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Changes in Surgical Volume and Outcomes Over Time for Women Undergoing Hysterectomy for Endometrial Cancer

Wright, Jason D., MD; Ruiz, Maria P., DO, MS; Chen, Ling, MD, MPH; Gabor, Lisa R., MD; Tergas, Ana I., MD, MPH; St. Clair, Caryn M., MD; Hou, June Y., MD; Ananth, Cande V., PhD, MPH; Neugut, Alfred I., MD, PhD; Hershman, Dawn L., MD

doi: 10.1097/AOG.0000000000002691
Contents: Gynecologic Oncology: Original Research

OBJECTIVE: To examine changes over time in surgeon and hospital procedural volume for hysterectomy for endometrial cancer and explore the association between changes in volume and perioperative outcomes.

METHODS: We used the Statewide Planning and Research Cooperative System database to analyze women who underwent abdominal or minimally invasive hysterectomy from 2000 to 2014. Annualized surgeon and hospital volume was estimated. The association between surgeon and hospital volume and perioperative morbidity, mortality, and resource utilization (transfusion, length of stay, hospital charges) was estimated by modeling procedural volume as a continuous and categorical variable.

RESULTS: A total of 44,558 women treated at 218 hospitals were identified. The number of surgeons performing cases each year decreased from 845 surgeons with 2,595 patients (mean cases=3) in 2000 to 317 surgeons who operated on 3,119 patients (mean cases=10) (P<.001) in 2014, whereas the mean hospital volume rose from 14 to 32 cases over the same time period (P=.29). When stratified by surgeon volume quartiles, the morbidity rate was 14.6% among the lowest volume surgeons, 20.8% for medium–low, 15.7% for medium–high, and 14.1% for high-volume surgeons (P<.001). In multivariable models in which volume was modeled as a continuous variable, there was no association between surgeon volume and the rate of complications, whereas excessive total charges were lowest and perioperative mortality highest for the high-volume surgeons (P<.001 for both).

CONCLUSION: Care of women with endometrial cancer has been concentrated to a smaller number of surgeons and hospitals. The association between surgeon and hospital volume for endometrial cancer is complex with an increased risk of adverse outcomes among medium-volume hospitals and surgeons but the lowest complication rates for the highest volume surgeons and centers.

Care for women with endometrial cancer has been concentrated to a smaller number of surgeons and hospitals.

Columbia University College of Physicians, Joseph L. Mailman School of Public Health, Columbia University, Herbert Irving Comprehensive Cancer Center, Columbia University College of Physicians and Surgeons, and New York Presbyterian Hospital, New York, New York.

Corresponding author: Jason D. Wright, MD, Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Columbia University College of Physicians and Surgeons, 161 Fort Washington Avenue, 8th Floor, New York, NY 10032; email:

Financial Disclosure Dr. Wright has served as a consultant for Tesaro and Clovis Oncology. Dr. Neugut has served as a consultant to Pfizer, Teva, Otsuka, and United Biosource Corporation. He is on the scientific advisory board of EHE, Intl. The other authors did not report any potential conflicts of interest.

Dr. Wright (NCI R01CA169121-01A1) and Dr. Hershman (NCI R01 CA166084) are recipients of grants from the National Cancer Institute. Dr. Hershman is the recipient of a grant from the Breast Cancer Research Foundation/Conquer Cancer Foundation.

Each author has indicated that he or she has met the journal's requirements for authorship.

Received February 22, 2018. Received in revised form April 3, 2018. Accepted April 12, 2018.

© 2018 by The American College of Obstetricians and Gynecologists. Published by Wolters Kluwer Health, Inc. All rights reserved.