Trends in Hysterectomy Rates Associated With the Coronavirus Disease 2019 (COVID-19) Pandemic : Obstetrics & Gynecology

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Trends in Hysterectomy Rates Associated With the Coronavirus Disease 2019 (COVID-19) Pandemic

Emont, Jordan MD, MPH; Wen, Timothy MD, MPH; Friedman, Alexander M. MD, MPH; Wright, Jason D. MD

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Obstetrics & Gynecology ():10.1097/AOG.0000000000005087, January 10, 2023. | DOI: 10.1097/AOG.0000000000005087
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On January 21, 2020, the first case of coronavirus disease 2019 (COVID-19) in the United States was documented in Washington state.1 The rapid rise in COVID-19 cases led to widespread quarantines and a massive redistribution of health care resources. As the pandemic evolved, many people delayed or avoided non–COVID-19–related health care due to both fear of exposure to COVID-19 and the reduced availability of resources for medical care for non–COVID-19–related conditions.2

One systematic review of international health care utilization during the pandemic documented a 37% decrease in overall health care utilization by patients. This included a 42% reduction in visits, a 31% reduction in diagnostics, and a 30% reduction in therapeutics.3 A study of a large integrated health system including nearly 5 million members reported a 30% reduction in inpatient services, a 37% reduction in emergency department visits, and an 81% reduction in outpatient services during 2020.4

To date, there have been limited data describing the effect of the COVID-19 pandemic on the utilization of gynecologic services, including surgery.5–7 An analysis of two academic medical centers identified a significant decline in gynecologic surgical cases with the onset of the pandemic. This study noted a 28% reduction in surgical volume in March of 2020 compared with March of 2019 and a 40% reduction in year-over-year procedures from April to June. The number of surgical encounters in the latter half of 2020 was on par with 2019.7 Nationwide estimates describing the performance of gynecologic procedures during the widespread outbreak of COVID-19 in the United States are lacking.

The objective of our study was to examine the association between the COVID-19 pandemic and performance of hysterectomy. First, we examined the overall changes in surgical volume with the COVID-19 pandemic. Second, we explored how COVID-19 was associated with performance of hysterectomy for different indications and routes of surgery. Lastly, we examined disparities associated with the decreased hysterectomy rate.

METHODS

We used data from the National Inpatient Sample (NIS) and the National Ambulatory Surgery Sample from 2019 to 2020.8 The NIS is one of the largest all-payer inpatient databases in the United States. This data set is assembled annually by the Agency for Healthcare Research and Quality's Healthcare Cost and Utilization Project. The NIS includes 20% of U.S. hospitalizations drawn proportionally from the individual hospitals included in the sample. The National Ambulatory Surgery Sample captures ambulatory surgical procedures at a sample of hospital-owned facilities from throughout the United States.9 The data sets contain a system of weights that allow for the calculation of national estimates, and the weights were applied to this analysis (Table 1).8

Table 1. - Conversion of Unweighted Data to Weighted Data
Unweighted Estimate Weighted Estimate
Year of surgery
 2019 333,325 548,802
 2020 297,662 480,990
Route of surgery
 Abdominal 47,165 208,643
 Laparoscopic 516,186 723,056
 Vaginal 67,636 98,092
Indication for surgery
 Benign 489,204 793,800
 Preinvasive 71,134 102,339
 Cancer 70,649 133,652

Hysterectomies were identified using International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) and Current Procedural Terminology codes. Coding was based on prior studies and restricted to 2019 and 2020.10 We also identified hysterectomy indication codes using diagnosis fields and ICD-10-CM codes provided in the NIS and the National Ambulatory Surgery Sample, including abnormal uterine bleed, endometriosis, dysmenorrhea, pelvic pain, pelvic organ prolapse, benign ovarian pathology, endometrial hyperplasia, uterine carcinoma, cervical carcinoma, ovarian carcinoma, and cervical dysplasia.10 We grouped indications into three mutually exclusive groups: cancer (uterine, cervical, and ovarian carcinoma), preinvasive (endometrial hyperplasia and cervical dysplasia), and benign (abnormal uterine bleeding, endometriosis, dysmenorrhea, pelvic pain, pelvic organ prolapse, benign ovarian pathology) indications. Patients without coding for cancer or a preinvasive condition were classified as having benign indications for surgery. Mode of surgery was classified as open, laparoscopic (including robotic-assisted), or vaginal based on ICD-10-CM codes and hierarchy preferences from prior studies (Appendix 1, available online at https://links.lww.com/AOG/D13).

Clinical and demographic factors included patient age (younger than 40 years, 40–49, 50–59, 60–69, 70–79, and 80 years or older); race (White, Black, Hispanic, Other, Unknown), which previously has been associated with route of hysterectomy; payer (Medicare, Medicaid, private insurance, self-pay, other, unknown); median income quartile by ZIP code (quartiles 1 [low] to 4 [high]); Elixhauser comorbidity index (none, one, two or more); hospital location (rural, urban nonteaching, urban teaching); and hospital region (Northeast, Midwest, South, West).11

For the primary objective of the study, we identified cases of the total counts of hysterectomy and assessed month-to-month trends. Trends analysis was conducted using the National Cancer Institute's Joinpoint Regression Program 4.8.0.1.12,13 This program uses linear segmented regression and logarithmic transformations to assess patterns in trends and expresses these changes as average interval percent changes (in this case defined as average monthly percentage change [AMPC] in month-to-month counts). The AMPC was determined by the underlying model and calculated using a weighted average of the slope coefficients in the underlying line that is proportional to each line segment. Measures of association were expressed in AMPC and 95% CI. We also directly compared the number of cases performed in a given month in 2020 with the corresponding month in 2019. These data are displayed graphically and reported as the ratio of cases for a given month in 2020 to the same month in 2019. A value less than 1 indicated fewer procedures performed during the given month in 2020.

For the second objective, we conducted trends analyses of the total counts of hysterectomy stratified by indication for surgery (malignant, preinvasive, and benign pathologies) and route of surgery. Finally, we compared demographic findings for the total sample stratified by the entire time period and specifically during March to June of each year, because this represented the acute pandemic period in 2020. Differences between groups were compared with χ2 tests.

Trends analyses were conducted using the Joinpoint Regression Program or SAS 9.4. This study followed the STROBE (Strengthening the Reporting of Observational Studies in Epidemiology) guidelines for cross-sectional studies.14 This study was considered exempt by the University of California, San Francisco, and Columbia University IRBs due to the de-identified nature of the data.

RESULTS

From 2019 to 2020, after weighting, 1,029,792 hysterectomies were performed, including 548,802 (53.2%) in 2019 and 480,990 (46.7%) in 2020. The majority of cases were performed using a laparoscopic route (70.2%), followed by abdominal (20.2%) and vaginal (9.5%) routs. The primary diagnoses for the cohort included benign pathology in 77.1%, followed by cancer (13.0%) and preinvasive lesions (9.9%). Overall, the largest group in the cohort were aged 40–49 years (38.2%); 63.9% were White, 14.2% were Black, and 13.2% were Hispanic (Table 2).

Table 2. - Clinical and Demographic Characteristics of the Cohort Stratified by Year of Surgery
Variable 2019 2020 P
Race >.99
 Black 77,752 (14.2) 68,499 (14.2)
 Hispanic 72,753 (13.3) 62,757 (13.1)
 White 350,288 (63.8) 307,502 (63.9)
 None of the above* 35,429 (6.5) 31,472 (6.5)
 Unknown 12,580 (2.3) 10,760 (2.2)
Age (y) .17
 Younger than 40 116,161 (21.2) 102,437 (21.3)
 40–49 211,209 (38.5) 181,811 (37.8)
 50–59 105,939 (19.3) 92,745 (19.3)
 60–69 70,755 (12.9) 63,436 (13.2)
 70–79 37,295 (6.8) 33,915 (7.1)
 80 or older 7,444 (1.4) 6,646 (1.4)
Payer .60
 Medicare 85,803 (15.6) 75,509 (15.7)
 Medicaid 74,842 (13.6) 67,682 (14.1)
 Private insurance 357,012 (65.1) 311,570 (64.8)
 Self-pay 14,500 (2.6) 11,711 (2.4)
 No charge 1,231 (0.2) 1,227 (0.3)
 Other 14,745 (2.7) 12,857 (2.7)
 Missing 670 (0.1) 434 (0.1)
Median income quartile by ZIP code .002
 1 135,317 (24.7) 115,464 (24.0)
 2 138,729 (25.3) 131,381 (27.3)
 3 145,738 (26.6) 120,420 (25.0)
 4 122,834 (22.4) 108,578 (22.6)
 Missing 6,185 (1.1) 5,147 (1.1)
Comorbidity <.001
 0 233,634 (42.6) 196,259 (40.8)
 1 158,323 (28.9) 141,637 (29.5)
 2 or more 156,845 (28.6) 143,094 (29.8)
Primary diagnosis .05
 Cancer 68,880 (12.6) 64,772 (13.5)
 Preinvasive 55,108 (10.0) 47,231 (9.8)
 Benign 424,814 (77.4) 368,986 (76.7)
Route of surgery .02
 Abdominal 114,661 (20.9) 93,982 (19.5)
 Laparoscopic 379,497 (69.2) 343,559 (71.4)
 Vaginal 54,644 (10.0) 43,448 (9.0)
Hospital location .95
 Rural 48,675 (8.9) 42,881 (8.9)
 Urban nonteaching 96,295 (17.6) 85,782 (17.8)
 Urban teaching 403,833 (73.6) 352,326 (73.3)
Hospital region .96
 Northeast 80,932 (14.8) 69,296 (14.4)
 Midwest 126,171 (23.0) 109,049 (22.7)
 South 233,010 (42.5) 205,179 (42.7)
 West 108,690 (19.8) 97,466 (20.3)
Hospital setting .05
 Outpatient 397,772 (72.5) 360,315 (74.9)
 Inpatient 151,030 (27.5) 120,675 (25.1)
Data are n (%) unless otherwise specified.
*None of the above includes Asian or Pacific islander, Native American, and “Other,” as characterized by the National Inpatient Sample database.

Hysterectomy volume remained slightly increased over time in 2019, from 39,998 cases in January 2019 to a peak of 48,607 cases in December of that year (Fig. 1). The AMPC in procedures from January 2019 to January 2020 was 1.5% (95% CI 0.6–2.5, P=.004) (Fig. 2A). Starting in January 2020, monthly cases declined significantly, from 40,240 to a nadir of 10,566 in April 2020 (AMPC −29.2%, 95% CI −39.8% to −16.8%) (P<.001). The subsequent months saw a significant increase in cases, from the nadir in April 2020 to 40,023 cases in July 2020 (AMPC 39.4%, 95% CI 18.6–63.9%) (P=.001), which then stabilized to the end of the year (AMPC −1.3%, 95% CI −4.8% to 2.4%) (P=.46).

F1
Fig. 1.:
Monthly number of inpatient hysterectomies performed in 2019 and 2020.
F2
Fig. 2.:
A. Joinpoint regression of average monthly percentage change in hysterectomies. B. Percentage decrease in monthly hysterectomies in a given month in 2020 vs the same month in 2019. *Annual percent change (APC) is significantly different from 0 at the alpha=.05 level.

Comparing individual months in 2020 with the corresponding month in 2019, there was a 0.6% increase in the number of hysterectomies in January 2020 compared with January 2019 (Fig. 2B). A pronounced decline in hysterectomies began in March 2020, with a 24.0% decrease, and continued in April (74.2% decrease) and May (35.1% decrease) compared with the respective months in 2019. The decline then stabilized and increased slightly in September, with a 7.1% increase in 2020 volume compared with 2019. The decrease in month-to-month hysterectomies then rose from October through the end of 2020, at which time there was a 9.9% decline in 2020 compared with 2019.

Beginning in March 2020, there was a decline in all routes of hysterectomy; this was most pronounced for vaginal hysterectomy and least pronounced for abdominal hysterectomy (Fig. 3A and B). The monthly ratio of vaginal hysterectomies in April 2020 compared with April 2019 (April 2020/April 2019) was 0.08. In the same month, the ratio was 0.25 for laparoscopic hysterectomy and 0.35 for abdominal hysterectomy. The ratio of 2020 to 2019 cases largely remained below 1 for the remainder of months in 2020, except for September.

F3
Fig. 3.:
A. Monthly number of hysterectomies stratified by route of surgery. B. Ratio of hysterectomies performed in a given month in 2020 to the same month in 2019 (2020:2019) stratified by route of surgery. A value less than 1 indicates fewer hysterectomies performed in 2020 than in 2019.

The number of hysterectomies performed for benign and preinvasive indications began to decline in March 2020; the number of procedures for cancer increased in March 2020 and then began to decrease in April 2020 (Fig. 4A and B). At the nadir, the monthly ratio of hysterectomies in April 2020 compared with April 2019 was 0.71 for cancers, 0.24 for preinvasive diseases, and 0.18 for benign indications. The number of procedures performed for all indications rose thereafter, with the ratio of 2020 to 2019 exceeding 1.0 for benign indications in September 2020 (1.09).

F4
Fig. 4.:
A. Monthly number of hysterectomies stratified by indication for surgery. B. Ratio of hysterectomies performed in a given month in 2020 to the same month in 2019 (2020:2019) stratified by indication for surgery. A value less than 1 indicates fewer hysterectomies performed in 2020 than in 2019.

During the period of greatest reduction in hysterectomy volume between March and June 2020, there were modest shifts in the demographic characteristics of patients who underwent hysterectomy compared with the corresponding period in 2019 (Table 3). During this time in 2020, patients with cancer, older patients, and those with medical comorbidities were more likely to undergo hysterectomy (P<.05 for all). There was no statistically significant association between either race or insurance status and the likelihood of undergoing hysterectomy in the peak of the pandemic in 2020.

Table 3. - Clinical and Demographic Characteristics of the Cohort Stratified by Year of Surgery for March–June 2019 and 2020
Variable March–June 2019 March–June 2020 P
Race .57
 White 102,986 (63.2) 70,050 (64.5)
 Black 23,996 (14.7) 14,805 (13.6)
 Hispanic 20,962 (12.9) 13,728 (12.7)
 Other 11,173 (6.9) 7,374 (6.8)
 Unknown 3,874 (2.4) 2,583 (2.4)
Age (y) <.001
 Younger than 40 35,701 (21.9) 24,141 (22.2)
 40–49 62,381 (38.3) 39,725 (36.6)
 50–59 31,356 (19.2) 20,572 (19.0)
 60–69 20,522 (12.6) 14,646 (13.5)
 70–79 10,771 (6.6) 7,859 (7.2)
 80 or older 2,259 (1.4) 1,596 (1.5)
Payer .44
 Medicare 24,919 (15.3) 17,386 (16.0)
 Medicaid 23,714 (14.6) 15,076 (13.9)
 Private insurance 104,720 (64.3) 69,675 (64.2)
 Self-pay 4,871 (3.0) 3,089 (2.9)
 No charge 315 (0.2) 247 (0.2)
 Other 4,280 (2.6) 2,975 (2.7)
 Missing 170 (0.1) 92 (0.1)
Median income quartile by ZIP code .004
 1 41,078 (25.2) 26,825 (24.7)
 2 40,571 (24.9) 29,525 (27.2)
 3 42,228 (25.9) 26,443 (24.4)
 4 37,313 (22.9) 24,492 (22.6)
 Missing 1,801 (1.1) 1,255 (1.2)
Comorbidity <.001
 0 69,541 (42.7) 43,864 (40.4)
 1 46,976 (28.8) 31,490 (29.0)
 2 or more 46,473 (28.5) 33,186 (30.6)
Primary diagnosis <.001
 Cancer 21,010 (12.9) 17,930 (16.5)
 Preinvasive 15,643 (9.6) 10,373 (9.6)
 Benign 126,337 (77.5) 80,238 (73.9)
Route of surgery .001
 Abdominal 38,306 (23.5) 24,979 (23.0)
 Laparoscopic 108,031 (66.3) 74,694 (68.8)
 Vaginal 16,653 (10.2) 8,867 (8.2)
Hospital location .84
 Rural 15,854 (9.7) 10,490 (9.7)
 Urban nonteaching 27,883 (17.1) 19,207 (17.7)
 Urban teaching 119,254 (73.2) 78,843 (72.6)
Hospital region .10
 Northeast 20,771 (12.7) 11,434 (10.5)
 Midwest 40,943 (25.1) 26,179 (24.1)
 South 65,866 (40.4) 46,021 (42.4)
 West 35,411 (21.7) 24,906 (23.0)
Hospital setting .27
 Outpatient 112,206 (68.8) 76,395 (70.4)
 Inpatient 50,785 (31.2) 32,145 (29.6)
Data are n (%) unless otherwise specified.

DISCUSSION

The onset of the COVID-19 pandemic created an unprecedented international limitation on health care resources and significantly affected the provision of care for all fields of medicine.3,4 In our sample of patients treated across the United States, we noted that the number of hysterectomies performed significantly decreased in 2020 compared with 2019. The decline in the hysterectomy rate was most pronounced from March through May of 2020. After June of 2020, the hysterectomy rate rose; however, it largely remained below the 2019 rate, and there was no clear compensatory rise in the hysterectomy rate after the April 2020 nadir. The decline in the hysterectomy rate was less pronounced for patients undergoing surgery for gynecologic cancers than for those with benign indications.

Our findings on the number of hysterectomies performed in the United States largely follow the arc of the COVID-19 pandemic.15 Initial cases of COVID-19 were reported in late January and early February of 2020. In March 2020, there was recognition of widespread COVID-19 in some regions of the country, which was followed by a spike in cases and deaths in April 2020. There was a subsequent decline in COVID-19 cases, followed by an increase in cases in the summer of 2020 and a larger surge in cases in November and December of 2020. Our data suggest that the hysterectomy rate declined substantially from March to May of 2020, corresponding to the initial wave of COVID-19. During this period, many hospitals restricted access for elective and semi-elective surgical procedures and many health care professionals were redeployed for COVID-19–related care.16–18 Interestingly, despite a large surge in COVID-19 cases in latter 2020, we noted a more modest decline in the number of hysterectomies performed in November and December of 2020 than was seen in the spring of 2020.

Not unexpectedly, the decline in the hysterectomy rate was more modest for patients undergoing hysterectomy for cancer compared with those undergoing hysterectomy for precancerous or benign indications. A number of reports have described surgical delays for gynecologic cancer care during the COVID-19 pandemic and suggested alternative or temporizing treatment strategies. Among a network of New York City hospitals, nearly 40% of patients with gynecologic cancer who were scheduled for surgery experienced modifications to their treatment plans during March and April of 2020.19 A study of more than 11,000 patients from the Netherlands with gynecologic cancer noted a significant reduction in the volume of surgical cases for cervical cancer and found that patients with ovarian cancer were significantly more likely to receive neoadjuvant chemotherapy.20 In another study in Italy during the peak of the COVID-19 pandemic, a survey of gynecologic oncologists showed that there was a prioritization placed on treatment for early-stage high-grade uterine cancers, newly diagnosed ovarian malignancies, and cervical cancers; hormonal therapy for low-grade uterine cancers was more commonly used.21 One of the largest international multicenter studies of the effects of COVID-19 on 3,973 patients with gynecologic malignancies found that 20.7% of patients experienced changes to their treatment plans due to the onset of the pandemic.22 At the peak of volume reductions in April 2020, our data showed that there were approximately 30% fewer hysterectomies performed for cancer and 75% fewer performed for preinvasive lesions than in the same time period in 2019.

The effect of delays in surgical management for gynecologic cancers on long-term outcomes remains uncertain. For cervical cancer, Matsuo and colleagues found that ,for stage 1A tumors, there was no difference in overall or disease-specific survival in patients who delayed surgical therapy for up to 8 weeks. A meta-analysis of existing studies on wait times for cervical cancer surgery had similar results.23 Studies examining the effect of delay in surgery on survival for endometrial cancer have reported conflicting findings. A report from the National Cancer Database of 112,000 patients with endometrial cancer found that a delay of more than 6 weeks between diagnosis and surgery was associated with a modest reduction in survival.24 Other studies have shown that a longer time to surgery did not increase the risk of receipt of adjuvant chemotherapy for low-risk endometrial cancers and did not affect survival for patients with high-risk tumors.24–26 Specifically looking at nonendometrioid histology, Nica and colleagues27 found that delays of more than 45 days for surgery did result in decreased overall survival.

Although the effects of surgical delay on mortality for patients undergoing hysterectomy for benign indications is less of a concern, these patients may experience significant symptoms, and delay may negatively affect quality of life. In April 2020, there was an 82% reduction in hysterectomy volume for benign indications. The hysterectomy rate then rose rapidly but, aside from the month of September, remained below the 2019 level. The reasons for this overall decrease from 2019 levels are unclear.

Among patients undergoing hysterectomy, concern has been raised about possible inequity in the provision of care during the height of the COVID-19 pandemic. An institutional report on approximately 900 patients who underwent hysterectomy before and after the COVID-19 pandemic showed that the percentage of hysterectomies performed in White patients after the COVID-19 pandemic increased by 12%, whereas the number performed in Hispanic patients decreased by 13%.28 Encouragingly, we found no racial or insurance-mediated disparities in the provision of hysterectomy during the COVID-19 surge.

We acknowledge a number of important limitations. First, our data capture inpatient and outpatient hysterectomy, but we cannot exclude the possibility that a small number of cases were not captured.10 Second, our data represent national estimates weighted to the entire United States. The rates of COVID-19, particularly early in the pandemic, varied widely across states, and we are unable to capture these more nuanced estimates. Third, although we are able to report trends in the rate of hysterectomy, we lack granular data on why procedures were deferred and whether alternative therapy was offered. The lower number of hysterectomies in March–May of 2020 is undoubtedly multifactorial and due in part to hospital restrictions on elective procedures, patient and physician preference, and decisions to utilize conservative, nonsurgical treatments.

In sum, these data highlight the changes in inpatient hysterectomy volume during the early months of the COVID-19 pandemic in the United States. There was a pronounced decline in the number of procedures performed, with a two-thirds reduction in cases in April 2020 compared with the prior year. The decreased number of hysterectomies performed was most notable for vaginal hysterectomy and for patients undergoing hysterectomy for benign indications. The COVID-19 pandemic led to unprecedented changes in the allocation of gynecologic care. Further data are clearly needed to determine the long-term effects of delays in care encountered by patients in 2020.

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