29 Moderate versus general anesthesia for operating room hysteroscopy: A cost analysis

Abstract

Hysteroscopy is a procedure that is moving out of the operating room and into the office and ambulatory centers, as it has found to be safe and feasible in these settings. However, many gynecologists are still restricted to taking their patients to the operating room. At our institution there is a high volume of hysteroscopy performed by gynecologists in the operating room, and there is wide variation in the anesthesia care given. The primary objective is to perform a cost analysis for general anesthesia versus moderate sedation for hysteroscopic procedures in the operating room. Our secondary purpose is to compare additional patient outcomes including OR time, PACU time, and opioid requirements. Subjects were identified through a search of CPT codes using the Deep Six Cohort Builder from January 1, 2018, through December 31, 2018. Inclusion criteria included patients who had a hysteroscopy procedure at our institution, an urban tertiary care center, and were at least 18 years old. Patients were excluded who had a concurrent procedure which required general anesthesia or an emergent procedure. The remaining variables were extracted from the electronic medical record. Subjects who had a polypectomy and myomectomy were placed in two separate groups for analysis. These two groups were subsequently analyzed by anesthesia type: general anesthesia with endotracheal tube (ETT), general with laryngeal mask airway (LMA), and monitored anesthesia care (MAC). Data was analyzed using the Kruskal-Wallis test and Chi-Square test. There were 467 patients included in the analysis (355 polypectomy and 112 myomectomy). For polypectomy there were 35 (ETT), 273 (LMA), and 45 (MAC) subjects. For myomectomy 14 (ETT), 90 (LMA), and 8 (MAC). General anesthesia with ETT had a higher cost compared to both general LMA and MAC for myomectomy and polypectomy (P = 0.0225, and P = 0.005). There was no difference in cost between general LMA and MAC (P = 0.36 and P = 0.10). General anesthesia ETT had longer OR times compared to LMA and MAC but no difference in PACU time or opioid use. For polypectomy, OR times for LMA use was also longer than MAC (60 minutes vs 54 minutes, P = 0.008). No patient factors could account for the use of an ETT or LMA; rather the chart review showed only anesthesiologist preference for the method. Hysteroscopy is a safe, relatively short procedure, shown to be safe in the office or ambulatory setting. Efforts must be made to minimize cost and intervention in the main OR given the low reimbursement of these procedures. General anesthesia with ETT had higher costs and longer OR times. Most patients received LMA for airway support, which for polypectomy had longer OR times compared with MAC. Going forward, this data will help standardize anesthesia care for hysteroscopy and guide implementation for a hysteroscopy ERAS protocol that could be used across multiple settings.