Grand Rounds

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

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

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

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

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

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