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Utilization of Minimally Invasive Surgery in Endometrial Cancer Care: A Quality and Cost Disparity

Fader, Amanda N. MD; Weise, R. Matsuno PhD; Sinno, Abdulrahman K. MD; Tanner, Edward J. III MD; Borah, Bijan J. PhD; Moriarty, James P. MS; Bristow, Robert E. MD, MBA; Makary, Martin A. MD, MPH; Pronovost, Peter J. MD, PhD; Hutfless, Susan PhD; Dowdy, Sean C. MD

doi: 10.1097/AOG.0000000000001180
Contents: Gynecologic Oncology: Original Research

OBJECTIVE: To describe case mix-adjusted hospital level utilization of minimally invasive surgery for hysterectomy in the treatment of early-stage endometrial cancer.

METHODS: In this retrospective cohort study, we analyzed the proportion of patients who had a minimally invasive compared with open hysterectomy for nonmetastatic endometrial cancer using the U.S. Nationwide Inpatient Sample database, 2007–2011. Hospitals were stratified by endometrial cancer case volumes (low=less than 10; medium=11–30; high=greater than 30 cases). Hierarchical logistic regression models were used to evaluate hospital and patient variables associated with minimally invasive utilization, complications, and costs.

RESULTS: Overall, 32,560 patients were identified; 33.6% underwent a minimally invasive hysterectomy with an increase of 22.0–50.8% from 2007 to 2011. Low-volume cancer centers demonstrated the lowest minimally invasive utilization rate (23.6%; P<.001). After multivariable adjustment, minimally invasive surgery was less likely to be performed in patients with Medicaid compared with private insurance (adjusted odds ratio [OR] 0.67, 95% confidence interval [CI] 0.62–0.72), black and Hispanic compared with white patients (adjusted OR 0.43, 95% CI 0.41–0.46 for black and 0.77, 95% CI 0.72–0.82 for white patients), and more likely to be performed in high- compared with low-volume hospitals (adjusted OR 4.22, 95% CI 2.15–8.27). Open hysterectomy was associated with a higher risk of surgical site infection (adjusted OR 6.21, 95% CI 5.11–7.54) and venous thromboembolism (adjusted OR 3.65, 95% CI 3.12–4.27). Surgical cases with complications had higher mean hospitalization costs for all hysterectomy procedure types (P<.001).

CONCLUSION: Hospital utilization of minimally invasive surgery for the treatment of endometrial cancer varies considerably in the United States, representing a disparity in the quality and cost of surgical care delivered nationwide.

Hospital utilization of minimally invasive surgery in endometrial cancer treatment varies considerably, representing a disparity in the quality and cost of surgical care delivered nationwide.

Kelly Gynecologic Oncology Service, Department of Gynecology and Obstetrics, the Department of Surgery, and the Armstrong Institute for Patient Safety and Quality, Johns Hopkins Hospital, Baltimore, Maryland; the University of California San Diego Medical Group, La Jolla, and the Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of California, Irvine, Irvine, California; and the Division of Health Care Policy & Research and the Division of Gynecologic Surgery, Mayo Clinic, Rochester, Minnesota.

Corresponding author: Amanda N. Fader, MD, 600 N Wolfe Street, Phipps 281 Baltimore, MD 21287; e-mail:

Supported by Sharon and Gregory Peters, Johns Hopkins Medicine, and the Ina Tornberg-Smith Endometrial Cancer Research Fund, Johns Hopkins Medicine.

Financial Disclosure The authors did not report any potential conflicts of interest.

Presented at the Society of Gynecologic Oncology Annual Meeting for Women's Cancers, March 28–31, 2015, Chicago, IL.

© 2016 by The American College of Obstetricians and Gynecologists. Published by Wolters Kluwer Health, Inc. All rights reserved.