Hysterectomy With a General Gynecologist vs Gynecologic-Oncologist in the Setting of Endometrial Intraepithelial Neoplasia: A Cost-Effectiveness Analysis
Authors: Chaiken Sarina R. , Bohn Jacqueline A. , Bruegl Amanda S. , Caughey Aaron B. , Munro Elizabeth G. 
Published: April 2023

ABSTRACT
Total hysterectomy performed by either general gynecologists or gynecologic oncologists is the standard of care treatment for endometrial intraepithelial neoplasia (EIN). Some patients with endometrial cancer found at the time of hysterectomy require a lymph node dissection (LND), which is only performed by gynecologic oncologists. When a general gynecologist performs the hysterectomy, the patient must wait until after the procedure for pathology results to determine if an LND is indicated. Undergoing a second surgery for LND is associated with increased negative outcomes, leading to discussion whether patients with EIN should be provided the option to receive the initial hysterectomy by a gynecologic oncologist.
This cost-effectiveness analysis of hysterectomy by general gynecologists versus gynecologic oncologists for patients with EIN aimed to assist decision-making over initial surgical provider choice for patients with EIN. A theoretical cohort of 200,000 patients, the approximate number of individuals diagnosed with EIN each year in the United States, was used to carry out the cost-effectiveness analysis. For patients in the gynecologic oncologist branch, intraoperative frozen section revealed either cancer or EIN or less, whereas patients in the general gynecologist branch had postoperative pathology that reveal cancer or EIN or less. Cancer results were staged according to the “Mayo criteria,” and patients with ≥stage IA, grade 3 cancer received a full LND in the primary surgery with a gynecologic oncologist or in a second surgery in the general gynecologist group. Probabilities in this model were derived from the literature. Costs were obtained from the literature and adjusted to 2020 US dollars. Study outcomes included perioperative mortality, surgical site infection, costs, and quality-adjusted life years (QALYs). After determination of total costs and QALYs, the incremental cost-effectiveness ratio was calculated to compare the difference between the 2 strategies (general gynecologist vs gynecologic oncologist). An incremental cost-effectiveness ratio below $100,000 per QALY was considered cost-effective.
Among the theoretical cohort, hysterectomy with a gynecologic oncologist was associated with a decrease of 10,811 second surgeries for LND, 87 surgical site infections (1611 vs 1698), and 9 perioperative mortalities (178 vs 187). The cost-effectiveness analysis revealed that hysterectomy with a gynecologic oncologist was considered the dominant strategy because it was associated with savings of $116 million and increased QALYs by 180. Multivariable sensitivity analysis of all probabilities, costs, and utilities showed that the model was cost-saving and associated with increased QALYs in 54.1% of simulations and cost-effective at the willingness-to-pay threshold of $100,000 per QALY in 54.8% of simulations.
The results of this theoretical cost-effectiveness analysis reveal that hysterectomy for EIN with a gynecologic oncologist versus a general gynecologist was associated with cost savings, increased QALYs, and a reduction in morbidity and mortality primarily driven by a reduction in second surgeries.