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.
Materials and Methods
This observational study reports on the findings of 1722 hysterectomies performed in VAs between October 1991 and September 1997. Data sources included the VA National Surgical Quality Improvement Program8–11 and VA's Patient Treatment File, an administrative file of admission and discharge data including surgery and procedure subfiles. The VA's surgical quality database, established in 1991, is an ongoing prospective data collection effort. This quality improvement program uses trained nurse abstractors to collect data on most major operations performed in 124 VA facilities. Specific elements include preoperative patient characteristics, risk and laboratory data, perioperative events, and surgical outcomes including mortality, complications, and postoperative length of stay.
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.
Between October 1, 1991, and September 30, 1997, 2947 hysterectomies were performed in VA hospitals, increasing from 335 cases in 1992 to 626 in 1995, but then dropping to 485 cases in 1997. Surgery quality data were available for 1722 hysterectomies (60% of total cases). The 40% not captured by the quality database were missing because data collection began with 44 tertiary care hospitals (the remaining 80 VAs began collecting data in January 1994) and some VAs did not capture 100% of cases because the volume of surgeries done at these facilities was extremely large requiring sampling. A comparison of cases identified in the quality database with those not captured found that cases not included were less likely to be married (29% versus 36%, P < .001). No other differences were found, suggesting no systematic bias for which cases were included in the database. For this study, 1722 cases were analyzed.
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.
Most operations were abdominal (74%, Table 1), 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%).
Indications for surgery differed by race (P < .01). White women underwent hysterectomy for leiomyomas (19%), abnormal bleeding (15%), endometriosis (13%), genital prolapse (11%), pain (10%), or cancer (5%). Indications for nonwhite women included uterine leiomyomas (51%), and abnormal bleeding (12%). When indication was controlled for, type of procedure did not differ by race with one exception. White women who underwent surgery for leiomyomas were more likely to have an LAVH than nonwhite women (7% versus 1%), whereas nonwhite women were more likely to have an abdominal operation (90% versus 83%, P < .002).
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%.
Examination of 1722 hysterectomies conducted in VA facilities over 6 years showed similarity to hysterectomies performed in non-VA settings. Abdominal hysterectomies were done most frequently for uterine leiomyomas, abnormal bleeding, or endometriosis, and postoperative complication rates at 9% are well within rates reported in the literature for the general US population.
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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