthcare resources after benign hysterectomy. The coaching TFU seemed to reduce unplanned telephone contacts and lower informal care costs. Careful consideration of the costs and the impact on clinical outcomes is important before implementing TFU after surgery. Trial registration This study is registered retrospectively in ClinicalTrial.gov: NCT01526668 on January 27, 2012. Date of enrollment of first patient: October 11; 2011.

Hysterectomy · Telephone follow-up · Cost minimization analysis · Healthcare · Patient-centered care Abbreviations CMA Cost minimization analysis CPP Cost per patient ERAS Enhanced recovery after surgery HRQoL Health-related quality of life TFU Telephone follow-up uTC Unplanned telephone contact uV Unplanned visit What does this study add to the clinical work Although coaching TFUs seemed to reduce unplanned telephone contacts and lower informal care costs, TFUs appeared to be a costly and inefficient way of using healthcare resources after benign hysterectomy. Careful consideration of the costs and the impact on clinical outcomes is important before implementing TFU after surgery. * Gulnara Kassymova [email protected] 1 Department of Obstetrics and Gynecology in Linköping, and Department of Biomedical and Clinical Sciences, Linköping University, 58245 Linköping, Sweden 2 Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden 3 Department of Anesthesiology and Intensive Care in Linköping and Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden 516 Archives of Gynecology and Obstetrics (2025) 312:515–523

Healthcare in Sweden is tax-funded and consequently has limited resources. Thus, the financial resources need to be managed wisely to achieve a high intervention efficiency while minimizing the costs, without compromising the quality and safety of care. Health economic evaluations are, among other things, used to help decision-makers deal with resource allocation and healthcare planning. By comparing the costs and effects of different interventions, policymakers and healthcare providers can make more informed decisions on how to allocate resources and improve health outcomes for patients and society [1]. Hysterectomy is one of the most common major gynecological procedures performed worldwide. Hysterectomy on benign indications is generally considered cost effective as it improves health-related quality of life at an acceptable cost. However, it is difficult to draw overall

on the cost-effectiveness of benign hysterectomy due to heterogeneity and methodological differences in studies addressing this topic [2]. An important issue to take into consideration concerning cost-effectiveness in surgery is the impact of postoperative recovery. The Enhanced Recovery After Surgery (ERAS) pathways are approaches to optimizing the pre- and perioperative care [3 , 4]. In ERAS settings, the overall hospital costs decreased after hysterectomy due to shorter hospitalization without increasing complication or readmission rates [5 ]. The patients’ experience of ERAS programs in qualitative studies indicates a desire to extend the program with contact from professional or experienced patient volunteers following hospital discharge, to offer support and guidance [6, 7]. Shortening of hospital stay can therefore also be an incentive to enhance the post-discharge support to speed up recovery. However, the literature is sparse on information of this issue, and there are no validated follow-up programs, guidelines, or treatment models to handle postoperative recovery. Based on healthcare traditions and the women’s preferences, different methods of follow-up contact are applied after benign hysterectomy. One of these methods is nurse-led telephone follow-up (TFU) contact after discharge from the hospital. The current evidence on the costs and cost-effectiveness of TFU after benign hysterectomy is scanty and heterogeneous [8 ]. Thus, it remains to be seen if TFU is cost effective. However, telephone-based health coaching for chronic diseases seemed to be a cost-effective intervention from a one-year perspective but with a substantial variation across patient groups [9 ]. Thus, applying a coaching model to the TFU may perhaps increase the possibility of achieving a cost-effective result of recovery also after benign hysterectomy. The implementation of TFUs after hysterectomy in Sweden has been debated. We have recently shown that TFUs, also including coaching, did not improve recovery after benign hysterectomy concerning health-related quality of life (HRQoL), duration of sick leave, intensity of postoperative symptoms, or analgesics consumption [10, 11]. Since no effect was seen in the recovery of HRQoL between different TFU models, it seemed inappropriate to analyze the cost-effectiveness of TFUs. Instead, a cost minimization analysis (CMA) could be appropriate. A CMA determines the least costly intervention when the outcomes of the interventions are equal. It involves identification, quantification, and valuing of the costs in monetary terms of at least two alternative strategies [12]. This study presents a secondary outcome of a randomized, single-blinded, four-arm, controlled multicenter study, the Post-hysterectomy Recovery trial (POSTHYSTREC) [10, 11]. The aim was to perform a CMA of four TFU models, from a societal perspective, of women undergoing benign hysterectomy, within six weeks after their discharge.

The POSTHYSTREC, a randomized single-blinded, four- arm, controlled multicenter intervention trial, was conducted at five departments of obstetrics and gynecology in five public hospitals in the southeast health region of Sweden between October 2011 and May 2017. This study was performed in line with the principles of the Declaration of Helsinki. Ethical approval was obtained from the Regional Ethical Board at Linköping University (Dnr.2011/106-31, approval date 23 May; 2011). Study population The study population, flow chart, the inclusion/exclusion cri- teria, the randomization process, the interventions, and sur- gery have previously been described in detail [10]. Briefly, women admitted to the hospitals for benign hysterectomy were eligible for this study. The main inclusion criteria were age between 18 and 60 years, speaking fluent Swed- ish, and having access to a private telephone or the internet. Exclusion criteria were genital prolapse as an indication for the hysterectomy, physical or mental disability, severe psychiatric disease, and current drug or alcohol abuse, pre- vious oophorectomy or the present operation would leave the woman without ovaries. After receiving written and oral information and having signed the consent document approximately one week before surgery, the participants were randomized into the ratio 1:1:1:1 to one of four TFU 517Archives of Gynecology and Obstetrics (2025) 312:515–523 models. The outcome of the allocation was kept secret from the participant until the moment of discharge from hospital and only information about the TFU model that should be used for the specific participant was given. Thus, the women were blinded to the other interventions. TFU intervention models • Group A—no planned follow-up contacts with the healthcare services after discharge. The patient was requested to contact the healthcare services, if necessary. • Group B—one planned, ordinary clinically structured TFU with the research nurse (RN) the day after discharge. Thereafter, the patient was requested to contact the healthcare services, if necessary. • Group C—planned, ordinary clinically structured TFU with the RN the day after discharge and then once weekly for six weeks. • Group D—planned, structured coaching TFU with the RN the day after discharge, and then once weekly for six weeks. The content of the TFU models and the orientation of the coaching model have previously been described in detail [10, 11]. Data collection Demographic and clinical data were collected prospectively. The participants filled in two generic HRQoL forms, the EQ-5D-3L [13, 14] and the SF-36 [15, 16], preoperatively and six weeks after the hysterectomy. The RN met all participants six weeks after the hysterectomy at the end of the study for collection of the study-specific forms and diaries, and for an interview. All readmissions and reoperations were registered. The RN registered the time consumption of the planned TFUs and the number and time consumption of unplanned telephone contacts (uTCs) along with the healthcare facility of unplanned visits (uVs) (hospital outpatient facility or primary healthcare) and the healthcare provider (gynecologist, physician, or nurse). The participants were requested to report in a diary, week- by-week, if and how many hours per week they had informal care from a family member, partner, friend, or neighbor after discharge due to disability caused by the hysterectomy. Determination of costs The calculations of costs followed the structure of a cost analysis [1 ] and the CHEERS 2022 requirements [17]. A societal perspective was used, capturing both direct healthcare costs, productivity losses, and costs due to informal care. The calculation of hospital costs was based on the CPP principles [18]. CPP is a method to estimate healthcare costs per care contact and patient. Thus, medical data and costs are linked to an individual patient. In this study, the 2022 CPP list from the University Hospital in Linköping was used. The CPPs relevant to this study have been extracted from the list and are presented in Table  1 as € in rounded values. The average exchange rate for 2022 was 1 € = 1.0501 US$ = 10.6317 Swedish kronor [19]. Direct cost covers all in-hospital costs and post- discharge costs. The latter included all planned and unplanned contacts. The indirect costs, that is the societal costs, as a measure of loss of production, were based on sick leave duration and information on the maximal level of compensation provided by the Social Insurance Agency for 2021 along with the costs for informal care. The costs of informal care were estimated by multiplying the mean number of hours spent by the mean national hourly gross wage, including employer and social security contributions [20, 21]. Leisure time was valued at 35% of the gross wage rate. In 2022, this value was about 7.3 € per hour. Statistics The software TIBCO Statistica® v13.5.0 (TIBCO Software Inc. 3307 Hillview Avenue, Palo Alto, CA 94304 USA) was used to process the data. Data are presented as mean and standard deviation (SD), median and interquartile range (IQR), or number and percent, as appropriate. Nominal data were analyzed by means of Pearson’s Chi-squared test. Continuous, normally distributed data were analyzed using one-way analysis of variance (ANOVA), and not normally distributed data were evaluated by means of Mann–Whitney Table 1 List for hospital costs per patient according to the CPP list, version 2022, from the University Hospital in Linköping [13] Average exchange rate 2022: 1 € = 1.0501 US$ = 10.6317 Swedish kronor Entity Basis of price Price in € Telephone contact or visit with nurse Standard price per contact or visit 76 Visit to gynecologist in hospital Standard price per visit 133 Visit to physician in outpatient care Standard price per visit 219 Informal care cost Price per hour 7.3 518 Archives of Gynecology and Obstetrics (2025) 312:515–523 U-test or Kruskal–Wallis ANOVA, as appropriate. The subsequent post hoc test between-group differences were conducted using multiple comparisons of mean ranks for all groups. The level of significance was set at p < 0.05 (two- sided testing).

Out of 525 women enrolled in this study, 487 completed this study. Baseline demographic and clinical outcomes including preoperative and six-week assessment of HRQoL outcomes in relation to intervention group are presented in Table  2. The data of the TFUs, uTCs, uVs, and informal care are shown in Table  3. Group C and D had the same number of TFUs but differed in the content of the TFU. In Group C, the nurse applied a traditional clinically structured counseling technique, whereas a coaching technique was used in Group D. The numbers of uTCs, uVs, and the consumption of informal care were similar in Groups A, B and C, whereas Group D had a substantially lower number of uTCs and time consumption of informal care. The CPP for the nurse TFUs was set at a fixed average price per session, independent of the de facto time consumption. However, a significant difference was seen in time consumption between the groups at the first and second TFU. The group with only one TFU (Group B) had the highest time consumption on that occasion, but the coaching TFU (Group D) seemed to be more time consuming on these two occasions compared with Group C, whereas no differences were seen later. The cost analysis is presented in Table  4. Since the duration of sick leave, and consequently the costs for sick leave, did not differ between the intervention groups, the indirect costs were made up of the informal care costs only in the cost analysis. The highest total cost per patient was seen in Group C with a cost of 2.4 times the total cost per patient in the group without TFUs (Group A). This was mainly attributed to the obviously higher costs for the TFUs in Group C and the higher costs of uVs. Compared with no use of TFU (Group A), the total cost per patient doubled when the TFUs included coaching (Group D). This was mainly caused by the higher costs for the TFUs in Group D, but the effect was counteracted by lower costs for fewer uTCs and lower costs for informal care in Group D.

This study found that TFUs after benign hysterectomy seemed to be a cost-driving intervention without notable benefits for the women or the healthcare services. Originally, the study was planned to determine the cost-effectiveness of TFUs after benign hysterectomy but due to the absence of differences in recovery measures including HRQoL measurements between the four randomizations groups, we conducted a cost analysis [ 10, 11]. CMA is a suitable

to provide a health economical evaluation of a “new” intervention. This study demonstrated that implementation of TFU after hysterectomy consumed societal resources without improvement of the quality of care or HRQoL. Choices between alternative interventions in healthcare are unavoidable. In contrast to everyday clinical decisions focusing on the individual patient, policy guidelines need to analyze a patient population and society from a broader perspective. Although qualitative studies have shown that women preferred nurse-led follow-up after surgery [7 , 22], a health economic evaluation can aid in identifying the most advantageous option considering the limitations in the available healthcare resources. The success of ERAS programs is often assessed by the duration of hospital stay. However, as emphasized by Kehlet and Joshi, this is only a surrogate marker of recovery [23]. In the perspective of having achieved shorter hospitalization times using ERAS programs, the programs could be extended to include factors that might influence the recovery after discharge from the hospital. Tailored TFU programs in different contexts may result in different outcomes. For instance, TFU of elderly patients after major gastro-intestinal surgery was associated with reduced length of postsurgical recovery [24]. When analyzing the different types of costs, it is obvious that TFU using structured coaching (Group D) had the lowest costs for uTCs as well as for informal care. Especially in comparison with Group C, which had the same number of planned TFUs, these findings indicate that the coaching content of the TFU program was of value. This finding seems to support the conclusion of Kersley Rydmark et al. in their qualitative study that empowerment to take control of the recovery process is a central theme in ERAS programs [25]. However, more studies are warranted to evaluate the impact of postoperative coaching follow-up models on recovery, especially in selected groups of vulnerable individuals at high risk of delayed recovery, and the health economic cost- effectiveness of the models. A limitation of this study was the absence of qualitative questions addressing whether the women were pleased with their follow-up program. Moreover, the RNs were not specif- ically interviewed about their opinions on the TFU. A need 519Archives of Gynecology and Obstetrics (2025) 312:515–523 to adapt the ERAS program to personal needs and individual goals has been identified from interviews [25]. It is possible that if sufficient information is provided to the women about postoperative recovery, in an ERAS setting, and the safety and assurance of contact possibility for questions and sup- port can be ensured; then planned TFUs may be redundant. CMA can be useful for healthcare decision-makers who need to allocate resources and make decisions and prioritize. However, it is important to remember that CMA is an instru- ment of economic evaluation, and other methods of analysis may be more appropriate depending on the specific context and goals of the analysis. The CMA in this study was con- ducted in a specific population and setting which may make it difficult to generalize the results. Another limitation of CMA is the sensitivity to changes in the price of interven- tions, which can have a significant impact on the results. Table 2 Demographic and clinical data of 487 women undergoing benign hysterectomy in relation to the intervention group Figures denote mean and (standard deviation) or number of women and (percent) EQ-5D-3L the EuroQol Group five dimensions with three level form; MCS mental component summary; PCS physical component summary; SF-36 Short-Form Health Survey a One-way ANOVA; bPearson’s Chi-squared test; cKruskal–Wallis ANOVA; dComplications within six weeks postoperatively Group A (n = 120) Group B (n = 122) Group C (n = 125) Group D (n = 120) p-value Age (years) 45.5 (5.3) 47.2 (5.6) 46.2 (5.3) 47.0 (5.8) 0.08a BMI (kg/m2) 26.8 (4.8) 27.0 (4.8) 26.7 (4.6) 26.5 (4.6) 0.85a Smoking 18 (15.5%) 9 (7.6%) 18 (14.4%) 11 (9.6%) 0.18b Gainfully employment 107 (89.2%) 117 (95.9%) 111 (88.8%) 113 (94.2%) 0.10b Comorbidity  Mental illness 23 (19.2%) 8 (6.6%) 20 (16.0%) 14 (11.7%) 0.02b  Chronic pain disorder 28 (23.3%) 30 (24.6%) 29 (23.2%) 31 (25.8%) 0.96b Hysterectomy indication  Myoma uteri 58 (48.3%) 65 (53.3%) 47 (37.6%) 53 (44.2%) 0.37b  Bleeding disorder 32 (26.7%) 23 (18.8%) 35 (28.0%) 35 (29.2%)  Myoma and bleeding 10 (8.3%) 14 (11.5%) 21 (16.8%) 13 (10.8%)  Cervical dysplasia 14 (11.7%) 12 (9.8%) 14 (11.2%) 9 (7.5%)  Pain 5 (4.2%) 8 (6.6%) 8 (6.4%) 9 (7.5%)  Others 1 (0.8%) 0 (0.0%) 0 (0.0%) 1 (0.8%) ASA classification  Class 1 84 (70.0%) 78 (63.9%) 79 (63.2%) 79 (65.8%) 0.37b  Class 2 35 (29.2%) 40 (32.8%) 39 (31.2%) 39 (32.5%)  Class 3 1 (0.8%) 4 (3.3%) 7 (5.6%) 2 (1.7%) Mode of hysterectomy  Abdominal 97 (80.8%) 98 (80.3% 98 (78.4%) 90 (75.0%) 0.68b  Vaginal 23 (19.2%) 24 (19.7%) 27 (21.6%) 30 (25.0%) Clavien–Dindo complication gradingd  Grade 1 17 (14.2%) 15 (12.3%) 16 (12.8%) 9 (7.5%) 0.64b  Grade 2 17 (14.2%) 19 (15.6%) 24 (19.2%) 16 (13.3%)  Grade 3 3 (2.5%) 6 (4.9%) 4 (3.2%) 3 (2.5%) Readmission within six weeks postoperatively 3 (2.5%) 7 (5.7%) 6 (4.8%) 8 (6.7%) 0.48b Sick leave duration (days) 26.8 (10.4) 28.1 (10.7) 28.0 (10.0) 26.9 (10.8) 0.71c EQ-5D-3L health index  Preoperatively 0.79 (0.22) 0.79 (0.21) 0.79 (0.22) 0.80 (0.18) 0.99c  Six weeks postoperatively 0.91 (0.14) 0.89 (0.17) 0.89 (0.19) 0.89 (0.17) 0.90c SF-36  PCS preoperatively 46.9 (10.6) 47.1 (9.9) 48.1 (9.1) 48.0 (8.5) 0.68c  MCS preoperatively 47.2 (10.7) 46.4 (10.3) 47.0 (11.1) 48.0 (10.1) 0.70c  PCS six weeks postoperatively 39.4 (7.8) 40.3 (9.3) 41.9 (8.3) 40.5 (8.8) 0.11c  MCS six weeks postoperatively 47.6 (10.2) 47.8 (10.6) 46.9 (12.2 49.4 (11.4) 0.17c 520 Archives of Gynecology and Obstetrics (2025) 312:515–523 The shortage of nurses is today a fact in Sweden and in some other countries. It is necessary to use the nurses’ compe- tence and working time effectively for the most cost-effective patient care. The nurses´ expenditure of time for TFU after benign hysterectomy can be replaced with time for other highly qualified tasks for nurses to improve the healthcare quality and the recovery of the patients. The unplanned contacts with a healthcare provider by telephone with a subsequent visit, if necessary, would perhaps be a more cost-effective alterna- tive for women with complications after benign hysterectomy. However, to be successful such a strategy requires clear and easily accessible paths with instructions for the patient to make use of. The results of this study should also be viewed in the per- spective of advances in the application of patient-centered care and through the use of telemedicine. The development of telemedicine in healthcare over the past decade by introduc- tion of health apps, online patient records, and virtual consul- tations appears to have improved patient health and reduced healthcare costs [26] and, possibly, indirectly to some extent contributed to addressing the shortage of nurses in healthcare. However, patients’ concerns about data security when using Table 3 Summary report of TFUs, uTCs, uVs, and informal care in relation to the intervention group IQR interquartile range; SD standard deviation; TFU telephone follow-up; uTC unplanned telephone contact; uV unplanned visit a Kruskal–Wallis ANOVA; bMann–Whitney U-test; cComparison between Group C and Group D; dPearson’s Chi-squared test; eMean (SD)/ median (IQR) number of uTCs in the group; fMedian (IQR) of the women who had uTCs; guVs either in primary healthcare, or in a hospital outpatient facility, or in both Group A (n = 120) Group B (n = 122) Group C (n = 125) Group D (n = 120) p-value Time consumption of TFU 1 (minutes), mean (SD) NA 9.8 (4.5) 8.3 (3.8) 8.7 (4.3) 0.02a Time consumption of TFU 2 (minutes), mean (SD) NA NA 7.4 (4.0) 8.5 (4.1) < 0.01b Time consumption of TFU 3 (minutes), mean (SD) NA NA 7.5 (3.9) 7.7 (3.8) 0.82b Time consumption of TFU 4 (minutes), mean (SD) NA NA 6.7 (3.4) 7.0 (3.6) 0.97b Time consumption of TFU 5 (minutes), mean (SD) NA NA 6.3 (2.8) 6.3 (2.7) 0.81b Time consumption of TFU 6 (minutes), mean (SD) NA NA 5.5 (3.0) 5.6 (2.9) 0.66b Summary time consumption (minutes), mean (SD) NA 9.8 (4.5) 41.6 (15.5) 43.8 (16.3) 0.39b,c Number of women with uTCs 57 (47.5%) 65 (53.3%) 62 (49.6%) 40 (33.3%) 0.01d Number of uTCs  Total number 110 135 109 73  Mean (SD) e 0.9 (1.4) 1.1 (1.5) 0.9 (1.2) 0.6 (1.2) 0.01a  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)  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 Time consumption uTCs (minutes)  Mean (SD) 5.4 (9.1) 6.9 (11.0) 5.3 (7.8) 3.2 (7.3) < 0.01a  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) Number of women with uVsg 57 (47.5%) 54 (44.3%) 62 (49.6%) 45 (37.5%) 0.25d  In primary healthcare 21 (17.5%) 22 (18.0%) 23 (18.4%) 12 (10.0%) 0.23d  In hospital outpatient facility 41 (34.2%) 43 (35.2%) 52 (41.6%) 38 (31.7%) 0.41d Number of uVsg Total 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 In primary healthcare  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 In hospital outpatient facility  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 Informal 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 Informal 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 Informal 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 Informal 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 Informal 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 Total time consumption for five weeks (hours), median (IQR) 12.5 (0.0–31.5) 11.0 (0.5–32.0) 10.0 (0.0–26.0) 7.0 (0.5–17.5) 0.23a Summary of informal care in five weeks (hours) 2942.5 2878.0 3189.8 1780.5 – 521Archives of Gynecology and Obstetrics (2025) 312:515–523 telemedicine have recently been noticed and appear to be an important factor to consider when offering telemedicine [27]. These factors should therefore be taken into consideration when offering telemedicine in a patient-centered healthcare system.

The TFU models after benign hysterectomy used in this study seemed to be a cost-driving and inefficient way of using healthcare resources. However, the coaching TFU model appeared to both result in fewer uTCs and lower costs for informal care. The cost evaluation of TFUs and their impact on clinical outcomes must be considered before implementation of planned TFUs after surgery or other medical follow-ups.

The authors thank all women who participated in this study. We are deeply grateful for the committed work con- ducted by all in the POSTHYSTREC study group, in particular by the research nurses for their meticulous work. The POSTHYSTREC Study Group consisted of members from five hospitals in the South- east region of Sweden: Linköping University Hospital: Peter Lukas, MD, Petra Langström, RN, Pernilla Nilsson, RN, Linda Shosholli, RN, Sofia Bergström, RN, and Åsa Rydmark Kersley, RN, MSc. Vrin- nevi Hospital, Norrköping: Leif Hidmark, MD, Anders Bolling, MD, Kristina Ekman, RNM, and Karin Granberg-Karlsson, RNM Ryhov Hospital, Jönköping: Laila Falknäs, MD, Maria Häggström, MD, Ewa Hermansson RNM Eksjö Highland Hospital: Tomaz Stypa, MD, PhD, Linda Myllimäki, MD, Iréne Johannesson, RNM, and Martina Ekeroth Wikander, RNM. Värnamo Hospital: Christina Gunnervik, MD, Fatima Johansson, MD, Magnus Trofast, MD, Mari-Ann Andersson, RNM, and Carita Jacobsson, RN. Author contributions The POSTHYSTREC study was conceptualized by PK, GS, LN and NBW who also wrote the main research protocol. PK, GK, LN and NBW were responsible for the data collection. The initiation and development of the research protocol of the current health economic study was done by GK together with PK and TD. Analyses of data were performed by GK, PK and TD. The main author is GK. All authors contributed to revising the manuscript, and all approved the final version of the manuscript. Funding Open access funding provided by Linköping University. This study was supported by grants from the Medical Research Council of Southeast Sweden (grant numbers FORSS-155141; FORSS-222211; FORSS-308441, and FORSS-387761), and Futurum—the Academy of Health and Care, Region Jönköping Council (grant numbers FUTURUM-487481, and FUTURUM 579171). Grant holder Preben Kjølhede. The funding sources were not involved in study design, collection, analysis and interpretation of data, or in writing, and decision of submission of the article for publication. Data availability No datasets were generated or analysed during the current study. Declarations Conflict of interest The authors declare no competing interests. Table 4 Accounting of costs for TFUs, uTCs, uVs, and informal care in relation to the intervention group h hours; TFU telephone follow-up; uTC unplanned telephone contact; uV unplanned visit a hospital outpatient care Group A Group B Group C Group D (n = 120) (n = 122) (n = 125) (n = 120) No. of occasions or hours € No. of occasions or hours € No. of occasions or hours € No. of occasions or hours € Total cost of TFUs 0 0 122 9272 750 57,000 720 54,700 Total cost of uTCs 110 8360 135 10,260 109 8284 73 5548 Total cost of uVs 97 12,509 143 14,632 153 18,305 113 13,579 In primary healthcare  Nurse 14 1064 62 4712 32 2432 18 1368  Physician 14 3066 4 876 16 3504 7 1533 In hospital carea  Nurse 14 1064 21 1596 28 2128 18 1368  Gynecologist 55 7315 56 7448 77 10,241 70 9310 Costs of informal care in five weeks 2942.5 h 21,408 2878 h 21,009 3190 h 23,285 1780.5 h 12,998 Total cost of post-discharge contacts 42,349 55,173 106,874 86,845 Total mean cost per patient 353 452 855 724 522 Archives of Gynecology and Obstetrics (2025) 312:515–523 Open Access This article is licensed under a Creative Commons Attri- bution 4.0 International License, which permits use, sharing, adapta- tion, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/.

1. Drummond MF, Sculpher MJ, Claxton K, Stoddart GL, Torrance GW (2015) Methods for the economic evaluation of health care programmes, 4th edn. Oxford University Press, Oxford 2. Pynnä K, Vuorela P, Lodenius L, Paavonen J, Roine RP, Räsänen P (2014) Cost-effectiveness of hysterectomy for benign gyneco- logical conditions: a systematic review. Acta Obstet Gynecol Scand 93(3):225–232. https:// doi. org/ 10. 1111/ aogs. 12299 3. Nelson G, Altman AD, Nick A, Meyer LA, Ramirez PT, Achtari C, Antrobus J, Huang J, Scott M, Wijk L, Acheson N, Ljun- gqvist O, Dowdy SC (2016) Guidelines for postoperative care in gynecologic/oncology surgery: enhanced recovery after surgery (ERAS(®)) society recommendations–Part II. Gynecol Oncol 140(2):323–232. https:// doi. org/ 10. 1016/j. ejso. 2020. 08. 006 4. Nelson G, Altman AD, Nick A, Meyer LA, Ramirez PT, Achtari C, Antrobus J, Huang J, Scott M, Wijk L, Acheson N, Ljungqvist O, Dowdy SC (2016) Guidelines for pre- and intra-operative care in gynecologic/oncology surgery: enhanced recovery after sur - gery (ERAS(®)) society recommendations–part I. Gynecol Oncol 140(2):313–322. https:// doi. org/ 10. 1016/j. ygyno. 2015. 11. 015 5. Pache B, Joliat GR, Hübner M, Grass F, Demartines N, Mathe- vet P, Achtari C (2019) Cost-analysis of enhanced recovery after surgery (ERAS) program in gynecologic surgery. Gynecol Oncol 154(2):388–393. https:// doi. org/ 10. 1016/j. ygyno. 2019. 06. 004 6. Gillis C, Gill M, Marlett N, MacKean G, GermAnn K, Gilmour L, Nelson G, Wasylak T, Nguyen S, Araujo E, Zelinsky S, Gramlich L (2017) Patients as partners in enhanced recovery after surgery: a qualitative patient-led study. BMJ Open 7(6):e017002. https:// doi. org/ 10. 1136/ bmjop en- 2017- 017002 7. Sibbern T, Bull Sellevold V, Steindal SA, Dale C, Watt-Watson J, Dihle A (2017) Patients’ experiences of enhanced recovery after surgery: a systematic review of qualitative studies. J Clin Nurs 26(9–10):1172–1188. https:// doi. org/ 10. 1111/ jocn. 13456 8. Dahlberg K, Philipsson A, Hagberg L, Jaensson M, Hälleberg- Nyman M, Nilsson U (2017) Cost-effectiveness of a systematic e-assessed follow-up of postoperative recovery after day surgery: a multicentre randomized trial. Br J Anaesth 119(5):1039–1046. https:// doi. org/ 10. 1093/ bja/ aex332 9. Oksman E, Linna M, Hörhammer I, Lammintakanen J, Talja M (2017) Cost-effectiveness analysis for a tele-based health coaching program for chronic disease in primary care. BMC Health Serv Res 17(1):138. https:// doi. org/ 10. 1186/ s12913- 017- 2088-4 10. Kassymova G, Sydsjö G, Borendal Wodlin N, Nilsson L, Kjølhede P (2021) The effect of follow-up contact on recovery after benign hysterectomy: a randomized, single-blinded, four-arm, controlled multicenter trial. J Womens Health (Larchmt) 30(6):872–881. https:// doi. org/ 10. 1089/ jwh. 2020 11. Kassymova G, Sydsjö G, Wodlin NB, Nilsson L, Kjølhede P (2023) Effect of nurse-led telephone follow-up on postoperative symptoms and analgesics consumption after benign hysterectomy: a randomized, single-blinded, four-arm, controlled multicenter trial. Arch Gynecol Obstet 307(2):459–471. https:// doi. org/ 10. 1007/ s00404- 022- 06722-x 12. Landfeldt E, Zethraeus N, Lindgren P (2019) Standardized ques- tionnaire for the measurement, valuation, and estimation of costs of informal care based on the opportunity cost and proxy good method. Appl Health Econ Health Policy 17(1):15–24. https:// doi. org/ 10. 1007/ s40258- 018- 0418-2 13. EuroQoL Group (1990) EuroQol–a new facility for the measure- ment of health-related quality of life. Health Policy 16(3):199– 208. https:// doi. org/ 10. 1016/ 0168- 8510(90) 90421-9 14. Burstrom K, Johannesson M, Diderichsen F (2001) Swedish popu- lation health-related quality of life results using the EQ-5D. Qual Life Res 10(7):621–635. https:// doi. org/ 10. 1023/a: 10131 71831 202 15. McHorney CA, Ware JE Jr, Lu JF, Sherbourne CD (1994) The MOS 36-item Short-Form Health Survey (SF-36): III. Tests of data quality, scaling assumptions, and reliability across diverse patient groups. Med Care 32(1):40–66. https:// doi. org/ 10. 1097/ 00005 650- 19940 1000- 00004 16. Sullivan M, Karlsson J, Ware JE Jr (1995) The Swedish SF-36 Health Survey–I. Evaluation of data quality, scaling assumptions, reliability and construct validity across general populations in Sweden. Soc Sci Med 41(10):1349–1358. https:// doi. org/ 10. 1016/ 0277- 9536(95) 00125-q 17. Husereau D, Drummond M, Augustovski F, de Bekker-Grob E, Briggs AH, Carswell C, Caulley L, Chaiyakunapruk N, Gree- berg D, Loder E, Mauskopf J, Mullins CD, Petrou S, Pwu R-F, Staniszewska S (2022) Consolidated health economic evaluation reporting standards (CHEERS) 2022 explanation and elaboration: a report of the ISPOR CHEERS II Good Practices Task Force. Value Health 25(1):10–31. https:// doi. org/ 10. 1016/j. jval. 2021. 10. 008 18. Sydöstra sjukvårdsregionen. Priser och ersättningar [in Swedish]. 2022. Available from: https:// sydos trasj ukvar dsreg ionen. se/ wp- conte nt/ uploa ds/ 2022/ 05/ Priser_ och_ ersat tning ar_ 20220 101_ 20220 331. pdf. Accessed 20 Dec 2024 19. Bank of Sweden. Annual average exchange rates. Available from: https:// www. riksb ank. se/ en- gb/ stati stics/ inter est- rates- and- excha nge- rates/ search- annual- and- month ly- avera ge- excha nge- rates/?a= Y&y= 2022&m= Select+ month &s= g130- SEKEU RPMI&s= g130- SEKUS DPMI& fs=3# result- secti on Accessed 20 Dec 2024 20. Statistics Sweden. Medellöner i Sverige [in Swedish]. [cited 2023 Apr 15]. Available from: https:// www. scb. se/ hitta- stati stik/ sveri ge-i- siffr or/ utbil dning- jobb- och- pengar/ medel loner-i- sveri ge/ Accessed 20 Dec 2024 21. Ekman B, McKee K, Vicente J, Magnusson L, Hanson E (2021) Cost analysis of informal care: estimates from a national cross- sectional survey in Sweden. BMC Health Serv Res 21(1):1236. https:// doi. org/ 10. 1186/ s12913- 021- 07264-9 22. Aasa A, Hovbäck M, Berterö CM (2013) The importance of pre- operative information for patient participation in colorectal sur - gery care. J Clin Nurs 22(11–12):1604–1612. https:// doi. org/ 10. 1111/ jocn. 12110 23. Kehlet H, Joshi G (2017) Enhanced recovery after surgery: cur - rent controversies and concerns. Anesth Analg 125(6):2154–2155. https:// doi. org/ 10. 1213/ ANE. 00000 00000 002231 24. Santana RF, Pereira SK, do Carmo TG, Freire VECS, Soares TDS, do Amaral DM, Vaqueiro RD (2018) Effectiveness of a telephone follow-up nursing intervention in postsurgical patients. Int J Nurs Pract 24(4):e12648. https:// doi. org/ 10. 1111/ ijn. 12648 523Archives of Gynecology and Obstetrics (2025) 312:515–523 25. Rydmark Kersley Å, Berterö C (2021) Women’s experiences of an enhanced recovery after surgery program: a qualitative study. Nurs Health Sci 23(1):263–272. https:// doi. org/ 10. 1111/ nhs. 12810 26. Elbert NJ, van Os-Medendorp H, van Renselaar W, Ekeland AG, Hakkaart-van Roijen L, Raat H, Nijsten TE, Pasmans SG (2014) Effectiveness and cost-effectiveness of ehealth interventions in somatic diseases: a systematic review of systematic reviews and meta-analyses. J Med Internet Res 16(4):e110. https:// doi. org/ 10. 2196/ jmir. 2790 27. Hoffmann S, Ott M, Bobbert F, Jacoby J, Henes M (2024) Data protection concerns are a statistically significant reason for refusal: exploratory study of the patient perspective on telemedi- cine services based on 735 gynecological surgery patients. Digital health 10:20552076241287064. https:// doi. org/ 10. 1177/ 20552 07624 12870 63 Publisher's Note Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.