Patient, surgeon, and hospital disparities associated with benign hysterectomy approach and perioperative complications

Hysterectomy Practice Patterns in the Postmorcellation Era

OBJECTIVE

To characterize long-term national trends in surgical approach for hysterectomy after the U.S. Food and Drug Administration (FDA) warning against power morcellation for laparoscopic specimen removal.

METHODS

This was a descriptive study using data from the American College of Surgeons National Surgical Quality Improvement Program from 2012 to 2016. We identified hysterectomies using Current Procedural Terminology codes. We used an interrupted time-series analysis to evaluate abdominal and supracervical hysterectomy trends surrounding The Wall Street Journal article first reporting morcellation safety concerns and the FDA safety communication. We compared categorical and continuous variables using χ, t, and Wilcoxon rank sum tests.

RESULTS

We identified 179,950 hysterectomies; laparoscopy was the most common mode of hysterectomy in every quarter. Before The Wall Street Journal article, there was no significant change in proportion of abdominal hysterectomies (0.3% decrease/quarter, P=.14). After The Wall Street Journal article, use of abdominal hysterectomy increased 1.1% per quarter for two quarters through the FDA warning (P<.001), plateaued for three quarters until March 2015 (P=.65), then decreased by 0.8% per quarter through 2016 (P<.001). Supracervical hysterectomy volume continuously decreased after the FDA warning (1.0% decrease per quarter, P<.001) and after three quarters (0.7% decrease per quarter, P=.01), then plateaued from April 2015 through 2016 (0.05% decrease per quarter, P=.40). Mode of supracervical hysterectomy was unchanged from 2012 to 2013 (P=.43), followed by two quarters of significant increase in proportion of supracervical abdominal hysterectomies (11.7%/quarter, P<.001). This change in mode of supracervical hysterectomy then plateaued through 2016 (P=.06).

CONCLUSION

Despite early studies suggesting that minimally invasive hysterectomy decreased in response to safety concerns regarding power morcellation, we found that this effect reversed 1 year after the FDA safety communication. However, there was a sustained decline in supracervical hysterectomy, and the remaining supracervical hysterectomies were more likely to be performed using laparotomy.

Contributors to Racial Disparities in Minimally Invasive Hysterectomy in the US Department of Veterans Affairs

BACKGROUND

Minimally invasive hysterectomy for fibroids decreases recovery time and risk of postoperative complications compared with abdominal hysterectomy. Within Veterans Affair (VA), black women with uterine fibroids are less likely to receive a minimally invasive hysterectomy than white women.

OBJECTIVE

To quantify the contributions of patient, facility, temporal and geographic factors to VA black-white disparity in minimally invasive hysterectomy.

RESEARCH DESIGN

A cross-sectional study.

SUBJECTS

Veterans with fibroids and hysterectomy performed in VA between October 1, 2012 and September 30, 2015.

MEASURES

Hysterectomy mode was defined using ICD-9 codes as minimally invasive (laparoscopic, vaginal, or robotic-assisted) versus abdominal. The authors estimated a logistic regression model with minimally invasive hysterectomy modeled as a function of 4 sets of factors: sociodemographic characteristics other than race, health risk factors, facility, and temporal and geographic factors. Using decomposition techniques, systematically substituting each white woman's characteristics for each black woman's characteristics, then recalculating the predicted probability of minimally invasive hysterectomy for black women for each possible combination of factors, we quantified the contribution of each set of factors to observed disparities in minimally invasive hysterectomy.

RESULTS

Among 1255 veterans with fibroids who had a hysterectomy at a VA, 61% of black women and 39% of white women had an abdominal hysterectomy. Our models indicated there were 99 excess abdominal hysterectomies among black women. The majority (n=77) of excess abdominal hysterectomies were unexplained by measured sociodemographic factors beyond race, health risk factors, facility, and temporal or geographic trends.

CONCLUSION

Closer examination of the equity of VA gynecology care and ways in which the VA can work to ensure equitable care for all women veterans is necessary.

Extirpative renal surgery volume in training: different roads to the (same?) destination

PURPOSE

To describe the overall extirpative renal surgery (ERS) training volume reported by PU and PS.

METHODS

Case log data from the Accreditation Council for Graduate Medical Education (ACGME) was examined from 2013-2016 for surgery residents (S_res), urology residents (U_res), pediatric surgery fellows (PS_fel) and pediatric urology fellows (PU_fel). Case log information for all levels of participation over all case categories that could potentially offer ERS volume were recorded. Volume was estimated using the mean number of included cases during residency and fellowship and the sum was used to estimate total training volume. Volume between groups was compared using the student's t test.

RESULTS

Case logs were included for 4447 residents (4259 S_res, 840 U_res) and fellows (188 PS_fel, 71 PU_fel). Mean PU volume was 113.1, which was higher than the mean PS volume of 10.3 (p < 0.001). For PU, more ERS were performed during residency than fellowship (p < 0.001). For PS the opposite was true (p < 0.001). When examining fellow training only, PU_fel performed more ERS than PS_fel (11.7 vs. 7.0 p < 0.001).

CONCLUSION

While previous publications note similar short-term outcomes for ERS for malignancy for PU and PS, ERS case volume during training is significantly different. Review of recent ACGME data indicate that PU have more overall experience with ERS, with most gained during residency. Additionally, PU_fel performed significantly more ERS than PS_fel. Further study into how these training differences affect long-term outcomes is necessary.

Racial/Ethnic Disparities/Differences in Hysterectomy Route in Women Likely Eligible for Minimally Invasive Surgery

STUDY OBJECTIVE

Evaluate racial/ethnic variation in hysterectomy surgical route in women likely eligible for minimally invasive hysterectomy.

DESIGN

Cross-sectional study.

SETTING

Multistate including Colorado, Florida, Maryland, New Jersey, and New York.

PATIENTS

Women aged ≥18 years without diagnoses of leiomyomas, obesity, or previous abdominopelvic surgery who underwent hysterectomy for benign conditions from the State Inpatient and Ambulatory Surgery Databases, 2010-2014.

INTERVENTIONS

None. Primary exposure is race/ethnicity.

MEASUREMENTS AND MAIN RESULTS

Racial/ethnic variation in annual hysterectomy rates and surgical route. To calculate hysterectomy rates per 100 000 women/year, denominators were adjusted for the proportion of women with previous hysterectomy. A marginal structural log binomial regression model was used to estimate adjusted standardized prevalence ratios (aPRs) for vaginal or laparoscopic vs abdominal hysterectomy, controlling for clustering within hospitals. In addition, hospitals were stratified into quintiles to examine surgical route in hospitals that serve a higher vs lower proportion of African American patients. A total of 133 082 adult women underwent hysterectomy for benign conditions from 2010 to 2014. Annual laparoscopic rates increased more slowly for African Americans (1.6-fold) than for whites (1.8-fold) and Hispanics (1.9-fold). African American and Hispanic women were less likely to undergo vaginal (aPR = 0.93; 95% confidence interval [CI], 0.90-0.96 and aPR = 0.95; 95% CI 0.93-0.97, respectively) and laparoscopic hysterectomy (aPR = 0.90; 95% CI, 0.87-0.94 and aPR = 0.95; 95% CI, 0.92-0.98, respectively) than white women; Asian/Pacific Islander women were less likely to undergo vaginal hysterectomy (aPR = 0.88; 95% CI, 0.81-0.96). Hospitals serving a higher proportion of African American persons performed more abdominal and fewer vaginal procedures across all groups, and more racial/ethnic minority women sought care at those hospitals than white women.

CONCLUSION

African American, Hispanic, and Asian/Pacific Islander women eligible for minimally invasive hysterectomy were more likely than white women to receive abdominal hysterectomy. The proportion of all women undergoing abdominal hysterectomy was highest at hospitals serving higher proportions of African American persons. This difference in treatment type can lead to disparities in outcomes, in part owing to their association with complications.

Comparison of Perioperative Outcomes of Autologous Bladder Neck Fascial Slings Based on Fascial Harvest Site: A Secondary Analysis of the National Surgical Quality Improvement Program Database

OBJECTIVES

The objective of this study was to compare perioperative outcomes of autologous bladder neck fascial slings (ABNFS) between rectus fascia and fascia lata harvest sites.

METHODS

We analyzed women undergoing ABNFS in the 2006 to 2015 American College of Surgeons National Surgical Quality Improvement Program database, separating rectus fascia and fascia lata harvest sites by Current Procedural Terminology codes. We compared the 2 harvest sites for perioperative outcomes within 30 days including adverse events, readmission, and reoperation as well as operative time and length of hospital stay. The primary outcome was a composite of postoperative adverse events, readmission, and reoperation. A multivariable logistic regression model was used incorporating race, smoking status, surgical specialty, anesthesia class, concurrent procedures, body mass index, operating time, and length of hospital stay.

RESULTS

A total of 161 women in the database underwent ABNFS: 126 (78.3%) rectus fascia and 35 (21.7%) fascia lata harvest. Patients undergoing rectus fascial harvest were more likely to be white (140 [90.5%] rectus vs 26 [74.3%] fascia lata, P=0.02) and more likely to have ABNFS by a urologist (117 [93%] rectus vs 23 [66%] fascia lata, P < 0.01). There were no significant differences in operative time, length of stay, rate of reoperation, nonserious or serious adverse events, or readmission between the 2 harvest site groups. The 2 harvest sites had similar composite morbidity (adjusted odds ratio of 0.88 for rectus fascia; 95% confidence interval, 0.21-3.75; P=0.87).

CONCLUSIONS

Rectus fascia and fascia lata harvest for ABNFS have similar perioperative outcomes.

Nationwide trends in mortality following penetrating trauma: Are we up for the challenge?

BACKGROUND

Despite a focus on improved prehospital care, penetrating injuries contribute substantially to trauma mortality in the United States. We therefore analyzed contemporary trends in prehospital mortality from penetrating trauma in the past decade.

METHODS

We identified patients in the The National Trauma Data Bank from 2007 to 2010 ("early period") and 2011 to 2014 ("late period") with gunshot wounds (GSW) and stab wounds (SW), who were treated at hospitals that recorded dead-on-arrival statistics. Multivariable logistic regressions assessed differences in body locations of trauma, prehospital mortality, and in-hospital mortality between the early and late periods. Models accounted for hospital clusters and adjusted for age, pulse, hypotension, New Injury Severity Score, Glasgow Coma Scale, and number of injured body parts.

RESULTS

From 2007 to 2014, 437,398 patients experienced penetrating traumas, with equal distributions of GSW and SW. There were unadjusted differences in prehospital mortality (GSW: early, 2.0% vs. late, 4.9%; SW: early, 0.2% vs. late, 1.1%) and in-hospital mortality (GSW: early, 13.8% vs. late, 9.5%; SW: early, 1.8% vs. late, 1.0%) by both mechanisms. After adjustment, patients in the late period relative to those in the early period had significantly higher odds of prehospital death (GSWs: adjusted odds ratio [aOR], 4.54; 95% confidence interval [CI], 3.31-6.22; SWs: aOR, 8.98; 95% CI, 5.50-14.67) and lower odds of in-hospital death (GSWs: aOR, 0.85; 95% CI, 0.80-0.90; SWs: aOR, 0.81; 95% CI, 0.71-0.92). Sensitivity analyses assessing GSWs and SWs by locations of body injury found similar results. Additionally, patients in the late period were more likely to experience penetrating injuries to the face, spine, and lower extremities.

CONCLUSION

In the United States, the prevalence of penetrating traumas remains a nationwide burden. The odds of prehospital mortality has increased over fourfold for GSWs and almost ninefold for SWs. Examining violence intensity, along with improvements in hospital care and data collection, may explain these findings.

LEVEL OF EVIDENCE

Prognostic and epidemiological, level IV.

Robotic vs Open Surgery for Endometrial Cancer in Elderly Patients: Surgical Outcome, Survival, and Cost Analysis

OBJECTIVE

This study aimed to compare robotic and open surgery in elderly women diagnosed as having endometrial cancer, in terms of costs, survival, surgical outcome, and operating time.

METHODS

Women 70 years or older undergoing open and robotic surgery for endometrial cancers were included consecutively before and after the introduction of robotic surgery at a tertiary center. Costs were calculated using the case-costing system, cost per patient, including the first 30 postoperative days. Relative and overall survival outcomes were obtained from the Swedish National Cancer Registry and analyzed using the Kaplan-Meier method. Surgical outcomes including operating and anesthesia times, estimated blood loss, hospital stay, and intraoperative and postoperative complications were reviewed.

RESULTS

In all, 137 and 141 women 70 years or older were identified to have undergone open and robotic surgery, respectively. The groups showed similar body mass index, comorbidities, and tumor characteristics. No statistically significant differences were seen in costs (robotic &OV0556;11,874 vs open &OV0556;11,521, P = 0.463) or 5-year survival outcomes (robotic 94% [95% confidence interval {CI}, 84-105] vs open 87% [95% CI, 78-98], P = 0.529). Robotic surgery was associated with significantly lower estimated blood loss (P < 0.001) and shorter hospital stay (P < 0.001) but longer anesthesia time (186 vs 174 minutes; P < 0.05) and operating theater time (205 vs 190 minutes; P < 0.05). There were no significant differences in intraoperative complications, but robotic surgery resulted in fewer postoperative Clavien-Dindo grade II complications.

CONCLUSIONS

Elderly women can safely undergo robotic surgery for endometrial cancer and could be offered this technique to the same extent as younger patients. They may benefit from shorter hospital stay, decreased blood loss, and postoperative complications, without resulting in higher costs to the health care system or jeopardizing their survival.

Surgical Trends and Time Frame Comparison of Surgical Types of Hysterectomy: A Nationwide, Population-based 15-year Study

STUDY OBJECTIVE

To investigate the surgical trends among different types of hysterectomy (abdominal, vaginal, laparoscopic, and subtotal) over a 15-year period in Taiwan.

DESIGN

A retrospective cohort study.

SETTING

A population-based National Health Insurance Research Database.

PATIENTS

Women undergoing various types of hysterectomy for noncancerous lesions.

INTERVENTIONS

Data for this study were extracted from the inpatient expenditures by admissions files of Taiwan's National Health Insurance Research Database from 1998 through 2012 and divided into three 5-year time frames: first (1998-2002), second (2003-2007), and third (2008-2012). The variables included types of hysterectomy, patient age, gynecologist age and sex, hospital accreditation level, and surgical volume. Chi-square and trend tests were used to examine the association between the variables.

MEASUREMENTS AND MAIN RESULTS

A total of 329 438 patients who underwent various types of hysterectomy were identified; 306 257 were included in the study. During the 15-year period, 45% underwent total abdominal hysterectomy, 41% underwent laparoscopic hysterectomy (LH), 9.8% underwent vaginal hysterectomy, and 4.2% underwent subtotal abdominal hysterectomy. The frequency of LHs increased from 35.9% in the first period to 43.9% in the second period and remained at 44.2% in the third period. During the same time period, there was a decrease in the frequency of total abdominal hysterectomies. Typically, younger patients underwent LHs by gynecologists with large volume surgical practices and medical centers.

CONCLUSION

This 15-year study describes an increase of LHs and subtotal abdominal hysterectomies over time and provides evidence of surgical trends and a paradigm shift of hysterectomies. Surgical skills and performance extended from high- to low-surgical volume gynecologists and from medical centers to regional and local hospitals. This shift may have a great influence on patient and health care provider choice of treatment.

Emergency general surgery in geriatric patients: A statewide analysis of surgeon and hospital volume with outcomes

BACKGROUND

Geriatric patients undergoing emergency general surgery (EGS) face significant morbidity and mortality. We assessed how surgeon and hospital volumes affected these outcomes.

METHODS

We identified patients at least 65 years old in Maryland's Health Services Cost Review Commission database from 2012 to 2014 who underwent one of 12 EGS procedures, as defined by the American Association for the Surgery of Trauma, and then calculated four outcomes: mortality rate, the incidence of at least one of eight common in-hospital EGS complications, failure-to-rescue (death after experiencing a postoperative complication), and the 30-day readmission rate. Median annual volumes of geriatric-EGS procedures divided both surgeons and hospitals into two groups (low volume and high volume). Multivariable logistic regressions calculated associations between the volume groups and outcomes after adjusting for patient, surgeon, and hospital factors, and hospital clusters.

RESULTS

We identified 3,832 patients who had an EGS procedure by 302 surgeons (median: 8 geriatric-EGS/year, IQR: 3-18) at 44 hospitals (median: 82 geriatric-EGS/year, IQR: 35-132). While operating on 16.5% of all geriatric-EGS patients, low-volume surgeons had higher risk-adjusted adverse outcomes: mortality (7.0% vs. 4.0%, p = 0.005), in-hospital complications (22.1% vs. 19.7%, p = 0.13), failure-to-rescue (17.3% vs. 12.1%, p = 0.021), and 30-day readmissions (11.2% vs. 10.0%, p = 0.55). After adjustment, low-volume surgeons were associated with higher mortality (adjusted odds ratio [aOR] 1.86, 95% CI [1.21-2.86]) and failure-to-rescue rates (aOR 1.74 [1.09-2.80]) but not in-hospital complications (aOR 1.20 [0.95-1.51]) or 30-day readmissions (aOR 1.07 [0.85-1.34]). In contrast, low-volume hospitals relative to high-volume hospitals, and hospitals serving lower proportions of geriatric-EGS patients, were not associated with adverse outcomes.

CONCLUSION

Relative to their higher-volume counterparts, surgeons performing eight or fewer geriatric-EGS procedures annually were associated with an 86% higher odds of death and 74% higher odds of failure-to-rescue in this elderly EGS patient population. These findings underscore the need for focused care of elderly surgical patients.

LEVEL OF EVIDENCE

Prognostic and epidemiological, level IV.

Hospital variation in mortality after emergent bowel resections: The role of failure-to-rescue

BACKGROUND

Hospital variation in failure-to-rescue (FTR) rates has partially explained nationwide differences in mortality after elective surgeries. To examine the role of FTR among emergency general surgery, we compared nationwide risk-adjusted mortality, complications, and FTR rates after emergent bowel resections.

METHODS

We identified patients who underwent emergent small or large bowel resections in the 2010 to 2011 Nationwide Inpatient Sample using the American Association for the Surgery of Trauma criteria. We then calculated risk-adjusted mortality rates for each hospital using multivariable logistic regressions and postestimation, which adjusted for patient age, sex, race and ethnicity, payer status, comorbidities, and hospital clustering. After excluding hospitals with fewer than 10 resections per year, we ranked the remaining hospitals by their risk-adjusted mortality rates and divided them into five quintiles. We compared both risk-adjusted complication rates and FTR rates between the top (lowest mortality) and bottom (highest mortality) quintiles.

RESULTS

We identified 21,564 emergent bowel resections, weighted to 105,925 procedures nationwide. The bottom quintile of hospitals had an overall risk-adjusted mortality rate that was 10.9 times higher than that of the top quintile of hospitals (15.3% vs. 1.4%). While risk-adjusted complication rates were similarly high for both the bottom and the top quintiles of hospitals (22.5% vs. 15.7%), the risk-adjusted FTR rates were 10.8 times higher in the bottom quintile of hospitals relative to the top quintile of hospitals (33.4% vs. 3.1%). Using larger hospital volume thresholds yielded similar findings. Furthermore, large variations existed in complication-specific FTR rates (surgical site infection [6.6%] to myocardial infarction [29.4%]).

CONCLUSION

Nationwide hospital variation in risk-adjusted mortality rates exist after emergent bowel resections. As complication rates were similar across hospitals, the significantly higher FTR rates at higher-mortality hospitals may drive this variation in mortality. System-level initiatives addressing the management of postoperative complications may improve patient care and reduce variation in outcomes.

LEVEL OF EVIDENCE

Prognostic and epidemiological study, level IV.

Examining Disparities in Route of Surgery and Postoperative Complications in Black Race and Hysterectomy

OBJECTIVE

To estimate the associations among race, route of hysterectomy, and postoperative complications among women undergoing hysterectomy for benign indications.

METHODS

A cohort study was performed. All patients undergoing hysterectomy for benign indications, recorded in the National Surgical Quality Improvement Program and its targeted hysterectomy file in 2015, were identified. The primary exposure was patient race. The primary outcome was route of hysterectomy and the secondary outcome was postoperative complication. Associations were examined using both bivariable tests and logistic regression.

RESULTS

Of 15,136 women who underwent hysterectomy for benign indications, 75% were white and 25% were black. Black women were more likely to undergo an open hysterectomy than white women (50.1% vs 22.9%; odds ratio [OR] 3.36, 95% CI 3.11-3.64). Black women had larger uteri (median 262 g vs 123 g; 60.7% vs 25.6% with uterus greater than 250 g), more prior pelvic surgery (58.5% vs 53.2%), and higher body mass indices (32.7 vs 30.4). After adjusting for these and other clinical factors, black women remained more likely to undergo an open hysterectomy (adjusted OR 2.02, 95% CI 1.85-2.20). Black women experienced more major complications than white women (4.1% vs 2.3%; P<.001) and more minor complications (11.4% vs 6.7%; OR 1.78, P<.001). Again these disparities persisted with adjustment (major adjusted OR 1.56, 95% CI 1.25-1.95; minor adjusted OR 1.27, 95% CI 1.11-1.47).

CONCLUSIONS

Black women undergo a higher proportion of open hysterectomy and experience more major and minor postoperative complications. These differences persisted even after adjusting for confounding medical, surgical, and gynecologic factors.

Race Differences in Reported Harmful Patient Safety Events in Healthcare System High Reliability Organizations

OBJECTIVES

The aim of the study was to determine whether race differences exist in voluntarily reported harmful patient safety events in a large 10 hospital healthcare system on a high reliability organization journey.

METHODS

From July 1, 2015, to June 30, 2017, employees in a healthcare system based in Washington, District of Columbia, and Maryland voluntarily reported harmful patient safety events by type using a Patient Safety Event Management System. Inpatients, outpatients, and observation patients were identified as "black," "white," or "other" (N = 5038). Using retrospective analysis and χ goodness of fit, comparisons of race proportions were conducted to determine differences at the health system level, by hospital, by event type, and by severity.

RESULTS

Significant race differences existed: (1) overall with higher proportions of whites and lower proportions of other in a Patient Safety Event Management System; (2) by type across races; (3) in six hospitals across races; and (4) by type and by hospital for blacks and whites. All differences were significant at P < 0.05.

CONCLUSIONS

Race differences in harmful events exist in voluntary reporting systems by type and by hospital setting. Healthcare organizations, particularly healthcare high reliability organizations, can use these findings to help identify areas of further study and investigation. Further study and investigation should include efforts to understand the root cause of the differences found in this study, including the role of reporting bias.

Associations between Race/Ethnicity, Uterine Fibroids, and Minimally Invasive Hysterectomy in the VA Healthcare System

BACKGROUND

In the general population, Black and Latina women are less likely to undergo minimally invasive hysterectomy than White women, which may be related to racial/ethnic variation in fibroid prevalence and characteristics. Whether similar differences exist in the Department of Veterans Affairs Healthcare System (VA) is unknown.

METHODS

Using VA clinical and administrative data, we identified all women veterans undergoing hysterectomy for benign indications in fiscal years 2012-2014. We identified hysterectomy route (laparoscopic with/without robot-assist, vaginal, abdominal) by International Classification of Diseases, 9th edition, codes. We used multinomial logistic regression to estimate associations of race/ethnicity with hysterectomy route and tested whether associations varied by fibroid diagnosis using an interaction term. Models adjusted for age, income, body mass index, gynecologic diagnoses, medical comorbidities, whether procedure was performed or paid for by VA, geographic region, and fiscal year.

RESULTS

Among 2,744 identified hysterectomies, 53% were abdominal, 29% laparoscopic, and 18% vaginal. In multinomial models, racial/ethnic differences were present among veterans with but not without fibroid diagnoses (p value for interaction < .001). Among veterans with fibroids, Black veterans were less likely than White veterans to have minimally invasive hysterectomy (laparoscopic vs. abdominal relative risk ratio [RRR], 0.52; 95% CI, 0.38-0.72; vaginal vs. abdominal RRR, 0.58; 95% CI, 0.43-0.73). Latina veterans were as likely as White veterans to have laparoscopic as abdominal hysterectomy (RRR, 1.34; 95% CI, 0.87-2.07) and less likely to have vaginal than abdominal hysterectomy (RRR, 0.32; 95% CI, 0.15-0.69).

CONCLUSIONS

Receipt of minimally invasive hysterectomy among women veterans with fibroids varied by race/ethnicity. Further investigation of the underlying mechanisms and potential interventions to increase minimally invasive hysterectomy among minority women veterans is needed.

Is there evidence of a July effect among patients undergoing hysterectomy surgery?

BACKGROUND

It is hypothesized that the quality of health care decreases during trainee turnovers at the beginning of the academic year. The influx of new gynecology and surgery residents into hospitals in this setting may be associated with poorer surgical outcomes, known as the July effect.

OBJECTIVE

We sought to systematically study hysterectomy outcomes in the state of Maryland during the 3-month period July through September as compared to all other months of the academic year, in order to assess for the presence of a July effect in hysterectomy surgery.

STUDY DESIGN

This is a retrospective study of the Maryland Health Services Cost Review Commission Database from July 2012 through September 2015 focused on women undergoing hysterectomies for benign or malignant disease, either by obstetricians and gynecologists or gynecologic oncologists, during July through September vs October through June. Multivariable logistic regressions accounted for clustering by hospitals and adjusted for several cofactors. The primary outcome includes at least 1 of 11 major perioperative in-hospital complications; the secondary outcomes were extended postoperative length of stay (defined as >2 days) and 30-day inpatient readmission rates.

RESULTS

We identified 6311 hysterectomies (78.2% benign) performed by 424 surgeons at 20 academic hospitals. Patients were primarily white (42.8%), 45-64 years old (54.4%), and had private insurance (66.3%). The unadjusted rate of in-hospital complications was 16.8%, extended length of stay was 30.3%, and 30-day readmissions was 6.6%. After adjustment, patients undergoing hysterectomies during July through September did not have more adverse outcomes relative to those undergoing surgery at other times of the year: complications (adjusted odds ratio, 0.87; 95% confidence interval, 0.75-1.01), length of stay >2 days (adjusted odds ratio, 1.03; 95% confidence interval, 0.90-1.19), and 30-day readmissions (adjusted odds ratio, 0.99; 95% confidence interval, 0.80-1.23). Sensitivity analyses assessing individual complications, hysterectomy outcomes at nonacademic hospitals, and benign vs malignant indications for hysterectomies yielded similar findings.

CONCLUSION

Women in Maryland undergoing hysterectomy surgery at academic hospitals during July through September of the academic year did not experience worse outcomes relative to women having surgery in other months. Additional studies are necessary to further assess the possibility of a July effect in hysterectomy on a national basis. Institutions should continue to provide effective surgical training environments for new interns and residents transitioning to more senior roles, while maintaining optimal patient safety.

Surgeon variation in operating times and charges for emergency general surgery

BACKGROUND

Patients and hospitals face significant financial burdens from emergency general surgeries (EGSs), which have been termed a public health crisis in the United States. We evaluated hospitalization charges, operating charges, and variations in operating time by surgeon volume for three common EGS procedures.

METHODS

Using Maryland's Health Services Cost Review Commission database, we performed a retrospective study of laparoscopic appendectomies, laparoscopic cholecystectomies, and open bowel resections performed by general surgeons among adult patients from July 2012 to September 2014. We compared operating charges to total hospitalization charges and quantified variations in operating time for each procedure. We then divided patients into quartiles based on their surgeon's procedure-specific case volume and used hierarchical linear regressions to calculate differences in both operating time and charges between quartiles.

RESULTS

We identified 3194 appendectomies, 4143 cholecystectomies, and 1478 bowel resections. Operating charges accounted for one-quarter (26.9%) of total hospitalization charges and widespread variation existed in operating time (appendectomies: median 79 min [interquartile range 66-100 min], cholecystectomies: 96 min [76-125 min], bowel resections: 155 min [117-209 min]). After adjustment, low-volume surgeons relative to high-volume surgeons did not operate statistically longer for appendectomies (+1%, 95% confidence interval [CI]: -2% to 5%) but operated +16% (95% CI: 12%-20%) longer for cholecystectomies (+14 min) and +40% (95% CI: 30%-50%) longer for bowel resections (+59 min). Adjusted median operating charges from low-volume surgeons relative to high-volume surgeons were $554 (26.7%), $621 (22.0%), and $1801 (47.0%) greater for appendectomies, cholecystectomies, and bowel resections, respectively.

CONCLUSIONS

Operating charges contributed substantially to total EGS hospitalization charges, where low-volume surgeons operated longer and had higher operative charges relative to high-volume surgeons. Reducing variations in operating times and charges represents an opportunity to alleviate the financial burden from EGS procedures.

A Swedish population-based evaluation of benign hysterectomy, comparing minimally invasive and abdominal surgery

OBJECTIVE

The aim was to evaluate surgical routes for benign hysterectomy in a Swedish population, including abdominal and minimally invasive surgery.

STUDY DESIGN

Prospectively collected data from the Swedish National GynOp Registry 2009-2015: 13 806 hysterectomy cases were included: abdominal (AH, n = 7485), vaginal (VH, n = 3767), conventional laparoscopic (LH, n = 1539) and robotically-assisted (RAH, n = 1015).

RESULTS

The VH group had the shortest operation time at 75 min, AH 97 min and RAH 104 min. LH was longest at 127 min (p < 0.005). The mean estimated blood loss was higher in the AH group (250 ml) compared to all minimally invasive surgery (MIS, 65-172 ml); p < 0.005). Conversion rates were 10% for LH, 4.8% for VH and 1.6% for RAH (p < 0.005). Hospitalization and patient-reported time to normal activities of daily living (ADL) were longer for AH compared to MIS (p < 0.005). Time to return to work was eight days longer in the AH group (35 days) compared with the MIS groups (p < 0.005). Complications were fewest in the VH group at 5.4% compared with AH 7.6% and RAH 8.7% (both p < 0.001), but did not significantly differ from the LH group at 6.6%. Overall patient satisfaction was reported to be 86-94% one year after surgery.

CONCLUSION

Women operated on for benign hysterectomy with minimally invasive methods in Sweden 2009-2015 had reduced length of hospitalization, as well as time to resuming normal ADL and return to work, compared to AH. Postoperative outcome measures were improved by minimally invasive methods and MIS should preferably be used.

Examining Healthcare Segregation Among Racial and Ethnic Minorities Receiving Spine Surgical Procedures in the State of Florida

STUDY DESIGN

This was a retrospective review of the Florida Inpatient Dataset (2011-2014).

OBJECTIVE

To examine healthcare segregation among African American and Hispanic patients treated with one of four common spine surgical procedures.

SUMMARY OF BACKGROUND DATA

Racial and ethnic minorities are known to be at increased risk of adverse events after spine surgery. Healthcare segregation has been proposed as a source for these disparities, but has not been systematically examined for patients undergoing spine surgery.

METHODS

African American, Hispanic, and White patients who underwent one of the four lumbar spine surgical procedures under study were included. Volume cut-offs were previously established for surgical providers and hospitals. Surgeons and hospitals were dichotomized based on these metrics as low- or high-volume providers. Multivariable logistic regression analysis was used to determine the likelihood of patients receiving surgery from a low volume provider, adjusting for sociodemographic and clinical characteristics.

RESULTS

African Americans were found to be at significantly increased odds of receiving surgery from a low-volume surgeon (P < 0.001) and were significantly more likely to receive surgery at a low-volume hospital (P < 0.007) for all procedures except decompression (P = 0.56). Like findings were encountered for Hispanic patients. Hispanic patients were 55% to three-times more likely to receive surgery from a low-volume surgeon depending on the procedure and 28% to 56% more likely to be treated at a low-volume hospital. African Americans were 34% to 82% more likely to receive surgery from a low-volume surgeon depending on the procedure and 10% to 17% more likely to be treated at a low-volume hospital.

CONCLUSION

The results of this work identify the phenomenon of racial and ethnic healthcare segregation among low-volume providers for lumbar spine procedures in the State of Florida. This may be a contributing factor to the increased risk of adverse events after spine surgery known to exist among minorities.

LEVEL OF EVIDENCE

3.

Effect of Surgeon and Hospital Volume on Emergency General Surgery Outcomes

BACKGROUND

Emergency general surgery (EGS) contributes to half of all surgical mortality nationwide, is associated with a 50% complication rate, and has a 15% readmission rate within 30 days. We assessed associations between surgeon and hospital EGS volume with these outcomes.

STUDY DESIGN

Using Maryland's Health Services Cost Review Commission database, we identified nontrauma EGS procedures performed by general surgeons among patients 20 years or older, who were admitted urgently or emergently, from July 2012 to September 2014. We created surgeon and hospital volume categories, stratified EGS procedures into simple (mortality ≤ 0.5%) and complex (>0.5%) procedures, and assessed postoperative mortality, complications, and 30-day readmissions. Multivariable logistic regressions both adjusted for clinical factors and accounted for clustering by individual surgeons.

RESULTS

We identified 14,753 procedures (61.5% simple EGS, 38.5% complex EGS) by 252 (73.3%) low-volume surgeons (≤25 total EGS procedures/year), 63 (18.3%) medium-volume surgeons (26 to 50/year), and 29 (8.4%) high-volume surgeons (>50/year). Low-volume surgeons operated on one-third (33.1%) of all patients. For simple procedures, the very low rate of death (0.2%) prevented a meaningful regression with mortality; however, there were no associations between low-volume surgeons and complications (adjusted odds ratio [aOR] 1.07; 95% CI 0.81 to 1.41) or 30-day readmissions (aOR 0.80; 95% CI 0.64 to 1.01) relative to high-volume surgeons. Among complex procedures, low-volume surgeons were associated with greater mortality (aOR 1.64; 95% CI 1.12 to 2.41) relative to high-volume surgeons, but not complications (aOR 1.06; 95% CI 0.85 to 1.32) or 30-day readmission (aOR 0.99; 95% CI 0.80 to 1.22). Low-volume hospitals (≤125 total EGS procedures/year) relative to high-volume hospitals (>250/year) were not associated with mortality, complications, or 30-day readmissions for simple or complex procedures.

CONCLUSIONS

We found evidence that surgeon EGS volume was associated with outcomes. Developing EGS-specific services, mentorship opportunities, and clinical pathways for less-experienced surgeons may improve outcomes.