A health maintenance organization's initial experience with laparoscopic-assisted vaginal hysterectomy and endometrial ablation

STUDY OBJECTIVE: To determine how the integration of laparoscopic-assisted hysterectomy (LAVH) and endometrial ablation into a health maintenance organization's (HMO) gynecologic practice affected quality of care and operating costs. DESIGN: A clinical study reviewing charts of HMO patients having a hysterectomy or endometrial ablation during 1990-1993. SETTING: A group practice in Worcester, Massachusetts. PATIENTS: Female members of the Fallon Community Health Plan, classic program. INTERVENTIONS: Total hysterectomies and endometrial ablations for 1990 through 1993; the numbers were 126, 105, 152, and 185, respectively. Hysterectomy was subdivided as total abdominal hysterectomy (TAH), vaginal hysterectomy (VH), vaginal hysterectomy with anterior or posterior colporrhaphy (VHC), and LAVH. All records of patients undergoing endometrial ablation (33), LAVH (59), and VH (44) were reviewed. Also reviewed were a random sample of the records of 60 patients (1990-1992) having TAH for benign conditions and 40 patients (1990-1993) having VHC. MEASUREMENTS AND MAIN RESULTS: We analyzed indications, uterine weights, endometriosis and adhesion classification, complications, surgical outcomes, total charges, trends in hysterectomy type, and annual hysterectomy rates. The annual hysterectomy rate did not change significantly over the study years, varying 1.83 to 2.71 per 1000 women. Menorrhagia as an indication for vaginal hysterectomy dropped from 58% in 1990-1991 to 17% in 1992-1993 after endometrial ablation was initiated. Postoperative complications were highest for TAH (45%) and lowest for LAVH (9%) and endometrial ablation (3%). The mean total charges were greatest for LAVH ($9739) and the least for endometrial ablation ($3580). The group reduced the rate of TAH from 78% (1990) to 47% (1993) of total procedures. For all procedures the number of weeks before return to work dropped from 5.57 to 4.45 during the study years. The mean cost per procedure did not change significantly, varying from $6634 to $7180. CONCLUSIONS: The integration of LAVH and endometrial ablation into an HMO's gynecologic practice improved quality of care by a marked reduction in surgical complications and more rapid return to work, but has not reduced operating costs due to the high total charges for LAVH. Continued study over the next few years may reveal further reduction in operating costs with an increased rate of endometrial ablation versus hysterectomy for menorrhagia.