Effect of physician gender and specialty on utilization of hysterectomy in New York, 2001-2005

In-hospital complications of vaginal versus laparoscopic-assisted benign hysterectomy among older women: a propensity score-matched cohort study

OBJECTIVE

This investigation compared the outcomes of vaginal and laparoscopic hysterectomies for nonprolapsed benign indications in older women.

METHODS

We conducted a population-based, retrospective propensity score-matched cohort study using data from the Taiwan's National Health Insurance program. Women who were aged 65 years or older with vaginal hysterectomy (n = 290) were compared with women who had laparoscopic hysterectomy for nonprolapsed benign indications (n = 290). Propensity score was calculated based on both patient- (age, socioeconomic status, residential urbanicity, comorbidity, status of any prior catastrophic illness, surgical diagnosis, and year of hysterectomy) and provider-related characteristics (physician's age and sex, hospital accreditation level, and ownership type).

RESULTS

Women undergoing laparoscopic hysterectomy were not associated with increased risk of inpatient readmission within 30 days, in-hospital mortality, and in-hospital (including intraoperative) complications when compared with those who had vaginal hysterectomy. Women in the laparoscopic group had significantly shorter hospital stays than those in the vaginal group. The bleeding complications were mostly due to blood transfusion (2.1% in vaginal and 0.7% in laparoscopic hysterectomy groups) and urinary tract infection (1.0% in vaginal and 1.7% in laparoscopic hysterectomy groups). The surgical injury (intraoperative) complications included mostly surgical laceration of the urinary tract (0.7% in vaginal and 0.3% in laparoscopic hysterectomy groups).

CONCLUSIONS

Advanced age alone should not be the limiting factor for surgical referral of laparoscopic hysterectomy. The shorter hospital stay and low in-hospital complications associated with laparoscopic, as opposed to vaginal hysterectomies, are important attributes of a surgical procedure essential to the postoperative care in older women aged 65 years or more.

Decreasing trend of hysterectomy in Taiwan: A population-based study, 1997-2010

OBJECTIVE

Gynecologists in Taiwan are lacking a comprehensive picture of the changes in clinical practice and indications of hysterectomy over a long period of time. The aims of this study were to examine the national trends in the utilization of hysterectomy and to explore changes in its utilization rate over a 14-year period from 1997 to 2010.

MATERIALS AND METHODS

We conducted a population-based trend analysis using the claims data from the Taiwan's National Health Insurance program.

RESULTS

We identified a total of 341,993 women aged 20 years or older who underwent hysterectomy between 1997 and 2010. The total number of hysterectomies increased from 22,961 in 1997 to 27,757 cases in 1999, followed by a decline to 22,351 in 2010. Overall, 5406 fewer hysterectomies (-19.5%) were performed in 2010 when compared with those performed in 1999. The number of hysterectomies performed decreased from 1997 to 2010 for precancerous lesions (-55.6%), chronic pelvic pain (-35.2%), uterine leiomyoma (-13.1%), and uterine prolapse (-7.2%). However, the utilization of hysterectomy increased for endometriosis (+76.3%) and gynecologic cancer (+22.7%) during the same time frame.

CONCLUSION

The clinical utilization and primary indications of hysterectomy changed substantially in Taiwan from 1997 to 2010. The continued monitoring of changes in hysterectomy rates will be critical for understanding the appropriate indications for hysterectomy and oophorectomy, the emergence of alternative managements for uterine disorders, and future trends in women's reproductive health.

Gynecologists' characteristics associated with the likelihood of performing laparoscopic-assisted hysterectomy: a nationwide population-based study

OBJECTIVE

With continuing development of minimally invasive techniques in gynecology, hysterectomy with laparoscopic assistance is increasingly performed. This study aimed to examine the relationship between the characteristics of gynecologists and the likelihood of performing laparoscopic-assisted hysterectomy (LH) under the case payment system of Taiwan's National Health Insurance.

STUDY DESIGN

A retrospective population-based study was conducted based on the data from Taiwan's National Health Insurance Research Database. A total of 56,532 female residents aged 20 years and older who underwent total hysterectomy with or without laparoscopic assistance between 2004 and 2006 were included in the study. The gender, age and practice volume of their gynecologists were noted. Odds ratios (ORs) and 95% confidence intervals (CIs) were estimated by univariate and multivariate logistic regression analyses.

RESULTS

Of the women selected, 30,478 underwent traditional total hysterectomy (TH) and 26,054 underwent LH. After controlling for clinical and nonclinical factors, male gynecologists (OR 1.65, 95% CI 1.55-1.76) were more likely to perform LH than their female colleagues. Gynecologists aged 60 years and older (OR 0.31, 95% CI 0.29-0.39) had the lowest likelihood of performing LH compared with their counterparts. In addition, surgeons with low-volume practice (OR 0.31, 95% CI 0.29-0.33) also had a significantly lower probability of performing LH compared with other surgeons.

CONCLUSION

A higher likelihood of performing LH was observed among male and younger gynecologists with high-volume practice in Taiwan. This finding suggests that differences in practice patterns and surgical treatment decision may explain the variation in the approaches to laparoscopy-assisted hysterectomies.

CONDENSATION

Differences in practice patterns and surgical treatment decisions may explain the variation in the approaches to laparoscopic-assisted hysterectomies.

No (wo)man is an island--the influence of physicians' personal predisposition to labia minora appearance on their clinical decision making: a cross-sectional survey

INTRODUCTION

Physicians are increasingly presented with women requesting a labia minora reduction procedure.

AIM

To assess the influencing factor of personal predisposition in general practitioners, gynecologists, and plastic surgeons to labia minora appearance in relation to their willingness to refer for, or perform, a surgical labia minora reduction.

METHODS

Cross-sectional self-administered questionnaire survey. Between May 2009 and August 2009, 210 physicians were surveyed. Primary care: general practitioners working in the north of the Netherlands. Secondary care: gynecologists and plastic surgeons working in five hospitals in the north of the Netherlands.

MAIN OUTCOME MEASURES

A five-point Likert scale appraisal of four pictures showing a vulva, each displaying different sizes of labia minora, indicating a physician's personal predisposition, manifesting as willingness to refer for, or perform, a labia minora reduction.

RESULTS

A total of 164/210 (78.1%) physicians completed the questionnaire, consisting of 80 general practitioners, 41 gynecologists, and 43 plastic surgeons (96 males, 68 females). Ninety percent of all physicians believe, to a certain extent, that a vulva with very small labia minora represents society's ideal (2-5 on the Likert scale). More plastic surgeons regarded the picture with the largest labia minora as distasteful and unnatural, compared with general practitioners and gynecologists (P < 0.01), and regarded such a woman as a candidate for a labia minora reduction procedure (P < 0.001). Irrespective of the woman's labia minora size and the absence of physical complaints, plastic surgeons were significantly more open to performing a labia minora reduction procedure than gynecologists (P < 0.001). Male physicians were more inclined to opt for a surgical reduction procedure than their female colleagues (P < 0.01).

CONCLUSIONS

The personal predisposition of physicians (taking account of their specific gender and specialty) concerning labia minora size and appearance influences their clinical decision making regarding a labia minora reduction procedure. Heightened awareness of one's personal predisposition vis-à-vis referral and willingness to operate is needed.

The effect of a gynecologist-interventional radiologist relationship on selection of treatment modality for the patient with uterine myoma

BACKGROUND

On the basis of consistent published scientific evidence, the American College of Obstetricians and Gynecologists has given uterine artery embolization (UAE) a level A recommendation as a viable alternative treatment for uterine myomas, describing it as a safe and effective option for appropriately selected women who wish to retain their uteri. Despite the growth of favorable clinical outcome information, many gynecologists do not routinely offer UAE as an alternative to abdominal hysterectomy or abdominal myomectomy. The percentage of laparoscopic hysterectomies in the United States remains less than 20%, reflecting the reluctance or inability of gynecologic surgeons to perform other minimally invasive procedures such as hysteroscopic myomectomy, laparoscopic myomectomy, laparoscopic hysterectomy, or even vaginal hysterectomy. Of great significance, many patients do not wish to have any kind of surgery, no matter how "minimally invasive." As a result, patients seeking less invasive treatments may bypass the gynecologist and be referred directly to an interventional radiologist by their primary care physician, or they may self-refer. Little has been published on the referral relationship between gynecologists and the interventional radiologist who performs uterine artery embolization. The absence of a structured routine referral relationship causes some women to undergo treatments that potentially are not aligned with all of her treatment desires. This study was undertaken to gain insight into the interventional radiologist-gynecologist dynamic and the benefit to patients who are informed of all of their options for the treatment of myomas.

STUDY OBJECTIVES

Investigate the course of myoma treatment in a cohort of patients either self-referred to an interventional radiologist or referred to the interventional radiologist by their gynecologist. Determine the effect of a cooperative referral network of interventional radiologists and gynecologists that informs patients about the options of UAE and minimally invasive surgical alternatives on the choice of myoma treatment.

STUDY DESIGN

Prospective data acquisition of patient referral source, UAE evaluation, patient decision on treatment options, and continued follow-up with a network gynecologist.

SETTING

Hospital-based interventional radiologist and gynecologist both practicing in a large urban teaching setting.

PATIENTS

A total of 226 women, representing 73% of women presenting to an interventional radiologist in 2007 seeking UAE for symptomatic myomas. One hundred thirty-eight of these patients were referred to the interventional radiologist by a gynecologist, and 88 were self-referred. Patient outcome relative to referral was traced with 76 patients in the myoma surgery group treated from 2007-2008 by a gynecologist in the referral network.

INTERVENTIONS

Evaluation for suitability for UAE procedure, followed either by UAE procedure with return to referring gynecologist for follow-up, return to referring gynecologist for treatment, or referral to another gynecologist for minimally invasive surgical management when the primary gynecologist is unable to perform alternative treatment.

MEASUREMENTS AND MAIN RESULTS

All patients in the study initially evaluated by the interventional radiologist were referred to a gynecologist. Overall, 62% of patients were candidates for UAE, and 38% underwent the procedure during the study period. Patients who did not receive UAE were returned to the referring gynecologist for further evaluation and treatment. Patients who underwent UAE were referred to a gynecologist for ongoing care. In all, 70% of self-referred patients and 92% of gynecologist-referred patients expressed satisfaction with their original gynecologist and were referred back to that physician. Patients who did not have a gynecologist or who were dissatisfied with their original gynecologist were referred to a network gynecologist for continued gynecologic care. In our study 26 self-referred women were sent as new patients to gynecologists in the interventional radiologist's referral network, resulting in a 119% return on the original 138 gynecologist-to-interventional radiologist-referred patients. Among the 8% of gynecologist-referred women who switched to a different gynecologist within the referral network, the primary reasons for dissatisfaction were the gynecologist's failure to fully disclose treatment options or offer desired minimally invasive procedures. On follow-up with a network gynecologist, 8 newly referred patients underwent myoma surgery, and 8 newly referred patients continued to be seen by that gynecologist. Four patients referred to the gynecologist for treatment were originally referred by the gynecologist to the interventional radiologist for UAE evaluation. Ten patients switched from their named gynecologist to a different gynecologist willing to disclose all treatment options for uterine myomas and able to provide minimally invasive surgical treatment as medically indicated. Of the 10 women who switched to this network gynecologist, 8 underwent myoma surgery.

CONCLUSIONS

Establishing a referral relationship with an interventional radiologist for comprehensive uterine myoma treatment supports a trusting, collaborative, long-term, noncompetitive "win-win" relationship between the gynecologist and radiologist, meets the patient's desire for full disclosure of all myoma treatment options, improves the patient's overall medical care and physician/patient experience, and has been demonstrated to improve patient flow to a gynecologist practice. With the guidelines established in this study, no patients were inappropriately left to the gynecologist for post-UAE care. The authors acknowledge that this dynamic is dependent on the individual interventional radiologist and their relationships and open communication with the gynecologist. Finally, the study revealed that failure to fully disclose alternative treatment options, or offer minimally invasive surgical techniques may result in a loss of patients due to patient dissatisfaction.

Patient clinical factors influencing use of hysterectomy in New York, 2001-2005

OBJECTIVE

To determine the effect of patient clinical factors on the utilization of hysterectomy and alternatives of hysterectomy.

STUDY DESIGN

The database of Empire Blue Cross Blue Shield was abstracted for all claims relating to a hysterectomy procedure or a hysterectomy-associated diagnosis during the 48 consecutive months of May 2001-April 2005. Two hundred ninety-five thousand one hundred forty-eight claim lines were abstracted and analyzed by CPT and diagnostic grouping codes.

RESULTS

One thousand nine hundred seventy-two hysterectomies were performed during the time analyzed, and 5,077 hysterectomy alternatives. The mean age of all patients encountered was 39.1 years. Patients undergoing a hysterectomy alternative or hysterectomy had mean ages of 46.0 and 49.7 years, respectively. Abnormal bleeding was associated with the most encounters, while leiomyomata was associated with the most hysterectomies performed.

CONCLUSION

Patients who undergo hysterectomy are, on average, older than those undergoing office management or hysterectomy alternatives. Procedures are most commonly associated with diagnosis of bleeding, leiomyomata, or cancer. Bleeding typically results in a hysterectomy alternative, while leiomyomata has the highest association with hysterectomy.