OBJECTIVE To examine the use of inpatient hysterectomy and explore changes in the use of various routes of hysterectomy and patterns of referral. METHODS The Nationwide Inpatient Sample was used to identify all women aged 18 years or older who underwent inpatient hysterectomy between 1998 and 2010. Weighted estimates of national trends were calculated and the number of procedures performed estimated. Trends in hospital volume and across hospital characteristics were examined. RESULTS After weighting, we identified a total 7,438,452 women who underwent inpatient hysterectomy between 1998 and 2010. The number of hysterectomies performed annually rose from 543,812 in 1998 to a peak of 681,234 in 2002; it then declined consistently annually and reached 433,621 cases in 2010. Overall, 247,973 (36.4%) fewer hysterectomies were performed in 2010 compared with 2002. From 2002 to 2010 the number of hysterectomies performed for each of the following indications declined: leiomyoma (−47.6%), abnormal bleeding (−28.9%), benign ovarian mass (−63.1%), endometriosis (−65.3%), and pelvic organ prolapse (−39.4%). The median hospital case volume decreased from 83 procedures per year in 2002 to 50 cases per year in 2010 (P<.001). CONCLUSION The number of inpatient hysterectomies performed in the United States has declined substantially over the past decade. The median number of hysterectomies per hospital has declined likewise by more than 40%. LEVEL OF EVIDENCE III

YSTERECTOMY FOR BENIGN gynecologic disease is one of the most commonly performed procedures for women. Overall, 1 in 9 women in the United States will undergo the procedure during her lifetime. 1-3 While hysterectomy has traditionally been performed abdominally via laparotomy, vaginally, or by laparoscopy, robotically assisted hysterectomy has been introduced as an alternative minimally invasive approach to hysterectomy. 1,2 The robotic surgical platform received approval from the US Food and Drug Administration in 2005 for the performance of gynecologic procedures and allows a surgeon to perform the procedure at a remote console. 3 Potential benefits of robotic surgery include increased range of motion with the instrumentation, 3-dimensional stereoscopic visualization, and improved ergonomics for the operating surgeon. 3,4 Unlike other procedures such For editorial comment see p 721.

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Although febrile neutropenia (FN) is a major source of morbidity and mortality for patients with solid tumors, little is known about the use of guidelinebased care.Objectives: To examine compliance with guidelinebased recommendations for FN treatment, explore the factors that influence adherence to consensus guidelines, and analyze how the use of guideline-based care affects the outcomes. Design:The Perspective database was used to examine the treatment of cancer patients with FN from January 1, 2000, through March 31, 2010. To capture initial decision making, we examined treatment within 48 hours of hospital admission. We determined use of guidelinebased antibiotics and nonguideline-based treatments, vancomycin, and granulocyte colony-stimulating factors (GCSF). Hierarchical models were developed to examine the factors associated with treatment. Patients were stratified into low-and high-risk groups, and the effect of the initial treatment on outcome (nonroutine hospital discharge and death) was examined.Setting and Participants: Twenty-five thousand two hundred thirty-one patients with solid tumors hospitalized for neutropenia.Main Outcome Measure: Use of guideline-based antibiotics, vancomycin, and GCSF and their affect on outcome.Results: Among 25 231 patients admitted with FN, guideline-based antibiotics were administered to 79%, vancomycin to 37%, and GCSF to 63%. Patients treated at high FN-volume hospitals (odds ratio [OR], 1.56; 95% CI, 1.34-1.81) by high FN-volume physicians (OR, 1.19; 95% CI, 1.03-1.38) and patients managed by hospitalists (OR, 1.49; 95% CI, 1.18-1.88) were more likely to receive guidelinebased antibiotics (P Ͻ .05). Vancomycin use increased from 17% in 2000 to 55% in 2010, while GCSF use only decreased from 73% to 55%. Among low-risk patients with FN, prompt initiation of guideline-based antibiotics decreased discharge to a nursing facility (OR, 0.77; 95% CI, 0.65-0.92) and death (OR, 0.63; 95% CI, 0.42-0.95).Conclusions and Relevance: While use of guidelinebased antibiotics is high, use of the nonguideline-based treatments, vancomycin, and GCSF is also high. Physician and hospital factors are the strongest predictors of both guideline-and nonguideline-based treatment.