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Grand Rounds

Would a ‘Minimal Number of Hysterectomies in the Past Year’ Requirement Benefit Patients?

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BACKGROUND AND PURPOSE:

  • Previous research has demonstrated an association between surgical experience (as measured by minimum volume of previous procedures) and patient outcomes
  • Debate remains whether there should be strict volume cut-offs
    • For: Will save lives
    • Against: Cut-offs are decided arbitrarily without evidence to prove adoption of such policies will results will reduce adverse outcomes
  • Ruiz et al. (Obstetrics & Gynecology, 2018) modeled the potential effect of an enforced minimum-volume standard for hysterectomy, evaluating surgeon practice patterns and patient outcomes

METHODS:

  • Retrospective cohort study
    • Data captured for all women undergoing hysterectomy from 2010-2014 (New York State)
    • Estimated the number of hysterectomies performed by each patient’s physician during the prior year
  • Multivariable models were used to
    • Estimate the ratio of observed to expected complications, based on each surgeon’s volume during the prior year
  • The means observed/expected ratio of surgeons was plotted by volume
    • Observed/expected ratio of <1: Morbidity rate lower than expected
    • Observed/expected ratio of ≥1: Morbidity same as or higher than predicted
  • The model calculated the effect a minimum-volume standard on
    • Number of patients and surgeons eliminated
    • Complication reduction
  • Separate analyses were performed for each route of hysterectomy

RESULTS:

  • 127,202 patients were included
    • 43.9% Abdominal hysterectomy | 34.0% laparoscopic | 11.1% Robotic-assisted | 11.1% Vaginal hysterectomy
  • Based on lowest percentiles and standard deviation, 1 surgery/year was used as a minimum
  • Abdominal hysterectomy
    • Increasing surgeon volume was associated with a decreasing rate of complications (P<.001)
    • 17.5% of surgeons had a prior year volume of one
    • The mean observed/expected morbidity ratio of surgeons with a prior year abdominal hysterectomy volume of one was 1.47
    • 31.4% had an observed/expected ratio of ≥1 | 68.7% <1
  • Robotic-assisted hysterectomy
    • 12.5% had prior year volume of one
    • Mean observed/expected morbidity ratio of 1.38
    • 20.3% had an observed/expected ratio of ≥1 | 79.7% <1
  • Laparoscopic hysterectomy
    • 16.8% had prior year volume of one
    • Mean observed/expected ratio was 0.86 (less complications than predicted)
  • Vaginal hysterectomy
    • 27.6% had a prior year volume of one
    • Mean observed/expected ratio of 1.24
  • Selection of a prior year volume standard of one would restrict
    • 12.5% of surgeons performing robotic-assisted hysterectomy
    • 16.8% of those performing laparoscopic hysterectomy
    • 27.6% of surgeons performing vaginal hysterectomy

CONCLUSION:

  • Implementing minimum-volume standards for hysterectomy would greatly limit the number of gynecologic surgeons, including many with outcomes that are better than predicted

Learn More – Primary Sources:

Effect of Minimum-Volume Standards on Patient Outcomes and Surgical Practice Patterns for Hysterectomy

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Related ObG Topics:

Does a Hysterectomy before 50 Shorten Lifespan?
Are There any Minor Risks Involved with the ‘Opportunistic’ Removal of Fallopian Tubes to Prevent Cancer During Hysterectomy or Sterilization Procedures
Uterine Artery Embolization, Focused Ultrasound, or Hysterectomy for Fibroids?

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