Apical Support Procedures at the Time of Hysterectomy for Benign Indications: A Cost-Effectiveness Analysis

To assess the cost effectiveness of performing routine concurrent apical support procedures at the time of hysterectomy for benign indications.

We developed a Markov decision model from the health care sector perspective to compare concurrent apical support (ie, McCall culdoplasty) at the time of hysterectomy for benign indications compared with hysterectomy alone. We modeled Markov transitions between asymptomatic, prolapse without treatment, and treated prolapse states for 3 years. Our primary outcome was incremental cost-effectiveness ratio, defined as the difference between groups in mean cost (2019 U.S. dollars) divided by the difference in mean quality-adjusted life-years (QALYs). Model parameter estimates were taken from the published medical literature. Cost estimates were obtained from Medicare reimbursement rates and the literature. One-way, two-way, and probabilistic sensitivity analyses were performed.

We assumed a base-case scenario of 13% posthysterectomy prolapse after hysterectomy alone and 2.1% after concurrent apical support, 5.8% and 0.9% undergoing subsequent surgical treatment for prolapse, respectively. Concurrent apical support at the time of hysterectomy had higher costs ($1,667 vs $1,423) but was more effective (2.34 vs 2.31 QALYs) than hysterectomy alone. Concurrent apical support was cost effective with an incremental cost-effectiveness ratio of $11,988/QALY, compared with general willingness-to-pay ranges of $50,000-150,000/QALY. In sensitivity analyses, concurrent apical support remained cost effective as long as the rate of posthysterectomy prolapse after concurrent apical support remained less than 8.7%. Monte Carlo simulation showed that concurrent apical support was cost effective in more than 60% of the simulated iterations.

Apical support at the time of hysterectomy for benign indications is cost effective compared with hysterectomy alone from the health care sector perspective at 3 years. Our results suggest that encouraging concurrent apical support procedures at time of hysterectomy is a cost-effective strategy in preventing posthysterectomy vaginal prolapse.