Abdominal versus vaginal hysterectomy: a statistical model for determining physician decision making and patient outcome.

To identify the effects of preoperative assessment and physician practice style on the outcomes of hysterectomy, the authors conducted a small-area analysis of 640 women under-going abdominal or vaginal hysterectomy in a St. Louis, Missouri, hospital. Of these patients, excluding outliers, 115 met the conditions for inclusion in the study. Hysterectomies were performed by the abdominal route in 55 (47.8%) and by the vaginal route in 60 (52.2%) of the 115 patients. A total of 29 physicians performed the hysterectomies. Of these 29, 15 (51.7%) were predisposed toward the abdominal approach, 13 (44.8%) had no appreciable predisposition, and one (3.5%) was predisposed toward the vaginal procedure. Path analysis revealed that physician decision making about the type of hysterectomy procedure performed was primarily influenced by practice style (predisposition) and variables related to physician preoperative assessments (uterine size and uterine mobility), some of which are prone to inaccuracy. Factors that traditionally determine operative approach (such as obesity) did not always act in the expected direction. Furthermore, the decision to perform hysterectomy vaginally had positive outcomes for both cost and length of hospital stay. Shorter hospital stays were associated with physician factors that included selection of the vaginal route, training site, predisposition toward the vaginal procedure, and preoperative assessment of uterine size. Length of hospital stay and duration of surgery were the strongest predictors of cost. Other factors being equal, the mean cost of a vaginal procedure is $224 less than that of an abdominal hysterectomy. Establishing the vaginal approach as the recommended procedure for this specific population should result in cost reductions and shorter hospital stays without negatively impacting quality of care.