Benign hysterectomy performed by gynecologic oncologists: Is selection bias altering our ability to measure surgical quality?

Emma L. Barber*, Emma C. Rossi, Amy Alexander, Karl Bilimoria, Melissa A. Simon

*Corresponding author for this work

Research output: Contribution to journalArticle

2 Citations (Scopus)

Abstract

Objective: To compare the characteristics of women undergoing hysterectomy for benign disease with either a benign gynecologist or a gynecologic oncologist and to assess for differences in complication rates with and without risk adjustment. Methods: Patients undergoing benign hysterectomy recorded in the National Surgical Quality Improvement Program (NSQIP) targeted hysterectomy file in 2015 were identified. The primary outcome was any postoperative complication. Stratified analysis was performed by route of surgery. Bivariable tests and modified Poisson regression were used to adjust for confounding by procedure type and patient characteristics. Results: We identified 17,639 patients who underwent hysterectomy for benign pathology, primary surgeon was a benign gynecologist (82%) or gynecologic oncologist (18%). Patients who underwent surgery with gynecologic oncologists were older (51yo v 46yo), had a higher mean BMI (32 v 30), and a higher prevalence of prior abdominal surgery (29% v 25%, p < 0.001), diabetes (10.6% v 7.0%), hypertension (34% v 25%) and higher ASA and Charlson comorbidity scores (p < 0.001, for all). For laparoscopy, surgery with a gynecologic oncologist was associated with a decreased risk of complication (RR 0.80, 95% CI 0.66–0.98). For laparotomy, surgery with a gynecologic oncologist was associated with an increased risk of complication (RR 1.18 95% CI 1.01–1.38), however, this was no longer the case with risk adjustment (aRR 0.90, 95% CI 0.76–1.07). Conclusions: Patients operated on by gynecologic oncologists have a higher prevalence of risk factors for complication compared to those operated on by benign gynecologists even with a benign indication for surgery. Quality measurement should account for this selection bias.

Original languageEnglish (US)
Pages (from-to)141-144
Number of pages4
JournalGynecologic oncology
Volume151
Issue number1
DOIs
StatePublished - Oct 2018

Fingerprint

Selection Bias
Hysterectomy
Risk Adjustment
Gynecologic Surgical Procedures
Quality Improvement
Laparoscopy
Laparotomy
Oncologists
Comorbidity
Pathology
Hypertension

Keywords

  • Benign hysterectomy
  • Gynecologic oncology
  • Referral bias
  • Selection bias
  • Surgical quality

ASJC Scopus subject areas

  • Oncology
  • Obstetrics and Gynecology

Cite this

@article{825003925ade477ea26eb7ca5e5f5424,
title = "Benign hysterectomy performed by gynecologic oncologists: Is selection bias altering our ability to measure surgical quality?",
abstract = "Objective: To compare the characteristics of women undergoing hysterectomy for benign disease with either a benign gynecologist or a gynecologic oncologist and to assess for differences in complication rates with and without risk adjustment. Methods: Patients undergoing benign hysterectomy recorded in the National Surgical Quality Improvement Program (NSQIP) targeted hysterectomy file in 2015 were identified. The primary outcome was any postoperative complication. Stratified analysis was performed by route of surgery. Bivariable tests and modified Poisson regression were used to adjust for confounding by procedure type and patient characteristics. Results: We identified 17,639 patients who underwent hysterectomy for benign pathology, primary surgeon was a benign gynecologist (82{\%}) or gynecologic oncologist (18{\%}). Patients who underwent surgery with gynecologic oncologists were older (51yo v 46yo), had a higher mean BMI (32 v 30), and a higher prevalence of prior abdominal surgery (29{\%} v 25{\%}, p < 0.001), diabetes (10.6{\%} v 7.0{\%}), hypertension (34{\%} v 25{\%}) and higher ASA and Charlson comorbidity scores (p < 0.001, for all). For laparoscopy, surgery with a gynecologic oncologist was associated with a decreased risk of complication (RR 0.80, 95{\%} CI 0.66–0.98). For laparotomy, surgery with a gynecologic oncologist was associated with an increased risk of complication (RR 1.18 95{\%} CI 1.01–1.38), however, this was no longer the case with risk adjustment (aRR 0.90, 95{\%} CI 0.76–1.07). Conclusions: Patients operated on by gynecologic oncologists have a higher prevalence of risk factors for complication compared to those operated on by benign gynecologists even with a benign indication for surgery. Quality measurement should account for this selection bias.",
keywords = "Benign hysterectomy, Gynecologic oncology, Referral bias, Selection bias, Surgical quality",
author = "Barber, {Emma L.} and Rossi, {Emma C.} and Amy Alexander and Karl Bilimoria and Simon, {Melissa A.}",
year = "2018",
month = "10",
doi = "10.1016/j.ygyno.2018.08.010",
language = "English (US)",
volume = "151",
pages = "141--144",
journal = "Gynecologic Oncology",
issn = "0090-8258",
publisher = "Academic Press Inc.",
number = "1",

}

TY - JOUR

T1 - Benign hysterectomy performed by gynecologic oncologists

T2 - Is selection bias altering our ability to measure surgical quality?

AU - Barber, Emma L.

AU - Rossi, Emma C.

AU - Alexander, Amy

AU - Bilimoria, Karl

AU - Simon, Melissa A.

PY - 2018/10

Y1 - 2018/10

N2 - Objective: To compare the characteristics of women undergoing hysterectomy for benign disease with either a benign gynecologist or a gynecologic oncologist and to assess for differences in complication rates with and without risk adjustment. Methods: Patients undergoing benign hysterectomy recorded in the National Surgical Quality Improvement Program (NSQIP) targeted hysterectomy file in 2015 were identified. The primary outcome was any postoperative complication. Stratified analysis was performed by route of surgery. Bivariable tests and modified Poisson regression were used to adjust for confounding by procedure type and patient characteristics. Results: We identified 17,639 patients who underwent hysterectomy for benign pathology, primary surgeon was a benign gynecologist (82%) or gynecologic oncologist (18%). Patients who underwent surgery with gynecologic oncologists were older (51yo v 46yo), had a higher mean BMI (32 v 30), and a higher prevalence of prior abdominal surgery (29% v 25%, p < 0.001), diabetes (10.6% v 7.0%), hypertension (34% v 25%) and higher ASA and Charlson comorbidity scores (p < 0.001, for all). For laparoscopy, surgery with a gynecologic oncologist was associated with a decreased risk of complication (RR 0.80, 95% CI 0.66–0.98). For laparotomy, surgery with a gynecologic oncologist was associated with an increased risk of complication (RR 1.18 95% CI 1.01–1.38), however, this was no longer the case with risk adjustment (aRR 0.90, 95% CI 0.76–1.07). Conclusions: Patients operated on by gynecologic oncologists have a higher prevalence of risk factors for complication compared to those operated on by benign gynecologists even with a benign indication for surgery. Quality measurement should account for this selection bias.

AB - Objective: To compare the characteristics of women undergoing hysterectomy for benign disease with either a benign gynecologist or a gynecologic oncologist and to assess for differences in complication rates with and without risk adjustment. Methods: Patients undergoing benign hysterectomy recorded in the National Surgical Quality Improvement Program (NSQIP) targeted hysterectomy file in 2015 were identified. The primary outcome was any postoperative complication. Stratified analysis was performed by route of surgery. Bivariable tests and modified Poisson regression were used to adjust for confounding by procedure type and patient characteristics. Results: We identified 17,639 patients who underwent hysterectomy for benign pathology, primary surgeon was a benign gynecologist (82%) or gynecologic oncologist (18%). Patients who underwent surgery with gynecologic oncologists were older (51yo v 46yo), had a higher mean BMI (32 v 30), and a higher prevalence of prior abdominal surgery (29% v 25%, p < 0.001), diabetes (10.6% v 7.0%), hypertension (34% v 25%) and higher ASA and Charlson comorbidity scores (p < 0.001, for all). For laparoscopy, surgery with a gynecologic oncologist was associated with a decreased risk of complication (RR 0.80, 95% CI 0.66–0.98). For laparotomy, surgery with a gynecologic oncologist was associated with an increased risk of complication (RR 1.18 95% CI 1.01–1.38), however, this was no longer the case with risk adjustment (aRR 0.90, 95% CI 0.76–1.07). Conclusions: Patients operated on by gynecologic oncologists have a higher prevalence of risk factors for complication compared to those operated on by benign gynecologists even with a benign indication for surgery. Quality measurement should account for this selection bias.

KW - Benign hysterectomy

KW - Gynecologic oncology

KW - Referral bias

KW - Selection bias

KW - Surgical quality

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U2 - 10.1016/j.ygyno.2018.08.010

DO - 10.1016/j.ygyno.2018.08.010

M3 - Article

C2 - 30121133

AN - SCOPUS:85051543237

VL - 151

SP - 141

EP - 144

JO - Gynecologic Oncology

JF - Gynecologic Oncology

SN - 0090-8258

IS - 1

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