Statewide geographic variation in hysterectomy approach for pelvic organ prolapse: a county-level analysis.

BACKGROUND: There are no definitive guidelines for surgical treatment of pelvic organ prolapse. Previous data suggests geographic variation in apical repair rates in health systems throughout the United States. Such variation can reflect lack of standardized treatment pathways. An additional area of variation for pelvic organ prolapse repair may be hysterectomy approach which could not only influence concurrent repair procedures, but also healthcare utilization. OBJECTIVE: This study aimed to examine statewide geographic variation in surgical approach of hysterectomy for prolapse repair and concurrent use of colporrhaphy and colpopexy. STUDY DESIGN: We conducted a retrospective analysis of Blue Cross Blue Shield, Medicare, and Medicaid fee-for-service insurance claims for hysterectomies performed for prolapse in Michigan between October 2015 and December 2021. Prolapse was identified with International Classification of Disease Tenth Revision codes. The primary outcome was variation in surgical approach for hysterectomy as determined by Current Procedural Terminology code (vaginal, laparoscopic, laparoscopic assisted vaginal, or abdominal) on a county level. Patient home address zip codes were used to determine county of residence. A hierarchical multivariable logistic regression model with vaginal approach as the dependent variable and county-level random effects was estimated. Patient attributes, including age, comorbidities (diabetes mellitus, chronic obstructive pulmonary disease, congestive heart failure, morbid obesity), concurrent gynecologic diagnoses, health insurance type, and social vulnerability index were used as fixed-effects. To estimate variation between counties in vaginal hysterectomy rates, a median odds ratio was calculated. RESULTS: There were 6974 hysterectomies for prolapse representing 78 total counties that met eligibility criteria. Of these, 2865 (41.1%) underwent vaginal hysterectomy, 1119 (16.0%) underwent laparoscopic assisted vaginal hysterectomy, and 2990 (42.9%) underwent laparoscopic hysterectomy. The proportion of vaginal hysterectomy across 78 counties ranged from 5.8% to 86.8%. The median odds ratio was 1.86 (95% credible interval, 1.33-3.83), consistent with a high level of variation. Thirty-seven counties were considered statistical outliers because the observed proportion of vaginal hysterectomy was outside the predicted range (as defined by confidence intervals of the funnel plot). Vaginal hysterectomy was associated with higher rates of concurrent colporrhaphy than laparoscopic assisted vaginal hysterectomy or laparoscopic hysterectomy (88.5% vs 65.6% vs 41.1%, respectively; P<.001) and lower rates of concurrent colpopexy (45.7% vs 51.7% vs 80.1%, respectively; P<.001). CONCLUSION: This statewide analysis reveals a significant level of variation in the surgical approach for hysterectomies performed for prolapse. The variation in surgical approach for hysterectomy may help account for high rates of variation in concurrent procedures, especially apical suspension procedures. These data highlight how geographic location may influence the surgical procedures a patient undergoes for uterine prolapse.

Predictors of same-day discharge following benign minimally invasive hysterectomy.

BACKGROUND: Same-day discharge following minimally invasive hysterectomy has been shown to be safe and feasible in select populations, but many nonclinical factors influencing same-day discharge remain unexplored. OBJECTIVE: To develop prediction models for same-day discharge following minimally invasive hysterectomy using both clinical and nonclinical attributes and to compare model concordance of individual attribute groups. STUDY DESIGN: We performed a retrospective study of patients who underwent elective minimally invasive hysterectomy for benign gynecologic indications at 69 hospitals in a statewide quality improvement collaborative between 2012 and 2019. Potential predictors of same-day discharge were determined a priori and placed into 1 of 7 attribute groupings: intraoperative, surgeon, hospital, surgical timing, patient clinical, patient socioeconomic, and patient geographic attributes. To account for clustering of same-day discharge practices among surgeons and within hospitals, hierarchical multivariable logistic regression models were fitted using predictors from each attribute group individually and all predictors in a composite model. Receiver operator characteristic curves were generated for each model. The Hanley-McNeil test was used for comparisons, 95% confidence intervals for the areas under the receiver operator characteristic curve were calculated, and a P value of <.05 was considered significant. RESULTS: Of the 23,513 patients in our study, 5062 (21.5%) had same-day discharge. The composite model had an area under the receiver operator characteristic curve of 0.770 (95% confidence interval, 0.763-0.777). Among models using factors from individual attribute groups, the model using intraoperative attributes had the highest concordance for same-day discharge (area under the receiver operator characteristic curve, 0.720; 95% confidence interval, 0.712-0.727). The models using surgeon and hospital attributes were the second and third most concordant, respectively (area under the receiver operator characteristic curve, 0.678; 95% confidence interval, 0.670-0.685; area under the receiver operator characteristic curve, 0.655; 95% confidence interval, 0.656-0.664). Models using surgical timing and patient clinical, socioeconomic, and geographic attributes had poor predictive ability (all areas under the receiver operator characteristic curve <0.6). CONCLUSION: Clinical and nonclinical attributes contributed to a composite prediction model with good discrimination in predicting same-day discharge following minimally invasive hysterectomy. Factors related to intraoperative, hospital, and surgeon attributes produced models with the strongest predictive ability. Focusing on these attributes may aid efforts to improve utilization of same-day discharge following minimally invasive hysterectomy.

Effects of Pharmacologic Venous Thromboembolism Prophylaxis in Benign Hysterectomy.

STUDY OBJECTIVE: To evaluate whether the addition of pharmacologic prophylaxis to mechanical prophylaxis for venous thromboembolism (VTE) is associated with changes in perioperative outcomes in hysterectomy for benign indications. DESIGN: Retrospective cohort study. SETTING: Michigan Surgical Quality Collaborative database. PATIENTS: Patients who underwent hysterectomy between July 2012 and June 2015 when VTE prophylaxis data were collected. INTERVENTIONS: Patients who received mechanical prophylaxis alone were compared with those receiving dual prophylaxis (mechanical and pharmacologic). Minimally invasive surgeries (MIS) included laparoscopic, vaginal, robotic-assisted, and laparoscopic-assisted vaginal hysterectomies and were analyzed separately from abdominal (ABD) hysterectomy. MEASUREMENTS AND MAIN RESULTS: Propensity score matching was used to minimize confounding because of the differences in demographic and perioperative characteristics. The primary outcome was estimated blood loss (EBL). The secondary outcomes were operative time, postoperative blood transfusion, VTE, surgical site infection, reoperation, readmission, and death. There were 1803 matched pairs in the MIS analysis. In the ABD hysterectomy analysis, 2:1 matching was used with a total of 1168 patients receiving mechanical prophylaxis alone matched to 616 patients receiving dual prophylaxis. EBL was higher by 54.5 mL (95% confidence interval [CI], 16.9-92.1) in those receiving dual prophylaxis in the ABD hysterectomy analysis but did not differ between groups in the MIS analysis. Operative time was significantly longer with dual prophylaxis in both MIS (18.3 minutes; 95% CI, 13.8-22.8) and ABD (15.3 minutes; 95% CI, 9.0-21.6) surgical approaches. There was no difference in other secondary outcomes. CONCLUSION: The addition of pharmacologic prophylaxis to mechanical prophylaxis in benign hysterectomy was associated with longer operative time, regardless of surgical approach and increased EBL in ABD hysterectomy. Given very low rates of VTE, no difference in other perioperative outcomes, and possible harm, it seems reasonable to encourage individualized rather than routine use of pharmacologic prophylaxis in patients undergoing benign hysterectomy receiving mechanical prophylaxis.

Development of a Preoperative Clinical Risk Assessment Tool for Postoperative Complications After Hysterectomy.

STUDY OBJECTIVE: To develop a preoperative risk assessment tool that quantifies the risk of postoperative complications within 30 days of hysterectomy. DESIGN: Retrospective analysis. SETTING: Michigan Surgical Quality Collaborative hospitals. PATIENTS: Women who underwent hysterectomy for gynecologic indications. INTERVENTIONS: Development of a nomogram to create a clinical risk assessment tool. MEASUREMENTS AND MAIN RESULTS: Postoperative complications within 30 days were the primary outcome. Bivariate analysis was performed comparing women who had a complication and those who did not. The patient registry was randomly divided. A logistic regression model developed and validated from the Collaborative database was externally validated with hysterectomy cases from the National Surgical Quality Improvement Program, and a nomogram was developed to create a clinical risk assessment tool. Of the 41,147 included women, the overall postoperative complication rate was 3.98% (n = 1638). Preoperative factors associated with postoperative complications were sepsis (odds ratio [OR] 7.98; confidence interval [CI], 1.98-32.20), abdominal approach (OR 2.27; 95% CI, 1.70-3.05), dependent functional status (OR 2.20; 95% CI, 1.34-3.62), bleeding disorder (OR 2.10; 95% CI, 1.37-3.21), diabetes with HbA1c ≥9% (OR 1.93; 95% CI, 1.16-3.24), gynecologic cancer (OR 1.86; 95% CI, 1.49-2.31), blood transfusion (OR 1.84; 95% CI, 1.15-2.96), American Society of Anesthesiologists Physical Status Classification System class ≥3 (OR 1.46; 95% CI, 1.24-1.73), government insurance (OR 1.3; 95% CI, 1.40-1.90), and body mass index ≥40 (OR 1.25; 95% CI, 1.04-1.50). Model discrimination was consistent in the derivation, internal validation, and external validation cohorts (C-statistics 0.68, 0.69, 0.68, respectively). CONCLUSION: We validated a preoperative clinical risk assessment tool to predict postoperative complications within 30 days of hysterectomy. Modifiable risk factors identified were preoperative blood transfusion, poor glycemic control, and open abdominal surgery.

Vaginal preparation with povidone-iodine or chlorhexidine before hysterectomy: a propensity score matched analysis.

BACKGROUND: Antiseptic vaginal preparation is recommended before gynecologic surgery; however, there is a lack of data regarding the effectiveness of different agents. OBJECTIVE: To compare rates of postoperative infectious complications and hospital utilization with preoperative vaginal preparation using povidone-iodine or chlorhexidine before hysterectomy. STUDY DESIGN: This was a retrospective analysis of patients who underwent hysterectomy for gynecologic indications at 70 hospitals in a statewide surgical collaborative between January 2017 and December 2019. The primary outcome was postoperative infectious complications (including urinary tract infection, surgical site infections involving superficial, deep, or organ space tissues, or cellulitis) within 30 days of surgery. To adjust for confounding, propensity score matching, 1:1 without replacement and with a caliper of.005 was performed to create cohorts that had vaginal preparation with either povidone-iodine or chlorhexidine and did not differ in observable characteristics. We compared the rates of infectious morbidity and hospital utilization (emergency department visits, readmission, reoperation) in the matched cohorts. RESULTS: In the statewide collaborative, there were 18,184 patients who received povidone-iodine and 3018 who received chlorhexidine. After propensity score matching of 2935 pairs, the povidone-iodine and chlorhexidine groups did not differ in demographics, comorbidities, choice of preoperative antibiotics, benign vs malignant surgical indication, and surgical approach. Povidone-iodine was associated with a lower rate of infectious morbidity (3.0% vs 4.3%; P=.01), urinary tract infection (1.1% vs 1.7%; P=.03) and emergency department visits (7.9% vs 9.7%; P=.01) than with chlorhexidine. There were nonsignificant trends of lower rates of surgical site infection (2.0% vs 2.7%; P=.07) and reoperation (1.6% vs 2.1%; P=.18). CONCLUSION: This propensity score matched analysis provides evidence that povidone-iodine is preferable to chlorhexidine for vaginal preparation before hysterectomy because of lower rates of infectious morbidity and fewer emergency department visits. However, the absolute differences in infectious morbidity rates were approximately 1%, and in the event of an iodine allergy, chlorhexidine appears to be a reasonable alternative.

Hysterectomy Complications Relative to HbA1c Levels: Identifying a Threshold for Surgical Planning.

STUDY OBJECTIVE: To evaluate whether diabetes diagnosis and level of diabetes control as reflected by higher preoperative glycosylated hemoglobin (HbA1c) levels are associated with increased complication rates after hysterectomy and to identify a threshold of preoperative HbA1c level past which we should consider delaying surgery owing to increased risk of complications. DESIGN: Retrospective cohort study. SETTING: Hospitals in the Michigan Surgical Quality Collaborative between June 4, 2012, and October 17, 2017. PATIENTS: Women with and without a diabetes diagnosis. INTERVENTIONS: Hysterectomy. MEASUREMENTS AND MAIN RESULTS: Data on demographics, preoperative HbA1c values, surgical approach, composite postoperative complications, readmissions, emergency department visits, and reoperations were abstracted. The risk of a postoperative complication when diabetes was stratified by preoperative HbA1c level was evaluated in a sensitivity analysis, and independent associations were identified in a mixed, multivariate logistic regression model. We identified 41 286 hysterectomies performed at 70 hospitals to be included for analysis. The sensitivity analysis identified 4 groups of risk for postoperative complications: group 1: no diabetes diagnosis and no HbA1c value; group 2: no diabetes diagnosis, with HbA1c levels between 4% and 6.5%; group 3: diabetes diagnosis and no HbA1c value or HbA1c levels <9%; and group 4: diabetes diagnosis with HbA1c levels ≥9%. In the adjusted model, there were significant 32% and 34% increased odds of postoperative complications for groups 2 and 3, respectively, compared with group 1. There were more than 2-fold increased odds of complications for women with diabetes and a preoperative HbA1c level ≥9% (group 4) compared with the women in group 1. Diabetes diagnosis with preoperative HbA1c levels ≥9% had increased odds of complications compared with diabetes diagnosis with preoperative HbA1c levels <9%. Patients with well-controlled diabetes seemed to have increased odds of complications with laparoscopic surgery. CONCLUSION: Diabetes diagnosis and measurement of preoperative HbA1c levels provide risk stratification for postoperative complications after hysterectomy, with the highest observed effect among patients with diabetes with a preoperative HbA1c level ≥9%.

Impact of a National Private Health Insurer's Prior Authorization Policy on Utilization of Vaginal Hysterectomy.

OBJECTIVES: On April 6, 2015, the largest private health insurer in the United States implemented a policy requiring prior authorization for all hysterectomies except those done as outpatient vaginal. The purpose of this policy was to increase utilization of vaginal hysterectomy; however, it is unknown whether this policy had its intended effect. We sought to analyze trends in hysterectomy routes before and after implementation of the prior authorization policy to see if utilization of vaginal hysterectomy increased. METHODS: This was a retrospective study using the Optum Clinformatics Data Mart national claims database of women enrolled in a single national private health insurer who underwent hysterectomy for any indication between January 1, 2010, and June 30, 2016. Per-quarter utilization of hysterectomy routes (abdominal, laparoscopic, vaginal, and laparoscopic-assisted vaginal) was compared between the prepolicy and postpolicy periods using interrupted time series analyses. RESULTS: Data for 305,139 hysterectomies were available-248,821 in the prepolicy period and 56,318 in the postperiod. Outpatient vaginal hysterectomy had the greatest increase in utilization of all routes and types; the average utilization per quarter in the prepolicy period was -0.61%, and this increased to 0.21% in the postpolicy period (P < 0.0001). Outpatient laparoscopic hysterectomy had the greatest decrease in utilization, with an average decrease of -1.50% per quarter. CONCLUSIONS: The prior authorization policy was associated with a short-term increase in utilization of vaginal hysterectomy.

New persistent opioid use after acute opioid prescribing in pregnancy: a nationwide analysis.

OBJECTIVE: To evaluate the association between opioid prescribing during pregnancy and new persistent opioid use in the year following delivery. MATERIALS AND METHODS: This nationwide retrospective cohort study included patients aged 12-55 years in Optum's deidentified Clinformatics Data Mart Database who were undergoing vaginal delivery or cesarean delivery from 2008 to 2016, with continuous enrollment from 2 years before birth to 1 year postdischarge. Women were included if they were opioid naive in pregnancy (ie, did not fill an opioid prescription 2 years to 9 months before delivery) and did not undergo a procedure within the year after discharge. The exposure was filling an opioid prescription in pregnancy. The primary outcome was new persistent opioid use, defined as a pharmacy claim for ≥1 opioid prescription between 4 and 90 days postdischarge and ≥1 prescription between 91 and 365 days postdischarge. Clinical and demographic covariates were included. Analyses included descriptive statistics and multivariable logistic regression, adjusting for clinical and demographic covariates. RESULTS: Of 158,425 childbirths identified, 101,013 (63.8%) were by vaginal delivery and 57,412 (36.2%) cesarean delivery. Among all patients, 6.0% (9429) filled an opioid prescription during pregnancy. The factors associated with filling an opioid in pregnancy were having a nondelivery procedure in pregnancy (adjusted odds ratio, 9.60; 95% confidence interval, 8.81-10.47) and having an emergency room visit during pregnancy (adjusted odds ratio, 2.48; 95% confidence interval, 2.37-2.59). Of women who received an opioid in pregnancy, 4% (379) developed new persistent opioid use. The factors most associated with new persistent opioid use were receiving an opioid prescription during pregnancy (adjusted odds ratio, 3.45; 95% confidence interval, 3.04-3.92) and filling a peripartum opioid prescription (1 week prior to 3 days postdischarge) adjusted odds ratio, 2.28, 95% confidence interval (2.02-2.57). Though having a procedure during pregnancy was associated with increased receipt of an opioid prescription, it was also associated with reduced new persistent opioid use (adjusted odds ratio, 0.72; 95% confidence interval, 0.52-0.99). CONCLUSION: Women who receive an opioid prescription during pregnancy are more likely to experience new persistent opioid use. Maternity care providers must balance pain management in pregnancy with potential risks of opioids.

Safety Bundles in Gynecology.

Patient safety bundles and checklists have been shown to improve outcomes in medicine, surgery, and obstetrics. Until recently, there has been less study into their use in the gynecology setting. Here, we review the available evidence and examples of successful checklist and bundle implementation in gynecology and encourage more robust implementation and standardization in our field going forward.

Better late than never: why obstetricians must implement enhanced recovery after cesarean.

Despite persistent concerns about high cesarean delivery rates internationally, there has been less attention on improving perioperative outcomes for the millions of women who will experience a cesarean delivery each year. Enhanced recovery after surgery, a standardized, evidence-based, interdisciplinary protocol, has been successfully used in other surgical specialties including gynecology to improve quality of care and patient satisfaction while reducing overall health care costs through reduced length of stay. Enhanced recovery after surgery society guidelines for cesarean delivery were just released in August 2018. Obstetric patients, who face the dual challenge of being postpartum and postoperative, could benefit greatly from protocols that optimize their return to physiological function and reduce surgical morbidity. Although enhanced recovery after surgery has been widespread in other surgical specialties, uptake of this protocol in obstetrics has lagged behind. We believe enhanced recovery after surgery for cesarean delivery can effectively address 3 challenges faced by obstetrician/gynecologists. These are: (1) improving care for the high number of women undergoing cesarean deliveries; (2) using evidence-based care bundles to prevent maternal morbidity and mortality, address disparities, and reduce costs; and (3) limiting postoperative opioid prescribing in response to the opioid crisis. Enhanced recovery after surgery for cesarean delivery and other standardized care protocols have the potential to reduce the disproportionately high rates of maternal morbidity and mortality in the United States, and ensure all patients, regardless of demographics or location, receive the same level of high-quality peripartum care.

Importance of Estimated Blood Loss in Resource Utilization and Complications of Hysterectomy for Benign Indications.

OBJECTIVE: To identify the variation in estimated blood loss at the time of hysterectomy for benign indications and to analyze how blood loss is associated with measures of resource utilization and complications. METHODS: We conducted a retrospective cohort study and analyzed hysterectomy for benign indications at hospitals in the Michigan Surgical Quality Collaborative between January 1, 2013, and May 30, 2015. A sensitivity analysis was performed to identify how estimated blood loss was associated with measures of utilization (transfusion, readmission, reoperation, and length of stay) and postoperative complications. A hierarchical logistic regression model was used to identify patient level factors independently associated with estimated blood loss greater than 400 mL and to calculate a risk- and reliability-adjusted rate for each hospital. RESULTS: There were 18,033 hysterectomies for benign indications from 61 hospitals included for analysis. The median estimated blood loss was 100 mL, and the 90th percentile estimated blood loss was 400 mL. A sensitivity analysis demonstrated increased risks of transfusion, readmission, reoperation, length of stay, and major postoperative complications with estimated blood loss greater than 400 mL. The proportion of hysterectomies at hospitals in the collaborative with estimated blood loss greater than 400 mL ranged from 3.5% to 16.9% after risk and reliability adjustments. The risk factors with the highest adjusted odds for estimated blood loss greater than 400 mL included abdominal surgery compared with laparoscopic hysterectomy (adjusted odds ratio [aOR] 2.8, CI 2.3-3.5), surgical time longer than 3 hours (aOR 3.9, CI 3.3-4.5), and specimen weight greater than 250 g compared with less than 100 g (aOR 4.8, CI 3.9-5.8). Adhesive disease, low surgeon volume, being younger than 40 years of age, having a body mass index greater than 35, and the need for a preoperative transfusion were also statistically significantly associated with estimated blood loss greater than 400 mL. CONCLUSION: There is fivefold variation in the hospital rate of hysterectomies with an estimated blood loss greater than 400 mL (90th percentile)-a threshold associated with significantly higher rates of health care utilization and complications. Avoidance of abdominal hysterectomy when possible may reduce intraoperative blood loss and associated sequelae.

Documenting pessary offer prior to hysterectomy for management of pelvic organ prolapse.

OBJECTIVES: To (1) determine the proportion of hysterectomy cases with documentation of pessary counseling prior to prolapse surgery and (2) identify variables associated with women offered a pessary. STUDY DESIGN: The Michigan Surgical Quality Collaborative (MSQC) is a hysterectomy improvement initiative. Hysterectomies from 2013 to 2015 in which prolapse was the principal diagnosis were included. "Pessary offer" was defined as documentation showing the patient declined, could not tolerate, or failed a pessary trial. Bivariate analyses were used to compare demographics, medical history, surgical route, concomitant procedures (colpopexy or colporrhaphy), and intra- and postoperative complications between women with and without pessary offer. Hierarchical logistic regression was used to determine factors independently associated with pessary offer. Risk-adjusted pessary offer rates by hospital were calculated. RESULTS: The adjusted rate of pessary offer was 25.2%, ranging from 3 to 76% per hospital. Bivariate comparisons showed differences between women with and without pessary offer in age, tobacco use, prior pelvic surgery, insurance status, surgical approach, secondary indication for surgery, concomitant prolapse procedure, teaching hospital status and hospital bed size. In logistic regression, odds of pessary offer increased with age > 55 years (OR 1.45, 95% CI 1.12-1.88, p = 0.006), Medicare insurance (OR 1.65, 95% CI 1.30-2.10, p < 0.0001), and a concomitant procedure (OR 1.5, 95% CI 1.16-1.93, p = 0.002). Postoperative urinary tract infections were more common in patients offered a pessary (6.4% vs. 2.5%, p < 0.0001), but other complications were similar. CONCLUSIONS: Overall, only one-quarter of hysterectomies for prolapse in MSQC hospitals had documentation of pessary counseling-suggesting an opportunity to improve documentation, counseling regarding pessary use, or both.

Preoperatively predicting non-home discharge after surgery for gynecologic malignancy.

OBJECTIVE: Returning home after surgery is a desirable patient-centered outcome associated with decreased costs compared to non-home discharge. Our objective was to develop a preoperative risk-scoring model predicting non-home discharge after surgery for gynecologic malignancy. METHODS: Women who underwent surgery involving hysterectomy for gynecologic malignancy from 2013 to 2015 were identified from the Michigan Surgical Quality Collaborative database. Patients were divided by discharge destination, and a multivariable logistic regression model was developed to create a nomogram to assign case-specific risk scores. The model was validated using the National Surgical Quality Improvement Program (NSQIP) database. RESULTS: Non-home discharge occurred in 3.1% of 2134 women. The proportion of non-home discharges did not differ by cancer diagnosis (uterine 3.5%, ovarian 2.5%, and cervical 1.6%, p = 0.2). Skilled nursing facilities were the most common non-home destination (68.2%). Among patients with comorbidities (hypertension, diabetes, coronary artery disease, chronic obstructive pulmonary disease /dyspnea, arrhythmia, and history of deep vein thrombosis/pulmonary embolism), non-home discharge was more common in women with 1 (adjusted OR [aOR] 3.4; p = 0.03) or ≥2 of these comorbidities (aOR 5.1; p = 0.003) compared to none. Non-home discharge was more common after laparotomy (aOR 6.7; p < 0.0001) than laparoscopy, and in those aged ≥70 years (aOR 3.4; p < 0.0001) with American Society of Anesthesiologists class ≥ 3 (aOR 4.5; p = 0.0004) and dependent functional status (aOR 8.7; p < 0.0001). The model C-statistic was 0.89. When the model was applied to 4248 eligible patients from the NSQIP dataset, the C-statistic was 0.84 (95% CI: 0.79-0.89). CONCLUSIONS: Non-home discharge after surgery for gynecologic malignancy was predicted with high accuracy in this retrospective analysis.

Definition development and prevalence of new persistent opioid use following hysterectomy.

BACKGROUND: Opioids used for postoperative pain control after surgery have been associated with an increased risk of chronic opioid use. Hysterectomy is the most common major gynecological procedure in the United States; however, we lack a data-driven definition of new persistent opioid use specific to hysterectomy. OBJECTIVE: The objectives of the study were as follows: (1) determine a data-driven definition of new persistent opioid use among opioid naïve women undergoing hysterectomy and (2) determine the prevalence of and risk factors for new persistent opioid use. STUDY DESIGN: We used data from Optum Clinformatics that include both medical and pharmacy data from a single national private health insurer. Hysterectomies performed from Jan. 1, 2011, to Dec. 31, 2014, were identified using current procedural terminology and International Classification of Diseases, ninth revision, codes. Inclusion criteria included the following: age ≤63 years at hysterectomy, no opioid fills for 8 months preceding (excluding the 30 days immediately prior), and no additional surgical procedures within 6 months after hysterectomy. The perioperative period was defined as 30 days prior to 14 days after hysterectomy. Number of opioid prescription fills, days supplied, and total oral morphine equivalents were analyzed to determine the distribution of opioid use in the perioperative and postoperative periods. We obtained demographics including age, race, educational level, and division of the country according to the US Census Bureau and used International Classification of Diseases, ninth revision, diagnosis codes to identify hysterectomy indications, surgical route, chronic pain disorders, depression/anxiety, and substance abuse. Bivariate analyses were used to compare persistent with nonpersistent opioid users. A hierarchical logistic regression model controlling for regional variation was used to determine factors associated with new persistent opioid use following hysterectomy. RESULTS: A total of 24,331 women were included in the analysis. New persistent opioid use was defined as follows: ≥2 opioid fills within 6 months of hysterectomy with ≥1 fill every 3 months and either total oral morphine equivalent ≥1150 or days supplied ≥39. Based on this definition, the prevalence of new persistent opioid use was 0.5% (n = 122). Median perioperative oral morphine equivalents prescribed to those who became new persistent users was 437.5 mg (interquartile range, 200-750) compared with 225 mg (interquartile range, 150-300) for nonpersistent users (P < .0001). Factors independently associated with new persistent opioid use included the following: increasing age (adjusted odds ratio, 1.04, 95% confidence interval, 1.01-1.06, P = .006), African-American race (reference: white, adjusted odds ratio, 1.61 95% confidence interval, 1.02-2.55, P = .04), gynecological malignancy (adjusted odds ratio, 7.61, 95% confidence interval, 3.35-17.27, P < .0001), abdominal route (adjusted odds ratio, 3.61, 95% confidence interval, 2.03-6.43, P < .0001), depression/anxiety (adjusted odds ratio, 2.62, 95% confidence interval, 1.71-4.02, P < .0001), and preoperative opioid fill (adjusted odds ratio, 2.76, 95% confidence interval, 1.87-4.07, P < .0001). The C-statistic for this model is 0.74. CONCLUSION: Based on our definition, the prevalence of new persistent opioid use among opioid-naïve women undergoing hysterectomy is low; however, 2 potentially modifiable risk factors are preoperative opioid prescription and abdominal route of surgery.

Structural, functional, and symptomatic differences between women with rectocele versus cystocele and normal support.

BACKGROUND: Prolapse of the anterior and posterior vaginal walls has been generally associated with apical descent and levator ani muscle defects. However, the relative contributions of these factors to the pathophysiology of descent in the different vaginal compartments is not well understood. Furthermore, symptoms uniquely associated with prolapse in these compartments have not been well characterized. OBJECTIVES: The objectives of the study were to compare the associations between the following: (1) apical support, (2) levator ani muscles, and (3) pelvic floor symptoms in women with posterior-predominant prolapse, anterior-predominant prolapse, and normal support. STUDY DESIGN: This is a cross-sectional study with 2 case arms: 60 women with posterior prolapse, 90 with anterior prolapse, and a referent control arm with 103 asymptomatic subjects with normal support, determined from pelvic organ prolapse quantification examinations. Levator muscle defects were graded from magnetic resonance imaging. Vaginal closure forces above resting were measured with an instrumented speculum during maximal contraction. Pelvic floor symptoms were measured via the Pelvic Floor Distress Inventory-Short Form. RESULTS: Mean point C location in controls was -6.9 cm [1.5] (mean [standard deviation]); and was higher in posterior prolapse (-4.7 cm [2.7], 2.2 cm below controls) than the anterior prolapse group (-1.2 cm [4.1]; 5.6 cm below controls, P < .001 for all comparisons). Normal-appearing muscles (ie, muscle without a visible defect) occurred at similar frequencies in posterior prolapse (45%) and controls (51%, P = .43) but less often in anterior prolapse (28%, P ≤ .03 for pairwise comparisons). Major levator ani defects occurred at similar rates in women with posterior (33%) and anterior prolapse (42%, P = .27) but less often in controls (16%, P ≤ .012 for both pairwise comparisons). Similarly, there were significant differences in generated vaginal closure forces across the 3 groups, with the prolapse groups generating weaker closure forces than the control group (P = .004), but the differences between the 2 prolapse groups were not significant after controlling for prolapse size (P = .43). Pelvic floor symptoms were more severe for the posterior (mean Pelvic Floor Distress Inventory score, 129) and anterior prolapse groups (score, 128) than the controls (score, 40.2, P < .001 for both comparisons); the difference between the 2 prolapse groups was not significant (P = .83). CONCLUSION: Posterior-predominant prolapse involves an almost 3-fold less apical descent below normal than anterior-predominant vaginal prolapse. Levator ani defects and muscle impairment also have a lower impact. Pelvic floor symptoms reflect the presence and size of prolapse more than the predominant lax vaginal compartment.

Rate of Pelvic Organ Prolapse Surgery Among Privately Insured Women in the United States, 2010-2013.

OBJECTIVE: To analyze utilization of, and payments for, pelvic organ prolapse procedures after the 2011 U.S. Food and Drug Administration (FDA) communication regarding transvaginal mesh. METHODS: This is a retrospective cohort study examining private claims from three insurance providers for inpatient and outpatient prolapse procedures from 2010 to 2013 in the Health Care Cost Institute. Primary outcomes were the change in utilization of prolapse procedures, with and without mesh, before and after the July 2011 FDA communication. Secondary outcomes were the changes in payments and reimbursements for these procedures. Utilization rates and payments were compared using generalized linear models and interrupted time-series analysis. RESULTS: Utilization of prolapse procedures decreased from 12.3 to 9.7 per 10,000 woman-years (P=.027) with a decrease of 30.7% (3.9 in 2010 to 2.7 in 2013, P=.05) in number of mesh procedures and 16.6% (8.4 in 2010 to 7.0 in 2013, P=.011) for nonmesh procedures. Quarterly utilization of mesh procedures was increasing before the FDA communication and then significantly declined after its release (slope=0.024 vs -0.025, P=.002). Nonmesh procedures, however, were already slightly decreasing before July 2011 and continued to decline at a more rapid pace after that time, although not significantly (slope=-0.004 vs -0.022, P=.47). Inpatient utilization decreased 52.2% (P=.002), whereas outpatient utilization increased 18.5% (P=.132). Payments for individual inpatient procedures, with and without mesh, increased by 12.0% ($8,315 in 2010 to $9,315 in 2013, P=.001) and 15.6% ($7,826 in 2010 to $9,048 in 2013, P=.005), respectively, whereas those for outpatient procedures increased by 41% ($4,961 in 2010 to $6,981 in 2013, P=.006) and 30% ($3,955 in 2010 to $5,149 in 2013, P=.004), respectively. CONCLUSION: Use of prolapse surgery declined during the study period. After the 2011 FDA communication regarding transvaginal mesh, there was a significant decrease in the utilization of procedures with mesh but not for those without mesh. A shift toward outpatient surgeries was observed, and payments for both individual inpatient and outpatient cases increased.

Nationwide trends in the utilization of and payments for hysterectomy in the United States among commercially insured women.

BACKGROUND: Laparotomy followed by inpatient hospitalization has traditionally been the most common surgical care for hysterectomy. The financial implications of the increased use of laparoscopy and outpatient hysterectomy are unknown. OBJECTIVES: The objective of the study was to quantify the increasing use of laparoscopy and outpatient hysterectomy and to describe the financial implications among women with commercially based insurance in the United States. STUDY DESIGN: Hysterectomies between 2010 and 2013 were identified in the Health Care Cost Institute, a national data set with inpatient and outpatient private insurance claims for more than 25 million women. Surgical approach was categorized with procedure codes as abdominal, laparoscopic, laparoscopic assisted vaginal, or vaginal. Payments were adjusted to 2013 US dollars to account for change because of inflation. RESULTS: Between 2010 and 2013, there were 386,226 women who underwent hysterectomy. The rate of utilization decreased 12.4%, from 39.9 to 35.0 hysterectomies per 10,000 women. The largest absolute decreases were observed among women younger than 55 years and among those with uterine fibroids, abnormal uterine bleeding, and endometriosis. The proportion of laparoscopic hysterectomies increased from 26.1% to 43.4%, with concomitant decreases in abdominal (38.6% to 28.3%), laparoscopic assisted vaginal (20.2 to 16.7%), and vaginal (15.1% to 11.5%) hysterectomies. There was also a shift from inpatient to outpatient surgery. In 2010, the inpatient and outpatient rates of hysterectomy were 26.6 and 13.3 per 10,000 women, respectively. By 2013, the rates were 15.4 and 19.6 per 10,000 women. In each year of analysis, the average reimbursement for outpatient procedures was 44-46% less than for similar inpatient procedures. Offsetting the lower utilization of hysterectomy and lower reimbursement for outpatient surgery were increases in average inpatient and outpatient hysterectomy reimbursement of 19.4% and 19.8%, respectively. Total payments for hysterectomy decreased 6.3%, from $823.4 million to $771.3 million. CONCLUSION: Between 2010 and 2013, laparoscopy emerged as the most common surgical approach for hysterectomy, and outpatient hysterectomy became more common than inpatient among women with commercially based insurance. While average reimbursement per case increased, overall payments for hysterectomy are decreasing because of decreased utilization and dramatic differences in how hysterectomy is performed.

Effect of Cystocele Repair on Cervix Location in Women With Uterus In Situ.

INTRODUCTION AND HYPOTHESIS: Our objective was to test the hypothesis that cystocele repair, in the absence of hysterectomy or apical suspension, results in higher cervix location in some women. METHODS: We performed a retrospective chart review of women with a uterus in situ who underwent native tissue anterior repair without hysterectomy/apical suspension from 2008 to 2014. Demographics, medical history, and preoperative and 6-week postoperative Pelvic Organ Prolapse Quantification System measurements were abstracted. Cervix location was defined by the clinic Pelvic Organ Prolapse Quantification System point C value. Women with higher (more negative) postoperative point C values were compared with those with a lower (more positive)/unchanged point C. RESULTS: Of the 33 women included, mean age was 59.8 ± 11.3 years. Median preoperative point C was -6.0 (interquartile range [IQR]: -6.75, -5.0) and point Ba was +2.0 (IQR: +0.5, +3.0). Point C was higher postoperatively in 21 (64%) of 33 women. Overall, point C was 1 cm higher post- versus preoperatively (-7.0 [IQR: -8.0, -6.0] vs -6.0 [IQR: -6.75, -5.0], P < 0.001) and point Ba was 4 cm higher (-2 [IQR: -3.0, -2.0] vs 2.0 [IQR: 0.5, 3.0], P < 0.001). Compared with women with lower/unchanged postoperative point C, those with higher point C were older (53.9 ± 12.3 vs 63.1 ± 9.4, P = 0.02) with lower parity (3.0 [IQR: 2.0, 3.0] vs 2.0 [IQR: 2.0, 3.0], P = 0.028). CONCLUSIONS: The test of our hypothesis shows that in certain women with cystocele, anterior repair alone may be associated with higher cervix location 6 weeks postoperatively.

The Use of Opportunistic Salpingectomy at the Time of Benign Hysterectomy.

STUDY OBJECTIVE: To delineate the use of opportunistic salpingectomy over the study period, to examine factors associated with its use, and to evaluate whether salpingectomy was associated with perioperative complications. DESIGN: A retrospective cross-sectional study (Canadian Task Force classification II-2). SETTING: The Michigan Surgical Quality Collaborative. PATIENTS: Women undergoing ovarian-conserving hysterectomy for benign indications from January 2013 through April 2015. INTERVENTIONS: The primary outcome was the performance of opportunistic salpingectomy with ovarian preservation during benign hysterectomy. The change in the rate of salpingectomy was examined at 4-month intervals to assess a period effect over the study period. Multivariate logistic regression was performed to evaluate independent effects of patient, operative, and period factors. Perioperative outcomes were compared using propensity score matching. MEASUREMENTS AND MAIN RESULTS: There were 10 676 (55.9%) ovarian-conserving hysterectomies among 19 090 benign hysterectomies in the Michigan Surgical Quality Collaborative in the study period. The rate of opportunistic salpingectomy was 45.8% (n = 4890). Rates of opportunistic salpingectomy increased over the study period from 27.5% to 61.6% (p < .001), demonstrating a strong period effect in the consecutive 4-month period analysis. Salpingectomy was more likely with the laparoscopic approach (odds ratio = 3.48; 95% confidence interval, 3.15-3.85) and among women younger than 60 years of age (odds ratio = 1.60; 95% CI, 1.34-1.92). There was substantial variation in salpingectomy across hospital sites, ranging from 3.6% to 79.9%. Salpingectomy was associated with a 12-minute increase in operative time (p < .001), but there were no differences in the estimated blood loss or perioperative complications. CONCLUSION: The rates of salpingectomy increased significantly over the study period. The laparoscopic approach and younger age are associated with an increased probability of salpingectomy. Salpingectomy is not associated with increased blood loss or perioperative complications.

Length of Catheter Use After Hysterectomy as a Risk Factor for Urinary Tract Infection.

OBJECTIVES: The aims of this study were to determine the effect of length of postoperative catheterization on risk of urinary tract infection (UTI) and to identify risk factors for postoperative UTI. METHODS: This was a retrospective case-control study. Demographic and perioperative data, including duration of indwelling catheter use and postoperative occurrence of UTI within 30 days of surgery, were analyzed for hysterectomies using the Michigan Surgical Quality Collaborative database. Catheter exposure was categorized as low-no catheter placed/catheter removed the day of surgery, intermediate-catheter removed postoperative day 1, high-catheter removal on postoperative day 2 or later, or highest-patient discharged home with catheter. A multivariable logistic regression model was developed to identify factors associated with UTI. An interaction term was included in the final model. RESULTS: Overall, UTI prevalence was 2.3% and increased with duration of catheter exposure (low: 1.3% vs intermediate: 2.1% vs high: 4.1% vs highest: 6.5%, P < 0.0001). High (odds ratio [OR] = 2.54 [1.51-4.27]) and highest (OR = 3.39 [1.86-6.17]) catheter exposure, operative time (OR = 1.15 [1.03-1.29]), and dependent functional status (OR = 4.62 [1.90-11.20]) were independently associated with UTI. Women who had a vaginal hysterectomy with sling/pelvic organ prolapse repair were more likely to have a UTI than those who had a vaginal hysterectomy alone (OR = 2.58 [1.10-6.07]) and more likely to have a UTI than women having an abdominal or laparoscopic hysterectomy with a sling/pelvic organ prolapse repair (OR = 2.13 [1.12-4.04]). CONCLUSIONS: Length of catheterization and operative time are modifiable risk factors for UTI after hysterectomy. An interaction between vaginal hysterectomy and concomitant pelvic reconstruction increases the odds of UTI.