Safety Warning about Laparoscopic Power Morcellation in Hysterectomy: A Cost-Effectiveness Analysis of National Impact

Xiao Xu; Vrunda B Desai; Peter E Schwartz; Cary P Gross; Haiqun Lin; Maria J Schymura; Jason D Wright

doi:10.1089/whr.2021.0101

Safety Warning about Laparoscopic Power Morcellation in Hysterectomy: A Cost-Effectiveness Analysis of National Impact

Womens Health Rep (New Rochelle). 2022 Mar 28;3(1):369-384. doi: 10.1089/whr.2021.0101. eCollection 2022.

Authors

Xiao Xu^{1

2}, Vrunda B Desai^{1

3}, Peter E Schwartz¹, Cary P Gross^{2

4}, Haiqun Lin^{5

6}, Maria J Schymura⁷, Jason D Wright⁸

Affiliations

¹ Department of Obstetrics, Gynecology and Reproductive Sciences, Yale School of Medicine, New Haven, Connecticut, USA.
² Yale Cancer Outcomes, Public Policy and Effectiveness Research (COPPER) Center, Yale School of Medicine, New Haven, Connecticut, USA.
³ CooperSurgical, Inc., Trumbull, Connecticut, USA.
⁴ Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut, USA.
⁵ Division of Nursing Science, Rutgers University School of Nursing, Newark, New Jersey, USA.
⁶ Department of Biostatistics and Epidemiology, Rutgers School of Public Health, Newark, New Jersey, USA.
⁷ New York State Cancer Registry, New York State Department of Health, Albany, New York, USA.
⁸ Department of Obstetrics and Gynecology, Columbia University College of Physicians and Surgeons, New York, New York, USA.

Abstract

Background: Following a 2014 safety warning (that laparoscopic power morcellation may increase tumor dissemination if patients have occult uterine cancer), hysterectomy practice shifted from laparoscopic to abdominal approach. This avoided morcellating occult cancer, but increased perioperative complications. To inform the national impact of this practice change, we examined the cost-effectiveness of hysterectomy practice in the postwarning period, in comparison to counterfactual hysterectomy practice had there been no morcellation warning.

Materials and methods: We constructed a decision tree model to simulate relevant outcomes over the lifetime of patients in the national population undergoing hysterectomy for presumed benign indications. The model accounted for both hysterectomy- and occult cancer-related outcomes. Probability-, cost-, and utility weight-related input parameters were derived from analysis of the State Inpatient Databases, State Ambulatory Surgery and Services Databases, data from the New York Statewide Planning and Research Cooperative System and New York State Cancer Registry, and published literature.

Results: With an estimated national sample of 353,567 adult women, base case analysis showed that changes in hysterectomy practice after the morcellation warning led to a net gain of 867.15 quality-adjusted life years (QALYs), but an increase of $19.54 million in costs (incremental cost-effectiveness ratio = $22,537/QALY). In probabilistic sensitivity analysis, the practice changes were cost-effective in 54.0% of the simulations when evaluated at a threshold of $50,000/QALY, which increased to 70.9% when evaluated at a threshold of $200,000/QALY.

Conclusion: Hysterectomy practice changes induced by the morcellation warning are expected to be cost-effective, but uncertainty in parameter values may affect the cost-effectiveness results.

Keywords: complications; cost-effectiveness; hysterectomy; laparoscopic power morcellation; occult uterine cancer.