Are perioperative bundles associated with reduced postoperative morbidity in women undergoing benign hysterectomy? Retrospective cohort analysis of 16,286 cases in Michigan

Abstract

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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