Departments of Obstetrics, Gynecology and Reproductive Sciences, Yale School of Medicine, New Haven, CT; Cancer Outcomes Public Policy and Effectiveness Research Center, Yale School of Medicine, New Haven, CT.
Departments of Obstetrics, Gynecology and Reproductive Sciences, Yale School of Medicine, New Haven, CT; Medical Affairs, CooperSurgical, Inc, Trumbull, CT.
Am J Obstet Gynecol. 2021 Jun;224(6):589.e1-589.e13. doi: 10.1016/j.ajog.2020.12.1207. Epub 2020 Dec 24.
Safety warnings about power morcellation in 2014 considerably changed hysterectomy practice, especially for laparoscopic supracervical hysterectomy that typically requires morcellation to remove the corpus uteri while preserving the cervix. Hospitals might vary in how they respond to safety warnings and altered hysterectomy procedures to avoid use of power morcellation. However, there has been little data on how hospitals differ in their practice changes.
This study aimed to examine whether hospitals varied in their use of laparoscopic supracervical hysterectomy after safety warnings about power morcellation and compare the risk of surgical complications at hospitals that had different response trajectories in use of laparoscopic supracervical hysterectomy.
This was a retrospective analysis of data from the New York Statewide Planning and Research Cooperative System and the State Inpatient Databases and State Ambulatory Surgery and Services Databases from 14 other states. We identified women aged ≥18 years undergoing hysterectomy for benign indications in the hospital inpatient and outpatient settings from October 1, 2013 to September 30, 2015. We calculated a risk-adjusted utilization rate of laparoscopic supracervical hysterectomy for each hospital in each calendar quarter after accounting for patient clinical risk factors. Applying a growth mixture modeling approach, we identified distinct groups of hospitals that exhibited different trajectories of using laparoscopic supracervical hysterectomy over time. Within each trajectory group, we compared patients' risk of surgical complications in the prewarning (2013Q4-2014Q1), transition (2014Q2-2014Q4), and postwarning (2015Q1-2015Q3) period using multivariable regressions.
Among 212,146 women undergoing benign hysterectomy at 511 hospitals, the use of laparoscopic supracervical hysterectomy decreased from 15.1% in 2013Q4 to 6.2% in 2015Q3. The use of laparoscopic supracervical hysterectomy at these 511 hospitals exhibited 4 distinct trajectory patterns: persistent low use (mean risk-adjusted utilization rate of laparoscopic supracervical hysterectomy changed from 2.8% in 2013Q4 to 0.6% in 2015Q3), decreased medium use (17.0% to 6.9%), decreased high use (51.4% to 24.2%), and rapid abandonment (30.5% to 0.8%). In the meantime, use of open abdominal hysterectomy increased by 2.1, 4.1, 7.8, and 11.8 percentage points between the prewarning and postwarning periods in these 4 trajectory groups, respectively. Compared with the prewarning period, the risk of major complications in the postwarning period decreased among patients at "persistent low use" hospitals (adjusted odds ratio, 0.88; 95% confidence interval, 0.81-0.94). In contrast, the risk of major complications increased among patients at "rapid abandonment" hospitals (adjusted odds ratio, 1.48; 95% confidence interval, 1.11-1.98), and the risk of minor complications increased among patients at "decreased high use" hospitals (adjusted odds ratio, 1.31; 95% confidence interval, 1.01-1.72).
Hospitals varied in their use of laparoscopic supracervical hysterectomy after safety warnings about power morcellation. Complication risk increased at hospitals that shifted considerably toward open abdominal hysterectomy.
2014 年有关电力碎石术的安全警告极大地改变了子宫切除术的实践，特别是对于通常需要碎石术来切除子宫体而保留子宫颈的腹腔镜子宫颈切除术。医院在应对安全警告和改变子宫切除术程序以避免使用电力碎石术方面可能存在差异。然而，关于医院在实践变化方面的差异的数据很少。
本研究旨在检查在有关电力碎石术的安全警告发布后，医院在使用腹腔镜子宫颈切除术方面是否存在差异，并比较在使用腹腔镜子宫颈切除术方面具有不同反应轨迹的医院的手术并发症风险。
这是对来自纽约州规划和研究合作系统以及来自其他 14 个州的州住院患者数据库和州门诊手术和服务数据库的数据的回顾性分析。我们确定了 2013 年 10 月 1 日至 2015 年 9 月 30 日期间在医院住院和门诊环境中因良性指征接受子宫切除术的年龄≥18 岁的女性。我们计算了每个医院在每个日历季度的风险调整后腹腔镜子宫颈切除术使用率，考虑了患者的临床风险因素。应用增长混合建模方法，我们确定了具有不同时间使用腹腔镜子宫颈切除术轨迹的不同医院群体。在每个轨迹组内，我们使用多变量回归比较了预警（2013 年第四季度至 2014 年第一季度）、过渡（2014 年第二季度至 2014 年第四季度）和预警后（2015 年第一季度至 2015 年第三季度）期间患者手术并发症的风险。
在 511 家医院接受良性子宫切除术的 212146 名女性中，腹腔镜子宫颈切除术的使用率从 2013 年第四季度的 15.1%下降到 2015 年第三季度的 6.2%。这 511 家医院使用腹腔镜子宫颈切除术表现出 4 种不同的轨迹模式：持续低使用率（腹腔镜子宫颈切除术的风险调整使用率从 2013 年第四季度的 2.8%变化到 2015 年第三季度的 0.6%）、使用率下降中等（17.0%至 6.9%）、使用率下降高（51.4%至 24.2%）和快速放弃（30.5%至 0.8%）。与此同时，在这 4 个轨迹组中，开放腹部子宫切除术的使用率分别在预警前和预警后期间增加了 2.1、4.1、7.8 和 11.8 个百分点。与预警期相比，在“持续低使用率”医院中，术后主要并发症的风险降低（调整后的优势比，0.88；95%置信区间，0.81-0.94）。相比之下，在“快速放弃”医院中，主要并发症的风险增加（调整后的优势比，1.48；95%置信区间，1.11-1.98），在“使用率下降高”医院中，次要并发症的风险增加（调整后的优势比，1.31；95%置信区间，1.01-1.72）。
在有关电力碎石术的安全警告发布后，医院在使用腹腔镜子宫颈切除术方面存在差异。转向开放腹部子宫切除术的医院并发症风险增加。
