Human Reproduction vol.11 no.2 pp.287-29O, 1996
Financial impact in the Italian Health Service of
laparoscopic versus laparotomic surgery for the
treatment of ovarian cysts
CBuUetti1-3, R-SeracchioU1, V.Polli1, AAlbonetti1,
S.Rossi1, L.Barbieri2, A.Callegaro2 and CFlamigni 1
'Unit of Special Pelvic Surgery, Operative Laparoscopy and
Hysteroscopy, 1st Institute of Obstetrics and Gynecology,
University of Bologna; Members of the the Special Group (GIS)
for Operative Laparoscopy and Hysterosalpingoscopy of the Italian
Society of Fertility and Sterility and Reproductive Medicine
(SIFES-MR), 2Health Care Administration of the Azienda S.Orsola
Malpighi, S.Orsola-Malpighi General Hospital, Via Massarenti, 13
40138 Bologna, Italy
^ o whom correspondence should be addressed
To assess the cost of two procedures for the removal of
ovarian cysts, 200 pre-menopausal women were recruited
for the surgical removal of ovarian cysts by laparoscopy
(n = 100) and laparotomy (n = 100) according to casecontrol criteria. Patients operated by laparoscopy (mean
age ± SD 32.22 ± 9.98 years) and laparotomy (mean age ±
SD 29.57 ± 6.62 years) for ovarian cysts (mean diameters ±
SD 4.98 ± 3.62 and 4.83 ± 2.78 cm) had a post-surgical
hospital stay of 3.12 ± 0.41 and 7.25 ± 1.08 days (P < 0.001)
respectively. The total rate of complications occurring in
patients operated by laparoscopy was 9 versus 53% (P <
0.001) of those operated by laparotomy; body temperature
>38°C was recorded in 52/100 of patients operated by
laparotomy versus 6/100 of those operated by laparoscopy.
The mean cost for each pure surgical treatment performed
by laparoscopy was US $498.17 versus US $642.47 when it
was performed by laparotomy (P < 0.001). The laparoscopic surgical approach is more expensive in the first 36
operations, thereafter becoming cheaper. The mean of the
entire overall expenditure was US $1142.08 and US $2138.72
for laparoscopy and laparotomy (P < 0.001) respectively.
The entire expenditure for laparoscopy is higher than
laparotomy only until eight operations. In conclusion,
laparoscopy versus laparotomy has resulted in a saving of
US $14 4293 for 100 operations while the saving on entire
costs was US $99 664.8.
Key words: financial costs/health care administration/operative
laparoscopy/ovarian cysts
Introduction
Administrative costs have been found to be one of the fastest
growing components of hospital budgets. In future, research
should not only determine the effect of these increases on the
quality of patient care but also carefully evaluate the low
costs/high quality of medical/surgical procedures. In addition
to this world-wide phenomenon, the Italian health system is
© European Society for Human Reproduction and Embryology
moving from a pure 'free of charge' social service without
financial restrictions to a budget-administered system because
of the enormous national internal debt (~2 000 000 trillion
Italian lira).
Over the last 15 years, operative laparoscopy has gained
increasing acceptance alongside the evidence that more and
more practitioners are becoming trained in this field. Although
the first attempt at endoscopy is attributed to Philip Bozzini
of Italy in 1805, using a tube and a candle (Nezhat et ah,
1992), the main promotion of laparoscopy in gynaecology was
by Steptoe (1969) in the UK and by French gynaecologists
who reported the first human tubal fulguration in 1962. Other
pioneers of operative laparoscopy were Victor Gomel in the
US, Kurt Semm in Germany, Bruhat, Manhes and Dubuisson
in France, and Cittadini in Italy. The benefits of substituting
laparoscopy for laparotomy or the vaginal route include
decreased trauma (Semm et ah, 1987), shorter recovery period
(Nezhat C. et ah, 1986, Baggish M. 1989), shorter hospitalization (Nezhat et ah, 1986), less disability (Baggish, 1989), and
financial savings for patients and the health care system (Levine
et ah, 1985; Goodman et ah, 1989). The present study
was undertaken to evaluate the financial impact of operative
laparoscopy in comparison with the classical laparotomic
approach in the Italian health care system. The weights of all
financial parameters on the entire expenditure were considered.
Materials and methods
The financial cost of the surgical treatment of 200 pre-menopausal
women having ovarian cysts was analysed. The women were divided
by the method of surgical removal: the abdominal route (n = 100)
and by operative laparoscopy (n = 100). The study was designed as
a case-control study based on number of previous operations, serum
concentration of CA125 <35 IU/ml and ovarian cyst size. Ultrasonography was performed before surgery to exclude a presumptive
diagnosis of ovarian cancer. Complications of the two procedures
included body temperature >38°C, haemoglobin <8.5 g/100 ml,
infiltration of the abdominal sutures, dysuria, reduction in blood
platelet count
All costs were calculated on the basis of 100 operations per study
group. Statistical analysis was performed by using Student's unpaired
f-test and MacNemar's test
The cost for a day's hospitalization in this study was US $206.4,
which included medical staff, nurses, administrative staff, direct costs
(employers other than doctors and nurses, consumptions, upkeep of the
medical centre, standard hospital equipment excluding the operating
room), specific medical and/or technical services Qaboratories, other
medical consultations and tests), structural costs including the medical
care and supervision, administration, maintenance, kitchen, building
and permanent structures, cleaning and laundry services, hospital
security and consumer service.
287
C.BuUetti et aL
Generical surgical instruments
Table I. Distribution of histological features of ovarian cysts according to
whether they were operated by laparoscopical or laparotomic procedure
Surgical staff
Number of women with ovarian cysts of different
histological type
Surgical technique used
Serous
Laparoscopy
Laparotomy
38
20
Mucous
Dermoid
Endometriotic
20
47
53
Direct costs
Throwaway material
Structural costs
The examinations requested for general anaesthesia were not
included in the present evaluation because they were performed in
advance and were exactly the same for both study groups. Preparation
for the operations was also the same for both study groups and they
were included in the amount of money requested for a day of
hospital ization.
The cost of pure surgical treatments included instruments and
equipment (for laparoscopy) or instruments (for laparotomy) plus
consumer products and personnel (one anaesthesiologist, two
surgeons, two nurses, one technician) of the operating room. The
functional lifespan of equipment for laparoscopy is 6.5 years, while
that for laparoscopy instruments is 3 years; for general surgical
instruments mainly required for laparotomy and partly for laparoscopy
the equivalent duration was 8 years. All calculations were made on
the basis of spreading the cost of these instruments/equipment over
their expected durability in years. Calculations were also made by
converting Italian lira into US dollars according to the Associazione
Giomalistica Italiana for 20 February, 1995 at 03:45 p.m. (when
$1000 « 1599 Italian lira). Values were reported as mean ± SD.
Specific services
[-,
Surgical instruments for laparoscopy
Generical surgical instruments
Throwaway material
Medical and
administrative staff
Structural costs
Results
The mean ages of the two groups of patients were not different
(32.22 ± 9.98 and 29.57 ± 6.62 years respectively).
The histological diagnosis of the ovarian cysts are shown
in Table I according to the type of operation. The mean
diameter of the ovarian cysts operated by laparoscopy (4.98 ±
3.62 cm) did not differ from those operated by laparotomy
(4.83 ± 2.78 cm).
The mean duration of hospital stay after surgical treatment
for the two groups of study was 3.12 ± 0.41 days for
laparoscopy and 7.25 ± 1.08 days for laparotomy (P < 0.001);
the mean total duration of hospital stay including 1 day of
preparation for the surgical procedure was 4.74 ± 0.94
and 8.39 ± 1.20 respectively (P < 0.001). Post-surgical
complications occurred in 53% of the laparotomy operations (52 cases with fever, two cases with haemoglobin <8.5 g/
100 ml, one with infiltration of the abdominal sutures, two
with dysuria, one with reduction in blood platelet number)
compared with 9% of the laparoscopic operations (six cases
with fever, two cases with haemoglobin <8.5 g/100 ml, one
case with infiltration of the abdominal sutures, one case with
dysuria) (P < 0.001).
The mean cost for each pure surgical treatment in the 100
operations was calculated as $498.17 and $642.47 for the
laparoscopic and laparatomic techniques (P < 0.001). The
mean cost for the hospital stay alone was $643.90 and $1496.25
for laparoscopy and laparotomy respectively (P < 0.001). The
mean total cost of each operation performed by laparoscopy
was $1142.08 while that of each one performed by laparotomy
288
Medical and administrative staff
Specific efforts
Figure 1. Pie chart showing the distribution of the various costs
associated with cyst removal by laparotomy (a) or laparoscopy (b).
The diagrams clearly show that the major cost is the hospital stay
which includes the direct costs, medical and administrative staff,
specific efforts and structural costs. The percentage of the purely
surgical expenses for the laparoscopic procedure does not appear
significantly higher than that for the laparotomic procedure when
100 operations arc performed.
was $2138.72 (P < 0.001). The total cost for pure surgery on
100 operations by the laparotomical route was $64 247.72,
while that for the same number of operations by laparoscopy
was $49 817.92. The total costs for hospitalization were $149
625 for patients operated by laparotomy compared with $64
390 for those operated by laparoscopy (P < 0.001). The entire
cost for 100 patients operated by laparotomy was $213 872.72
versus $114 207.92 for those operated by laparoscopy (P <
0.001).
Figure 1 shows how the costs were distributed in the two
groups. The direct cost for laparotomy was 33.59 versus 27.07%
for laparoscopy; medical staff, nurses, and administrative staff
correspond to 18.89 and 15.23% of the total charge for a
single patient undergoing surgical laparotomy and laparoscopy
respectively; specific medical and/or technical services
accounted for 4.89 and 3.94% of the costs of laparotomy and
laparoscopy and structural costs were 12.59 and 10.15%
respectively. The proportion of costs accounted for by
throwaway material, surgical staff and instruments was similar
for the two procedures, as shown in Figure 1. Instruments and
Financial impact of laparoscopic surgery
LAPABO3COPY
LAPAROSCOPY
LAPAROTOMY
LAPAROTOMr
100
25
BO
75
Number of caMt
LAPAROSCOPY
LAPAROSCOPY
LAPAROTOMY
LAPAROTOMY
Kumb«f of cas*s
Number ol cas«*
Figure 2. Total costs of pure surgical treatment of 200 ovarian
cysts as a function of number of operations performed by
laparoscopical (n = 100) versus laparotomic (n = 100) procedure.
The costs became lower for laparoscopy after 36 operations had
been performed (a). Extrapolation of the graph up to 500
operations for ovarian cysts shows that the total cost was less by
using the laparoscopic instead of the laparotomic, and the saving
amounted to $76 041.22 (b).
Figure 3. Total cost of surgery and hospital stay for 200 cases of
ovarian cysts removed by laparoscopic (n = 100) versus
laparotomic (n = 100) procedures related to the number of
operations. The costs became lower for laparoscopy after eight
operations had been performed (a). Extrapolation of the graph up to
500 operations for ovarian cysts shows that the entire cost was less
by using the laparoscopic instead of laparotomic procedure and
after 500 operations the saving was calculated as $603 341.22 (b).
was the reduced length of hospital stay in connection with
laparoscopy.
equipment for laparoscopy accounted for 2.83 and 5.32% of
the total expense of the laparoscopic operations (Figure 1).
Figure 2 shows the curves relating to the total cost of the
entire procedures to the number of operations performed for
surgical removal of ovarian cysts as performed both by
laparoscopy and laparotomy. Figure 3 shows the corresponding
curves but including the hospital stay. In Figures 2a and 3a
the curves were drawn from data for 100 versus 100 cases
and then in Figures 2b and 3b the data were extrapolated up
to 500 cases. The intersection point occurred at 36 and eight
operations in Figures 2a and 3a respectively, illustrating the
different balance of costs when hospital stay was included.
The separation between the extrapolated curves from 100 to
500 operations gradually increased, suggesting a cumulative
saving of $99 664.80, $207 279.80, $314 894.80, $422 509.80
and $530 124.80 for operative laparoscopy in 100, 200, 300,
400 and 500 ovarian cyst cases respectively (P < 0.001).
The increase of the crude saving continued after this number
(data not shown). The major contribution to these savings
Discussion
The safety and efficacy of the laparoscopic surgical procedure
was previously demonstrated to be at least comparable to that
of laparotomy (Albini et al., 1994). Benefits of this procedure
have frequently been reported in recent literature by convincing
studies (Deckardt et al, 1994). The laparoscopic surgery was
demonstrated to be more cost-effective than laparotomy for
the treatment of ectopic pregnancy (Maruri and Azziz, 1993).
A matched case study was performed comparing the financial
impact of substituting laparoscopy for laparotomy; laparoscopy
was less costly for the patient and more profitable for the
hospital (Davison et al., 1993). The present study clearly
demonstrated both the shorter hospitalization and the lower
cost of the laparoscopic versus laparotomic procedure in a
European country when the number of procedures per year is
higher than eight
The post-surgical complications recorded by laparoscopy
289
CBuUettl et aL
were significantly lower than those recorded by laparotomy,
especially concerning the most frequent complication reported
for the laparotomic procedure, i.e. a transient body temperature >38°C. These results should only be considered in the
context of the Italian Health Community and specifically for
the area of Bologna, where the S.Orsola General Hospital is
one of the biggest in Europe (>2500 beds). The contribution
of administrative costs to the entire cost was not separately
defined because it is part of the direct costs which include
other expenses (see above). The direct costs represent the
highest percentage contribution to the total (27.1% for laparoscopy versus 33.6% for laparotomy), although it is not possible
to compare them directly with that of other medical communities such as the USA (corresponding average 25%). The
administrative costs are similar in countries with high and
low rates of enrolment in health maintenance organizations
(Woolhandler et al, 1993).
In the recent past the Italian Health System has mainly
focused on health care as a social non-profit making and free
of charge service. Recently the system was changed to a
partial-charge service and the contribution by the citizen
for each health service is increasing. In the past, hospital
administrations received payment for their annual debts from
the National Health Care Service because of the social context
in which they operated. The purpose of the hospital therefore
justified payment of its debts. Currently, however, the hospital
administration must work within their budget and are no longer
allowed to accrue debts. Calculation of the cost for each
procedure thus became necessary both to curb the continuous
large increases in health care expenses and to identify the most
profitable procedures in terms of cost/benefit balance. Other
clinical treatments have also been recently evaluated; a costeffectiveness analysis of natural versus stimulated cycles in
in-vitro fertilization (TVT) programmes was carried out with
interesting results by Daya et al. (1995).
The removal of ovarian cysts represents one of the most
common gynaecological operations. The main procedure used
until a few years ago was laparotomy, and it is still widely
used in Italy. Subsequently, laparoscopy was introduced for
the surgical treatment of adnexal masses, including ovarian
cysts, and these are considered one of the most appropriate
indications for operative laparoscopy (Nezhat et al, 1992).
The routine time for hospitalization in our institution for
laparoscopy and laparotomy is longer than that for the same
operations in other institutions (Albini et al., 1994). Thus in
our study, the expense of both laparoscopic and laparotomic
approaches may be over-estimated; adopting a shorter hospital
stay should reduce the cost of the entire procedure for both
surgical approaches.
The saving achieved by the laparoscopic versus laparotomic
procedure purely for surgical treatment of ovarian cysts is
significant and consistent for a programme which includes
more than 36 operations. By extrapolating from data of this
study, we can calculate that a hospital that performs 200, 300,
400 or 500 operations per year would save $207 279.80,
$314 894.80, $422 509.80 and $530 124.80 respectively;
greater savings could be achieved by including other types
of laparoscopic operations such as myomectomy, ectopic
290
pregnancy, adhesiolysis, etc. When the total costs of the two
procedures are compared, the curves intersect after only eight
operations (Figure 3a), thus indicating the financial advantage
of laparoscopy over laparotomy even for small institutions in
which only small programmes of operative laparoscopy are
performed.
In conclusion, in the present health care system in Italy, the
laparoscopic procedure may provide a modern, safe and less
expensive approach than laparotomy for the surgical removal
of ovarian cysts. In addition, the surgical training programme
in our school of medicine is the same for the laparotomic and
the laparoscopic approach to the surgical removal of ovarian
cysts. It is the time taken to perform at least 25 operations for
the removal of ovarian cysts, assisted by an expert surgeon.
An additional future comparison in the evaluation of health
care administration of medical/surgical procedures is the comparison of costs for the same type of operation performed in
different hospitals. It will be necessary also to establish a cost/
benefit value comparable between hospitals of the same health
care organization, as well as the specific value of institutions
(expressed as scores of intrinsic value of doctors and quality
of the institutional organization).
Acknowledgements
This study was supported by The Italian National Council of Research,
grant no. 940840.
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Received on June 28, 1995; accepted on November 14, 1995