Elective Hysterectomy: Costs, Risks, and

Benefits

October 1981

NTIS order #PB82-122326
CASE STUDY #15

THE IMPLICATIONS OF

COST-EFFECTIVENESS

ANALYSIS OF

MEDICAL TECHNOLOGY

OCTOBER 1981

BACKGROUND PAPER #2: CASE STUDIES OF

MEDICAL TECHNOLOGIES

CASE STUDY #15: ELECTIVE HYSTERECTOMY: COSTS, RISKS,

AND BENEFITS

Carol Korenbrot, Ph.D.

Ann B. Flood, Ph. D..

Michael Higgins, Ph.D.

Noralou Roos, Ph.D.

John P. Bunker, M.D.

Division of Health Services Research

Stanford University

Stanford, Calif.

t 1

OTA Background Papers are documents that contain information believed to be

useful to various parties. The information undergirds formal OTA assessments or is

an outcome of internal exploratory planning and evaluation. The material is usually

not of immediate policy interest such as is contained in an OTA Report or Technical

Memorandum, nor does it present options for Congress to consider.

L J

CONGRESS OF THE UNITED STATES

Office of Technology Assessment

Washington, D C 20510
Foreword

This case study is one of 17 studies comprising Background Paper #2 for OTA’s

assessment, The Implications of Cost-Effectiveness Analysis of Medical Technology.

That assessment analyzes the feasibility, implications, and value of using cost-effectiveness and cost-benefit analysis (CEA/CBA) in health care decisionmaking. The major, policy-oriented report of the assessment was published in August 1980. In addition

to Background Paper #2, there are four other background papers being published in

conjunction with the assessment: 1) a document which addresses methodological

issues and reviews the CEA/CBA literature, published in September 1980; 2) a case

study of the efficacy and cost-effectiveness of psychotherapy, published in October

1980; 3) a case study of four common diagnostic X-ray procedures, to be published in

summer 1981; and 4) a review of international experience in managing medical technology, published in October 1980. Another related report was published in

September of 1979: A Review of Selected Federal Vaccine and Immunization Policies.

The case studies in Background Paper #2: Case Studies of Medical Technologies

are being published individually. They were commissioned by OTA both to provide

information on the specific technologies and to gain lessons that could be applied to

the broader policy aspects of the use of CEA/CBA. Several of the studies were specifically requested by the Senate Committee on Finance.

Drafts of each case study were reviewed by OTA staff; by members of the advisory panel to the overall assessment, chaired by Dr. John Hogness; by members of

the Health Program Advisory Committee, chaired by Dr. Frederick Robbins; and by

numerous other experts in clinical medicine, health policy, Government, and economics. We are grateful for their assistance. However, responsibility for the case studies remains with the authors.

&

/y8~

●

.

JOHN H. GIBBONS

‘Director

. . .

111
Advisory Panel on The Implications of

Cost-Effectiveness Analysis of Medical Technology

John R. Hogness, Panel Chairman

President, Association of Academic Health Centers

Stuart H. Altman Sheldon Leonard

Dean Manager

Florence Heller School Regulatory Affairs

Brandeis University General Electric Co.

James L. Bennington

Chairman

Department of Anatomic Pathology and

Clinical Laboratories

Children’s Hospital of San Francisco

John D. Chase

Associate Dean for Clinical Affairs

University of Washington School of Medicine

Joseph Fletcher

Visiting Scholar

Medical Ethics

School of Medicine

University of Virginia

Clark C. Havighurst

Professor of Law

School of Law

Duke University

Barbara J. McNeil

Department of Radiology

Peter Bent Brigham Hospital

Robert H. Moser

Executive Vice President

American College of Physicians

Frederick Mosteller

Chairman

Department of Biostatistics

Harvard University

Robert M. Sigmond

Advisor on Hospital Affairs

Blue Cross and Blue Shield Associations

Jane Sisk Willems

VA Scholar

Veterans Administration
OTA Staff for Background Paper #2

Joyce C. Lashof, Assistant Director, OTA

Health and Life Sciences Division

H. David Banta, Health Program Manager

Clyde J. Behney, Project Director

Kerry Britten Kemp, * Editor

Virginia Cwalina, Research Assistant

Shirley Ann Gayheart, Secretary

Nancy L. Kenney, Secretary

Martha Finney, * Assistant Editor

Other Contributing Staff

Bryan R. Luce Lawrence Miike Michael A. Riddiough

Leonard Saxe Chester Strobel*

OTA Publishing Staff

John C. Holmes, Publishing Officer

John Bergling Kathie S. Boss Debra M. Datcher Joe Henson

● OTA contract personnel.
Preface

This case study is one of 17 that comprise

Background Paper #2 to the OTA project on the

Implications of Cost-Effective) less Analysis of

Medical Technology. * The overall project was

requested by the Senate Committee on Labor

and Human Resources. In all, 19 case studies of

technological applications were commissioned

as part of that project. Three of the 19 were specifically requested by the Senate Committee on

Finance: psychotherapy, which was issued separately as Background Paper #3; diagnostic Xray, which will be issued as Background Paper

#.5; and respiratory therapies, which will be included as part of this series. The other 16 case

studies were selected by OTA staff.

In order to select those 16 case studies, OTA,

in consultation with the advisory panel to the

overall project, developed a set of selection

criteria. Those criteria were designed to ensure

that

●

●

●

●

●

●

●

as a group the case studies would provide:

examples of types of technologies by function (preventive, diagnostic, therapeutic,

and rehabilitative);

examples of types of technologies by physical nature (drugs, devices, and procedures);

examples of technologies in different stages

of development and diffusion (new, emerging

, and established);

examples from different areas of medicine

(such as general medical practice, pediatrics, radiology, and surgery);

examples addressing medical problems that

are important because of their high frequency or significant impacts (such as

cost ) ;

examples of technologies with associated

high costs either because of high volume

(for low-cost technologies) or high individual costs;

examples that could provide informative

material relating to the broader policy and

methodological issues of cost-effectiveness

or cost-benefit analysis (CEA /CBA); and

● examples with sufficient evaluable literature.

On the basis of these criteria and recommendations by panel members and other experts,

OTA staff selected the other case studies. These

16 plus the respiratory therapy case study requested by the Finance Committee make up the

17 studies in this background paper.

All case studies were commissioned by OTA

and performed under contract by experts in academia. They are authored studies. OTA subjected each case study to an extensive review

process. Initial drafts of cases were reviewed by

OTA staff and by members of the advisory

panel to the project. Comments were provided

to authors, along with OTA’S suggestions for

revisions. Subsequent drafts were sent by OTA

to numerous experts for review and comment.

Each case was seen by at least 20, and some by

40 or more, outside reviewers. These reviewers

were from relevant Government agencies, professional societies, consumer and public interest

groups, medical practice, and academic medicine. Academicians such as economists and decision analysts also reviewed the cases. In all,

over 400 separate individuals or organizations

reviewed one or more case studies. Although all

these reviewers cannot be acknowledged individually, OTA is very grateful for their comments and advice. In addition, the authors of

the case studies themselves often sent drafts to

reviewers and incorporated their comments.

These case studies are authored works

commissioned by OTA. The authors are responsible for the conclusions of their specific case study. These cases are not statements of official OTA position. OTA does

not make recommendations or endorse particular technologies. During the various

stages of the review and revision process,

therefore, OTA encouraged the authors to

present balanced information and to recognize divergent points of view. In two cases,

OTA decided that in order to more fully

present divergent views on particular technologies a commentary should be added to

the case study. Thus, following the case
studies on gastrointestinal endoscopy and

on the Keyes technique for periodontal disease, commentaries from experts in the appropriate health care specialty have been

included, followed by responses from the

authors.

The case studies were selected and designed to

fulfill two functions. The first, and primary,

purpose was to provide OTA with specific information that could be used in formulating

general conclusions regarding the feasibility y and

implications of applying CEA/CBA in health

care. By examining the 19 cases as a group and

looking for common problems or strengths in

the techniques of CEA/CBA, OTA was able to

better analyze the potential contribution that

these techniques might make to the management

of medical technologies and health care costs

and quality. The second function of the cases

was to provide useful information on the specific technologies covered. However, this was

not the major intent of the cases, and they

should not be regarded as complete and definitive studies of the individual technologies. In

many instances, the case studies do represent excellent reviews of the literature pertaining to the

specific technologies and as such can stand on

their own as a useful contribution to the field. In

general, though, the design and the funding

levels of these case studies were such that they

should be read primarily in the context of the

overall OTA project on CEA/CBA in health

care.

Some of the case studies are formal CEAs or

CBAs; most are not. Some are primarily concerned with analysis of costs; others are more

concerned with analysis of efficacy or effectiveness. Some, such as the study on end-stage

renal disease, examine the role that formal

analysis of costs and benefits can play in policy

formulation. Others, such as the one on breast

cancer surgery, illustrate how influences other

than costs can determine the patterns of use of a

technology. In other words, each looks at evaluation of the costs and the benefits of medical

technologies from a slightly different perspective. The reader is encouraged to read this study

in the context of the overall assessment’s objectives in order to gain a feeling for the potential

role that CEA/CBA can or cannot play in health

care and to better understand the difficulties and

complexities involved in applying CEA/CBA to

specific medical technologies.

The 17 case studies comprising Background

Paper #2 (short titles) and their authors are:

Artificial Heart: Deborah P. Lubeck and John P.

Bunker

Automated Multichannel Chemistry Analyzers:

Milton C. Weinstein and Laurie A. Pearlman

Bone Marrow Transplants: Stuart O. Schweitzer and C. C. Scalzi

Breast Cancer Surgery: Karen Schachter and

Duncan Neuhauser

Cardiac Radionuclide Imaging: William B.

Stason and Eric Fortess

Cervical Cancer Screening: Bryan R. Luce

Cimetidine and Peptic Ulcer Disease: Harvey V.

Fineberg and Laurie A. Pearlman

Colon Cancer Screening: David M. Eddy

CT Scanning: Judith L. Wagner

Elective Hysterectomy: Carol Korenbrot, Ann

B. Flood, Michael Higgins, Noralou Roos,

and John P. Bunker

End-Stage Renal Disease: Richard A. Rettig

Gastrointestinal Endoscopy: Jonathan A. Showstack and Steven A. Schroeder

Neonatal Intensive Care: Peter Budetti, Peggy

McManus, Nancy Barrand, and Lu Ann

Heinen

Nurse Practitioners: Lauren LeRoy and Sharon

Solkowitz

Orthopedic Joint Prosthetic Implants: Judith D.

Bentkover and Philip G. Drew

Periodontal Disease Interventions: Richard M.

Scheffler and Sheldon Rovin

Selected Respiratory Therapies: Richard M.

Scheffler and Morgan Delaney

These studies will be available for sale by the

Superintendent of Documents, U.S. Government Printing Office, Washington, D.C. 20402.

Call OTA’s Publishing Office (224-8996) for

availability and ordering information.
Case Study #15

Elective Hysterectomy:

Costs, Risks, and Benefits

Carol Korenbrot, Ph. D.

Ann B. Flood, Ph. D.

Michael Higgins, Ph. D.

Noralou Roos, Ph. D.

John P. Bunker, M.D.

Division of Health Services Research

Stanford University

Stanford, Calif.

AUTHORS’ ACKNOWLEDGMENTS

Technical assistance in the preparation of this paper was provided by Mitchell

LaPlante. Ann B. Barnes, M. D., Phillip Hoffman, M. D., Leslie Roos, Ph. D., and

George M. Ryan, Jr., M. D., read early drafts of the manuscript and provided valuable

comments.
.—-— .. .

Contents

Page

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

Hysterectomies for Sterilization and Cancer

Prophylaxis . . . . . . . . . . . . . . . . . . . . . . . . . 5

Health Risks of Hysterectomy . . . . . . . . . . . . . . . 7

Operative and Early Postoperative Outcome. . 7

Long-Term Postoperative Complications. . . . . 10

Comparison of Health Risks of Hysterectomy

With Those of Tubal Ligation . . . . . . . . . . . 14

Comparison of Health Risks of Hysterectomy

WithThose of Future Cancer . . . . . . . . . . . . 15

Quantitative Evaluation of Risks, Costs, and

Benefits of Elective Hysterectomy . . . . . . . . 17

The Health Risks and Costs of Hysterectomy. . 17

The Effect of Hysterectomy on Direct Costs

for Medical Care . . . . . . . . . . . . . . . . . . . . . 18

Quantitative Analysis Comparing

Hysterectomy With Tubal Ligation . . . . . . . 20

The Role of Elective Hysterectomy in

Subgroups . . . . . . . . . . . . . . . . . . . . . . . . . 20

Conclusions and Recommendations . . . . . . . . . . 23

Appendix A: The Manitoba Study . . . . . . . . . . . 25

Appendix B: An Analysis of Elective

Hysterectomy and Tubal Ligation . . . . . . . . 27

References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31

LIST OF TABLES

Table No. Page

1.

2.

3.

4.

PSRO List of Medical Indications for

Vaginal and Abdominal Hysterectomy . . . . . 4

Indications for Hysterectomy: Five Levels

of Urgency .. . $ . . . . . . . . . . . . . . . . . . . . . . 4

Comparative Indications and

Hysterectomies, 1945-73 . . . . . . . . . . . . . . . . 7

Comparative Incidence and Rates of

Mortality Among Patients Undergoing

Hysterectomy, Cholecystectomy, or

Appendectomy . . . . . . . . . . . . . . . . . . . . . . . 8

5.

6.

7.

8.

9.

10.

11.

12.

13.

14.

15.

Morbidity and Mortality 7 Days After

Hysterectomy . . . . . . . . . . . . . . . . . . . . . . . . 9

Morbidity and Mortality 40 Days After

Hysterectomy: Remaining Health Problems . 10

Morbidity and Mortality 40 Days After

Hysterectomy: Comparative Health Status . . 10

Hospitalizations in the 12 Months Before

and 12 Months After Hysterectomy. . . . . . . . 11

Hospital Outpatient and Emergency Room

Visits and Physician Office and Home

Visits in the 12 Months Before and 12 Months

After Hysterectomy . . . . . ........ . . . . . 1 1

Selected Diagnoses Associated With

Hospitalizations in the 12 Months Before

and 12 Months After Hysterectomy. , . . . . . . 12

Selected Diagnoses Associated With

Hospital Outpatient and Emergency Room

Visits and Physician Office and Home Visits

in the 12 Months Before and 12 Months

After Hysterectomy . . . . . . . . . . . . . . . . . . . 13

Visits for Neuroses and Psychiatric

Disorders and for Menopausal Symptoms

in the 12 Months Before and 12 Months

After Hysterectomy, By Type of Operation

and Age of Patient. . . . . . . . . . . . . . . . . . . . . 14

Age-Adjusted Rates for Visits for

Menopausal Symptoms in the 12 Months

Before and 12 Months After Hysterectomy . . 14

Estimated Lifetime Savings and Costs of

Elective Hysterectomy for 1 Million Women . 17

Lifetime Savings and Costs of Elective

Hysterectomy . . . . . . . . . . . . . . . . . . . . . . . . 19

LIST OF FIGURES

Figure No. Page

1. Hysterectomy Rates per 100,000 Women

Aged 15 and Over, 1965-77 . . . . . . . . . . . . . . 6

2. Net Cost Differences Between Tubal Ligation

and Hysterectomy on the Basis of Mean

“All Female” Earnings, By Age at

Operation and Selected Discount Rates . . . . . 21
Case Study #15

Elective Hysterectomy:

Costs, Risks, and Benefits

Carol Korenbrot,

Ann B. Flood,

Michael Higgins,

Noralou Roos,

Ph. D.

Ph. D.

Ph. D.

Ph. D.

John P. Bunker, M.D.

Division of Health Services Research

Stanford University

Stanford, Calif.

INTRODUCTION

Hysterectomy, surgical removal of the uterus,

is performed at a rate higher than that of any

other major operation. The National Center for

Health Statistics (NCHS) estimates that in 1977

704,800 hysterectomies were performed in the

United States (57). This represents a rate of

817.3 per 100,000 females 15 years old and

over. 1 It is frequently alleged that many hysterectomies are performed “unnecessarily,” an

allegation that leads to unresolved controversies

over the definition of “necessary care. ” A more

useful approach, which we adopt in this case

study, is to consider hysterectomies that are performed for indications that could be treated by

alternative therapies or by no therapy at all,

with fewer resultant health risks to the woman

and lower economic costs in general. In this

category, we focus special attention on hysterec-

——

‘This rate is calculated on the basis of the entire female population over 15 years of age. When corrected for women who have

already undergone hysterectomy, a rate of 937.1 per 100,000

females at risk is obtained. The number of hysterectomies for

females under 15 was reported by NCHS to have increased from

200 to 3,300 between 1967 and 1977. (These figures are below the

standards of reliability of precision of the National Hospital Discharge Survey. )

tomies carried

prophylaxis.

Professional

out for sterilization and cancer

Standards Review Organizations

(PSROs) in 1977 provided a list of medically

appropriate indications for hysterectomy (see

table 1). Included on the list are malignant and

premalignant disease of the endometrium

(mucus membrane of the uterus) and cervix;

fibroma (tumor) of the cervix, fundus, or broad

ligament; abnormal bleeding; and prolapsed

uterus (protrusion of the uterus through the

vaginal orifice). Anatomic proximity to malignant or infectious disease (e.g., cancer of the

colon and tubal infections) or conditions in conjunction with vaginal repair are also included as

medical justifications for hysterectomy. Sterilization in the absence of concomitant uterine

disease, however, is specifically excluded from

the list.

The PSRO list of indications for hysterectomy is intended to include all acceptable medical indications. However, the presence of one

or more such indications does not alone mandate a hysterectomy as the only, or even the
4 ● Background Paper #2: Case Studies of Medical Technologies

Table 1.--PSRO List of Medical Indications for

Vaginal and Abdominal Hysterectomy

Vaginal hysterectomy

Reasons for procedure (one of the following):

1. Premalignant lesions of the endometrium (e.g.,

adenomatous hyperplasia)

2. Premalignant and malignant conditions of the uterine

cervix (e.g., dysplasia or carcinoma in situ)

3. Continued severe bleeding after several menstrual

periods and two nondiagnostic dilatation and

curettage

4. In conjunction with vaginal repair of cystocele,

rectocele, or enterocele.

5. Uterine prolapse.

Comment: Sterilization by vaginal hysterectomy is

acceptable only in the presence of concomitant uterine

disease.

Abdominal hysterectomy

Reasons for procedure (one of the following:

1.

2.

3.

4.

5.

Malignant disease of cervix, uterus, ovaries, or

fallopian tubes

Nonmalignant disease of the tubes and ovaries where

the uterus is not primarily involved in disease, but is

removed because of its anatomic proximity to

diseased adnexa or appendages, such as in chronic

advanced tubal infections or extensive endometriosis

Removal of the uterus in nongynecologic pelvic

surgery where necessary to encompass disease

originating elsewhere, as in uterine involvement in

colon cancer or in abscess secondary to diverticulitis

Obstetrical catastrophes, such as uncontrollable

postpartum bleeding, uterine rupture, uncontrolled

uterine sepsis developing from septic abortion, etc.

in the absence of any of the above indications, and in

patients whose disease process apparently is

confined to the uterus, one of the following:

a. Continued severe bleeding after several menstrual

periods and two nondiagnostic dilatation and

curettage, or

b. Fibroids that are either:

(1) Symptomatic (e.g., causing bladder pressure),

(2) Submucous with bleeding,

(3) Asymptomatic, but uterus and fibroid are 12 cm

or more in diameter,

(4) Showing progressive enlargement, or

(5) Failing to atrophy after menopause.

Comment: Sterilization by abdominal hysterectomy is

acceptable only in presence of concomitant uterine

disease.

These sample criteria are for screening patient

care for subsequent physician review only and do not

constitute standards of care.

SOURCE: Professional Standards Review Organizations Program, fiscal year

1977

best, means of treatment. The indications for

hysterectomy comprise a spectrum from saving

life at one end to improving it at the other end.

Thus, the Executive Board of the American College of Obstetricians and Gynecologists has

recently distinguished five levels of urgency for

hysterectomy :

2 emergency, mandatory, urgent,

advisable, and elective (see table 2). Elective

hysterectomies, according to this classification,

would include those for sterilization and for

prophylaxis against potential disease such as

uterine cancer.

Personal circumstances may play an important role in the selection of hysterectomy over

other modes of treatment, whether the decision

is made primarily by the patient or by the physician. For example, a desire to end troublesome

menstruation, a wish to avoid contraceptive

failures (especially in conjunction with termination of an existing unwanted pregnancy), or a

fear of cancer (especially in a woman with a

family history of cervical cancer) may motivate

a patient to request her physician to prescribe a

hysterectomy.

Any overuse of hysterectomy for personal

reasons, either the patient’s or physician’s, is a

matter of concern. Given limited resources for

health care and the health risks of undergoing

surgery, it is important to identify and to minimize low-priority hysterectomies. In this case

study, we adopt the American College of Obstetricians and Gynecologists classification of

hysterectomies performed for sterilization and

for cancer prophylaxis as “elective.” This definition of elective hysterectomy is basically a con-

‘Hysterectomies are performed mainly by gynecologists, but

also by general surgeons, and, to a lesser extent, general practitioners. Board-certified gynecologists perform four to five times as

many abdominal hysterectomies as general surgeons. Vaginal hysterectomies are performed much more frequently by gynecologists

than general surgeons (1).

Table 2.—indications for Hysterectomy: Five Levels

of Urgency

1. Emergency: e.g., intra-abdominal hemorrhage such as a

ruptured ecotopic pregnancy.

2. Mandatory.’ e.g., the presence of a malignancy such as

an adenocarcinoma of the endometrium.

3. Urgent: e.g., abnormal uterine bleeding which requires

further diagnostic evaluation or definitive treatment.

4. Advisable: e.g., pelvic relaxation such as that

associated with urinary stress incontinence.

5. Elective: e.g., surgical procedures for family planning

purposes such as sterilization.

SOURCE: American College of Obstetricians and Gynecologists, executive

board statement of policy, May 7, 1977.
Case Study #15: Elective Hysterectomy: Costs, Risks, and Benefits ● 5

servative one. There do exist other minor gynecological conditions that can be satisfactorily

treated with alternative therapies or no therapy

at all. 2.

It is the purpose of this case study to ascertain, insofar as possible using existing data, the

risks, costs, and benefits associated with hysterectomies for sterilization and cancer prophy- 3.

laxis. The case study encompasses five areas for

consideration in cost-benefit analyses (CBAs):

1. hysterectomies for sterilization and cancer 4.

prophylaxis:

—evidence of medical acceptance of steri- 5.

lization and cancer prophylaxis as indications for hysterectomy, and

—evidence of extent to which elective hysterectomies are performed;

health risks of (all) hysterectomies:

—operative and early postoperative complications, and

—long-term postoperative complications;

comparison of health risks of hysterectomy with those of tubal ligation (ligation

of the uterine tubes for purposes of sterilization);

comparison of health risks of hysterectomy with those of future cancer; and

quantitative evaluation of risks, costs,

and benefits of elective hysterectomy.

HYSTERECTOMIES FOR STERILIZATION AND

CANCER PROPHYLAXIS

Legal and social changes in the late 1960’s,

particularly the emphasis on limiting population, increased acceptance of sterilization as a

means of contraception. Gynecologists for the

first time recommended that hospitals no longer

require a medical staff committee to review

requests for sterilization based on parity and

age. In 1969, Wright (86) wrote of the “radical

changes” then occurring in the indications for

hysterectomy to explain why tissue committees

were presented with such large numbers of uteri

free of pathological changes. Concerning sterilization, he wrote (86):

To sterilize a patient and allow her to keep a

useless and potentially lethal organ is incompatible with modern gynecologic concepts. Hysterectomy is the only logical approach to surgical

sterilization.

And in view of the precedent set with the acceptance of total hysterectomies in the mid-1940's,3

of cancer prophylaxis, he wrote (86):

‘Since the mid-1940’s, most gynecologists have performed total

hysterectomies. Prior to that time, “subtotal hysterectomies” leaving a cervical stump were performed, primarily because subtotal

hysterectomy was faster and there was generally a lack of adequate blood transfusions. The retained cervix did become cancerous in some women, and eventually, with the advent of improved surgical techniques and supporting technologies, total

hysterectomy became the predominant type of hysterectomy

(59,63).

Today, when laparotomy becomes necessary

for adnexal disease, and the patient has completed her family, total hysterectomy should be

performed as a prophylactic procedure. Under

these circumstances, the uterus becomes a useless, bleeding, symptom-producing, potentially

cancer-bearing organ, and therefore should be

removed. 4

Whether or not gynecologists agreed with the

rationale given by Wright, physicians attending

a general meeting of the American College for

Obstetricians and Gynecologists on June 15,

1971, voted by applause to support sterilization

as an appropriate medical indication for hysterectomy.

From published reports, it is apparent that

sterilization became a primary indication for

hysterectomy in the late 1960’s. Laros and Work

(46) reported that 68.5 percent of the vaginal

hysterectomies they analyzed at the University

Hospital and Wayne County General Hospital

in Ann Arbor, Mich., between 1965 and 1970

were primarily for sterilization for “socioeco4

In a reply to Wright’s editorial, Dr. Stanley Friedman wrote

(35): “From 1960 to 1965 the death rate from prostatic cancer was

about equal to that from all uterine cancers (National Vital Statistics Division and Bureau of the Census, United States). Applying

Wright’s ‘logic of one basic principle, ’ it would seem equally rational to perform elective prostatectomy on every male whose wife

is to undergo elective hysterectomy y.”
6 ● Background Paper #2: Case Studies of Medical Technologies

nomic” and “multiparity” reasons. Hibbard (36)

reported that in 1970, 20 to 25 percent of

hysterectomies at Los Angeles County University of Southern California Medical Center were

solely or primarily for sterilization. Hibbard

also reported that the rate of sterilization by

hysterectomy rose 293 percent between June

1968 and January 1970. California Blue Cross

reported an increase of 79 percent in hysterectomies during just the first 6 months of 1970,

which one B1ue Shield reviewer attributed to the

liberalization of California State abortion and

sterilization laws (37).5 Of 242 selected hysterectomies performed at the time of cesarean sections at the University of Arkansas Medical

Center between 1970 and 1974, 68 percent were

for sterilization (6).

The total number of hysterectomies performed nationally, as reported by NCHS, rose

from 525,500 in 1970 to 690,000 in 1973, an increase of over 30 percent (57). Figure 1 presents

hysterectomy rates for women aged 15 and over

from 1965 through 1977. Note the sharp increase in rates between 1970 and 1973 and the

relatively stable rates in the preceding and succeeding years.

A number of findings indicate that changes in

hysterectomy rates are not a function of changes

in pelvic disease or age patterns in the population. Hysterectomy rates have been shown to

vary regionally and in ways that correlate with

surgeon-to-patient ratios or hospital bed availability (14,78,79,80,81,82). Furthermore, medical audits have been shown to result in sharply

decreased hysterectomy rates (30,48,50). Retrospective reviews of hospital charts have repeatedly found that at least 30 percent of hysterectomies performed were not justified by

medical indications alone (28,33,36,54,76,84).

The implications are—although there can be no

proof—that many of these hysterectomies were

performed for sterilization or cancer prophylaxis.

5Regulations in California since 1977 have prohibited elective

sterilization within 14 days of the patient’s signing the consent

form for sterilization. The waiting period may be reduced to 72

hours if the patient voluntarily requests in writing that the procedure be performed sooner. Under no circumstances can persons

under 18 years of age or persons judicially declared incompetent

obtain an elective sterilization.

Figure 1 .-H ysterectomy Rates per 100,000 Women

Aged 15 and Over, 1965=77

900

800

700

500

400

300

200

100

1965 1967 1969 1971 1973 1975 1977

SOURCE: National Center for Health Statistlcs. Division of Health Resources

Utilization Statistics, unpublished data from the National Hospital

Discharge Survey for 1965-68 and 1970-77, n d.

The precise extent to which hysterectomies

are performed for sterilization and cancer prophylaxis cannot be measured because of the unreliability of the written medical record. For

many reasons, the true indications for hysterectomy are often not included in a patient’s hospital charts (4,20). The reasons include peer

review; nonreimbursement; and patient, physician, or hospital religious affiliations which

make it expedient at some hospitals to write in

only approved indications such as “abnormal

bleeding” and “prolapsed uterus. ”

Cava (20) has documented how indications

for hysterectomies reported on hospital charts

have changed over the years, with an increasing

percentage of cases of “prolapsed uterus” (including “descensus” and “pelvic relaxation”) in

selected studies (see table 3). According to

Cava, the increased use of prolapsed uterus as
Case Study #15: Elective Hysterectomy: Costs, Risks, and Benefits ● 7

Table 3.—Comparative Indications and

Hysterectomies, 1945

1945a 1956b1968c1972-73

Operation:

Abdominal . . . . . . . 65.8%d 69.2% 81 .0% 59.6%

Vaginal . . . . . . . . . . 4.8 25-30 15.5 40.0

Indications:

Bleeding. . . . . . . . . 41.4% 43.2% 34.0% 35.7%

Prolapse. . . . . . . . . 4.4 12.5 20.5 37.9

aData for 1945 from N. F. Miller, “Hysterectomy: Therapeutic Necessity or Surgical Racket,” Am. J. Obstet. Gyneco/. 51:804, 1946.

bData for 1956 from R. Brandfass and N. Nasser-Mehrigi, c’Hysterectomies in

Community Hospitals,” W. b%. A4ecl J. 64:471, 1968.

cData for 1* from L, T, Hibbard, “.Sexual Sterilization by Elective Hysterectomy,” Am. J. Obstet. Gynecol. 112:1076, 1972.

dsubtotal hysterectomy.

SOURCE: E. F. Cava, “Hysterectomy in a Community Hospital,” Am. J. Obstet.

Gynecol. 122:434, 1975.

an indication was due to the change in hospital

practices to accommodate elective hysterectomy

for sterilization at a time when third-party payment for hysterectomies for sterilization was unpredictable.b

Cancer prophylaxis is a much discussed byproduct of hysterectomy for sterilization and is

considered by some physicians to be an indication for hysterectomy by itself. To undergo

periodic genital and breast examinations for the

purpose of detecting cancer is the most frequent

reason asymptomatic women seek gynecological care. Pap examinations can lead to

hysterectomies directly by revealing an abnormal condition (e.g., severe dysplasia, car6Note that approved diagnoses such as “abnormal bleeding” or

“prolapsed uterus” are consistent with a pathology report of “normal uterus. ”

cinema in situ, or invasive carcinomas of the

cervix) that may be appropriately treated by

hysterectomy. Such examinations can also lead

indirectly to hysterectomies by bringing asymptomatic women to gynecologists, who then detect in these women upon pelvic examination an

abnormal condition (e.g., uterine myomas, mild

cervical dysplasia, or minimal prolapse of the

uterus or vagina without associated pain or

pressure) which would not by itself justify a

hysterectomy; for these women, elective hysterectomy may be prescribed with the argument

that the uterus will probably develop more disease in time. It is also possible that women

motivated to seek Pap smears may be particularly anxious to avoid cancer. Because

socioeconomically disadvantaged women are

more likely than others to develop benign or

malignant disease of the cervix and dysfunctional uterine bleeding and are less likely to use

medical services, some physicians prefer hysterectomies to tubal ligation for sterilization of

these women at the time of delivery of the last

desired child. It is argued that these women are

less likely to have routine pelvic examinations

and are therefore less likely to detect uterine disease at treatable stages (44,77).

Thus, it is clear that elective hysterectomies

are frequently performed and are considered

justified for purposes of sterilization or prophylaxis against future endometrial or cervical

cancer or other uterine disease. Before these indications are accepted, however, the health

risks and economic costs of the operation and its

alternatives should be considered.

HEALTH RISKS OF HYSTERECTOMY

In the following discussion of health risks, information has been almost entirely drawn from

past studies which have not distinguished elective from all other kinds of hysterectomies. Use

of this information was necessary, because there

are no available data for elective hysterectomy

as a separate category.7 The health risks cited

‘Because of the absence of a study of morbidity and mortality in

elective hysterectomy patients, we are currently studying the indications for surgery and outcomes of 2,600 hysterectomy patients

in the Stanford study (73). Preliminary results are cited in this

study .

here are expected to surpass the risks encountered by an elective hysterectomy patient in

good health prior to surgery.

Operative and Early Postoperative

Outcome

Death, although an infrequent consequence of

hysterectomy, is of particular concern when any

major surgery is undertaken for purely elective

reasons and less risky alternatives are available.
8 • Background Paper #2: Case Studies of Medical Technologies

Through the years, hysterectomy has had an

associated mortality rate of 0.1 to 0.4 percent in

studies compiling postoperative outcomes of

500 patients or more (3,23,38,47,83). The Commission on Professional and Hospital Activities

(CPHA) reported mortality rates for surgical

procedures performed at 1,592 Professional Activity Study hospitals in 1972-73 (22). The reported mortality rate for abdominal hysterectomy was 0.17 percent (350,661 patients) and

for vaginal hysterectomy was 0.08 percent

(155,589 patients).8 Mortality reported in the

prospective study of surgical care in hospitals

conducted by the staff of the Stanford Center

for Health Care Research—hereafter referred to

as the Stanford study (72,73)—with information

from 17 hospitals participating in the Professional Activity Study in 1972, was 0.1 percent

within 7 days and 0.3 percent within 40 days

after abdominal hysterectomies (1,491 patients)

(see table 4).9 NO deaths occurred within 40

days among the 1,124 women on whom vaginal

hysterectomies were performed (see table 4). By

way of comparison with other major operations

in the same study, the mortality rate in women

(1,059 patients) within 40 days after cholecystectomies (surgical removal of the gall bladder)

was 0.9 percent, or more than twice as high as

the mortality rate for abdominal hysterectomies; there were no deaths after appendectomies for women in the same study (272 patients).

‘Abdominal hysterectomy is excision of the uterus through an

incision in the abdominal wall; vaginal hysterectomy is excision of

the uterus through the vagina.

“In the Stanttm.f study (72, 73), patients with gynecologic

mal ignancie> were excludecf trt>m the analysis. All t ive patents

wh(> died had u ndergt~ne ntmemergerlcy abd(~mindt hy\terect(~mie~, and a]l d iecf with in ] 4 days td \LI rgcrv.

Although the mortality rate for hysterectomy

is low, the number of hysterectomies performed

is so large that the number of women who die

each year is substantial. If 30 percent of hysterectomies are elective (as estimated by studies

reviewed earlier), and we assume a mortality

rate for abdominal and vaginal hysterectomies

of 0.1 percent (which is low), with the 704,800

hysterectomies performed in the United States

in 1977 (57), we estimate that at least 210

women died that year during or soon after elective hysterectomy. Of special importance to the

present study is whether women undergoing

elective hysterectomies had an even lower risk

of death than other women undergoing hysterectomies because of the former’s presumed better general health at the time of surgery. One

must bear in mind, however, that the total number of women undergoing hysterectomy for

sterilization and cancer prophylaxis is considerably underreported. In the Stanford study

(72,73), none of the 155 women for whom

“sterilization, “ “abortion,” or “multiparity” was

one of the stated indications for surgery died. IO

The average age, physical status, and cardiovascular status at the time of surgery of the

five hysterectomy patients who did die in the

Stanford study, however, were only slightly less

favorable than the average for all hysterectomy

patients.

Much more common outcomes following

hysterectomy than death are nonfatal operative

and postoperative complications. Operative

10That none of these women died does not mean that the mortality risk is zero, but that many more cases are needed to determine mortality risks.

Table 4.—Comparative Incidence and Rates of Mortality Among Patients Undergoing

Hysterectomy, Cholecystectomy, or Appendectomy

7 days postoperative 40 days postoperative

Total number of Number Percentage of Number Percentage of

Operation women patients of deathsa

patients of deathsapatients

Vaginal hysterectomy. . . . . . . . 1,124 0 0% 0 0%

Abdominal hysterectomy. . . . . 1,491 2 0.1 5 0.3

Cholecystectomy . . . . . . . . . . . 1,176 1 <0.001 10 0.9

Appendectomy . . . . . . . . . . . . . 272 0 0 0 0

aNone of tf-@ patients Who ctied underwent emergency Sww.

SOURCES: Stanford Center for Health Care Research, StUdy of the /nstifut/orra/ Dfffererrces m Post-Operative Morrahty, 1974; and Stanford Center for Health Care

Research, Impact ot Hosplta/ Characterlstlcs on Surgical Outcomes and Length of Stay, 1978.
Case Study #15: E/ective Hysterectomy: Costs, Risks, and Benefits ● 9

complications of hysterectomy can include

bleeding and, with considerably less frequency,

bladder, urethral, and rectal injuries. Bleeding,

if severe, requires transfusions; the other complications require corrective surgery at the time

of operation or later (if not discovered during

surgery) (23,83). There is no accepted definition

of postoperative morbidity and no uniformity

in the registration of complications. Fever is the

most common postoperative complication after

hysterectomy, but hemorrhage and transfusion,

urinary dysfunction, wound and pelvic infections, intestinal obstruction, and thromboembolic disease are quite frequent (3,23,83).

Anywhere from 62 percent (41) to 81 percent

(46,83) of hysterectomy patients have been reported to develop some degree of morbidity

after the operation. Seven days after surgery in

the Stanford study (72,73), there was some degree of morbidity in 64 percent of the nonemergency abdominal hysterectomy patients (see

table 5). 11 Of greater consequence, 7.5 percent

of nonemergency abdominal hysterectomy patients in this study experienced moderate to lifethreatening complications. Moderate morbidity

was reported for 7.0 percent of the nonemergency vaginal hysterectomy patients, with no complications in the severe and life-threatening

categories. In a measure of morbidity of seven

separate organ systems, urinary system morbidity was higher for vaginal hysterectomies

(4.9 percent of the patients had moderate or

‘ IM(~rbicfitv is measured as the extent (If (werall c(~mplicati(ms a>

assessed by the pa ticn t‘s nu rw on the ward. The percen ta~e expressed here is the proportion experiencing at least minimal

problems 7 days after surgery.

severe complications) than for abdominal

hysterectomies (1.1 percent had moderate and

severe complications). This difference has been

noted by others and has been attributed to the

longer use of indwelling urethral catheters in

vaginal hysterectomy patients (23,83). In the

Stanford study (72,73), more vaginal hysterectomy patients had indwelling “tubes” of one

type or another at 7 days after surgery than did

abdominal hysterectomy patients.

Patients undergoing vaginal hysterectomy are

more likely than patients undergoing abdominal

hysterectomy to have postoperative fever (38 v.

31 percent) and to receive antibiotic treatment

(54 V . 45 percent) (47), (69.7 v. 49.6 percent)

(73). Vaginal hysterectomy patients may undergo further surgery at a rate as high as 5 to 10

percent (41,46,83).12 Patients undergoing abdominal hysterectomies were reported to be

more likely than those undergoing vaginal hysterectomies to receive blood transfusions (17 v.

13 percent) and to receive anticoagulants during

their hospital stay (1.4 v. 0.7 percent) (47). The

average length of postoperative hospital stay of

abdominal hysterectomy patients tends to be

longer than that of vaginal hysterectomy patients, but the reported difference is not statistically significant (46).

‘

zWhite, et al. (83) reported that s percent (>f 600 patients studied had a second operation. Eight patients had one during the in itial hospital stay; 22 returned t~} the hospital later. The second

operations were for incisional hernias, intestinal obstruction, vaginal hemorrhage, intra-abdomina] hemorrhage, septic vaginal or

pelvic hematornas, stress incontinence (recurrent (Jr new), ovarian

cysts, appendicitis, prolapsed fallopian tube, and ulcer in the

sacral region.

Table 5.—Morbidity and Mortality 7 Days After Hysterectomy

Abdominal hysterectomy patients Vaginal hysterectomy patients

Number Percentage Number Percentage

Evaluation of health statusa NEb

Total NEbTotal NEbTotal NEbTotal

No problems. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 529 535 36.2% 35.9% 305 305 27.3% 27.1%

Minimal problems . . . . . . . . . . . . . . . . . . . . . . . . . . . 821 838 56.2 56.2 735 741 65.7 65.9

Moderate problems. . . . . . . . . . . . . . . . . . . . . . . . . . 97 102 6.6 6.8 78 78 7.0 6.9

Severe problems . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13 14 0.9 0.9 0 0 0 0

Life-threatening problems . . . . . . . . . . . . . . . . . . . . o 0 0 0 0 0 0 0

Dead . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 2 0.1 0.1 0 0 0 0

Total . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1,462 1,491 100% 100% 1,118 1,124 100% 100%

aEValUatlOnS Of rnorbldlty Were made by a nurse In attendance to the Patlen!

bNE means nonen-rergency status, as rated by the anesthetist at the time of surgery according to the American SOCMY of Anestheslologlsts’ deflnltlon

SOURCES. Stanford Center for Health Care Research, Stucfy of fhe /rrsf/fuf/orra/ Dffererrces m Post. Operatwe Mor(a//fy, 1974, and Stanford Center for Health Care

Research, /rnpact of Hosp/ra/ C/raracfer/st/cs on Surg/ca/ Outcomes arid Length 01 Stay, 1978
—.

10 ● Background Paper #2: Case Studies of Medical Technologies

Long-Term Postoperative

Complications

How rapidly hysterectomy patients recover

their normal functional level has not been well

documented; for elective hysterectomy patients,

this information has not even been sought. In a

questionnaire given 3 years after their surgery,

Richards (66) asked 56 patients undergoing hysterectomies and 56 patients undergoing cholecystectomies, appendectomies, or partial mastectomies how long it took for them to recover

fully from surgery. Hysterectomy patients reported an average of 11.9 months, whereas the

others reported 3 months. In the Stanford study

(72,73), 40 days after surgery, 35.9 percent of

abdominal hysterectomy patients and 34.0 percent of vaginal hysterectomy patients reported

that they still had some problem related to their

operation (see table 6). For each operation,

about 30 percent of the problems remaining

were categorized by the patients as “minor”

problems. For both operations, about 65 percent of patients reported feeling “better” or

“much better” than they had been 30 days prior

to surgery (see table 7). By way of comparison,

7.4 percent of cholecystectomy and appendectomy patients reported feeling “worse” or

“much worse. ” ●

Roos and Roos (69), using claims data from

the Manitoba National Health Insurance sysTable 6.—Morbidit y and Mortality 40 Days After

Hysterectomy: Remaining Health Problems’

Responses to the question, “Do you have any remaining problems related to your operation?”

Abdominal Vaginal

hysterectomy hysterectomy

patients patients

Response Number Percentage Number Percentage

None . . . . . . . . . . . 877 64.2% 675 66.0%

Minor. . . . . . . . . . . 393 28.8 285 27.9

Moderate . . . . . . . 73 5.3 47 4.6

Considerable . . . . 19 1.4 15 1.5

Dead . . . . . . . . . . . 5 0.4 0 0

Tota l

b . .......1,367 100% 1,022 100%

devaluations were responses of patients to questions on a questionnaire.

b

total number of patients responding to this particular question. Note: 124 abdominal and 102 vaginal hysterectomy patients did not respond or did not

return the questionnaire.

SOURCES: Stanford Center for Health Care Research, Study 01 Ifre Institutional

Differences in Post-Operative Mortality, 1974; and Stanford Center

for Health Care Research, Impact of Hosp/ta/ Ctraracter/sties on

Surg)cal Outcomes and Length of Stay, 1978.

Table 7.—Morbidity and Mortality 40 Days After

Hysterectomy: Comparative Health Statusa

Responses to the question, “How does your present

health compare to your health status a month before

your recent hospitalization?”

Abdominal Vaginal

hysterectomy hysterectomy

patients patients

Response Number Percentage Number Percentage

Much better now . 342 25.4% 260 25.7%

Better now . . . . . . 537 39.9 392 38.7

About the same . . 389 28.9 319 31.5

Worse now . . . . . . 59 4.4 31 3.0

Much worse now . 14 1.0 11 1.1

Dead . . . . . . . . . . . 5 0.4 0 0

Total b . . . . . . . .l,346 . 100% 1,013 100%

devaluations were responses of patients to questions on a questionnaire.

%otal number of patients responding to this particular question. Note: 145 abdominal and 111 vaginal hysterectomy patients did not respond or did not

return the questionnaire.

SOURCES: Stanford Center for Health Care Research, Study of the hrstitutional

Differences in Post-Operative Mortality, 1974; and Stanford Center

for Health Care Research, /mpact of Hospita/ Characteristics on

Surgical Outcomes and Length of Stay, 1978.

tern, have analyzed the pattern of hospital admissions and visits to physicians in 1,075

women during the 12 months before and the 12

months following hysterectomy for all indications. Their study, hereafter referred to as the

Manitoba study, is described in appendix A.

The data in the Manitoba study are for elective

and nonelective hysterectomies, since there was

insufficient information in the claims forms to

distinguish elective from nonelective hysterectomies, but they do give an idea of the overall

effect of hysterectomy on health. Roos and Roos

found that in the year following hysterectomy,

fewer women were hospitalized (13.4 percent)

than in the year preceding hysterectomy (31.1

percent). Additionally, the total number of

hospital admissions was reduced from 488 prior

to hysterectomy to 191 after (see table 8). These

investigators also found that the number of

women making one or more visits to hospital

outpatient and emergency rooms decreased in

the year following hysterectomy (31 percent

compared to 24 percent), and that the total

number of visits was also reduced (611 compared to 520). Over 90 percent of the women

had contact with a physician (office or home

visit) in both the year before and the year after

hysterectomy, but the number of visits fell from

9,106 in the year before to 7,394 in the year after

(see table 9).
Case Study #15: Elective Hysterectomy: Costs, Risks, and Benefits ● 11

Table 8.—Hospitalizations in the 12 Months Before and 12 Months After Hysterectomy”

12 months before hysterectomy 12 months after hysterectomy

Number of hospital Percentage of Percentage of

discharges Number of women total women Number of women total women

o . . . . . . . . . . . . . . . . . . . . 741 68.9% 931 86.6%

1 . . . . . . . . . . . . . . . . . . . . 238 22.1 109 10.1

2 . . . . . . . . . . . . . . . . . . . . 60 5.6 26 2.4

3 21 2.0 6 0.6

4+. : : : : : : : : : : : : : : : : : : 15 1.4 3 0.3

Total. . . . . . . . . . . . . . . 1,075 100% 1,075 100%

Total discharges. . . . . . . 488 191

aSee app. A.

SOURCE: N Roosand L Roos, Unwersity of Manitoba, Winnipeg, Manitoba, work in progress, 1979.

Table 9.—Hospital Outpatient and Emergency Room Visits and Physician Office and Home Visits in the

12 Months Before and 12 Months After Hysterectomy

12 months before hysterectomy 12 months after hysterectomy

Number of Percentage of Number of Percentage of

Number of visits women total women women total women

Outpatient and emergency room visits

o . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 740 68.8% 813 75.6%

1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 219 20.4 166 15.4

2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60 5.6 49 4.6

3 29 2.7 22 2.1

4 to 9. : : : : : : : : : : : : : : : : : : : : : : : : : : : 23 2.1 21 2.0

10+ . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4 — 4 —

Physician office and home visits

o 29 2.7% 79 7.3%

1 to 9. : : : : : : : : : : : : : : : : : : : : : : : : : : : 713 66.3 716 66.6

10 to 19 . . . . . . . . . . . . . . . . . . . . . . . . . 258 24.0 234 21.8

20+ . . . . . . . . . . . . . . . . . . . . . . . . . . . . 75 7.0 46 4.3

Total outpatient and emergency room visits. 611 520

Total physician office and home visits. . . . . . 9,106 7,394

Grand total visits . . . . . . . . . . . . . . . . . . . . . 9,717 7,914

aSee app. A.

SOURCE: N. Roos and L. Roos, University of Manitoba, Winnipeg, Manitoba, work in progress, 1979

The reasons given most frequently in the

Manitoba study for hospitalization prior to surgery were gynecological in nature (e.g., disorders for menstruation, uterine fibroids, and

pregnancy-related diagnoses), although urinary

tract infections, “neuroses and psychiatric

disorders,” and gallbladder disease were also

frequent (see table 10). In the year following

hysterectomy, the number of hospital admissions for most of these indications decreased.

While there were fewer physician, outpatient,

and emergency room visits for gynecological

diagnoses in the year following hysterectomy,

there was an increase in visits for urinary tract

infections, neuroses and psychiatric disorders,

infections and inflammatory conditions of the

skin, and menopausal symptoms (see table 11).

In addition, “back problems,” which is at times

given as an indication for hysterectomy, was

associated with a small rise in visits (185 to 212)

following hysterectomy.

Although the majority of women who have

undergone hysterectomy for all indications

report that they are glad they had the operation

and many report feeling better emotionally (65),

some women experience psychological disturbances as a late postoperative complication of

hysterectomy. Some women are likely to experience concerns about sexual desire, loss of femi-
12 ● Background Paper #2: Case Studies of Medical Technologies

Table 10.-Selected Diagnoses Associated With Hospitalizations in the

12 Months Before and 12 Months After Hysterectomya

12 months before hysterectomy 12 months after hysterectomy

First Second Third First Second Third

Diagnosis (ICDA-8) diagnosis diagnosis diagnosis diagnosis diagnosis diagnosis

Uterine fibroma (218). . . . . . . . . . . . . . . . . . . . . . . . . 24 7 1 0 0 0

Benign neoplasms (219-228). . . . . . . . . . . . . . . . . . . 8 5 1 0 0 0

Neoplasms of unspecified nature

(including carcinoma in situ) (234). . . . . . . . . . . . 26 3 0 0 0 0

Disorders of menstruation (626). . . . . . . . . . . . . . . . 111 27 9 1 0 0

Pregnancy-related diagnoses (632-661). . . . . . . . . . 28 9 2 0 0 0

Anemia (280-285,289). . . . . . . . . . . . . . . . . . . . . . . . . 2 10 12 0 2 1

Neuroses and psychiatric disorders

(291-307,780,790) . . . . . . . . . . . . . . . . . . . . . . . . . . 18 11 6 15 11 7

Diseases of kidney and urinary tract infections

(580-599,786,789) . . . . . . . . . . . . . . . . . . . . . . . . . . 16 12 6 17 4 3

Diseases of parametrium and pelvic peritoneum

(616). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14 6 1 6 1 0

Other diseases of uterus, including endometriosis

(625) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14 22 4 0 2 

Gallbladder diseases (574-576) . . . . . . . . . . . . . . . . . 28 1 1 10 0 0

Other miscellaneous diagnoses . . . . . . . . . . . . . 199 142

Total discharges . . . . . . . . . . . . . . . . . . . . . . . . 488 191

aSee app. A.

SOURCE: N. Roos and L. Roos, University of Manitoba, Winnipeg, Manitoba, work in progress, 1979

ninity, strength, childbearing ability, and menstruation, or effects on aging, appearance, and

lowered self-esteem (2,12,25,29,32,53,61).

Raphael (64) analyzed the literature available

on the development of psychological problems

subsequent to hysterectomy. In her own interviews of 100 patients, she found that 60 percent

of women experienced “postoperative blues”

characterized by weeping, sadness, and uncontrolled distress, usually occurring about the

fourth to fifth day after hysterectomy, while

only 20 percent of women experienced such distress after cholecystectomy. Moore and Tolley

(55) found that 32 percent of 47 patients were

depressed postoperatively as assessed by a selfrating depression scale. But this postoperative

incidence of depression 12 weeks after surgery

was the same as preoperative incidence, as

measured by the same scale 1 day prior to hysterectomy. Moore and Tolley concluded that

those patients who were depressed after the

operation were likely to be depressed before

surgery because they had had misgivings about

the operation.

Barker (7) found that 7 percent of 729 women

who had undergone hysterectomy were referred

to psychiatrists within a period of 4% years

after their surgery. This referral rate was 21⁄2

times the rate expected for a matched group of

women in the general population. Eighty percent of the psychiatric referrals occurred within

the first 2 years, and psychiatric referral was not

associated with premature menopause in this

series. Several factors characterized those who

were referred for psychiatric care: 1) women

undergoing hysterectomy in the absence of pelvic disease were referred for psychiatric care

twice as often as those who had had pelvic disease; 2) women who had psychiatric care prior

to hysterectomy were 10 times as susceptible to

further mental illness postoperatively; and 3)

women who had a history of marital disruption

were 6 times as likely to be referred for psychiatric care after a hysterectomy.

Depression is a particularly common psychological disturbance following hysterectomy.

Richards (66) in England surveyed 112 patients,

half of whom underwent hysterectomies, the

other half of whom received other operations.

Data were collected between 1966 and 1969

from a four-partner group practice that included

Richards. Patients were surveyed retrospective1 ~_rhe ~lther ~perati{>ns compared were cholecystectornies, appendectomies, and partial mastectomies.
Case Study #15: Elective Hysterectomy: Costs, Risks, and Benefits ● 13

Table 1 I.–Selected Diagnoses Associated With

Hospital Outpatient and Emergency Room Visits and

Physician Office and Home Visits in the 12 Months

Before and 12 Months After Hysterectomy’

Number of visits

12 months 12 months

Diagnosis (ICDA-8) associated before hys- after hyswith primary indication for surgery terectomy terectomy

Uterine fibroma (218) . . . . . . . . . . . . . . . 409 3

Benign neoplasms and those of

unspecified nature (including

carcinoma in situ) (219-221,234). . . . . . 108 12

Salpingitis and oöphoritis (612-615) . . . 45 3

Diseases of parametrium and pelvic

peritoneum (616). . . . . . . . . . . . . . . . . . 158 43

Infective and other diseases of the

uterus (620-62,625) . . . . . . . . . . . . . . . . 325 202

Uterovaginal prolapse (623). . . . . . . . . . 270 21

Disturbances of menstruation (626) . . . 1,161 20

Other diseases of female genital

organs (629). . . . . . . . . . . . . . . . . . . . . . 185 113

Anemia (280-285,289) . . . . . . . . . . . . . . . 226 127

Diseases of kidney and urinary tract

infections (580-599,786,789). . . . . . . . . 430 523

Menopausal symptoms (627). . . . . . . . . 235 355

Neuroses, psychiatric disorders

(291-307,780,790). . . . . . . . . . . . . . . . . . 675 837

Infections of skin and subcutaneous

tissues (680-686) . . . . . . . . . . . . . . . . . . 46 89

Other inflammatory conditions of skin

(690-698). . . . . . . . . . . . . . . . . . . . . . . . . 140 206

Miscellaneous other diagnoses . . . . . . 5,304 5,354

Total visits. . . . . . . . . . . . . . . . . . . . . 9,717 7,908

aSee app A

- -

SOURCE N Roos and L Roos, Unlverslty of Manitoba, Wlnnlpeg. Manitoba,

work In progress, 1979

ly as to whether in the 3 years after their

hysterectomies they had experienced any of a

list of symptoms common for posthysterectomy

patients seeking psychiatric treatment. The

results showed that depression, both treated

with antidepressive drugs and untreated, was

more common in the hysterectomy group (70

percent) than in the control group of women

who had had other surgical procedures (30 percent). The average duration of depression, both

treated and untreated, was reported to be longer

for the hysterectomy group (12.9 months for

treated and 8.5 months for untreated patients)

when compared with the controls (4.2 and 5.9

months, respectively). Six percent of the hysterectomy patients were admitted to mental hospitals. Richards also found that hysterectomy

patients were more likely to have manifested

preoperative depression. When he excluded all

patients in both groups who had had preoperative depression, the occurrence of postoperative

depression was still more frequent in hysterectomy patients (33 percent of 36 patients) than

in the controls (14 percent of 44 patients).

In the Manitoba study (69), it was reported

that there was an increase in overall patient

visits to physicians for “neuroses and psychiatric disorders” from 675 in the year prior to

hysterectomy to 837 in the following year (see

table 11). Most of this increase was accounted

for by women in the 20- to 39-year-old age

group, particularly those who underwent

oöphorectomy (removal of the ovaries) (see

table 12). There was also an increase in the

number of visits to psychiatrists from 103 in the

year prior to surgery to 139 in the following

year. (Comparable data for women undergoing

cholecystectomy are being compiled; see app.

A.)

To what extent are these posthysterectomy

changes physiological? There is a specialized

blood supply between the ovary and uterus such

that the ovary can be exposed to substances

leaving the uterus. To what extent ovarian function is actually influenced by uterine function is

not known and has apparently been little studied. Richards (66) found that 61 percent of

women under 45 years of age (19 patients) who

had a hysterectomy, but in whom one or both

ovaries were preserved, had hot flashes, 14 a

symptom generally considered to indicate an

impaired estrogen supply. Only 20 percent of

the control patients under 45 years of age receiving other operations (29 patients) reported hot

flashes. In the Manitoba study (69), there was a

39-percent increase in age-adjusted incidence of

ambulatory visits to physicians’ offices for

menopausal symptoms within 1 year after abdominal hysterectomy in women whose ovaries

were kept intact (see table 13). In patients who

had undergone oöphorectomy at the time of

hysterectomy, there was an 85-percent increase

in ambulatory visits. A large part of the increase

in visits for menopausal symptoms, both with

and without removal of the ovaries was accounted for by women in the 20- to 39-year-old

age group (see table 12).

I ~In the same series, 12 out of 17, or 71 percent, ~Jf patients l~Jsing both ovaries in the same period experienced hot flashes.
14 ● Background Paper #2: Case Studies of Medical Technologies

Table 12.—Visits for Neuroses and Psychiatric Disorders and for Menopausal Symptoms in the

12 Months Before and 12 Months After Hysterectomy, By Type of Operation and Age of Patient*

Number of visits by vaginal

Number of visits by abdominal hysterectomy patients hysterectomy patients

With oöphorectomy Without oöphorectomy Without oöphorectomy

20-39 40-49 50+ 20-39 40-49 50+ 20-39 40-49 50+

Diagnosis (ICDA-8) BAB AB A BAB AB A BAB AB A

Neuroses and psychiatric disorders

(291-307,760,790) . . . . . . . . . . . . . . . . . . 49 121 101 122 62 56 143 173 166 151 31 76 50 49 43 43 29 42

Menopausal symptoms. . . . . . . . . . . . . . . 1 46 43 86 67 59 5 17 61 78 24 32 0 2 16 15 18 20

Number of women . . . . . . . . . . . . . . . . . . . 99 162 138 154 192 74 59 67 120

B =12 months before hysterectomy; A= 12 months after hysterectomy.

aSee app. A.

SOURCE: N. Roos and L. Roos, University of Manitoba, Winnipeg, Manitoba, work in progress, 1979.

Table 13.--Age- Adjusted Rates for Visits for Menopausal Symptoms

in the 12 Months Before and 12 Months After Hysterectomy

Number of visits by vaginal

Number of visits by abdominal hysterectomy patients hysterectomy patients

With oöphorectomy Without oöphorectomy Without oöphorectomy

12 months before hysterectomy . . . . . . . 278.6 254.2 152.1

12 months after hysterectomy. . . . . . . . . 515.4 352.6 161.9

Percentage increase. . . . . . . . . . . . . . . . . 85% 38.7% 6.4%

aSee app. A.

SOURCE: N. Roos and L. Roos, University of Manitoba, Winnipeg, Manitoba, work in progress, 1979.

COMPARISON OF HEALTH RISKS OF HYSTERECTOMY

WITH THOSE OF TUBAL LIGATION

The alternative to hysterectomy for sterilization of a woman is tubal ligation. In 1975-76,

394,000 tubal ligations were performed at a rate

of 360 per 100,000 females (57). There are three

prevalent types of tubal ligations performed:

1) abdominal (most frequently by the Pomeroy

technique), 2) vaginal, and 3) endoscopic (most

frequently by laparoscopic techniques).15 As can

vaginal and abdominal hysterectomies, these

techniques can be applied for sterilization at the

time of abortion, at the time of delivery, or

when the patient is not pregnant.

Death rarely occurs with tubal ligations. A

mortality rate of 2 per 10,000 women (0.02 percent) was reported by CPHA for 1,592 Profes-

—.—ISL~P~~OSCOPlc tuba[ [i~ati(~n is the technique =SOciated with

fewest medical risks overall, but this technique requires expensive

equipment and specially trained gynecologists.

sional Activity Study hospitals in 1972-73 (22).

Reviews of combined studies indicate mortality

rates between 0.0025 percent (laparoscopic

tubal ligation only) (39), and 0.02 percent (60).

Thus, the risk of death from tubal ligation is

substantially less than that estimated above for

a healthy 35-year-old woman undergoing elective hysterectomy (0.05 to 0.10 percent). The

risk of death from tubal ligation is estimated to

be less than 5 to 10 percent of the risk of death

from subsequent pregnancy in women 25 to 35

years old and 10 to 20 percent of the risk of

death from pregnancy in women 35 to 40 years

old (75).

Morbidity reportedly occurs in far fewer patients with tubal ligations than with hysterectomies. Serious complications have been reported in one study to occur in about 4.2 per-
Case Study #15: Elective Hysterectomy: Costs, Risks, and Benefits ● 15

cent of abdominal tubal ligations and 2.6 percent of vaginal tubal ligations (62). In the same

study, 8.0 percent of vaginal hysterectomies

were associated with serious complications.

Serious complications after laparoscopic tubal

ligations were reported in another study to occur in 1.7 percent of the patients (85). Postoperative fevers persisted in only 1.5 percent of

laparoscopic tubal ligation patients and 20.7

percent of abdominal tubal ligation patients, as

compared with 42.7 percent of patients sterilized by vaginal hysterectomy and 45.2 percent

of those sterilized by abdominal hysterectomy

(45). No morbidity was recorded for 91.6 percent of laparoscopic tubal ligation patients, as

compared with 47.1 percent of abdominal tubal

ligation patients and 20.4 percent and 16.1 percent for vaginal and abdominal hysterectomy

patients, respectively (45). Transfusions were

not needed for abdominal, vaginal, or laparoscopic tubal ligations, but were administered in

13.4 percent of vaginal hysterectomies (44). The

average postoperative hospital length of stay

reported was 2 to 3 days for laparoscopic and

vaginal tubal ligations (44,45,60). For abdominal tubal ligation, the average postoperative

length of stay has been variously measured as

8.54 days (45) and 4 to 6 days (44). Average

postoperative lengths of stay for vaginal and

abdominal hysterectomies in the same studies

were 8.52 and 10.2 days (45), and 8.6 and 8.4

days (44).

Psychological sequelae of tubal ligations have

not been reported to occur as frequently or to be

as severe as sequelae of hysterectomies. Regret

at having been sterilizedl6 was reported more

‘“The belief that sterilization by tubal ligation is potentially reversible, as opposed to sterilization by hysterectomy, may reduce

often than depression, and then among only 1 to

4 percent of women (9,19,27,43,49,74). Younger patients and socioeconomically disadvantaged patients are more likely to express regret

over the decision (19,43).

Despite higher risks of postoperative complications, two benefits of hysterectomy are

commonly given for preferring hysterectomy

over tubal ligations as a means for sterilization:

1) hysterectomies are 100-percent effective in

preventing conception; and 2) they remove the

chance of future uterine/cervical disease. The

conception rate after tubal ligation is about 0.3

to 2 percent depending on the technique of tubal

ligation (71). Furthermore, a portion of these

pregnancies appear to be ectopic (out of normal

position), generally necessitating further

surgery (39). Gynecologic disease subsequent to

tubal ligation develops in 24 to 40 percent of

women in 3 to 10 years after surgery, and 13 to

19 percent result in hysterectomies in the same

period (39,56). However, the original studies

lacked sufficient controls to be able to determine

whether or not the women had a higher incidence of gynecologic disease than would be expected. Women who have had hysterectomies

can still develop certain gynecologic diseases

(see Manitoba study, app. A). Nevertheless,

women sterilized with tubal ligations do have a

risk of pregnancy and uterine disease. Women

who have undergone hysterectomy do not have

these risks.

the psychological impact of sterilization on some women, and may

make the increased risk of conception more acceptable to some

women.

COMPARISON OF HEALTH RISKS OF HYSTERECTOMY

WITH THOSE OF FUTURE CANCER

Of all deaths in women 15 years old and over, possibility of future cancer of the cervix or the

cancer of the cervix accounts for approximately endometrium —and the resultant average in0.72 percent; cancer of the endometrium, 0.68 crease in life expectancy is substantial, about

percent; and cancer of the ovary, 1.24 percent 21⁄2 months for a 35-year-old woman (21). Only

(58). Removal of the normal uterus by total those 1.4 percent of women who would have

hysterectomy can be assumed to preclude the later succumbed to cancer of the cervix or en-
16 ● Background Paper #2: Case Studies of Medical Technologies

dometrium actually receive this benefit; for

them, the average increase in life expectancy is

14.3 years (or, perhaps more correctly, for

them, a decrease in life expectancy of 14.3 years

is prevented) (21).

In achieving these benefits, the patient takes

the risks of undergoing hysterectomy. The overall mortality rate for all hysterectomies is about

0.17 percent, but in a 35-year-old woman in

good physical condition, the risk of death is

smaller, estimated to be somewhere between

0.05 to 0.10 percent, or the equivalent of 1 or 2

weeks of life expectancy (21). Thus, the average

loss in life expectancy in a good-risk 35-year-old

woman undergoing hysterectomy is smaller

than the average gain. However, the women

who die at the time of surgery immediately lose

remaining years of life, whereas the gain in life

expectancy for the women who without the elective surgery would have died of cancer occurs at

some indefinite time in the future. Furthermore,

for an older woman or a woman in worse physical condition, there may be a considerably increased risk in anesthesia and surgery, further

lessening the apparent advantage of elective

surgery (16). Whether an individual patient considers the potential gains of elective hysterectomy to be worth accepting the risks is a highly

personal matter which can be resolved only by

the patient herself. However, there are some

data to suggest that many patients may be

averse to accepting immediate risks in order to

gain uncertain benefits sometime in the future

(52).

In attempting to assess hysterectomy as cancer prevention, a comparison should be made

with optimal, nonsurgical gynecological care

rather than with no care or average care.

Prompt response to early symptoms and signs

of cervical and fundal malignancy, followed by

appropriate treatment (hysterectomy, radiotherapy, ionization of the cervix, or a combination), is believed to result in a high cure rate,

although reliable data are not available (34). It

is assumed, however, that regular examination,

early diagnosis, and prompt treatment can appreciably reduce the risk of death, perhaps by as

much as 75 to 80 percent for fundal cancer (67).

If this assumption is correct, the apparent advantage of hysterectomy in preventing cancer of

the cervix or endometrium may largely disappear.

It is important to acknowledge that socioeconomically disadvantaged women, who are at

high risk of developing cervical cancer, are less

likely than others to seek routine medical services. Some of the added risk of cervical cancer

is offset by the finding that endometrial cancer

primarily affects middle- and upper-income

women (21). But the combined cancer mortality

risk of disadvantaged women is 1.5 to 2.0 times

greater than the average for all women (21). We

have noted above that some physicians consider

hysterectomy the treatment of choice for disadvantaged women, because such women have

a greater risk of malignancy and are less likely

to seek medical care. An argument of equal or

greater validity is that the routine gynecological

care of such women should be improved. The

relative costs of these two alternatives are explored in the next part of this case study.

Removal of normal ovaries at the time of

hysterectomy prevents future cancer of the

ovaries in the 1 percent of women who otherwise might have died of this disease. Combining

this effect with prevention of uterine cancer by

hysterectomy, elective total hysterectomy and

oophorectomy in a 45-year-old woman will result in an average gain in life of 13.9 years for

the 2.3 percent of women saved (21).17 This

assumes that hormonal replacement therapy

does not increase the chance of developing a

malignancy of any remaining organ (e.g.,

breast, liver).

In contrast to cancer of the cervix, there is no

method of screening to allow early diagnosis of

cancer of the ovary.

18 Prophylactic removal of

normal ovaries at the time of hysterectomy

might therefore seem a worthwhile life-prolonging measure. However, some or all of this advantage may be offset by the possibility that

metabolic and endocrine disturbances may delzRather than 14.3 years, 13.9 years are saved, because the

operation is carried out with the patient at an older age

lswhen an ovarian mass is found or suspected, ultrasound may

be effective in distinguishing large solid tumors (which are apt to

be malignant) from ovarian cysts (which are usually benign).

Ultrasound is not useful in detecting small, early malignancies.
—

Case Study #15: Elective Hysterectomy: Costs, Risks, and Benefits ● 17

velop if oöphorectomy is performed, and there cidence of atherosclerotic heart disease, which

is no assurance that the customary estrogen might result from loss of ovarian function,

replacement would reverse these changes. As could offset any potential gain in life expectancy

Cole has pointed out, a small increase in the in- from cancer prevention (17).

— — — — — —- . ——-— — QUANTITATIVE EVALUATION OF

OF ELECTIVE HYSTERECTOMY

The findings of four studies that have attempted to evaluate the cost effectiveness of

elective hysterectomy in prolonging life (16,

21,24,40) are summarized below. Also summarized are the initial findings of a new analysis

undertaken by the authors of this case study.

The model and the data that we used in that

analysis are described more fully in appendix B.

The Health Risks and Costs

of Hysterectomy

As discussed in the previous part of this case

study, the removal of a normal uterus eliminates the risk of future endometrial and cervical

cancers, but at the same time subjects the patient to the small but significant risk of surgical

mortality. Cole and Berlin (21) estimated the net

effect of these two factors on patient survival by

the use of a simple probabilistic model. For the

sake of illustration, they postulated a population of 1 million 35-year-old women for whom a

policy decision was to be made: Should the entire female population undergo elective hysterectomy to prevent the development of endometrial and cervical cancers? Or should it instead receive routine gynecologic care? Under

the second option, some women would eventually succumb to uterine disease.

The premise of Cole and Berlin’s analysis is

that the net benefits of elective hysterectomy are

defined by the difference in mortality rates

under the two alternatives. The authors concluded that the benefits of elective hysterectomy

, in terms of patient mortality, would

equal roughly 182,000 woman-years of added

life for the hypothetical population. This

number was translated into an economic value

and compared to an estimate of the net cost of

hysterectomies for 1 million women (see table

14). From their calculations, Cole and Berlin

RISKS, COSTS, AND BENEFITS

Table 14.—Estimated Lifetime Savings and Costs of

Elective Hysterectomy for 1 Million Women

(in millions of dollars)

Savings

Medical care for cancera. . . . . . . . . . . . . . . . . . . . . ... .$ 331

Gynecologic procedures . . . . . . . . . . . . . . . . . . . . . . . 300

Pap smearsc

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 226

Contraceptives d 

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 270

Menstrual preparations . . . . . . . . . . . . . . . . . . . . . . . . 170

Down’s syndromef . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 120

Total . . . . . . . . . . . . . . . . . . . . ... ... ... ... ... ... .$1,417

costs

1 million hysterectomies . . . . . . . . . . . . . . . . . . . . ... .$2,600

Related expensesg 

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 300

Total. . . . . . . . . . . . . . . . . . . . . ... ... ... ... ... .. .$2,900

a34,~ cases prevented; 50 percent “cured.’ at $4.000 each; 50 PerCent “’nOt

cured’” at $15.000 each

bLlfetime gynecologic care, uterus-related, estimated at $300 Per woman

cAnr_jually for 45 percent of women at $12 per smear.

doral contraceptives for 50 percent of women for 15 years at $36 per year.

e$lo per year per woman for 17 years.

f~o affected biflhs prevented; half the cases would bS institutionalized at

$8,000 per year for an average of 50 years.

9Wages lost for 4 weeks at $150 per week for 25 percent of women; child-care

expenses estimated for 4 weeks at $75 per week for 50 percent of women.

SOURCE: P. Cole and J. Berlin, “Elective Hysterectomy,” Obs@t Gyrreco/

129:1 17, 1977.

concluded that the present value of costs of hysterectomy over benefits, discounted at 6 percent, is $12,800 per woman-year of added life.

The analysis presented by Cole and Berlin is

subject to at least four criticisms. First, as noted

by the authors themselves, the presence of competing causes of death was ignored. The authors

assumed that a patient freed of the risk of one

type of cancer would not be subject to a disproportionately higher risk of death from some

other cause. 19 However, it is possible that

eliminating one type of cancer results in an increased risk of another fatal disease, so the

analysis by Cole and Berlin may have overestimated the benefits of prophylactic surgery.

‘“It should be noted that all four quantitative analyses of hysterectomy y found in the literature employ this same assumption.
18 ● Background Paper #2: Case Studies of Medical Technologies

A second objection to the analysis by Cole

and Berlin is the subjective nature of the cost

estimates. The authors provided little empirical

support for the cost values they used. Taken as

a whole, their estimates appear reasonable, but

their estimate of $300 per woman for a lifetime

of uterine-related gynecological “procedures”

seems very low. Cole and Berlin estimated the

savings for those who had undergone hysterectomy in terms of avoided menstrual and contraceptive costs, but did not consider costs of

unwanted pregnancies, abortions, or tubal ligations should contraceptives fail. The total cost

of uterine-related care foregone in hysterectomy

patients was estimated to be only $1,417. By

contrast, Jackson, et al. (40) reported average

lifetime costs for uterine-related care for a 35-

year-old woman in King County, Wash., to be

$2,350 (1974 dollars, not discounted) excluding

costs of contraception and pregnancy.

We question the inclusion under cost savings

by Cole and Berlin of an estimated 600 children

with Down’s syndrome who would be born to

the women not having hysterectomies at age 35.

Such inclusion assumes that women who elect

hysterectomies for cancer prophylaxis would

have had the same birth rate as women in general. It seems reasonable to assume, to the contrary, that women who elect hysterectomies for

cancer prophylaxis would be more likely than

others to take advantage of tubal ligations, amniocentesis, contraceptives, and abortions, and

would therefore be less likely to bear children

afflicted with Down’s syndrome.

Finally, the conclusions of Cole and Berlin apply to a typical woman facing the average risk

of cancer by the Nation as a whole. The actual

decision concerning a specific patient would be

based on risks confronting that particular

woman. Although Cole and Berlin address the

role of elective hysterectomy for the entire

female population and for an average 35-yearold woman, they do not address the role of

hysterectomy for specific subgroups of women

for whom the relative risks and benefits of

hysterectomy might be quite different. The risks

and benefits for subgroups are discussed in a

separate section of this case study below.

Bunker, et al. (16) analyzed the effect of elective hysterectomy and oophorectomy on life expectancy of premenopausal women. Like Cole

and Berlin, these analysts assumed that the

surgical removal of the normal uterus and ovaries precluded the subsequent development of

cancer at those sites and prevented the associated loss of life expectancy. Unlike Cole and

Berlin, however, they adjusted the risk of

surgical mortality to reflect the characteristics of

the patient. Bunker, et al., concluded that the

increased life expectancy with hysterectomy and

oöphorectomy was small, amounting to 14 days

for a 40-year-old woman in good general health.

For a so-year-old woman suffering from moderately severe hypertension, elective hysterectomy was estimated to result in a loss of life

expectancy of 60 days.

The Effect of Hysterectomy on

Direct Costs for Medical Care

Jackson, et al. (40) reported an empirical

study of the direct costs of medical care with

and without elective hysterectomy. They based

their findings on the actual medical care provided to women for uterine-related diseases by a

comprehensive health care facility. Arguing that

expenditures for such diseases could have been

avoided had the woman undergone hysterectomy, they computed that the present value of

savings resulting from the procedure at age 30

would amount to between $1,240 and $1,822,

depending on the discount rate (see table 15).

These savings were compared to the average

cost of hysterectomy for 22 women, which was

found to be $1,637. Thus, Jackson and his colleagues concluded that the net savings in direct

costs resulting from elective hysterectomy is at

most $185 per woman and decreases as the discount rate is increased. If the age of recommended elective hysterectomy is raised to 35 or

above, the net dollar benefit of elective hysterectomy disappears at all discount rates.

The study by Jackson and his collaborators is

an important contribution to our understanding

of the role of hysterectomy in that it reported

observed costs of patient care. The generalizability of the results of this study can be ques-
Case Study #15: Elective Hysterectomy: Costs, Risks, and Benefits . 19

Table 15.—Lifetime Savings and Costs of Elective Hysterectomy

Outpatient cost data

Period 1 costs (6/71-6/73) Average annual

outpatient

Adjusted to Period 2 costs Total outpatient Patient years cost per woman (in

Age 1972 dollars 1974 dollars (7/73-2/75) costs of exposure rounded dollars)

30-34 . . . . . . $7.363 $8,320 $4,496 $12,816 349 $37

35-39 . . . . . . 4,098 4,631 5,226 9,857 252 39

40-44 . . . . . . 2,276 2,572 4,807 7,379 200 37

45-49 . . . . . . 6,194 6,999 3,187 10,186 230 44

50-54 . . . . . . 4,345 4,910 2,631 7,541 191 39

55-59 . . . . . . 1,629 1,841 1,222 3,063 139 22

60-65 . . . . . . 707 799 696 1,495 160 9

Inpatient cost data

Period 1 costs (6/71-6/73)

Average annual

Adjusted to Period 2 costs Total inpatient Patient years inpatient cost

Age 1972 dollars 1974 dollars 7/73-2/75 costs of exposure per woman

30-34 . . . . . . $6,157 $7,142 $6,790 $13,932 349 $40

35-39 . . . . . . 8,673 10,061 4,787 14,848 252 59

40-44 . . . . . . 3,050 3,538 6,019 9,557 200 48

45-49, . . ... . 13,903 16,127 4,111 20,238 230 88

50-54 . . . . . . 2,992 3,471 1,308 4,779 191 25

55-59 . . . . . . 3,924 4,552 283 4,835 139 35

60-65 . . . . . . 1,887 2,189 1,778 3,967 160 25

Exposure and expenditure data from the Prepaid Health Care Project

Annualized average expected expenditure per woman

(in rounded dollars) for uterine-related diagnoses

Present value Present value

Calculated Total amount of total cost of total cost

total woman of projected for each age for each age

years of Outpatient Inpatient Total expenditures interval at 6.5% interval at 3%

- Age exposure costs costs costs undiscounted interest interest

30-34 . . . . . . . . . 349 $37 $40 $ 7 7 $ 385 $ 341 $ 363

35-39 . . . . . . . . . 252 39 59 98 490 317 399

40-44 . . . . . . . . . 200 37 48 85 425 200 299

45-49 . . . . . . . . . 230 44 88 132 660 227 400

50-54 . . . . . . . . . 191 39 25 64 320 80 167

55-59 . . . . . . . . . 139 22 35 57 285 52 128

60-64 . . . . . . . . . 160 9 25 34 170 23 66

Total projected expenditure (direct costs). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $2,735 $1,240 $1,822

Undiscounted Discounted Discounted

at 6.5% at 3%

SOURCE: M. N. Jackson, et al., “Elective Hysterectomy: A Cost-Benefit Analysis,” Inquiry 15:275, 1978.

tioned, however, because of the institutional

characteristics of the prepaid health plan from

which cost figures were derived. Costs incurred

as the result of pregnancy, abortion, contraception, or associated morbidity were not included,

because it was assumed that women electing

hysterectomies would not plan further pregnancies, and reportedly only 17 percent of women

in the United States had unplanned pregnancies

after the age of 35. However, the assumption

that women not undergoing hysterectomy received 100-percent” effective contraception at no

cost underestimates their costs.

Furthermore, the results reported by Jackson,

et al., apply to a general population of women

and not to specific individuals characterized by

various levels of risk. For example, a physician

might be able to stratify women into groups according to the risk of uterine prolapse, one of
20 . Background Paper #2: Case Studies of Medical Technologies

the uterine diseases considered in the study. If

women at high risk of endometrial or cervical

cancers received hysterectomies immediately,

and surgery was deferred until indicated for patients in low-risk groups, savings would have

been increased.

Quantitative Analysis Comparing

Hysterectomy With Tubal Ligation

Deane and Ulene (24), in their analysis, compared both the expected cost (including lost

earnings) and life expectancy associated with

tubal ligation and hysterectomy. Deane and

Ulene assumed that a woman is confronted with

two alternatives: 1) hysterectomy, or 2) tubal

ligation with hysterectomy deferred until medically indicated. Thus, a woman choosing tubal

ligation who subsequently needs hysterectomy

is exposed to the risk of uterine cancers only until the organ is removed. By adjusting the incidence of uterine cancers to reflect the chances

of subsequently undergoing hysterectomy, these

analysts were able to model the effect of nonmalignant uterine diseases on the relative merits

of tubal ligation and elective hysterectomy.

Deane and Ulene reported unusually small

differences in life expectancy for the two alternatives. A 20-year-old woman, on the average,

would lose 1.88 days if she were to choose tubal

ligation over hysterectomy. This loss in life expectancy decreased if future time was discounted. The direct costs for each surgical procedure included average hospital and surgical

fees, but assumed no complications generating

further costs. Indirect costs included an estimation of lost earnings during recovery, and the

authors estimated that 53 days was an average

leave of absence from work for recovery after

hysterectomy and 39 days was the average time

required after tubal ligation. These estimates,

especially compared to likely recovery times

from laparoscopic tubal ligation, are surprisingly high. A “mean daily earning” was determined

as a function of age for all women 20 to 79 years

of age. The author’s inclusion of women over 65

in their study of women likely to be candidates

for elective hysterectomy is a highly questionable maneuver, since, in practice, the age of

such women alone excludes them as candidates

for purely elective surgery. Furthermore, since

women over 65, on the whole, are not likely to

be earning wages, their inclusion dilutes the

economic value of women. Deane and Ulene did

not attempt to evaluate wages for housework,

cooking, and childcare.

Indirect costs for tubal ligation patients included by Deane and Ulene were the estimated

lost earnings resulting from menstrual irregularities developed, or surgical and hospital expenses and lost earnings from a subsequent

hysterectomy if endometrial or cervical cancer

developed, or if a dilatation and curretage for

bleeding irregularities was needed. The hospital,

surgical costs, and lost earnings of tubal ligation

patients developing uterine cancer were also included as costs. Further indirect costs after tubal

ligation included an adjustment based on the

assumption that all pregnancies after failed

tubal ligations occurred in the second year after

tubal ligation and all patients received an abortion and a second, effective tubal ligation.

Differences in expected cost, Deane and Ulene

found, ranged up to about $500, depending on

the age of the woman and the discount rate (see

fig. 2). In general, a comparison of cost and life

expectancy indicated that hysterectomy was

preferable in younger women at lower discount

rates. Conversely, tubal ligation was slightly

preferable at higher discount rates when the

woman was older.

The quantitative results obtained by Deane

and Ulene may be questioned because of the

data assumptions used in their model. Nevertheless, these analysts have made a significant

contribution by modeling the complex interactions involved in the comparison of hysterectomy with an alternative. Perhaps further review of the literature or future empirical studies

will generate more accurate estimates for the

variables used in their model.

The Role of Elective Hysterectomy

in Subgroups

While differing somewhat in approach, the

four studies discussed above (16, 21, 24, 40) all

support similar conclusions. The consensus is

that, for the average woman, elective hysterec-
Case Study #15: Elective Hysterectomy: Costs, Risks, and Benefits ● 21

Figure 2.— Net Cost Differences Between Tubal

Ligation and Hysterectomy on the Basis of Mean

“All Female” Earnings, By Age at Operation and

Selected Discount Rates

“Present value of the cost of a hysterectomy performed at age t and dis

counted al rate r

SOURCE: R T Deane and A Ulene, “Hysterectomy or Tubal Llgatlon for

Sterilization: A Cost Effectiveness Analysis,”’ Inquiry 1473, 1977

tomy does not contribute importantly to either

life expectancy or the cost of subsequent medical

care. Therefore, the appropriateness of elective

hysterectomy would appear to depend upon the

other factors involved in the decision to undergo

an elective hysterectomy. These factors might

be referred to as the “quality of life.” If it is true

that the role of hysterectomy is most dependent

on these less tangible risks and benefits, then the

development of a good general policy to maximize benefits and minimize risks and costs is in

doubt.”

What has not been adequately explained is

whether subgroups of women might clearly benefit from either elective hysterectomy or its

alternatives. As previously noted, low

socioeconomic background has been observed

to be a risk factor for cervical cancer. Furthermore, low-income women tend to have less access to regular medical care, implying that when

cancer develops in these women, it is likely to be

detected at later stages with lower survival

rates. For these reasons, it has been suggested

that hysterectomy has additional benefits as a

means of sterilization for low-income women.

2UDePartment of Hea]t h and Human Services regula t i~~ns of

sterilization practices prohibit payment for hysterectomy as a

means of sterilization.

Conversely, women who undergo routine gynecological care are likely to have potential

malignancies detected at stages when response

to therapy is apt to be favorable. It might

follow, therefore, that this group of women

would benefit more from tubal ligation and less

from elective hysterectomy.

In order to examine the assertion that certain

subgroups of women will clearly benefit either

from hysterectomy or one of its alternatives, the

authors of this case study undertook an analysis

of their own. In the remainder of this section,

we will discuss the general features of the approach that we used and the conclusions that we

reached. The model and the data it incorporated

are described more fully in appendix B.

The following scenario was used as a vehicle

for our analysis. A 35-year-old woman in good

health and without any apparent uterine malignancy desires sterilization. Two alternatives are

available: 1) hysterectomy, or 2) tubal ligation

by the Pomeroy technique. If a pregnancy occurs subsequent to tubal ligation, then the

woman will undergo abortion and a repeat of

the same sterilization procedure. If any uterine

cancer, including cervical cancer in situ, is detected later in life, then the woman will undergo

hysterectomy as part of her therapy. The

woman will also undergo hysterectomy if indicated for nonmalignant conditions such as

uterine prolapse. The incidence of these indications for hysterectomy will be equal to their incidence in women of similar age.

Clearly, alternatives to hysterectomy other

than tubal ligation are available to the woman

who desires sterilization. For the purposes of

this analysis, however, we felt that tubal ligation most closely matched hysterectomy. Admittedly, not every aspect of our scenario is

completely representative. Some women might

object to abortion in the event of pregnancy.

Laparoscopic tubal ligation is becoming more

commonplace, with lower mortality risks. Furthermore, hysterectomy is not always the

preferred treatment of uterine cancers. Nevertheless, omission of these alternatives was found

to contribute little to the final conclusions; at

the same time, it greatly reduced the complexity

of the analysis.
22 . Background Paper #2: Case Studies of Medical Technologies

Given a specific scenario such as that outlined

above, it is possible to estimate the probability

of death at a particular age for either of the two

alternatives. In the event of elective hysterectomy, it was assumed that the woman would

either die immediately as a result of the procedure, or that her survival would match the national average for women, excluding death from

uterine diseases. Estimating the survival function for women undergoing tubal ligation was

far more complex. The analysis incorporated

the age-specific incidence for various stages of

uterine cancers, survival after diagnosis for each

stage of cancer,21 the frequency of hysterectomy

for nonmalignant uterine diseases, and the agespecific incidence for nonuterine-related causes

of death.

The model estimated that for the average 35-

year-old woman, hysterectomy would result in

an increase of life expectancy of 0.3 year over

tubal ligation. It also estimated that the expected direct medical costs for a woman undergoing hysterectomy would be $84 less than the

costs for tubal ligation. This cost difference is in

agreement with the estimates by Deane and

Ulene (24). The survival difference is considerably larger than that reported by Deane and

Ulene, but agrees quite closely with the values

reported by the other three studies cited above

(16,21,40) .

We do not believe that giving equal weight to

costs and life in the future and to costs and life

today (as we do in the previous paragraph)

properly reflects the perception of differences

between the alternatives. Given the real interest

rate (monetary interest rate minus inflation

rate), it is clear that future monetary costs

should be discounted to their present values. A

similar argument can be applied to future years

of life. A rational individual will pay a price to

avoid a risk of death. If the risk is small, then

the maximum price an individual would pay to

avoid the risk would also be small. If the risk is

large, then the maximum price would also be

large. Therefore, a risk of death in the future

can be approximated by an equivalent future

monetary cost. Since it can also be argued that a

~lThiS term was nOl included in any of the previously published

analyses.

rational individual will decrease the amount she

is willing to pay to avoid death depending on

how remote in time the chance of death is, it

follows that life expectancy should be computed

by discounting future years.

The difference in life expectancy and direct

costs for various interest rates are as follows:

Hysterectomy minus tubal ligation

Real interest rate Life expectancy Direct cost

o% 0.3 year –$ 8 4

1 0.2 year – 41

2 0.2 year 4

3 0.1 year 46

4 0.1 year 82

5 0.1 year 114

The trend is expected. Hysterectomy involves a

higher initial cost than tubal ligation, but offers

the potential of savings in the future. Therefore,

as the rate at which the future is discounted increases, the cost given hysterectomy increases

relative to the cost given tubal ligation. Conversely, hysterectomy implies a high risk initially with a reduction in risk later in life. Therefore, life expectancy with hysterectomy decreases relative to life expectancy with tubal

ligation, as the discount rate increases.

The goal of our analysis was to determine if,

women with different risks of developing

uterine cancers or with varying levels of access

to care would alter the comparison of hysterectomy and tubal ligation. We focused on cervical

cancer, although our analysis could be varied to

include endometrial cancer. We asked what is

the relative risk of high-risk women compared

to low-risk women in regard to cervical cancer?

Barron and Richart (11) identified relative risk

ratios of 2.0 for subsets of women in their study

population. Therefore, in order to approximate

the age-specific incidence for a high-risk

woman, we doubled the values used in the initial calculations. Admittedly, this approximation ignored any shift to lower age groups for

cancer in high-risk women. At a real interest

rate of 2 percent, the result of this higher cancer

risk was to decrease the life expectancy of patients undergoing tubal ligation by 0.2 year and

to increase the expected cost by $80. Therefore,

our analysis predicted that a high-risk woman

who underwent hysterectomy at age 35 would
Case Study #15: Elective Hysterectomy: Costs, Risks, and Benefits . 23

increase her life expectancy by 0.4 year and decrease the expected cost for her medical care by

$76. Our analysis assumed that any increase in

noncancer risk associated with an increase in

cervical cancer risk would balance between the

two alternatives.

Finally, the effect of intensive screening on

the comparison was approximated by assuming

that half of the cancer currently detected in late

stages would be detected in stage I by more frequent testing. Otherwise, the age-specific incidence was left equal to the rates observed in

the general population. It was assumed that the

intensive screening added $20 per year to a

woman’s gynecologic care (prior to undergoing

hysterectomy). Our analysis predicted that

hysterectomy would still increase life expectancy by 0.2 year. Hysterectomy would increase

expected cost by about $19. Again these values

were computed by discounting the future at 2

percent per year.

The conclusion that can be drawn from our

analysis is that changes in the risk of cancer or

access to care probably do not change the comparison of hysterectomy and tubal ligation appreciably. For example, the higher risk of cancer

increases the life expectancy differences; however, the change was approximately the same as

differences between hysterectomy and tubal ligation at more typical cancer risks. The shifts in

expected costs were as expected; however, the

magnitudes were probably smaller than the

errors in the analysis. Thus, if hysterectomy and

tubal ligation were equivalent methods of sterilization for the population as a whole, the same

equivalence would apply to an identifiable subpopulation as well.

CONCLUSIONS AND RECOMMENDATIONS

Evidence has been cited previously that an estimated 30 percent of hysterectomies currently

being performed in the United States today can

be considered “elective,” in the sense that sterilization or prevention of endometrial and cervical cancers or other nonmedical indications

dominate the decision for a woman to undergo a

hysterectomy. In view of the costs in morbidity

&d mortality that are associated with hysterectomy, such utilization practices are worthy

of careful scrutiny. Furthermore, with the goals

of lowering the dollar costs of health care to

both society and the individual, elective hysterectomies could be discouraged without

lowering the quality of health care. For these

reasons, cost analyses of the risks and benefits

of elective hysterectomies are important. Such

analyses, as described above, have been undertaken by four different groups (16, 21,24, 40).

None of the quantitative analyses of risks,

costs, and benefits of hysterectomies has found

hysterectomies to be cost effective for sterilization or prevention of uterine cancer. The cost

and risk differences between elective hysterectomy and tubal ligation are so small that the

cost-effective decision depends on factors not

entered into the analyses. This finding results

largely because the majority of costs and mortality and morbidity risks of hysterectomy occur in the present, whereas the majority of savings and benefits occur when uterine diseases

are avoided in the relatively distant future. If

risks and savings are discounted, even at very

low rates of 2 to 3 percent, any monetary savings or increased life expectancy achieved by

hysterectomy becomes offset by the monetary

costs and immediate health risks of the operation.

Published studies of costs, risks, and benefits

of hysterectomy share a number of limitations.

For instance, all of the studies have used mortality and morbidity costs measured or estimated from studies of all hysterectomies. Data

are needed on actual risks of hysterectomy in

the absence of serious uterine disease or clear

medical indication. Of special concern is the apparent increase in frequency of psychological sequelae following hysterectomy. (In one study of

psychiatric complications after hysterectomy,

women with no prior pelvic disease were referred for psychiatric care twice as often as

women with pelvic disease.
24 ● Background Paper #2: Case Studies of Medical Technologies

The cost analyses of published studies have

also lacked reliable data on postoperative

recovery, e.g., how long a period of time is

needed to return to the workplace or domiciliary duties. Furthermore, no study of costs of

hysterectomy has attempted to deal with the

special considerations of the value of women’s

lives in respect to lost earnings for work done in

the home and in the care of children.

None of the published studies has included

costs of surgical complications, except insofar as

average surgical fees for hysterectomy, average

daily hospital charges, and estimated average

recovery time reflect costs of complications.

Such complications may require, for example,

additional surgical repair procedures, treatment

of urinary tract infections, and psychiatric

counseling, all entailing additional costs. All of

the studies mention such complications, but

none of the studies attempted a cost adjustment

for such longer term complications for some

women.

Furthermore, none of the studies has accounted for the fact that women at higher than

average risk of developing uterine cancers in the

future might obtain sufficiently greater benefits

by electing hysterectomy over tubal ligation as a

means of sterilization. However, our own analysis presented in this case study found that at a

twofold increased risk of developing cervical

cancer, discounting future benefits at 2 percent,

a woman undergoing hysterectomy at age 35

would increase her life expectancy by only 0.4

year and decrease the expected cost for her

medical care by only $76. Thus, it does not appear that under these conditions a woman

would obtain significant savings or benefits.

The process of analysis of risks, costs, and

benefits of elective hysterectomy has shown

how the majority of risks and costs are immediate, whereas the majority of benefits are realized

in the future. On balance, the net benefits and

cost savings are small. The average increase in

life expectancy is less than 21⁄2 months, and the

average cost savings are approximately $200,

but the increase in life expectancy and savings

disappear at discount rates as low as 2 to 3 percent. Thus, the ultimate decision as to whether

or not to undergo hysterectomy for sterilization

or for cancer prophylaxis can largely be determined by perceived benefits that are not quantifiable in the present analysis. Such perceived

benefits include the strong desire to avoid

pregnancy in a woman who maintains a firm

moral objection to abortion.

To lessen the abuse of major surgery for

minor benefits to the patient (e.g., relief of

relatively minor menstrual difficulties) or for

the economic advantage of the physician, elective hysterectomy policy should be directed

towards implementation of the current standards of care as developed by the PSRO program

and the reimbursement policy of the Department of Health and Human Services. The PSRO

medical indications for hysterectomy specifically state that sterilization by vaginal or abdominal hysterectomy is acceptable only in the

presence of concomitant uterine disease; and the

medicare law specifically excludes reimbursement of hysterectomy for sterilization. Implementing these standards and policies will not

be easy. Although some modest successes have

been achieved in limiting the numbers of elective hysterectomies by medical audit and peer

review in individual institutions, implementing

a program to audit hysterectomies on a continuous basis at the national level would be a

formidable task. Furthermore, under present

conditions of reimbursement incentives, the effort would not be likely to succeed—indeed, to

disapprove indications for hysterectomy such as

sterilization could be expected to encourage further misrepresentation of diagnoses. If reimbursement patterns are restructured, perhaps

along the lines of competing health maintenance

organizations (31), however, problems of overutilization of elective hysterectomy could be

controlled.
Case Study #15: Elective Hysterectomy: Costs, Risks, and Benefits • 25

APPENDIX A: THE MANITOBA STUDY*

The Manitoba Health Care System

and Claims Data

In carrying out this research, claims data were used

from records of the Manitoba Health Services Commission (MHSC), which operates the Manitoba

health insurance program. The entire population of

Manitoba (in 1973, 1,027,866 people) is covered by

health insurance. The program includes virtually

universal coverage (including visits to chiropractors)

for residents wherever their care is rendered. There is

no fee associated with physician visits or hospital

usage, and there are few coverage limits. Cosmetic

surgery is excluded as is routine dental care. There

are also limits on certain types of services. Only one

eye examination a year is covered unless medical

conditions indicate otherwise. Similarly, there is an

upper limit on the amount of chiropractic services

covered (in 1979, the limits were $70 per single person, $140 for a family of three or less, etc). A small

number of physicians have opted out of the Provincial insurance scheme. In such cases, the Province

pays the patient rather than the physician for services

delivered, and the physician may charge the patient

the difference between the MHSC benefit and his or

her posted fee.

Physicians are paid on a fee-for-service basis, and

in order to be paid, they must submit a claim identifying services rendered to their patients. These claims

contain identifying information on the patient, the

physician, and the diagnosis (coded at MHSC by

ICDA-8). Every discharge from Manitoba hospitals

also results in a claim that will contain information

on the attending physician and surgeon as well as the

patient, up to three diagnoses, and up to three

surgical procedures. Each of these files is maintained

separately, with no routine record integration. However, since patient numbers and physician numbers

are unique across files, it is possible to build files on

individuals (all instances of care received from various physicians and in various hospitals over time).

The Hysterectomy Research

For our research on hysterectomy in Manitoba, a

sample of hospital discharges in 1973 which included

hysterectomy (ICDA procedure codes 69.1-69.7) as

“Sources N I’ 1{(Nw, {’t al , A New Audit Procedure Applled to an Old

QucStl(~n 1+ the Frequem y of T & A ]u~tltld?’Lld Cu(u I S( I): 1 , IW7;

and 1.. R(KW, Ir , ct d I ‘LJ.lng Admlnl. tratlvc Data ~anks t(v Research and

Evalu.I tlon A C’.IW Stud}, ~iILI/I(L~tI[))I QI(LI, tcr/I/ 3(2 I 236, 1979

the first, second, or third surgical procedure was

abstracted for further analysis. Exactly 1,148 cases

meeting this initial criterion were selected. Given this

all inclusive definition, hysterectomy rates in

Manitoba are as follows: 4.37/1,000 females aged 15

to 20; 4,87/1,000 females aged 21 to 39; 15.82/1,000

females aged 40 to 49; 5.80/1,000 females aged 50

and over. Seventy-two percent of the surgery was

done by gynecologists, 14 percent by general practitioners, and 13 percent by general surgeons. Fortythree percent was done in Winnipeg teaching hospitals, 33 percent in Winnipeg nonteaching hospitals, 6

percent in rural hospitals with 125 beds or more, and

18 percent in smaller rural hospitals. Approximately

half of Manitoba’s and 79 percent of the active physicians (above a minimum earning level) practice in

Winnipeg, the Provincial capital and site of the

medical school.

After examination of the diagnoses and the additional surgical procedures which these women had

undergone, we decided to exclude all women who

had had as a first, second, or third diagnosis a

malignancy (ICDA 140-209). Seventy-two women

were excluded from the study on this basis. One additional woman who had had a complete abdominal

hysterectomy combined with a cesarean section was

excluded from the study. Subsequent analysis of

hysterectomy patients has since been restricted to the

1,075 women remaining. These include only women

who have had an abdominal hysterectomy (partial,

subtotal, or complete, ICDA 69.1-69.2) or a vaginal

hysterectomy (total and subtotal, ICDA 69.4),

For these 1,075 women, we abstracted all discharges from hospitals which occurred in the 12

months following hysterectomy as well as the 12

months prior to hysterectomy. For each of these

discharges, it was possible to examine up to three

associated diagnoses and up to three operative procedures. In addition, for the 12 months before and

the 12 months after hysterectomy, all claims for visits

to emergency room or outpatient clinics were abstracted (including one diagnosis and one operative

procedure if performed). Finally, all out-of-hospital

physician visits (whether they occurred at home or in

the physician’s office) for the 12 months before and

the 12 months after hysterectomy were abstracted.

These claims included one diagnosis. For a woman

who had a hysterectomy in January 1973, the periods

of claims examined would be as follows: 1) for the 12

months before, claims from January 1972 through

December 1972 would be pulled; and 2) for the 12
26 ● Background Paper #2: Case Studies of Medical Technologies

months after period, claims from February 1973

through January 1974 would be examined.

By using the unique family registration number

combined with sex and birth year, it was possible to

build histories for individual women.

Validity and Reliability of Claims Data

We have been doing health services research using

claims data from the Manitoba insurance system for

the past 5 years. An important part of this research

effort has been devoted to examining the validity and

reliability of the claims as a data source. Two articles

have been published (68,70) and report some of the

extensive analysis which we have done on the validity and reliability of claims information in conjunction with our research on tonsillectomy. We have

found that the data-transcription error rate from

physician’s written diagnosis to claims ICDA-coded

diagnosis is less than 3 percent. The interobserver

and intraobserver reliability of diagnosis recorded on

the claims compares favorably with published studies

in clinical settings. Reliability is higher when

diagnoses are grouped than when any single diagnosis is examined. The diagnoses are valid in the

sense that surgeons performed operations consistent

with previous diagnoses recorded for the patient.

We have conducted reliability checks comparing

diagnoses recorded on medical and hospital claims

with diagnoses recorded in hospital and physician

records. The overall correspondence between diagnoses in these two sources is reasonably good. (Disagreements range from 10 to 30 percent, depending

on how fine the distinctions being made are. ) We

have also made comparisons between diagnoses recorded on hospital claims and diagnoses recorded in

Vital Statistics. These comparisons suggest a very

close correspondence between diagnostic information contained in Vita/ Statistics and the diagnostic

information contained on a hospital claim during the

admission when a patient died.

In a special study of validity of claims as they

relate to hysterectomies, the procedures billed for by

surgeons and anesthetists were compared with the

procedures recorded in the hospital file when a hysterectomy was coded. The reverse comparison was

also made; that is, the procedures recorded in the

hospital file were compared with those for which the

surgeon and/or anesthetist had billed for hysterectomy. In both comparisons, 94 percent of the records

were an identical match. Where there were discrepancies, the discrepancy was almost always due to

a date discrepancy or to the surgeon’s billing for a

more extensive procedure associated with an abdominal malignancy to which the hysterectomy

would have been incidental. In all these cases, the

more extensive procedure was also recorded in the

hospital claims.
—

Case Study #15: Elective Hysterectomy: Costs, Risks, and Benefits ● 27

APPENDIX B: AN ANALYSIS OF ELECTIVE HYSTERECTOMY

AND TUBAL LIGATION

Introduction

The purpose of this analysis is to compare the

length of life and direct medical expenditures for a

woman undergoing either elective hysterectomy or

tubal ligation on her 35th birthday. This comparison

is based on the estimation of the probability that the

woman’s lifetime equals a specific length and the

probability that direct medical expenses equals a

specific amount, given her choice of sterilization procedure. These estimates are based on an analysis that

incorporates the influence of controlled events (e.g.,

elective surgery) and uncontrolled events (e.g., the

development of cancer) on life expectancy.

In order to simplify the analysis, it will be assumed

that all events significant occur on the patient’s birthday. Therefore, at precisely 12-month intervals, the

woman undergoes surgery, is diagnosed and treated

for disease, and risks dying from the various causes

of death to which she is exposed. This assumption reduces the field of interest to a finite number of points

in the woman’s life. The other assumptions incorporated in the analysis are described in the next section

below.

Given the complete history of events that actually

do occur on a woman’s birthdays, it is possible to

determine the total direct cost of her gynecologic

care. Thus, the analysis computes the probability

that direct costs equal a particular value by surveying

the probability of all possible histories that correspond to that level of cost. Future costs are discounted according to a fixed estimate for the real interest rate.

Assumptions

A response to future events in one’s life can vary

from one individual to another. Furthermore, when

several alternatives are available, it is often difficult

to state with certainty in advance of the actual decision which alternative will be chosen. However, for

the sake of simplicity, it will be assumed that the

following decisions are made conditional on corresponding events.

If a woman becomes pregnant after tubal ligation,

she will undergo abortion and repeat sterilization. It

will be assumed that any pregnancies after tubal ligation occur 1 year after the procedure. It will also be

assumed that subsequent tubal ligations do not fail.

If any uterine cancer develops in a woman after

tubal ligation, then she will undergo hysterectomy as

part of her therapy. Admittedly, many cancers are

often treated without surgery, particularly cervical

cancers detected in situ. Nevertheless, so as to simplify the analysis, it will be assumed that surgery is

indicated in the treatment of uterine cancer. Sensitivity analysis indicates that this assumption does

not affect the comparison. Furthermore, it is not

unreasonable to expect that a woman who has previously undergone a sterilization procedure will undergo hysterectomy after the subsequent detection of

cancer.

Finally, it will be assumed that causes of death are

independent. Therefore, reducing the chance of death

from one cause does not disproportionately increase

the chance of death from another cause. This independence assumption can be expressed mathematically as follows. Suppose that all possible causes of

death have been lumped together into “n” groups.

For example, the jth group might be all uterine related causes of death. Let “P(i,j)” denote the probability that a woman dies on her ith birthday from

the jth cause (actually, a cause from the jth group).

Then “P(38,j)” would denote the probability of death

from uterine disease on a woman’s 38th birthday.

The independence assumption is then:

Probability of death at ith birthday from jth P(i,j)

cause given did not die from kth cause = 1- P(i, k)

In general, this independence assumption does not

always hold—e.g., consider a very risky surgical

procedure which is only performed for a disease that

is always fatal if not cured. Let death from the

surgical procedure denote one cause of death and

death from the disease another. If the surgery is

always attempted as a final effort to save the patient’s

life, then few patients would actually die from the

disease itself. On the other hand, eliminating one

cause of death by either discontinuing the surgery or

else preventing the disease by some other approach

will disproportionately alter the probability of the

other cause of death. Therefore, these two causes of

death are dependent.

This analysis will consider the following groupings

of causes of death:

● uterine cancers,

• complications during hysterectomy,

● complications during tubal ligation,

. complications during abortion,

● complications during dilatation and curettage,

and

● all other causes of death.

Dependencies between the first and second causes of

deaths are eliminated in the analysis by combining
28 ● Background Paper #2: Case Studies of Medical Technologies

deaths due to uterine cancer with deaths during therapeutic hysterectomy.

The Woman Undergoing Hysterectomy

The woman who undergoes elective hysterectomy

faces only two causes of death from the list above: 1)

death as a result of the procedure, or 2) death from

the “other” causes (which exclude gynecologic

causes). The age-specific risk of death during hysterectomy was obtained from The National Halothane

Study (18). The overall death rate for low-risk surgical operations was observed to be 23 deaths per

10,000 procedures, which equaled the weighted average for mortality rates in 12 studies (24). Thus, it was

assumed that the age-specific death rate for death

from hysterectomy matched that for all low-risk procedures.

Age-specific surgical mortality rates for hysterectomy

Age Deaths/10,000

30 8.9

40 14.5

50 33.9

60 54.1

70 116.5

80 281.8

90 500.0

100 500.0

The age-specific mortality rates for nongynecologic death was determined from the Vital Statistics of

the United States for 1976 (58).

Age-specific nongynecologic annual death rates

Age Deaths/100,000

30 68

35 93

40 146

45 244

50 381

55 586

60 931

65 1,336

70 2,095

75 3,678

80 6,125

100 15,932

Let the following symbols denote the probability

for the respective events on the 35-year-old woman’s

ith birthday:

Symbol Event

A Alive at start of birthday

L Death during birthday

R Risk from hysterectomy

M Nongynecologic mortality rate

then:

A(i) = A(i-1) – L(i-1), with A(35) = 1

That is, the probability of being alive on her ith

birthday equals the probability of being alive on her

i-lst birthday minus the probability of dying on her i1st birthday. If the woman undergoes elective

hysterectomy, then:

L(35) = R(35) + M(35)

Therefore, during subsequent years the probability

of death on a particular birthday can be computed

from the following equation:

L(i) = A(i) x M(i)

The Woman Undergoing Tubal Ligation

Lower mortality rates are observed for tubal ligation than for elective hysterectomy. Deane and Ulene

(24) reported that the weighted average tubal ligation

mortality rate for 13 studies was 12 deaths per 10,000

patients. This is approximately half of the weighted

average hysterectomy mortality rate. Therefore, the

age-specific mortality rate for tubal ligation was

estimated by halving the rates reported by The National Halothane Study for low-risk procedures (18).

Age-specific surgical mortality rates for tubal ligation

Age Deaths/10,000

30 4.5

40 7.2

50 16.9

Therefore, since it is assumed that the woman has no

gynecologic diseases, the probability of death during

her 35th birthday can be computed as follows:

L(35) = T(35) + M(35),

where T(i) is the mortality rate for tubal ligation at

age i.

During the following year, the tubal ligation may

fail. McElin, et al. (51) reported a subsequent

pregnancy in 5 of 902 patients sterilized by the

Pomeroy technique. Therefore, a failure rate of 5 per

1,000 was used in the analysis. It was assumed that

pregnancy, if it occurred, did so in the year following

the procedure. The unsuccessful tubal ligation was

followed by a repeat of the procedure together with a

dilatation and curettage. The age-specific risk of

death for this combined procedure was approximated

to be the same mortality rate assumed for tubal ligation.

Women choosing tubal ligation are subjected to a

variety of other risks besides subsequent pregnancy.

The risk of death on any particular birthday is computed by adding the risk of death from each particular cause. The nongynecologic causes comprise one

group of risks. As before, the risk from nongynecologic causes is estimated by multiplying the probability of being alive by the age-specific mortality rate:

Risk of death from nongynecologic causes = A(i) x M(i)

In order to be exposed to a gynecologic cause of

death, a woman must not have previously undergone

hysterectomy. Let H(i) denote the probability of un-
Case Study #15: Elective Hysterectomy: Costs, Risks, and Benefits . 29

dergoing hysterectomy on ith birthday for an indication, and let B(i) denote the probability of living until

the start of ith birthday without previously undergoing hysterectomy. Then:

B(i) = B(i-1) - H(i-1) [l-R(i-l)] - L(i-1),

where R is the age-specific risk from hysterectomy

and L is the probability of death on the ith birthday.

In other words, the probability of being alive with a

uterus still intact on one’s ith birthday equals the

probability of being alive with a uterus intact at the

previous birthday minus the probability of death or

hysterectomy during the previous birthday.

In this analysis, the indications for hysterectomy

are divided into two groups: cancer and noncancer.

The age-specific incidence of noncancer hysterectomies was determined from unpublished data from

the National Hospital Discharge Survey (57) and the

findings reported by Ledger and Child (47) from their

study of 12,026 hysterectomies.

Age-specific hysterectomy rate for

causes other than cancer

Age Procedures/10,000

30 94

40 177

50 124

60 49

80 26

100 0

Recall that the analysis assumed that hysterectomy

was performed for all women in whom uterine cancer

is diagnosed. Therefore, the rate of hysterectomy for

cancer equals the age-specific incidence of the disease. The analysis aggregated the various stages and

sites for uterine cancer into three groups: 1) localized

cancer of the cervix uteri, 2) invasive cancer of the

cervix uteri, and 3) cancer of the corpus uteri. Agespecific rates reported by Kim, et al. (42) were used:

Age-specific incidence for uterine cancers

Localized Invasive

Age cervical cervical Corpus

30 126.2 11.6 1.5

35 72.3 10.8 6.2

40 50.3 16.8 14.4

45 19.2 24.0 32.4

50 19.6 35.3 53.6

55 10.2 21.9 45.2

60 11.6 21.6 73.1

65 12.5 22.9 74.9

’70 10.0 14.8 91.6

75 6.1 15.2 61.0

15.2 61.0

If I1(i), I2(i), and I3(i) denote the incidence of localized

cervical, invasive cervical, and corpus uteri cancer,

respectively, then the probability that a woman undergoes hysterectomy on her ith birthday is:

H(i) = B(i) x [U(i) + I1(i) + I2(i) + I3(i)],

where U(i) is the incidence of hysterectomy for nonmalignant diseases. This includes elective procedures.

The risk of death on a woman’s ith birthday can

then be computed as follows:

Probability of death from hysterectomy

on ith birthday = H(i) x R(i)

A woman who has not undergone hysterectomy may

also develop excessive bleeding that warrants dilatation and curettage, which implies a small risk. Rates

for dilatation and curettage were determined from

Deane and Ulene (24):

Age-specific frequency of undergoing

dilatation and curettage

Age Procedures/10,000

_< 50 16

>50 4

Age-specific death rates from this procedure were

approximated by the risks during abortion. Therefore, if G(i) denotes the age-specific risk during abortions and J(i) the age-specific frequency, then:

Probability of death from dilatation

and curettage = B(i) x J(i) X G(i)

Finally, some of the women who choose tubal ligation will die from uterine cancer. The survival of

these patients after diagnosis depends upon the location and extent of their disease. In this analysis, these

survival rates were estimated from data reported in

Recent Trends in Survival of Cancer Patients (5) for

the years 1960 to 1971.

Probability of death from uterine cancer

after various numbers of years

Localized Invasive

Years cervical cervical Corpus

1 0.06 0.19 0.11

3 0.05 0.09 0.05

5 0.02 0.05 0.03

10 0.01 0.01 0.02

It was assumed that if a patient died from uterine

cancer, then the death occurred within 10 years of the

initial diagnosis.

The probability of death from a particular type of

cancer diagnosed k years earlier equals the probability that the cancer was discovered at that time, times

the probability that the patient survived the initial

therapy and subsequent risk, times the probability of

death from that cancer k years after it is diagnosed.

The probability of death from all cancers on a particular birthday then equals the sum of all three

cancers for the previous 10 years.

Cost of Gynecologic Care

The analysis used the following estimates of the

direct cost for gynecologic care. These values were

obtained from Deane and Ulene (24).

Cost of elective hysterectomy ... ... ... ... ... .. $1,545

Cost of hysterectomy for cervical cancer. . . . . . . . . 2,400
.30 ● Background Paper #2: Case Studies of Medical Technologies

Cost of hysterectomy for corpus cancer. . . . . . . . . . 3,200

Annual cost of uncured cervical cancer . . . . . . . . . . 800

Annual cost of uncured corpus cancer . . . . . . . . . . . 800

Annual cost of uterine care premenopause. . . . . . . . 20

Annual cost of uterine care postmenopause. . . . . . . 10

Cost of abortion . . . . . . . . . . . . . , . . . . . . . . . . . . . 645

Cost of therapeutic dilatation and curretage . . . . . . 415

Cost of tubal ligation. . . . . . . . . . . . . . . . . . . . . . . . 1,100

It is felt that these figures are perhaps lower than the

actual values; however, the reduction appears to be

uniform. In addition to the above cost for medical

care, it was assumed that a woman incurs a $10,000

expense during the last months of her life. This expense represents the “cost of dying” but not the “cost

of death” (i. e., the value of life) which would be considerably larger.

Basic Result

The analysis estimated the probabilities for death

for each year after the initial sterilization procedure.

The value of these estimates is listed below for every

10th birthday.

Probability of death on selected birthdays

Age on birthday Hysterectomy Tubal ligation

35 0.00111 0.00055

45 0.00221 0.00256

55 0.00519 0.00552

65 0.01099 0.01122

75 0.02411 0.02405

85 0.03322 0.03280

95 0.01799 0.01766

Notice that the woman sterilized by hysterectomy is

more likely than the woman undergoing tubal ligation to die at the time of the procedure (age 35). This

increase in operative deaths corresponds to a slight

improvement in subsequent survival in that the age

at death is shifted to the later years. For example, the

probability of death at age 75 is approximately the

same for both procedures. On the other hand, death

at age 95 is more likely when the woman undergoes

hysterectomy. Thus, overall, the life expectancy is

81.3 years, as opposed to 81.0 years with tubal ligation.

The probability for different ranges of total expected costs is listed below. Future costs were discounted at 2 percent per year.

Probability distribution for direct cost

(2-percent discount rate)

Range Hysterectomy Tubal ligation

_< $5,000 0.158 0.226

_< 6,000 0.578 0.568

_< 7,000 0.826 0.806

_< 8,000 0.921 0.913

_< 9,000 0.965 0.958

_< 10,000 0.986 0.982

_< 11,000 0.996 0.994

_< 12,000 1.000 0.997

_< 13,000 1.000 0.998

_< 18,000 1.000 1.000

The expected direct costs are $6,048 and $6,052 for

hysterectomy and tubal ligation, respectively. Although the difference is not large, the higher average

cost is associated with tubal ligation because of the

chance of expensive cancer therapy and early death.
Case Study #15: Elective Hysterectomy: Costs, Risks, and Benefits •31

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