16 Cost-effectiveness of vaginal hysteropexy compared to vaginal hysterectomy with apical suspension for the treatment of pelvic organ prolapse: A 5-year markov model

Abstract

Uterine preserving hysteropexy (HP) for the treatment of uterine prolapse has become more popular in recent years. Studies suggest that hysteropexy has equivalent medium-term efficacy compared to traditional vaginal hysterectomy (VH) with apical suspension (sacrospinous ligament fixation (SS) or uterosacral ligament suspension (US)), but costs between uterine-sparing and traditional prolapse repair have not been compared. Our objective was to perform a cost-effectiveness analysis of hysteropexy (HP) versus vaginal hysterectomy (VH) with apical suspension for the treatment of uterine prolapse. We used TreeAge Pro® software to construct a decision model tree comparing the cost-effectiveness of four surgical options: HP with SS (HP-SS), HP with US (HP-US), VH with SS (VH-SS), and VH with US (VH-US). Using a Markov model, we modeled a population of healthy women undergoing surgery over a 5-year time horizon. We used data from a recent randomized controlled trial to model 5-year prolapse recurrence, prolapse retreatment and complications. Costs, probabilities, and utilities were gathered from Medicare reimbursement data, published literature and Stanford Hospital billings department (Table 1). We modeled effectiveness as health utility values with quality-adjusted-life years (QALY) which ranged from 0-1. Cost-effectiveness was defined as an incremental cost-effectiveness ratio (ICER) of $100,000/QALY. Base-case, tornado plots, one-way and two-way sensitivity analyses were performed. In the base case scenario, HP strategies were the optimal cost-effective strategies. The surgical strategy with the lowest cost per patient was HP-SS costing $42,287.81 with Total QALYs 4.13 for HP-SS. The incremental HP-US cost was $1,065.37 with Total QALYs 4.19. VH-SS and VH-US were dominated strategies with higher incremental costs ($7,642.20 and $8,706.08), and lower QALYs (-0.06 and -0.02). Tornado plots showed that the variables that most influenced CEA results were the cost of the four surgical strategies and the probability of complications following HP. VH strategies were cost-effective when the cost of HP-SS was >$47,300 and the cost of HP-US was >$51,800. VH strategies were also cost-effective when the probability of complications after HP-SS was >30% and the probability of complications after HS-US was >32%. At all probabilities of prolapse recurrence after HS and VH and at all probabilities of repeat surgery after HS and VH surgical failure, HS surgeries remained the optimal cost-effective strategies. In this cost-effectiveness analysis, HP surgeries were the most cost-effective surgical strategies. Even if we assumed higher rates of prolapse recurrence and repeat POP surgery after surgical failure, they remained the optimal surgical strategies.