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ORIGINAL RESEARCH |
From the Midwest Center for Health Services and Policy Research, Cooperative Studies Coordinating Center, VA Information Resource Center, Hines VAMC, Hines, Illinois; the Institute for Health Services Research and Policy Studies, Northwestern University, Evanston, Illinois; Department of Medicine, Loyola University Chicago, Maywood, Illinois; College of Medicine, University of Illinois, Chicago, Illinois; Boston VA Healthcare System, Boston, Massachusetts; Departments of Medicine and Surgery, Harvard Medical School, Boston, Massachusetts.
Address reprint requests to: Frances Weaver, PhD Hines VAMC Midwest Center for Health Services and Policy Research P. O. Box 5000 (151H) Hines, IL 60141-5000 E-mail: weaver{at}research.hines.med.va.gov
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Abstract |
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Methods: Data on hysterectomies performed in VAs from 1991 to 1997 were abstracted from a surgical quality improvement program.
Results: Records of 1722 women who had hysterectomies in VAs over 6 years were examined. Women were predominately white (62%) and their average age was 42.5 years. Operations included abdominal (74%), vaginal (22%), and laparoscopic-assisted (4%) methods. The most common indications for surgery included uterine leiomyomas (31%), abnormal uterine bleeding (14%), and endometriosis (11%). Indications differed by race (P < .01); nonwhite women were most likely to have surgery for leiomyoma (51%), whereas white women had hysterectomies for leiomyomas (19%), abnormal bleeding (15%), endometriosis (13%), and genital prolapse (11%). The mean postoperative stay was significantly longer for abdominal hysterectomies (4.51 days) than either vaginal or laparoscopic-assisted hysterectomies (2.92 and 2.21 days, respectively; P < .001). The overall complication rate within 30 days was 9%, and the most frequent complication was urinary tract infection (3.3%).
Conclusion: Women who underwent hysterectomies in VAs had low complication rates, comparable to hysterectomy complication rates in the United States generally.
It is estimated that 590,000 women aged 15 years and older undergo hysterectomy each year.1 More than one-third of women have had a hysterectomy by age 60.2 Hysterectomy rates increased to 670 per 100,000 women in 1975, then declined and stabilized since the 1980s at approximately 568 per 100,000.3 This decrease may be due in part to the increase in alternative approaches to managing problems that might otherwise result in hysterectomy4 and/or to increased use of second opinions.5
Published information about hysterectomy rates, trends, and outcomes do not include information about operations performed in Department of Veterans Affairs (VA) facilities. Until recently, few women veterans used the VA health care system. The number of women veterans in the United States in 1997 was 1.2 million. It is estimated that this number will increase to 2 million (10% of all veterans) by 2010.6 Between 1994 and 1997, the number of women treated in VA outpatient settings increased by 32% and gender-specific services including Papanicolaou smears, mammograms, and reproductive health visits increased from 85,000 to 121,000 encounters.6 The most recent data continue to show increases in women using VA outpatient care to more than 142,000 women in 1999.7 This care is provided in a health care system that is oriented primarily for men.
This report describes the characteristics of, and indications for, surgery in women who undergo hysterectomy in VA hospitals, and compares morbidity from hysterectomies performed in VA hospitals to what has been reported in the general population.
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Materials and Methods |
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We identified hysterectomies within the surgical quality database using the following current procedural terminology codes: 56308, 58150, 58152, 58180, 58260, 58262, 58267, 58270, 58275, and 58280. We merged these cases with the VA administrative files based on unique patient identifiers and surgery date matching on 98.1% using a 30-day window around the surgery date. This effort was sufficient to capture additional sociodemographic data not available in the surgery quality database. Indications for hysterectomy were defined using primary diagnoses (ICD-9). Data were analyzed using chi-square to test for differences in proportions and analysis of variance to test for mean differences between groups.
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Results |
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Hysterectomies were performed in 97 VA facilities from October 1991 through September 1997. Frequency varied across facilities. Ten VAs performed only one procedure each. Three other facilities accounted for 15% of all hysterectomies. VAs in Veterans Integrated Service Network 16 (Network 16), which includes Mississippi, Louisiana, Arkansas, and Oklahoma, accounted for 17% of cases, whereas hospitals in the Northeast performed less than 5%. Although Network 16 included the largest number of women served (8%), a disproportionate number of women underwent hysterectomy (0.8%), twice as high as the next highest area (an area that includes Tennessee and Virginia; 0.46%). Only 0.1% of women veterans in the Northeast underwent a hysterectomy during the same time period.
Women were predominately white (62%), with an average age of 42.5 years (Table 1
). A minority was married (37%). Forty percent were smokers, 5% were frequent alcohol users (self-report of more than 2 drinks/day), and 5% had a history of drug addiction. There were few comorbid conditions; 14% had a history of hypertension requiring medications, 5% had dyspnea with exertion or rest, and 4% had diabetes. Almost all underwent general anesthesia (97%) and 65% had operative wounds classified as clean contaminated.
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), whereas 22% were vaginal and 4% were laparoscopically assisted vaginal hysterectomies (LAVH). Of note, 41 operations (2.3%) began as laparoscopically assisted procedures but were converted to abdominal (n = 41) during the procedure. The method used also differed by race (P < .001). Nonwhite women more often underwent abdominal surgery than whites (82.5% versus 68.5%, P < .001). Most operations were performed by gynecologists (81%). Almost all LAVH were performed by gynecologists (97%), whereas only 66% (47 of 71) of operations with a cancer diagnosis were performed by gynecologists; the remaining one-third were performed by general surgeons. There were no significant differences in complication rate by surgical speciality (P < .528).
The most frequent indications for hysterectomy (Table 2) were uterine leiomyoma (31%), abnormal uterine bleeding (14%), and endometriosis (11%). Other indications included genital prolapse, benign neoplasms, and pain. The type of operation varied by indication. The most frequent indications for vaginal hysterectomy were prolapse (26%) and bleeding (21%); for abdominal hysterectomy indications included leiomyomas (37%), abnormal bleeding (12%), and endometriosis (11%); and for LAVH they included leiomyomas (31%) and endometriosis (22%).
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Postoperative lengths of stay varied by procedure. Lengths of stay were significantly longer for abdominal hysterectomy (mean 4.51 days), and shorter for vaginal and LAVH patients (means 2.92 and 2.21 days, respectively; P < .001). One abdominal hysterectomy patient died within 30 days of surgery. There were no other postoperative deaths. The overall complication rate within 30 days of surgery was 9%.10 Patients experiencing one or more complications represented 6% of those undergoing LAVH, 8% of those undergoing vaginal hysterectomy, and 9% of those undergoing abdominal hysterectomy, a statistically insignificant difference. Complications included urinary tract infections (3.3%), superficial (1.6%) and deep wound (1.2%) infections, prolonged ileus/obstruction (1.4%), wound dehiscence (0.9%), pneumonia (0.6%), and bleeding requiring transfusion (0.6%). There were only four complications identified in the LAVH group; all were urinary tract infections. Urinary tract infections accounted for more than 50% of complications for vaginal, but only 26% of all complications for abdominal procedures. Superficial infections, deep wound infections, and wound dehiscence accounted for another 35%.
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Discussion |
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In the present study, a significant difference in indication for hysterectomy by race was noted. Although disagreement exists about the reasons for differences in rates of hysterectomy between white and nonwhite women,5,12 previous literature has reported racial differences for surgery indications. Black women are twice as likely to undergo a hysterectomy for uterine leiomyomas than white women in the United States.3,5 In this study, nonwhite women were almost three times more likely to undergo surgery for uterine leiomyomas. Endometriosis and uterine prolapse as indications for surgery have been reported to be more common in white women,3,5 as was found in the present study. Rates of hysterectomies in the United States are highest in the South (6.8 for every 1000 women) with the youngest mean age (41.6 years), and lowest in the Northeast (3.9/1000) with the highest mean age (47.7 years).5,13 Approximately 75% of hysterectomies in the United States are performed using an abdominal approach, and one-fourth are performed vaginally.2,14 These findings are comparable to our results in VA hospitals. There has been an increase in the use of LAVH, ranging from 1.4% in 1990 to 14.2% in 1993.5 In the present study, 4% were performed laparoscopically.
Complication rates in VA hospitals are in the range reported by others (6–11% for indications not involving either pregnancy or cancer).1 However, definitions of some complications (eg, febrile morbidity, bleeding) differed across studies, and many studies did not analyze perioperative and early postoperative complications separately from those occurring after hospital discharge, making comparisons more difficult. Overall, hysterectomy is a relatively safe procedure, with mortality rates well below 1%.12,15 Reported complication rates range from 32.8% to 42.8% for abdominal hysterectomies and from 21.5% to 24.5% for vaginal hysterectomies.15,16 These figures included febrile morbidity, which accounted for the most overall postoperative morbidity. This complication was not documented in the VA database. Other complications cited in the literature include urinary tract infections (1–5%), operative site infections (9–21%),17 and postoperative bleeding requiring transfusion (8.3–15.4%; 3.4%).15,18 Injury to adjacent organs (1–2%), obstruction (1%), and life-threatening events (0.2%) are much less frequent.17,18 In this study, urinary tract infection rates were comparable (3%), but wound infections were lower (4%).
The VA database is unique in that it contains preoperative characteristics including comorbid conditions, risk behaviors (eg, smoking, alcohol use), and preoperative laboratory data. Although the literature on VA users has shown that both male and female veterans who used VA hospitals have poor health status and low education,19–21 data from this sample of women indicate that they are relatively healthy and experience good outcomes after surgery.
Our study demonstrates that women undergoing hysterectomies in VAs have low morbidity and mortality rates. This result is not surprising, as most VAs have surgery programs affiliated with academic medical centers, and most surgeons treat patients in both settings. As the number of women treated in VAs increases, some increase in hysterectomy rates is also anticipated. Women requiring hysterectomy can have their surgery safely performed in the VA.
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Footnotes |
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The authors acknowledge the invaluable input of their expert panel: Drs. Kavita Nanda, Dee Fenner, and Ramona Slupik, programming support of Bharat Thakkar, MS, and project management support of Dolores Ippolito, MPH.
The views expressed in this article are those of the authors and do not necessarily represent the views of the Department of Veterans Affairs.
Received September 14, 2000. Received in revised form December 26, 2000. Accepted February 8, 2001.
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References |
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2. Pokras R, Hufnagel VG. Hysterectomies in the United States, 1965–84. Vital and health statistics, series 13, no. 92. DHHS publication no. (PHS) 87-1753. Hyattsville, MD: National Center for Health Statistics, 1987.
3. Wilcox LS, Koonin LM, Pokras R, Strauss LT, Xia Z, Peterson HB. Hysterectomy in the United States, 1988–1990. Obstet Gynecol 1994;83:549–55.[Medline]
4. Carlson K, Miller B, Fowler F. The Maine women’s health study, II: Outcomes of nonsurgical management of leiomyomas, abnormal bleeding, and chronic pelvic pain. Obstet Gynecol 1994;83:566–72.[Medline]
5. Lepine LA, Hills SD, Marchbanks PA, Koonin LM, Morrow B, Kieka BA, et al. Hysterectomy surveillance—United States, 1980–1993. Mor Mortal Wkly Rep CDC Surveill Summ 1997 Aug 8; 46:1–15.
6. VA health care for women: Progress made in providing services to women veterans. Washington, D.C.: United States General Accounting Office. (GAO/HEHS-99-38).
7. Women veterans health services survey. FY1998 & 1999 report. Department of Veterans Affairs, Veteran Health Administration, Office of Policy and Planning, Healthcare Analysis & Information Group, April 2000.
8. Khuri S, Daley J, Henderson W, et al. The National Veterans Administration Surgical Risk Study: Risk adjustment for the comparative assessment of the quality of surgical care. J Am Coll Surg 1995;180:519–31.[Medline]
9. Khuri S, Daley J, Henderson W, Hur K, Gibbs J, Barbour G, et al. Risk adjustment of the postoperative mortality rate for the comparative assessment of the quality of surgical care: Results of the National Veterans Affairs Surgical Risk Study. J Am Coll Surg 1997;185:315–27.[Medline]
10. Daley J, Khuri S, Henderson W, Hur K, Gibbs J, Barbour G, et al. Risk adjustment of the postoperative morbidity rate for the comparative assessment of the quality of surgical care: Results of the National Veterans Affairs Surgical Risk Study. J Am Coll Surg 1997;185:328–40.[Medline]
11. Khuri S, Daley J, Henderson W, Hur K, Demakis J, Aust JB, et al. The Department of Veterans Affairs’ NSQIP: The first national, validated, outcome-based, risk-adjusted, and peer-controlled program for the measurement and enhancement of the quality of surgical care. National VA Surgical Quality Improvement Program. Ann Surg 1998;228:491–507.[Medline]
12. Kjerulff KH, Guzinski GM, Langenberg PW, Stolley PD, Moye NE, Kazandjian VA. Hysterectomy and race. Obstet Gynecol 1993;82: 757–64.
13. Dicker RC, Scally MJ, Greenspan JR, Layde PM, Ory HW, Maze JM, et al. Hysterectomy among women of reproductive age. Trends in the United States, 1970–1978. JAMA 1982;248:323–7.[Abstract]
14. Wilcox L. Important directions in public health surveillance and community-based research in maternal and child health: A CDC perspective. J Public Health Manag Pract 1997;3:17–9.
15. Dicker RC, Greenspan JR, Strauss LT, Cowart MR, Scally MJ, Peterson HB, et al. Complications of abdominal and vaginal hysterectomy among women of reproductive age in the United States. The collaborative review of sterilization. Am J Obstet Gynecol 1982;144:841–8.[Medline]
16. Kalogirou D, Antoniou G, Karakitsos P, Zioris C, Salampasis C. Comparison of abdominal and vaginal hysterectomy. Study of omplications. Clin Exp Obstet Gynecol 1996;23:161–7.[Medline]
17. Harris W. Early complications of abdominal and vaginal hysterectomy. Obstet Gynecol Surv 1995;50:795–805.[Medline]
18. Hill D. Complications of hysterectomy. Baillieres Clin Obstet Gynaecol 1997;11:181–97.[Medline]
19. Turpin RS, Darcy LA, Weaver FM, Kruse K. Assessing health care delivery to male versus female veterans. Women Health 1992;18: 81–95.[Medline]
20. Romeis JC, Gillespie KN, Thorman KE. Female veterans’ use of health care services. Med Care 1988;26:589–95.[Medline]
21. Wolinsky FD, Coe RM, Mosely RR, Homan SM. Veterans’ and nonveterans’ use of health services: A comparative analysis. Med Care 1985;23:1358–71.[Medline]
22. Kramer MG, Reiter RC. Hysterectomy: Indications, alternatives and predictors. Am Fam Phys 1997;55:827–34.[Medline]
23. Brooten D, Naylor M, Brown L, York R, Hollingsworth A, Cohen S, et al. Profile of postdischarge rehospitalizations and acute care visits for seven patient groups. Public Health Nurs 1996;13:128–34.[Medline]
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