Achieving high value in the surgical approach to hysterectomy

Current and Future Trends in Performance of Vaginal Hysterectomy in the United States

OBJECTIVE

To describe the current and future use of vaginal hysterectomy in the United States for benign indications.

METHODS

In this retrospective cohort study using data from the PINC AI Healthcare Database, we analyzed patients who underwent hysterectomy for benign indications from 2006 to 2020. Hysterectomy was classified as abdominal, vaginal, or minimally invasive (laparoscopic or robotic-assisted). Demographic and clinical characteristics, as well as surgeon and hospital characteristics and practice settings associated with the performance of vaginal hysterectomy, were estimated using multivariable models. To examine trends in the route of hysterectomy for benign indications, we plotted a trajectory to 2030 estimated from the vector autoregressive moving average processes model.

RESULTS

A total of 1,558,107 patients-including 852,356 (54.7%) who underwent minimally invasive hysterectomy, 472,234 (30.3%) who underwent abdominal hysterectomy, and 233,517 (15.0%) who underwent vaginal hysterectomy-were identified. The rate of vaginal hysterectomy declined from 22.6% in January 2006 to 8.3% in December 2020. Vaginal hysterectomy was more commonly performed in hospitals with a high volume of prolapse and incontinence cases and by surgeons who performed a high number of hysterectomies for prolapse and incontinence and who are high-volume. The rate of vaginal hysterectomy was projected to decline to 7.3% by January 2030. By January 2030, vaginal hysterectomy was estimated to be used in 11.9% of patients undergoing hysterectomy for prolapse and in 3.5% of hysterectomies for other indications. For all indications, a minimally invasive hysterectomy will be the most common route of surgery.

CONCLUSION

The performance of vaginal hysterectomy has declined substantially and is expected to fall to fewer than 8% of hysterectomies by 2030.

Determinants of Surgical Approach for Benign Outpatient Hysterectomy

STUDY OBJECTIVE

Identify determinants of the surgical approach to a benign, outpatient, minimally invasive hysterectomy.

DESIGN

A cross-sectional sample of patients undergoing outpatient hysterectomy between the 4th quarter of 2015 and the 4th quarter of 2022, excluding those with a diagnosis of gynecologic malignancy, was obtained from the Vizient Clinical Data Base. The primary outcome was surgical approach to hysterectomy that was analyzed using mixed-effects regression, including a surgeon-level random effects to capture unobserved surgeon-level differences influencing variation in surgical approach.

SETTING

The Vizient Clinical Data Base includes patient encounter data from >50 healthcare systems and >400 community hospitals and represents approximately 97% of academic medical centers in the United States.

PATIENTS

Women >18 years undergoing an outpatient benign hysterectomy.

INTERVENTION

Surgical approach to hysterectomy.

MEASUREMENT AND MAIN RESULT

The final sample included 411 208 cases performed by 6089 surgeons. Among observed variables, patient diagnosis, surgeon specialty, and insurance type were strongly associated with choice of approach. However, after controlling for patient, hospital, and observable surgeon characteristics, unobserved surgeon-level differences still accounted for 72% of the variance in the use of transvaginal hysterectomy (95% confidence interval, 71-73) and 85% of the variance in the use of robot-assisted total hysterectomy (95% confidence interval, 84-86).

CONCLUSION

The strongest determinant of surgical approach to a benign outpatient hysterectomy in the United States was not patient- or hospital-level variability, but unexplained differences across individual surgeons. This has implications in how surgeons are trained and incentivized to deliver high-value surgical care.

Determinants of Cost for Outpatient Hysterectomy for Benign Indications in a Nationwide Sample

OBJECTIVE

To identify surgeon-level variation in cost to produce an outpatient hysterectomy for benign indications in the United States.

METHODS

A sample of patients undergoing outpatient hysterectomy in October 2015 to December 2021, excluding those with a diagnosis of gynecologic malignancy, was obtained from the Vizient Clinical Database. The primary outcome was total direct hysterectomy cost, which is a modeled cost to produce care. Patient, hospital, and surgeon covariates were analyzed with mixed-effects regression, which included surgeon-level random effects to capture unobserved differences influencing cost variation.

RESULTS

The final sample included 264,717 cases performed by 5,153 surgeons. The median total direct cost of hysterectomy was $4,705 (interquartile range $3,522-6,234). Cost was highest for robotic hysterectomy ($5,412) and lowest for vaginal hysterectomy ($4,147). After all variables were included in the regression model, approach was the strongest of the observed predictors, but 60.5% of the variance in costs was attributable to unexplained surgeon-level differences, implying a difference in costs between the 10th and 90th percentiles of surgeons of $4,063.

CONCLUSION

The largest observed determinant of cost to produce an outpatient hysterectomy for benign indications in the United States is approach, but differences in cost are attributable primarily to unexplained differences among surgeons. Standardization of surgical approach and technique and surgeon awareness of surgical supply costs could address these unexplained cost variations.

To Robot or Not To Robot: The Use of Robotics in Benign Gynecologic Surgery

The use of robotic-assisted laparoscopic surgery has continued to grow since the Food and Drug Administration approval for robotic-assisted gynecologic surgery in 2005. However, despite this growth in utilization, the data supporting its use in benign gynecologic surgery has not strongly supported its advantages over conventional laparoscopy. Controversy exists between supporters of robotic-assisted laparoscopic surgery and conventional laparoscopy. This article discusses the current literature regarding the use of robotic-assisted surgery in benign gynecologic surgery.

What Is New in Recovery After Gynecologic Surgery for Benign Indications?: Best Articles From the Past Year

This month we focus on current research in recovery after gynecologic surgery for benign indications. Dr. Whiteside discusses four recent publications, which are concluded with a "bottom line" that is the take-home message. A complete reference for each can be found on on this page along with direct links to the abstracts.