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.

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-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 claims for more than 25 million women. Surgical approach was categorized with Care Cost Institute, a national dataset with inpatient and outpatient private insurance procedure codes as abdominal, laparoscopic, laparoscopic assisted vaginal, or vaginal. Payments were adjusted to 2013 U.S. dollars to account for change due to 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 less 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.

Background Pelvic organ prolapse has two components; 1) protrusion of the pelvic organs beyond the hymen and 2) descent of the levator ani. The Pelvic Organ Prolapse Quantification system measures the first component, however, there remains no standard measurement protocol for the second mechanism. Objectives Test the hypotheses that 1) difference in the protrusion area is greater than the area created by levator descent in prolapse patients compared with controls and, 2) Prolapse is more strongly associated with levator hiatus compared to urogenital hiatus. Study Design Mid-sagittal MRI scans from 30 controls, 30 anterior predominant and 30 posterior predominant prolapse patients were assessed. Levator area was defined as the area above the levator ani and below the sacrococcygeal inferior pubic point line. Protrusion area was defined as the protruding vaginal walls below the levator area. The levator hiatus and urogenital hiatus were measured. Bivariate analysis and multiple comparisons were performed. Bivariate logistic regression was performed to assess prolapse as a function of levator hiatus, urogenital hiatus, levator area, and protrusion. Pearson correlation coefficients were calculated. Results The levator area for the anterior (34.0±6.5cm2) and posterior (35.7±8.0cm2) prolapse groups were larger during Valsalva compared to controls (20.9±7.8cm2, p<.0001 for both); similarly, protrusion areas for the anterior (14.3±6.2cm2) and posterior (14.4±5.7cm2) were both larger than controls (5.0±1.8cm2, p<.0001 for both). The levator hiatus length for the anterior (7.2±1cm) and posterior (6.9±1cm) were longer during Valsalva compared to controls (5.2±1.5cm, p<.0001 for both); similarly, urogenital hiatus lengths for the anterior (5.7±1cm) and posterior (6.3±1.1cm) were both longer than controls (3.8±0.8cm, p<.0001 for both). The difference in levator area in prolapse patients compared with controls was greater than the difference in protrusion area (14.0 ± 7.2cm2 v. 9.4 ± 5.9cm2, p<.0002). The urogenital was more strongly associated with prolapse than the levator hiatus (OR: 12.9, 95% CI: (4.1–39.2), OR: 4.3, 95% CI: (2.3–7.5)). Levator hiatus and urogenital hiatus are both correlated with levator and protrusion areas, and all were associated with maximum prolapse size (p≤0.001, for all comparisons). Conclusions In prolapse, the levator area increases more than the protrusion area and both the urogenital hiatus and levator hiatus are larger. The odds of prolapse for an increase in the urogenital hiatus are three times larger than for the levator hiatus, which leads us to reject both the original hypotheses.

Background Healthcare teams that frequently follow a bundle of evidence-based processes provide care with lower rates of morbidity. Few process bundles to improve surgical outcomes in hysterectomy have been identified. Objectives To investigate if a bundle of four perioperative care processes is associated with fewer postoperative complications and readmissions for hysterectomies in the Michigan Surgical Quality Collaborative (MSQC). Study Design A bundle of perioperative care process goals was developed retrospectively with 30 day peri- and post-operative outcome data from the Hysterectomy Initiative in MSQC. All benign hysterectomies performed between January 2013 and January 2015 were included. Based on evidence of lower complication rates after benign hysterectomy, the following processes were considered the “bundle”—use of guideline-appropriate preoperative antibiotics, a minimally invasive surgical approach, operative duration less than 120 minutes, and avoidance of intraoperative hemostatic agent use. Each process was considered present or absent and the number of processes was summed for a bundle score ranging from zero to four. Cases with a score of zero were excluded. Outcomes measured were rates of complications (any and major) and hospital readmissions, all within 30 days of surgery. Postoperative events considered a “major complication” included acute renal failure, cardiac arrest requiring cardiopulmonary resuscitation, central line infection, cerebral vascular accident, death, deep vein thrombosis, intestinal obstruction, myocardial infarction, pelvic abscess, pulmonary embolism, rectovaginal fistula, sepsis, surgical site infection (deep and organ-space), unplanned intubation, ureteral obstruction, ureterovaginal and vesicovaginal fistula. The outcome “any complication” included all those events already described in addition to blood transfusion within 72 hours of surgery, urinary tract infection, and superficial surgical site infection. Outcomes were adjusted for patient demographics, surgical factors, and hospital-level clustering effects. Results 16,286 benign hysterectomies were available for analysis. Among all hysterectomies reviewed, 33.6% met criteria for all bundle processes; however, there was wide variation in the rate among the 56 hospitals in the study sample with 9.1% of cases at the lowest quartile and 60.4% at the highest quartile of hospitals meeting criteria for all bundle processes. Overall, the rate of any complication was 6.8% and major complication 2.3%. The rate of hospital readmissions was 3.6%. After adjustment for confounders, in cases where all bundle criterion were met compared to cases where all bundle criterion were not met, the rate of any complications increased from 4.3% to 7.8% (p<0.001), major complications increased from 1.7% to 2.6% (p<0.001) and readmissions increased from 2.6% to 4.1% (p<0.001). After adjustment for confounders, hospitals with greater rates of meeting all four criteria were significantly associated with lower hospital-level rates of p...

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