Determinants of Surgical Approach for Benign Outpatient Hysterectomy

Abstract

Study objective: Identify determinants of the surgical approach to a benign, outpatient, minimally invasive hysterectomy.

Design: A cross-sectional sample of patients undergoing outpatient hysterectomy between the 4th quarter of 2015 and the 4th quarter of 2022, excluding those with a diagnosis of gynecologic malignancy, was obtained from the Vizient Clinical Data Base. The primary outcome was surgical approach to hysterectomy that was analyzed using mixed-effects regression, including a surgeon-level random effects to capture unobserved surgeon-level differences influencing variation in surgical approach.

Setting: The Vizient Clinical Data Base includes patient encounter data from >50 healthcare systems and >400 community hospitals and represents approximately 97% of academic medical centers in the United States.

Patients: Women >18 years undergoing an outpatient benign hysterectomy.

Intervention: Surgical approach to hysterectomy.

Measurement and main result: The final sample included 411 208 cases performed by 6089 surgeons. Among observed variables, patient diagnosis, surgeon specialty, and insurance type were strongly associated with choice of approach. However, after controlling for patient, hospital, and observable surgeon characteristics, unobserved surgeon-level differences still accounted for 72% of the variance in the use of transvaginal hysterectomy (95% confidence interval, 71-73) and 85% of the variance in the use of robot-assisted total hysterectomy (95% confidence interval, 84-86).

Conclusion: The strongest determinant of surgical approach to a benign outpatient hysterectomy in the United States was not patient- or hospital-level variability, but unexplained differences across individual surgeons. This has implications in how surgeons are trained and incentivized to deliver high-value surgical care.

Keywords: Hysterectomy; Policy; Techniques; Training.