NEW YORK (Reuters Health) – Complications, including death, are more common after hysterectomies performed by surgeons who do only one such procedure per year, researchers report.
“Surgical volume may be a target for quality improvement in gynecology,” Dr. Jason D. Wright from Columbia University College of Physicians and Surgeons, in New York, told Reuters Health by email. “For some patients, targeted referral strategies may be warranted.”
It has long been recognized that patients operated on by high-volume surgeons and at high-volume centers have superior outcomes. With the declining trend in hysterectomies, many gynecologic surgeons are experiencing reduced procedural volumes. Little is known about the impact of these changes on hysterectomy outcomes.
Dr. Wright’s team used data from the New York Statewide Planning and Research Cooperative System database to examine the changes in surgeon and hospital procedural volume for hysterectomy over time and to explore the associations between very low surgeon procedural volume and outcomes.
Physicians were classified as very-low-volume surgeons if they averaged one hysterectomy per year and as higher-volume surgeons if their annualized volume was greater than one.
The percentage of surgeons classified as very-low-volume was 14.8% in 2000, 10.4% in 2007 and 13.7% in 2014, and 1.0% of patients were treated by very low-volume surgeons.
Very-low-volume surgeons were most likely to perform abdominal hysterectomies, whereas higher-volume surgeons were more likely to perform laparoscopic and vaginal hysterectomies, the researchers report in Obstetrics & Gynecology, online May 7.
Overall complication rates were significantly higher for women treated by very-low-volume surgeons (32.0%) than for those treated by higher-volume surgeons (9.9%), a 97% greater relative risk when adjusted for other factors.
Women treated by very-low-volume surgeons were also much more likely to have a prolonged length of stay and excessive hospital charges, compared with higher volume surgeons.
In-hospital mortality was 2.5% for very low-volume surgeons, compared with only 0.2% for higher volume surgeons (P<0.001), nearly a threefold risk difference after adjustment for other factors.
There were similar trends when the analyses were stratified by the route of hysterectomy.
“As the number of hysterectomies performed each year declines and practice patterns in gynecology shift, the number of surgeons with very low case volumes may increase,” Dr. Wright said.
“Undoubtedly, future research is warranted aimed at determining whether surgeon characteristics such as innate ability, level of surgical training, and surgical experience have an effect on the quantity, frequency, or quantity and frequency of surgical repetitions needed to minimize patient morbidity,” writes Dr. Douglas N. Brown from Massachusetts General Hospital, Harvard Medical School, in Boston, in a linked editorial.
“In these situations, introspection and self-examination can be extremely valuable,” he notes. “In certain situations it may not be possible, but, when it is feasible, we must remember to put our egos aside and to always put the patient first.”
Dr. Alex Mowat from Royal Brisbane and Women’s Hospital, University of Queensland, Australia, who has also described higher rates of adverse outcomes for gynecologists performing procedures once a month or less, told Reuters Health by email, “The most shocking thing about this paper is that a higher-volume surgeon is one who does more than one hysterectomy a year.”
“There is now mounting evidence that volume matters to outcomes and health economics,” she said. “This paper found that if a low-volume surgeon does your hysterectomy, you have a 2.5% risk of dying!”
“The paper adds to peer-reviewed literature that there is a strong argument for all surgery to be done by high-volume surgeon where they are available,” Dr. Mowat said.
SOURCE: https://bit.ly/2IxPf6k and https://bit.ly/2IaYuGg
Obstet Gynecol 2018.
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