The economic impact of surgical care for morbidly obese endometrial cancer patients: a nationwide study

doi:10.1016/j.ajog.2015.10.015

American Journal of Obstetrics and Gynecology

Volume 214, Issue 4, April 2016, Pages 498.e1-498.e6

Presented at the Society of Gynecological Oncologists, Tampa, FL, March 22-25, 2014.

https://doi.org/10.1016/j.ajog.2015.10.015 Get rights and content

Background

Obesity significantly impacts the cost of cancer treatment, yet the impact of morbid obesity on inpatient hospital charges related to endometrial cancer treatment is not well-defined.

Objectives

The purpose of this study was to determine the charges that are associated with inpatient surgery, hospitalization, and postoperative care of morbidly obese patients with endometrial cancer.

Study Design

Data were obtained from the National Inpatient Sample from 2010. Chi-square test, t-test, and linear regression were used for statistical analyses.

Results

Six thousand five hundred sixty patients who underwent hysterectomy for endometrial cancer were identified. Mean age was 62 years (range, 22-99 years). The majority were white (78%), and the remainder were black (10%), Hispanic, (8%), Asian (3%), and Native American (1%). Insurance types were private (45%), Medicare (45%), Medicaid (5%), and uninsured (7%). One thousand eighty-eight of these patients (17%) were coded as morbidly obese. The mean postoperative stay for the morbidly obese was 4.0 days (range, 0-46 days) compared with 3.5 days (range, 0-81 days) for the non–morbidly obese patients (P < .01). Morbidly obese patients required more intensive care with mechanical ventilation (5.5% vs 1.6%; P < .01). The median hospital charges were higher for morbidly obese patients compared with their counterparts ($46,654 vs $41,164; P < .01). After adjustment for charges that were associated with insurance type, hospital type, and the surgery that was performed, the incremental increase in hospital charges that were associated with treating the morbidly obese patient was $5096 per patient (95% confidence interval, $2593–$7598; P < .01).

Conclusion

In this economic analysis, the health care charges that were associated with inpatient endometrial cancer treatment in the morbidly obese patient was significantly higher compared the non–morbidly obese patient. Resources are needed to support the needs of this population, and programs to encourage weight loss and optimize general health should be encouraged.

Section snippets

Study design and sample population

Data were extracted from the US Agency for Health Care Administration and the National Inpatient Sample (NIS).⁹ The NIS represents a 20% stratified sample of US hospital discharges and comprises data from approximately 1051 hospitals. The NIS records contain demographic data and clinical information that include diagnosis, procedures, admission and discharge status, payment source, and hospital information.

The NIS database was queried for all discharge reports of patients with endometrial

Demographics and socioeconomic of morbidly obese

Of 6560 women with endometrial cancer, the mean age was 62 years (range, 22–99 years). The majority were white (78%); the remainder black (10%), Hispanic (8%), Asian/Pacific Islander (3%), and Native American (1%; Table 1). Of the overall study group, 1088 women (17%) were diagnosed as morbidly obese. A greater proportion of Native American and black women were morbidly obese vs white, Hispanic, and Asian/Pacific Islander women (33% and 18% vs 16%, 15%, and 4%; P < .01). The Midwest had the

Comment

Endometrial cancer is the most common gynecologic cancer in the United States, with an estimated 52,630 new cases in 2014.³ More than one-half of these uterine cancer cases may be attributed to obesity.¹¹ Even though obesity impacts cancer treatment with associated incremental costs, few reports have reviewed the direct impact on medical expenditures that are related to the treatment. In addition, these studies have not analyzed the charges on a nationwide level. In this current economic

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Cited by (12)

Dietary omega-3 fatty acids and endometrial cancer risk in the Epidemiology of Endometrial Cancer Consortium: An individual-participant meta-analysis
2023, Gynecologic Oncology
Citation Excerpt :
Endometrial cancer is curable when detected early and the mortality rate remains relatively low in White women compared to other cancers. However, other factors, including higher mortality rates [3–6], $3 billion annually in uterine cancer care expenditure [7,8], patient anxiety [9,10], and surgical complications [11] must be considered when evaluating endometrial cancer's impact. Increasing evidence suggests that interplay between unopposed estrogens and inflammatory signaling are important in endometrial cancer etiology [12,13].
Limited data from prospective studies suggest that higher dietary intake of long-chain omega-3 polyunsaturated fatty acids (LCn3PUFA), which hold anti-inflammatory properties, may reduce endometrial cancer risk; particularly among certain subgroups characterized by body mass and tumor pathology.
Data from 12 prospective cohort studies participating in the Epidemiology of Endometrial Cancer Consortium were harmonized as nested case-control studies, including 7268 endometrial cancer cases and 26,133 controls. Habitual diet was assessed by food frequency questionnaire, from which fatty acid intakes were estimated. Two-stage individual-participant data mixed effects meta-analysis estimated adjusted odds ratios (OR) and 95% confidence intervals (CI) through logistic regression for associations between study-specific energy-adjusted quartiles of LCn3PUFA and endometrial cancer risk.
Women with the highest versus lowest estimated dietary intakes of docosahexaenoic acid, the most abundant LCn3PUFA in diet, had a 9% increased endometrial cancer risk (Quartile 4 vs. Quartile 1: OR 1.09, 95% CI: 1.01–1.19; P trend = 0.04). Similar elevated risks were observed for the summary measure of total LCn3PUFA (OR 1.07, 95% CI: 0.99–1.16; P trend = 0.06). Stratified by body mass index, higher intakes of LCn3PUFA were associated with 12–19% increased endometrial cancer risk among overweight/obese women and no increased risk among normal-weight women. Higher associations appeared restricted to White women. The results did not differ by cancer grade.
Higher dietary intakes of LCn3PUFA are unlikely to reduce endometrial cancer incidence; rather, they may be associated with small to moderate increases in risk in some subgroups of women, particularly overweight/obese women.
Class III Obesity and Other Factors Associated with Longer Wait Times for Endometrial Cancer Surgery: A Population-Based Study
2020, Journal of Obstetrics and Gynaecology Canada
Citation Excerpt :
Class III obesity, defined as a body mass index (BMI) ≥40 kg/m2,8 is rising most rapidly9 and confers perioperative challenges, including difficult ventilation,10 increased intraoperative and postoperative morbidity,10,11 and higher rates of conversion to laparotomy when a minimally invasive approach is attempted.12 Not every surgeon or centre is equipped to manage women with severe obesity,13,14 which may lead to delays in accessing surgical care. It is unknown whether women with class III obesity experience longer wait times for endometrial cancer surgery.
To evaluate the impact of class III obesity (body mass index >40 kg/m²) on wait times for endometrial cancer surgery in Ontario, as well as other factors that influence wait time.
We performed a population-based cross-sectional study evaluating diagnosis-to-surgery time for women with endometrioid adenocarcinoma of the endometrium, during the period of 2006 to 2015, using linked administrative databases. Wait time differences between women with and without class III obesity were evaluated using a Wilcoxon rank-sum test. A multivariable generalized linear model under a generalized estimating equations approach was used to evaluate patient factors (i.e., obesity, age, comorbidities, marginalization, recent immigration, diagnosis year, geographic location), tumour characteristics (i.e., grade, stage), provider type (i.e., surgeon specialty), and institutional characteristics (i.e., rurality, hysterectomy volume, availability of minimally invasive surgery) that influence wait times.
In total, 9797 women met the criteria for inclusion; 2171 (22%) had class III obesity. The overall median wait time was 55 days (interquartile range [IQR] 37–77 d) and the median wait time was significantly longer for women with class III obesity (62 [IQR 43–88] vs. 53 [IQR 36–74] d, standardized mean difference, 0.30). Age <40 or >70 years, comorbidities, lower-grade disease, surgery at an urban teaching hospital, and surgery at a high-volume hospital with greater availability of minimally invasive surgery were associated with longer wait times. After adjusting for these variables, women with class III obesity waited 12% longer.
Class III obesity, comorbidities, and older age are associated with a longer diagnosis-to-surgery time. As the prevalence of obesity and endometrial cancer rise, processes are needed to promote equitable, timely access to care.
Évaluer les conséquences de l'obésité de classe III (indice de masse corporelle > 40 kg/m²) sur le temps d'attente pour subir un traitement chirurgical du cancer de l'endomètre en Ontario ainsi que les autres facteurs qui influencent les temps d'attente.
Nous avons effectué une étude transversale sur une population en évaluant le temps d'attente entre le diagnostic et l'intervention chirurgicale pour les femmes atteintes d'adénocarcinome endométrioïde de l'endomètre, au cours de la période de 2006 à 2015, à l'aide de bases de données administratives couplées. Les différences de temps d'attente entre les femmes atteintes d'obésité de classe III et celles qui ne souffrent pas de ce type d'obésité ont été évaluées à l'aide d'un test de Wilcoxon. Un modèle linéaire généralisé multivariable avec modélisation d’équations d'estimation généralisées a été utilisé pour évaluer les facteurs individuels des patientes (obésité, âge, comorbidités, marginalisation, immigration récente, année de diagnostic, emplacement géographique), les caractéristiques de progression de la tumeur (grade, stade), le type de fournisseur de soins de santé (spécialisation du chirurgien), et les caractéristiques des établissements (ruralité, volume d'hystérectomies réalisées, disponibilité de la chirurgie mini-invasive) qui influencent les temps d'attente.
Au total, 9 797 femmes répondaient aux critères d'inclusion; de ce nombre, 2 171 (22 %) étaient atteintes d'obésité de classe III. Le temps d'attente médian global était de 55 jours (intervalle interquartile [IIQ] : 37–77 j) et le temps d'attente médian était significativement plus long pour les femmes atteintes d'obésité de classe III (62 [IIQ : 43–88] par rapport à 53 [IIQ : 36–74] j, différence moyenne normalisée : 0,30). L’âge de < 40 ans ou de > 70 ans, les comorbidités, une maladie de bas grade, une intervention chirurgicale dans un hôpital universitaire urbain, et une intervention chirurgicale dans un hôpital à fort volume avec une plus grande disponibilité de chirurgie mini-invasive étaient associés à des temps d'attente plus longs. Après ajustement pour ces variables, le temps d'attente pour les femmes atteintes d'obésité de classe III était 12 % plus long.
L'obésité de classe III, les comorbidités et l’âge avancé sont associés à un temps d'attente plus long entre le diagnostic et l'intervention chirurgicale. À mesure que la prévalence de l'obésité et du cancer de l'endomètre augmente, des processus sont nécessaires pour faciliter un accès équitable et rapide aux soins.
Factors associated with outcomes and inpatient 90-day cost of care in endometrial cancer patients undergoing hysterectomy - implications for bundled care payments
2018, Gynecologic Oncology
Citation Excerpt :
Given that our data show higher complication and readmission rates, it was not surprising that obesity was associated with higher costs for hysterectomy as treatment for endometrial cancer. Although these findings are similar to prior studies [1,11], we also show new information relevant to future reimbursement models. First, our data shows that the cost increases over the 90-day time frame independently for each variable considered.
To investigate the association of obesity and other comorbidities as well as route of surgery with postoperative outcomes, as well as 30- and 90-day inpatient cost of care after hysterectomy for endometrial cancer.
From the 2013 National Readmission Database release, patients who underwent hysterectomy for endometrial cancer were included. Obesity was classified as non-obese (body mass index [BMI] < 35 kg/m²); class I/II obesity (BMI ≥ 35 but <40 kg/m² and without obesity related medical condition qualifying it as morbid obesity), class III obesity (BMI ≥ 40 kg/m² OR BMI ≥ 35 kg/m² with an obesity-related medical condition). Incremental cost at 30 and 90 days was calculated using cost-to-charge ratio.
A total of 27,658 patients were identified. Compared to non-obese patients those with class III obesity had higher rate of any medical (non-surgical) complication (22.3% vs 17.2%, p = 0.004), and higher rate of 30-day readmission (6% vs 4.4%, p = 0.003), but similar rates of surgical complications. There were no significant differences in perioperative outcomes between non-obese patients and those with class I/II obesity. Non-obese patients had higher rates of traditional laparoscopy (8.4% vs 13.6%, p < 0.001) and lower conversion rates from a minimally invasive to abdominal (5.5% vs. 8.2%, p < 0.001) than those with class III obesity. Based on multivariate regression model compared to non-obese patients, class I/II obesity (OR 1.05, 95% CI 1.02–1.09) and class III obesity (OR 1.1, 95% CI 1.1–1.18) were associated with higher cost of care. Other factors increasing cost of care included: comorbidity score per unit increase (OR 1.08, 95% 1.07–1.08), insurance status and route of surgery.
Class III obesity was associated with higher medical (but not surgical) complication rates as well as increased overall inpatient care cost when compared to the non-obese population. Number of comorbidities significantly impacted the cost and outcomes after hysterectomy. As more healthcare initiatives focus on bundled payments, our results suggest that payment packages should adjust for obesity rates and medical comorbidities stratified by region and hospital type in order to fairly compensate for increased costs of care.
Quality of Life and Endometrial Cancer
2022, Handbook of Quality of Life in Cancer
Preoperative weight loss in women with obesity in gynaecologic oncology: A retrospective study
2021, Clinical Obesity
The role of obesity in the development and management of gynecologic cancer
2020, Obstetrical and Gynecological Survey

View all citing articles on Scopus

: Supported by The Denise & Prentis Cobb Hale Chair and John A. Kerner, MD, research fund.

: R.A.B. was a consultant for Intuitive surgical product development, $5000 honorarium 2013; the remaining authors report no conflict of interest.

: Cite this article as: Brooks RA, Blansit K, Young-Lin N, et al. The economic impact of surgical care for morbidly obese endometrial cancer patients: a nationwide study. Am J Obstet Gynecol 2016;214:498.e1-6.

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Original ResearchGynecologyThe economic impact of surgical care for morbidly obese endometrial cancer patients: a nationwide study

Background

Objectives

Study Design

Results

Conclusion

Section snippets

Study design and sample population

Demographics and socioeconomic of morbidly obese

Comment

Gynecol oncol

Gynecol Oncol

Ann Thorac Surg

Am J Med Sci

Overweight, obesity, and mortality from cancer in a prospectively studied cohort of U.S. adults

N Engl J med

Cancer statistics, 2014

CA Cancer J Clin

Determining the cost of obesity and its common comorbidities from a commercial claims database

Clin obes

Improving health care cost projections for the medicare population 2010

Impact of morbid obesity on medical expenditures in adults

Int J Obes

Original Research
Gynecology
The economic impact of surgical care for morbidly obese endometrial cancer patients: a nationwide study