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

Abstract

Hysterectomies are among one of the most common major surgical procedures performed in women. However, little is known regarding contemporary U.S. hysterectomy trends for women with benign disease with respect to both operative technique and perioperative complications. We sought to document these trends and to determine the association between these two factors with patient, surgeon, and hospital characteristics. Hysterectomies performed for benign indications by generalist gynecologists from 2012-2014 were analyzed in the all-payer Maryland Health Services Cost Review Commission database. We included both open hysterectomies and those performed by minimally invasive surgery (MIS). Perioperative complications were defined using the Agency for Healthcare Research and Quality Patient Safety Indicators. Surgeon hysterectomy volume was analyzed by quartiles (0-5 = very low, 6-10 = low, 11-20 = medium, and 21+ cases = high volume). We utilized negative binomial regression and logistic regression to identify patient, surgeon, and hospital characteristics associated with MIS utilization and perioperative complications, respectively. A total of 5660 hospitalizations were identified during the study period. Most patients (61.5%) had an open hysterectomy; the remaining (38.6%) underwent a MIS procedure (25.1% robotic, 46.6% laparoscopic, and 28.3% vaginal). Most surgeons (68.2%) performed 10 or fewer hysterectomies during the 2+ year study period. Factors associated with a lower likelihood of undergoing MIS were older patient age (ref: 45-64 years; 20-44: OR = 1.17, 95% CI = 1.06-1.28), black race (ref: white; OR = 0.72, 95% CI = 0.65-0.80), Hispanic ethnicity (OR = 0.62, 95% CI = 0.48-0.79), smaller hospital size (ref: large; small: OR = 0.25, 95% CI = 0.15-0.44; medium: OR = 0.83, 95% CI = 0.75-0.91), and lower surgeon volume (ref: high; medium: OR = 0.87, 95% CI = 0.78-0.97). Complications occurred in 25.8% of open and 8.2% of MIS hysterectomies (P < 0.0001). While MIS hysterectomy was associated with fewer complications (OR = 0.22, 95% CI = 0.17-0.27), patient payer, including Medicare (ref: private; OR = 1.88, 95% CI = 1.34-2.64), Medicaid (OR = 1.70, 95% CI = 1.34-2.11) and self-pay status (OR = 2.49, 95% CI = 1.47-4.27), and low surgeon hysterectomy volume (ref: high; very low: OR = 1.91, 95% CI = 1.34-2.73; low: OR = 1.73, 95% CI = 1.22-2.47) were associated with perioperative complications. Use of minimally invasive hysterectomy for benign indications remains variable, with most patients undergoing open, more morbid procedures. Older and black patients, lower volume surgeons, and smaller hospitals were associated with open hysterectomy. Patient race and payer and lower surgeon volume were also associated with perioperative complications. Hysterectomies performed by high volume surgeons, and especially those with expertise in minimally invasive techniques, may represent an opportunity to reduce adverse events.