Effect of Minimum-Volume Standards on Patient Outcomes and Surgical Practice Patterns for Hysterectomy
Ruiz, Maria et al Obstetrics & Gynecology: November 2018 - Volume 132 - Issue 5 - p 1229–1237 doi: 10.1097/AOG.0000000000002912 modelled the effect of implementing minimum-volume standards for women who underwent hysterectomy on patient outcomes and surgeon practice patterns, using a retrospective cohort study of all women who underwent hysterectomy in the “New York Statewide Planning and Research Cooperative System” from 2010 to 2014. They identified a total of 127,202 patients. For abdominal hysterectomy, increasing surgeon volume was associated with a decreasing rate of complications (P<.001). Overall, 17.5% of surgeons (n=1,260) had a prior year volume of one abdominal hysterectomy. The mean observed/expected ratio of surgeons with a prior year abdominal hysterectomy volume of one was 1.47 (SD 2.71). Within this group of surgeons, 31.4% had an observed/expected ratio of 1 or greater, indicating a higher than expected complication rate, and 68.7% of the surgeons had a observed/expected ratio of less than 1, suggesting a lower complication rate than expected based on case mix. Selection of a prior year volume standard of one would restrict 12.5% of surgeons performing robotic-assisted, 16.8% of those performing laparoscopic, and 27.6% of surgeons performing vaginal hysterectomy. Implementing minimum-volume standards for hysterectomy, for even the lowest volume physicians, would restrict a significant number of gynecologic surgeons, including many with outcomes that are better than predicted.