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Risk adjustment for complications of hysterectomy: utility of routinely collected administrative data
OTHER GYNECOLOGIC SURGERY
Risk of complications following gynecological laparoscopic surgery R. Mirhashemi, B.L. Harlow, E. Ginsberg, L.B. Signorello, R. Berkowitz, S. Feldman The Obstetrics and Gynecology Epidemiology Center and Department of Obstetrics and Gynecology, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts Objective: To determine the incidence and predictors of risk for operative complications, conversions to laparotomy, and postoperative admissions following laparoscopic procedures. Methods: We obtained demographic information and medical history on all 843 women who underwent laparoscopic procedures at the Brigham and Women’s Hospital between January and December 1994. All major complications following surgery were recorded. Major operative complications were defined as bowel, bladder, ureter, or vascular injuries, or significant abdominal wall or other internal bleeding. Categorical analysis was used to compare differences in the rates of operative complications, conversions to laparotomy, and postoperative admissions following laparoscopy. We also estimated the influence of specific laparoscopic procedures on the risk of adverse complications following surgery. Results: Operative complications and conversion to laparotomy occurred at rates of 19.0 and 47.4 per 1,000 laparoscopic procedures, respectively. Of 843 women studied, complications included 4 bowel, 2 bladder, 1 ureteral, 2 vascular, and 5 abdominal wall injuries. There were 165 (19.6%) patients admitted postoperatively. Aside from the type of operative procedure, age was the single most important predictor of complications. Women with government or HMO insurance were somewhat more likely to have their laparoscopy converted to a laparotomy than women with private insurance. Relative to all other operative procedures, women receiving laparoscopic-assisted treatment of endometriosis and women undergoing ovarian cystectomy had generally low rates of operative complications, conversions to laparotomy, and postoperative admissions. In contrast, 12.5% of women receiving laparoscopic-assisted vaginal hysterectomy experienced operative injuries or abdominal bleeding and 90.0% were hospitalized postoperatively. Conclusion: Serious operative complications after major gynecologic laparoscopy were rare in this data set. The complexity of the laparoscopic procedure is directly proportional to the rate of operative complications, conversions to laparotomy, and postoperative admissions to the hospital.
202
Risk adjustment for complications of hysterectomy: utility of routinely collected administrative data Evan R. Meyers, MD, MPH, John F. Steege, MD Department of Obstetrics & Gynecology, Duke University Medical Center Objective: To determine the ability of risk adjustment methods that use routinely collected administrative data to explain variability in complication rates after hysterectomy. Methods: Discharge data on all non-radical hysterectomies performed in North Carolina between January 1988 and September 1994 were obtained from the North Carolina Medical Database Commission. Complications were categorized as 1) surgical (eg, hemorrhage, organ injury) and 2) medical (eg, myocardial infarction, pneumonia). Comorbidities included peritoneal adhesions and chronic medical problems. Hospital charges were adjusted for inflation. Univariate analyses were performed using the Kruskall-Wallis test for skewed continuous variables and x2 tests for categorical variables. Multivariate analysis was performed using unconditional logistic regression, with complication rate as the dependent variable. Results: There were 107,648 cases performed at 134 hospitals, with an overall complication rate of 9.5%. When cancer and pregnancy cases were excluded, the surgical complication rate was 5.0%, medical 3.2%. Patients with surgical complications were significantly younger (median age 42 vs 46) and had significantly higher total hospital charges (median $8,127 vs $7,496) than patients with medical complications. Complication rates for individual hospitals varied from 1.5% to 29.3%, with rates highest for academic medical centers (24.3% vs 7.2% for non-teaching hospitals). Significant predictors of complications in univariate analyses included type of hysterectomy, indication, age $65 years, insurance status, and teaching hospital status. Coded comorbid conditions were variable in their association with complications. Adjusted odds ratios, controlled for indication and type of procedure, for age $65, Medicaid or no insurance, and teaching hospital status were all greater for medical complications than for surgical complications in multivariate analysis (Table). The predictive ability of multivariate analysis was better for medical complications than for surgical complications (Cstatistic for medical complication model 0.763 vs 0.644 for surgical complications).
© 1998 Elsevier Science Inc. 1068-607X/98/$19.00
Prim Care Update Ob/Gyns
OTHER GYNECOLOGIC SURGERY
Surgical Complications Risk Factor Age $65 years Medicaid/ no insurance (compared to private/ Medicare/HMO Academic medical center (compared to non-teaching hospital)
Medical Complications
Adjusted odds ratio
95% CI
Adjusted odds ratio
95% CI
1.73 1.36
1.58, 1.90 1.26, 1.47
4.54 1.62
4.16, 4.96 1.48, 1.77
1.86
1.74, 1.99
3.28
3.06, 3.52
Conclusions: Surgical complications of hysterectomy are more common, occur in younger women, and are associated with higher hospital charges than medical complications. Complication rates vary widely between hospitals, with teaching hospitals having the highest rates. This difference persists after adjustment for coded comorbidities. Possible explanations for the inability of multivariate analysis to explain the wide range in observed complication rates include 1) shortcomings in the available data or models, such as variability in coding practices between hospitals or variability in surgical difficulty between hospitals that is not captured with ICD-9-CM codes (eg, uterine size, cancer stage) and 2) variability in the quality of care between hospitals. Further research is needed to help determine the role of each of these explanations. Risk adjustment methods that use administrative data based on currently available coding standards are poor predictors of surgical complication rates after hysterectomy and should not be used to reach conclusions about quality of care.
Functional outcomes and satisfaction after abdominal hysterectomy Anne M. Weber, MD, Mark D. Walters, MD, Leslie R. Schover, PhD, James M. Church, MD, Marion R. Piedmonte, MA Cleveland Clinic Foundation, Cleveland, Ohio Objective: To compare urinary, lower gastrointestinal (GI), and sexual function and to describe patients’ expectations and satisfaction before and after hysterectomy. Methods: Forty-three women completed questionnaires before and about 1 year after abdominal hysterectomy for benign gynecologic conditions. Symptoms related to urinary, lower GI, and sexual function were assessed. Women responded with “agree,” “disagree,” or “neutral” to statements about treatment options, the decision for hysterectomy, expectations about surgery and recovery, and satisfaction with their relationship with their doctor and their treatment. Comparisons were made between preoperative and postoperative responses. Statistical significance was accepted for P 5 .002 to account for multiple comparisons. Volume 5, Number 4, 1998
Results: The mean age was 45.4 6 6.7 years. Sixty percent were white, and 88% were premenopausal. The most common indication for hysterectomy was myomas in 76%. There were no statistically significant changes in urinary or bowel symptoms before and after hysterectomy with preoperative symptoms resolving in some women after surgery, and developing in others. Fewer women experienced abdominal bloating after hysterectomy than before. Frequency of intercourse and satisfaction with their sexual relationship did not change in the 34 sexually active women. The level of satisfaction with their treatment and their relationship with their doctor was very high. Conclusion: Women experience a high degree of satisfaction with treatment 1 year after abdominal hysterectomy for benign gynecologic conditions. Symptoms related to urinary, GI, or sexual function occur frequently before and after surgery, but hysterectomy does not result in consistent changes.
Hysterectomy in a decade of change: more than a weighty matter John H. Kirk, MD, Beth Y. Karlan, MD, Patricia Cane, PhD, Kimberly Gregory, MD, MPH Department of Obstetrics & Gynecology, Cedars Sinai Medical Center & UCLA School of Medicine Objective: Hysterectomy is the second most common surgical procedure performed in the United States. Interest to decrease use of hysterectomy has focused on developing explicit criteria for surgery, peer review and second opinion, as well as changing reimbursement incentives. The purpose of this study is to describe the change in the number of hysterectomies, the indications for hysterectomies, and the histopathology of hysterectomy specimens over the last 10 years at one private, nonprofit, academic, community hospital that does not have a formal system for monitoring hysterectomy use. Methods: Retrospective study utilizing administrative data matched with pathology reports for nonmalignant hysterectomies performed in 1985, 1990, and 1995. Uterine weight and histopathologic diagnoses were recorded. When pathology reports were unavailable, cases were reviewed to determine if the indication was related to prolapse or urinary incontinence. Outcome measures included number of procedures performed, indications for procedures and uterine pathology (uterine weight, histopathology). We utilized the Cochran-Mantel-Haenszel x2 and the Kruskal-Wallis rank sum statistic (P , .05). Results: The number of hysterectomies declined from 631 in 1985 to 461 in 1995 (P 5 .007). The median uterine weight increased (P 5 .0007), and there was a decrease in the number
203
Risk of complications following gynecological laparoscopic surgery R. Mirhashemi, B.L. Harlow, E. Ginsberg, L.B. Signorello, R. Berkowitz, S. Feldman The Obstetrics and Gynecology Epidemiology Center and Department of Obstetrics and Gynecology, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts Objective: To determine the incidence and predictors of risk for operative complications, conversions to laparotomy, and postoperative admissions following laparoscopic procedures. Methods: We obtained demographic information and medical history on all 843 women who underwent laparoscopic procedures at the Brigham and Women’s Hospital between January and December 1994. All major complications following surgery were recorded. Major operative complications were defined as bowel, bladder, ureter, or vascular injuries, or significant abdominal wall or other internal bleeding. Categorical analysis was used to compare differences in the rates of operative complications, conversions to laparotomy, and postoperative admissions following laparoscopy. We also estimated the influence of specific laparoscopic procedures on the risk of adverse complications following surgery. Results: Operative complications and conversion to laparotomy occurred at rates of 19.0 and 47.4 per 1,000 laparoscopic procedures, respectively. Of 843 women studied, complications included 4 bowel, 2 bladder, 1 ureteral, 2 vascular, and 5 abdominal wall injuries. There were 165 (19.6%) patients admitted postoperatively. Aside from the type of operative procedure, age was the single most important predictor of complications. Women with government or HMO insurance were somewhat more likely to have their laparoscopy converted to a laparotomy than women with private insurance. Relative to all other operative procedures, women receiving laparoscopic-assisted treatment of endometriosis and women undergoing ovarian cystectomy had generally low rates of operative complications, conversions to laparotomy, and postoperative admissions. In contrast, 12.5% of women receiving laparoscopic-assisted vaginal hysterectomy experienced operative injuries or abdominal bleeding and 90.0% were hospitalized postoperatively. Conclusion: Serious operative complications after major gynecologic laparoscopy were rare in this data set. The complexity of the laparoscopic procedure is directly proportional to the rate of operative complications, conversions to laparotomy, and postoperative admissions to the hospital.
202
Risk adjustment for complications of hysterectomy: utility of routinely collected administrative data Evan R. Meyers, MD, MPH, John F. Steege, MD Department of Obstetrics & Gynecology, Duke University Medical Center Objective: To determine the ability of risk adjustment methods that use routinely collected administrative data to explain variability in complication rates after hysterectomy. Methods: Discharge data on all non-radical hysterectomies performed in North Carolina between January 1988 and September 1994 were obtained from the North Carolina Medical Database Commission. Complications were categorized as 1) surgical (eg, hemorrhage, organ injury) and 2) medical (eg, myocardial infarction, pneumonia). Comorbidities included peritoneal adhesions and chronic medical problems. Hospital charges were adjusted for inflation. Univariate analyses were performed using the Kruskall-Wallis test for skewed continuous variables and x2 tests for categorical variables. Multivariate analysis was performed using unconditional logistic regression, with complication rate as the dependent variable. Results: There were 107,648 cases performed at 134 hospitals, with an overall complication rate of 9.5%. When cancer and pregnancy cases were excluded, the surgical complication rate was 5.0%, medical 3.2%. Patients with surgical complications were significantly younger (median age 42 vs 46) and had significantly higher total hospital charges (median $8,127 vs $7,496) than patients with medical complications. Complication rates for individual hospitals varied from 1.5% to 29.3%, with rates highest for academic medical centers (24.3% vs 7.2% for non-teaching hospitals). Significant predictors of complications in univariate analyses included type of hysterectomy, indication, age $65 years, insurance status, and teaching hospital status. Coded comorbid conditions were variable in their association with complications. Adjusted odds ratios, controlled for indication and type of procedure, for age $65, Medicaid or no insurance, and teaching hospital status were all greater for medical complications than for surgical complications in multivariate analysis (Table). The predictive ability of multivariate analysis was better for medical complications than for surgical complications (Cstatistic for medical complication model 0.763 vs 0.644 for surgical complications).
© 1998 Elsevier Science Inc. 1068-607X/98/$19.00
Prim Care Update Ob/Gyns
OTHER GYNECOLOGIC SURGERY
Surgical Complications Risk Factor Age $65 years Medicaid/ no insurance (compared to private/ Medicare/HMO Academic medical center (compared to non-teaching hospital)
Medical Complications
Adjusted odds ratio
95% CI
Adjusted odds ratio
95% CI
1.73 1.36
1.58, 1.90 1.26, 1.47
4.54 1.62
4.16, 4.96 1.48, 1.77
1.86
1.74, 1.99
3.28
3.06, 3.52
Conclusions: Surgical complications of hysterectomy are more common, occur in younger women, and are associated with higher hospital charges than medical complications. Complication rates vary widely between hospitals, with teaching hospitals having the highest rates. This difference persists after adjustment for coded comorbidities. Possible explanations for the inability of multivariate analysis to explain the wide range in observed complication rates include 1) shortcomings in the available data or models, such as variability in coding practices between hospitals or variability in surgical difficulty between hospitals that is not captured with ICD-9-CM codes (eg, uterine size, cancer stage) and 2) variability in the quality of care between hospitals. Further research is needed to help determine the role of each of these explanations. Risk adjustment methods that use administrative data based on currently available coding standards are poor predictors of surgical complication rates after hysterectomy and should not be used to reach conclusions about quality of care.
Functional outcomes and satisfaction after abdominal hysterectomy Anne M. Weber, MD, Mark D. Walters, MD, Leslie R. Schover, PhD, James M. Church, MD, Marion R. Piedmonte, MA Cleveland Clinic Foundation, Cleveland, Ohio Objective: To compare urinary, lower gastrointestinal (GI), and sexual function and to describe patients’ expectations and satisfaction before and after hysterectomy. Methods: Forty-three women completed questionnaires before and about 1 year after abdominal hysterectomy for benign gynecologic conditions. Symptoms related to urinary, lower GI, and sexual function were assessed. Women responded with “agree,” “disagree,” or “neutral” to statements about treatment options, the decision for hysterectomy, expectations about surgery and recovery, and satisfaction with their relationship with their doctor and their treatment. Comparisons were made between preoperative and postoperative responses. Statistical significance was accepted for P 5 .002 to account for multiple comparisons. Volume 5, Number 4, 1998
Results: The mean age was 45.4 6 6.7 years. Sixty percent were white, and 88% were premenopausal. The most common indication for hysterectomy was myomas in 76%. There were no statistically significant changes in urinary or bowel symptoms before and after hysterectomy with preoperative symptoms resolving in some women after surgery, and developing in others. Fewer women experienced abdominal bloating after hysterectomy than before. Frequency of intercourse and satisfaction with their sexual relationship did not change in the 34 sexually active women. The level of satisfaction with their treatment and their relationship with their doctor was very high. Conclusion: Women experience a high degree of satisfaction with treatment 1 year after abdominal hysterectomy for benign gynecologic conditions. Symptoms related to urinary, GI, or sexual function occur frequently before and after surgery, but hysterectomy does not result in consistent changes.
Hysterectomy in a decade of change: more than a weighty matter John H. Kirk, MD, Beth Y. Karlan, MD, Patricia Cane, PhD, Kimberly Gregory, MD, MPH Department of Obstetrics & Gynecology, Cedars Sinai Medical Center & UCLA School of Medicine Objective: Hysterectomy is the second most common surgical procedure performed in the United States. Interest to decrease use of hysterectomy has focused on developing explicit criteria for surgery, peer review and second opinion, as well as changing reimbursement incentives. The purpose of this study is to describe the change in the number of hysterectomies, the indications for hysterectomies, and the histopathology of hysterectomy specimens over the last 10 years at one private, nonprofit, academic, community hospital that does not have a formal system for monitoring hysterectomy use. Methods: Retrospective study utilizing administrative data matched with pathology reports for nonmalignant hysterectomies performed in 1985, 1990, and 1995. Uterine weight and histopathologic diagnoses were recorded. When pathology reports were unavailable, cases were reviewed to determine if the indication was related to prolapse or urinary incontinence. Outcome measures included number of procedures performed, indications for procedures and uterine pathology (uterine weight, histopathology). We utilized the Cochran-Mantel-Haenszel x2 and the Kruskal-Wallis rank sum statistic (P , .05). Results: The number of hysterectomies declined from 631 in 1985 to 461 in 1995 (P 5 .007). The median uterine weight increased (P 5 .0007), and there was a decrease in the number
203