Trends and characteristics of inpatient vs ambulatory surgery for endometriosis

BACKGROUND: It is unknown to what extent the surgical management of endometriosis occurs in the outpatient settings and which factors are associated with ambulatory vs inpatient surgical care. OBJECTIVE: The objective of this study was to perform a nationwide analysis comparing trends, clinical factors, disease manifestations, surgical approaches, and hospital charges between ambulatory and inpatient surgical cases for endometriosis. STUDY DESIGN: This serial cross-sectional study analyzed inpatient and ambulatory surgeries from 2016 to 2022 with a primary diagnosis of endometriosis. Inpatient surgeries were analyzed using the National Inpatient Sample, a nationally representative inpatient database. Ambulatory surgeries were analyzed using the Nationwide Ambulatory Surgery Sample, a nationally representative ambulatory surgical database. Surgical trends were analyzed using joinpoint regression and presented as the average annual percent change. Demographic and clinical characteristics associated with inpatient vs ambulatory surgery were reported. Surgical procedures, endometriosis involvement sites, and surgical complications were also compared between inpatient and ambulatory surgeries. RESULTS: A nationwide total of 70,535 weighted inpatient and 561,894 weighted ambulatory surgical encounters for endometriosis were identified between 2016 and 2022. Over the study period, inpatient surgical volume decreased by 49% from 14,080 cases in 2016 to 7110 cases in 2022 (average annual percent change, -11.5% [95% confidence interval, -14.4% to -8.7%]), whereas outpatient surgical volume increased by 17% from 73,270 cases in 2016 to 85,896 cases in 2022 (average annual percent change, 2.8% [95% confidence interval, 0.2%-5.4%]). Inpatient surgical cases were more likely to occur among patients who were older (median age, 40 vs 37 years), who had a higher Elixhauser comorbidity index, who were more likely to be enrolled in Medicaid insurance (20% vs 16%), and who lived in the lowest median income ZIP code quartile (26% vs 21%). Ovarian involvement (37% vs 26%), bowel involvement (10% vs 3%), multiorgan involvement (40% vs 30%), concurrent pelvic infection (3.0% vs 1.4%), and intraoperative complications were all more common among patients undergoing inpatient compared with ambulatory surgery. Hysterectomy with salpingo-oophorectomy was most frequent in the inpatient setting but also accounted for a large proportion of ambulatory procedures (61% vs 47%), with a significant shift of this operation from inpatient to ambulatory care over the study period. CONCLUSION: An increasing proportion of surgeries for endometriosis, including hysterectomy, is now being performed in the outpatient setting. Inpatient surgical cases are more common among medically complex patients and those with distinct socioeconomic characteristics.