Movement to outpatient hysterectomy for benign indications in the United States, 2008-2014.

Hysterectomy is the most common procedure for women with benign gynecological conditions. Adoption of conservative gynecologic treatments during the past decade, including minimally invasive procedures, have occurred alongside steady declines in inpatient hysterectomies [ 1 – 3 ]. Minimally invasive surgery (MIS) approaches–including laparoscopic hysterectomy (LH), vaginal hysterectomy (VH), and robotic-assisted hysterectomy (RH)–are becoming increasingly common relative to abdominal hysterectomy (AH) even for complex cases, which is supported by improvements in surgical equipment and emerging developments in specialized fellowship training programs [ 4 – 5 ]. The benefits of MIS for benign hysterectomy (BH) have been clearly documented [ 1 – 4 ]. Patients who have undergone MIS experience fewer medical and surgical complications, better quality of life, and substantially lower medical costs overall [ 2 , 5 – 11 ]. Major professional societies in gynecology now recommend MIS as a first line to avoid the morbidity of laparotomy [ 1 , 12 ]. LH and RH in the outpatient setting are generally considered safe and feasible [ 5 , 13 – 16 ]. Given the benefits of minimally invasive hysterectomy and the safety and feasibility profile in an outpatient setting, private payers implemented prior authorization for inpatient surgery starting in 2015 [ 17 , 18 ]. Beginning in 2016, Centers for Medicare & Medicaid Services (CMS) Medicare Part B Outpatient Prospective Payment System substantially increased reimbursement rates for most BH procedures, providing further incentive for outpatient BH [ 19 ]. According to two large database studies, AH was the most commonly performed surgical approach for all BH cases and for inpatient BH by first quarter 2010 [ 20 , 21 ]. However, these studies were unable to capture the increasingly common outpatient hysterectomy. A recent cross-sectional study of State Ambulatory Surgery and Services Databases from 16 states for year 2011 estimated approximately 100,000–200,000 outpatient hysterectomies per year; approximately 81.5% performed laparoscopically and 16% vaginally [ 22 ]. To our knowledge, no previous study has examined trends in care setting over time. This is important because one of the purported benefits of MIS is that it may enable more outpatient surgery. Our objective in the present study was to examine trends in surgical approaches and care settings among patients in the United States (US) who underwent BH from 2008–2014. We conducted a nationwide analysis of hysterectomy trends stratified by inpatient and outpatient settings using a large hospital administrative database of hospitals in the United States. The influence of patient-, physician-, hospital-level preoperative factors, and surgical approaches on patient pathway to inpatient vs. outpatient BH were also explored.

The descriptive characteristics for patients who had a BH in 2008 and 2014 are presented in Table 1 . In 2008, AH (44.5%) was the most common surgical approach, and RH was the least common (2.8%). In 2014, LH (31.4%) became the leading surgical approach, followed by RH (29.3%). In both 2008 and 2014, patient characteristics varied significantly across different surgical approaches (all P <0.001). Specifically, compared to AH, more patients in the MIS cohorts (ie, patients who underwent VH, LH, and RH) were white and were less likely to have adhesions, obesity, or ≥2 complexities (all P <0.0001). The indication of surgery also varied across the four cohorts: AH had more patients with fibroids, and VH had more patients with pelvic prolapse. When comparing changes in patient population between 2008 to 2014, more black, Medicare or Medicare insured, and complex patients had MIS BH in 2014, and substantially more RH procedures were done in nonteaching and in smaller bed size hospitals in 2014. Notably, by analyzing different types of hospitals, both procedure volume and proportion of VH declined substantially among nonteaching hospitals, regardless of bed size. a BMI ≥30. AH, open/abdominal hysterectomy; BH, benign hysterectomy; BMI, body mass index; CCI, Charlson Comorbidity Index; LH, laparoscopic hysterectomy; MIS, minimally invasive surgery; OBGYN, obstetrics and gynecology; RH, robotic hysterectomy; SD, standard deviation; VH, vaginal hysterectomy, y, year. From the first quarter (Q1) of 2008 to the last quarter (Q4) of 2014, RH and LH approaches increased (1.7% to 29.3% and 29.4% to 31.2%, respectively), which coincided with decreases in VH and AH (21.2% to 13.5% and 47.8% to 25.9%, respectively; P <0.0001; Fig 2A ). A statistically significant shift from the inpatient to the outpatient setting was observed; 13.3% of BH were performed as outpatient procedures in 2008 vs. 57.5% in 2014 ( P <0.0001; Fig 2B ; Fig 2C ). Among outpatient procedures performed from Q1 2008 to Q4 2014, RH increased from 3.6% to 41.1%, while AH decreased from 2.6% to 0.9%. LH decreased from 69.0% to 42.2%, and VH decreased from 24.8% to 15.8% ( S1 Fig ; S2 Table ). For outpatient surgeries with ≥2 complexities, RH increased from 10.9% to 53.0%, and LH decreased from 78.3% to 42.6% ( S2 Fig ). (A) All Visits by Surgical Approach, (B) All Visits by Care Setting, and (C) All Visits by Surgical Approach and Care Setting, 2008 and 2014 only. BH, benign hysterectomy; RH, robotic hysterectomy; y, year. The MLR analysis revealed that in predicting outpatient BH in 2014, patient-level factors contributed 58.99%, surgeon-level factors 20.85%, and hospital-level factors 7.18% ( Table 2 ). Surgical approach (51.84%) and surgeon MIS experience (19.92%) in the outpatient setting were the top two individual contributing factors. Among patient-level factors, subtotal hysterectomy was associated with increased likelihood of outpatient BH; being older, nonwhite, obese, insured by Medicaid, or with a higher CCI was associated with decreased likelihood of outpatient BH ( S3 Table ). Surgeon with experience in outpatient MIS, OBGYN surgeon, and hospitals in the South region were associated with increased likelihoods of outpatient BH. BH, benign hysterectomy; CCI, Charlson Comorbidity Index; MIS, minimally invasive surgery. With regard to the effect of surgical approach ( Table 3 ), compared with the reference group of LH, RH was associated with a modestly increased odds of outpatient BH (OR 1.23; 95% CI, 1.16–1.31). In those patients with complexities, RH was associated with an increased odds of outpatient BH, particularly among patients with adhesions (OR 1.74; 95% CI, 1.49–2.04). Compared to AH, strongly increased odds of outpatient MIS were observed for VH (OR 80.52; 95% CI, 70.29–92.24), LH (OR 111.38; 95% CI, 98.91–125.56), and RH (OR 137.27; 95% CI, 121.69–154.85). AH, open/abdominal hysterectomy; BH, benign hysterectomy; BMI, body mass index; CI, confidence interval; g, grams; LH, laparoscopic hysterectomy; OR, odds ratio; RH, robotic hysterectomy; Robotic BH hospital, hospitals with a robot for BH in 2014; VH, vaginal hysterectomy. *Adjusted for age, race, insurance type, hysterectomy type (total/subtotal), Charlson comorbidity score, indication for surgery (fibroids, endometriosis, pelvic prolapse, uterus bleeding, and chronic pelvic pain), obese, uterine weight (>250 g vs. ≤250 g), physician specialty, teaching, hospital region, hospital area (urban/rural), bed size. † Adjusted for age, race, insurance type, hysterectomy type (total/subtotal), Charlson comorbidity score, indication for surgery (fibroids, endometriosis, pelvic prolapse, uterus bleeding, and chronic pelvic pain), adhesion, uterine weight (>250 g vs. ≤250 g), physician speciality, physician experience of outpatient minimally invasive surgery, teaching, hospital region, hospital area (urban/rural), bed size. ‡ Adjusted for age, race, insurance type, hysterectomy type (total/subtotal), Charlson comorbidity score, indcation for surgery (fibroids, endometriosis, pelvic prolapse, uterus bleeding, and chronic pelvic pain), obese, uterine weight (>250 g vs. ≤250 g), physician speciality, physician experience of outpatient minimally invasive surgery, teaching, hospital region, hospital area (urban/rural), bed size. § Adjusted for age, race, insurance type, hysterectomy type (total/subtotal), Charlson comorbidity score, indication for surgery (fibroids, endometriosis, pelvic prolapse, uterus bleeding, and chronic pelvic pain), obese, adhesion, physician speciality, physician experience of outpatient minimally invasive surgery, teaching, hospital region, hospital area (urban/rural), bed size. Stratifying the data for robotic BH hospitals, similar patterns were found ( Table 3 ). In this subgroup of hospitals, the odds of outpatient BH for RH vs. LH was similar to that observed for all hospitals. The analysis of 2008 data shows similar results ( S4 Table ).

A shift in setting for BH from inpatient to outpatient was observed from 2008–2014. In outpatient settings, statistically significant increases in MIS, especially the increase of RH in overall and complex cases, were observed. Utilization of RH as the surgical approach was associated with an increased odds of outpatient BH, particularly for patients with adhesions. Further comprehensive cost-effectiveness analysis of BH surgical approaches incorporating patient pathway of inpatient and outpatient setting and real-world comparative effectiveness of surgical outcomes is warranted. Further, the adoption of MIS in outpatient settings may improve access to disadvantaged patient groups.

The Premier Hospital Perspective ® Database (Premier) includes more than 700 hospitals that cover more than 45 million inpatient visits and approximately 210 million outpatient visits from acute care facilities, ambulatory surgery centers, and clinics across the United States [ 23 ]. Women aged ≥18 years who underwent BH from 2008 to 2014 were identified in the Premier database. International Classification of Disease, version 9 (ICD-9) procedure codes were used to identify surgical approaches, defined as BH [AH (68.3, 68.39, 68.4, 68.49, 68.9) VH; (68.59); LH (68.31, 68.41, 68.51, V64.41), and RH (17.41, 17.42, 17.44, 17.49, or recorded charged code for robotic instrumentation)]. We excluded 11.8% of women who underwent hysterectomy with: a diagnosis of cancer (ICD-9 CM 179, 180.0, 180.1, 180.8, 180.9, 181, 182.0, 182.1, 182.8, 183.0, 183.2, 183.3, 183.4, 183.5, 183.8, 183.9, 184.0, 184.1, 184.2, 184.3, 184.4, 184.8, 184.9, 233.1, 233.2, 233.3, 233.31, 233.32, 233.39, 236.0, 236.1, 236.2, 236.3); pelvic or lower abdominal trauma (ICD-9 CM 867.4, 867.5, 867.6, 867.7, 867.8, 867.9, 868.00, 868.03, 868.04, 868.09, 868.10, 868.13, 868.14, 868.19, 869.0, 869.1, 879.6, 879.7, 879.8, 879.9, 906.0, 908.1, 908.2, 929.1, 947.4); pregnancy, childbirth, or location in the puerperium (Major diagnosis category 00014)( Fig 1 ). Inpatient or outpatient BH was defined based on the outpatient/inpatient indicator in Premier ( S1 Table ). Patients were classified as inpatient if admitted to a hospital, skilled nursing facilities, or long-term care. Patients were classified as outpatients if they spent less than 24 hours in the hospital after surgery, had same day, or ambulatory surgery. Patient socio-demographic variables included age, race, and insurance type (Medicare, Medicaid, commercial, or self-pay/others); patient clinical characteristics included Charlson Comorbidity Index (CCI), uterine weight (≤250 g vs. >250 g), adhesion (including intra-abdominal and vaginal), obesity (body mass index [BMI] ≥30), indications for surgery (fibroids, endometriosis, uterus bleeding, pelvic prolapse, or chronic pelvic pain) [ 20 , 24 ], and type of hysterectomy (total or subtotal). Race was included to explore any disparity in the access to healthcare and/or advanced techniques. The specialty information of physicians prefoming hysterectomy was provided from Premier and was defined as obstetrics and gynecology/OBGYN, gynecologic oncology/GYN ONC, or others. Physician outpatient MIS experience was defined as if the physician had performed at least one outpatient BH through MIS (VH, LH, or RH) since January 1, 2008. Hospital characteristics included location (rural or urban), hospital type (community or teaching), region (Midwest, Northwest, South, or West), and bed size (600). Institutional Review Board (IRB) exemption was obtained from Western Institutional Review Board documenting the analysis of data with no patient, provider, or hospital identifiers. The proportions of the four surgical approaches performed for inpatient vs. outpatient BH were calculated in each quarter. Trend analysis among outpatient BH were performed with further examination of cases with ≥2 complexities (defined as obesity [BMI≥30]), adhesions, or uterine weight >250 g). Since not all hospitals have a robot for RH, the analysis was then limited to hospitals that performed ≥1 RH during 2008–2014, which was used as the proxy for the measure of hospitals with robotic technology for BH. The rates of each surgical approach were calculated by number of quarters after the introduction of RH at a given hospital. The descriptive analysis of patient, physician, and hospital characteristics observed between 2008 and 2014 were determined by chi-square tests for categorical variables and t tests for continuous variables. Trends of each surgical approach within inpatient and outpatient visits were reported. Ordinary least square regression was performed to assess the linear time trend across quarters during the entire timeframe examined. The analyses of inpatients were weighted to obtain nationally representative estimates [ 25 ]. No weight was available for the outpatient setting and thus the analyses including outpatient cases were unweighted. Multivariate logistic regression (MLR) analysis was conducted among women receiving BH to assess the impact of patient, physician, and hospital preoperative factors as well as surgical approach on the odds of the BH being performed in an outpatient vs. inpatient setting [ 26 ]. The MLR was conducted using the most recent year of data, 2014. Adjusted R-squared was used for model diagnostics and reported for contributions of variation predicting the likelihood of outpatient BH from different factors. Adjusted odds ratios (ORs) were used to estimate the impact of surgical approach (AH, VH, LH, or RH) on the odds of outpatient BH, using LH as the reference group. Subgroup analyses were conducted among patients with ≥2 complexities and in hospitals having a robot for BH. Additional analysis was repeated using 2008 data to provide a reference for the trend analysis. All analyses were conducted with SAS version 9.4 (SAS Institute, Cary, NC, USA).

SNF, skilled nursing facility; TCU, transitional care unit. (DOCX) Click here for additional data file. AH, open/abdominal hysterectomy; BH, benign hysterectomy; LH, laparoscopic hysterectomy; RH, robotic hysterectomy; VH, vaginal hysterectomy. *% of outpatient BH. (DOCX) Click here for additional data file. BH, benign hysterectomy; BMI, body mass index; CCI, Charlson Comorbidity Index; CI, confidence interval; g, grams; OBGYN, obstetrics and gynecology; OR, odds ratio. (DOCX) Click here for additional data file. AH, open/abdominal hysterectomy; BH, benign hysterectomy; BMI, body mass index; CI, confidence interval; g, grams; LH, laparoscopic hysterectomy; OR, odds ratio; RH, robotic hysterectomy; Robotic BH hospital, Hospitals with a robot for BH in 2008; VH, vaginal hysterectomy. *Adjusted for age, race, insurance type, hysterectomy type (total/subtotal), Charlson comorbidity score, indication for surgery (fibroids, endometriosis, pelvic prolapse, uterus bleeding, and chronic pelvic pain), obese, uterine weight (>250 g vs. ≤250 g), physician specialty, teaching, hospital region, hospital area (urban/rural), bed size. † Adjusted for age, race, insurance type, hysterectomy type (total/subtotal), Charlson comorbidity score, indication for surgery (fibroids, endometriosis, pelvic prolapse, uterus bleeding, and chronic pelvic pain), adhesion, uterine weight (>250 g vs. ≤250 g), physician speciality, physician experience of outpatient minimally invasive surgery, teaching, hospital region, hospital area (urban/rural), bed size. ‡ Adjusted for age, race, insurance type, hysterectomy type (total/subtotal), Charlson comorbidity score, indication for surgery (fibroids, endometriosis, pelvic prolapse, uterus bleeding, and chronic pelvic pain), obese, uterine weight (>250 g vs. ≤250 g), physician speciality, physician experience of outpatient minimally invasive surgery, teaching, hospital region, hospital area (urban/rural), bed size. § Adjusted for age, race, insurance type, hysterectomy type (total/subtotal), Charlson comorbidity score, indication for surgery (fibroids, endometriosis, pelvic prolapse, uterus bleeding, and chronic pelvic pain), obese, adhesion, physician speciality, physician experience of outpatient minimally invasive surgery, teaching, hospital region, hospital area (urban/rural), bed size. ¶ In 2008, there were 12384 AH cases observed at hospitals with robotic for BH. 12291 (99.25%) of them were performed in inpatient setting and 93 (0.75%) cases an outpatient setting. There is not enough cases to complete estimation for OR of AH vs. LH. (DOCX) Click here for additional data file. BH, benign hysterectomy; RH, robotic hysterectomy; y, year. (TIF) Click here for additional data file. BH, benign hysterectomy; RH, robotic hysterectomy; y, year. (TIF) Click here for additional data file.