Data are from the Truven Health Analytics Commercial Claims and Encounters Database. To calculate the annual rates, we divided the number of women receiving a hysterectomy by the total number of women who were enrolled in the health plans in each month and multiplied this value by 100 000 to represent the rate per 100 000 health plan enrollees.
Data are from the Truven Health Analytics Commercial Claims and Encounters Database. To calculate the annual rates, we divided the number of women receiving an oophorectomy by the total number of women who were enrolled in the health plans in each month and multiplied this value by 100 000 to represent the rate per 100 000 health plan enrollees.
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Doll KM, Dusetzina SB, Robinson W. Trends in Inpatient and Outpatient Hysterectomy and Oophorectomy Rates Among Commercially Insured Women in the United States, 2000-2014. JAMA Surg. 2016;151(9):876–877. doi:10.1001/jamasurg.2016.0804
A hysterectomy is the second most common surgical procedure among women in the United States, with approximately 600 000 performed annually for benign gynecologic conditions.1 Trends in hysterectomy rates are an important marker for innovation and quality in gynecology as treatment alternatives increase and as evidence of the underuse of these treatment alternatives emerges.2 The accurate identification of a hysterectomy requires capturing data from both inpatient and outpatient services, given the shifting setting of care over recent years. Yet, the highest-quality national trend estimates have been significantly limited by the exclusion of data on outpatient procedures due to the use of databases restricted to inpatient settings.3,4 Prior studies that included inpatient and outpatient settings have focused on small geographic areas only, limiting their generalizability.5 The lack of national outpatient data is a critical gap because the rapid dissemination of robotic surgery has likely shifted the proportion of hysterectomies that are performed in outpatient settings.
The same shifting pattern may also be true for an oophorectomy, another common procedure among US women. As with hysterectomy rates, the ability to analyze trends in oophorectomy rates is limited by the use of data restricted to inpatient settings.
Using the Truven Health Analytics Commercial Claims and Encounters Database, commercial insurance data representing more than 50 million insured adults and containing data on both inpatient and outpatient procedures, we report the long-term trends in hysterectomy and oophorectomy rates from 2000 to 2014. In particular, we estimate the care received in inpatient and outpatient settings separately over this period to provide a comprehensive picture of the receipt of gynecologic surgery among commercially-insured US women.
We focused our analysis on women 18 to 64 years of age who did not receive cancer-related care during the period spanning 1 day before and 30 days after a hysterectomy and/or an oophorectomy because this population is the most amenable to alternative treatment options. To calculate the annual rates of these procedures, we divided the number of women receiving each procedure by the total number of women 18 to 64 years of age who were enrolled in the health plans in each month and multiplied this value by 100 000 to represent the rate per 100 000 health plan enrollees. This study was considered exempt from review by the institutional review board of the University of North Carolina because it is a secondary analysis of deidentified data.
From 2000 to 2014, there were 809 905 hysterectomies and 257 573 oophorectomies recorded. Overall annual hysterectomy rates decreased 39% from 2000 to 2014 (from 631/100 000 to 385/100 000) (Figure 1). The proportion of hysterectomies performed in outpatient settings increased from 14% in 2000 to 70% in 2014. Over the same time period, overall annual oophorectomy rates decreased from 166/100 000 to 134/100 000. The proportion of oophorectomies performed in outpatient settings increased from 57% in 2000 to 84% in 2014 (Figure 2).
This work demonstrates a current gap in gynecologic surgery research. Analyses limited to inpatient procedures likely underestimate the hysterectomy and oophorectomy rates, providing an incomplete picture of overall trends. Falsely low hysterectomy rates based on inpatient-only data can imply a greater use of alternative therapies (to hysterectomy) than what may actually be occurring. In addition, with a shift in standard of care to outpatient surgery, inpatient populations may represent a biased group of sicker, poorer patients whose outcomes we should not generalize to the greater population.
To accurately assess changing treatment patterns in gynecology, studies should include inpatient and outpatient procedures. Given the often subjective indications6 and previously reported geographic, socioeconomic, and racial variations in surgery rates, tracking treatment patterns is important. Our work highlights important trends in hysterectomy and oophorectomy rates and the extent to which care has shifted largely to outpatient settings. Recognizing gaps in data that provide only a partial view of surgical care patterns may help us avoid drawing incorrect conclusions regarding access to care or the quality of care received.
Corresponding Author: Kemi M. Doll, MD, Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina, Campus Box 7411, Chapel Hill, NC 27599 (firstname.lastname@example.org).
Published Online: May 11, 2016. doi:10.1001/jamasurg.2016.0804.
Author Contributions: Drs Doll and Dusetzina had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.
Study concept and design: All authors.
Acquisition, analysis, or interpretation of data: All authors.
Drafting of the manuscript: Doll.
Critical revision of the manuscript for important intellectual content: All authors.
Statistical analysis: Doll, Dusetzina.
Obtained funding: Robinson.
Administrative, technical, or material support: Dusetzina, Robinson.
Study supervision: Doll.
Conflict of Interest Disclosures: None reported.
Funding/Support: Dr Doll is supported by the National Cancer Institute of the National Institutes of Health under award R25CA116339. Dr Dusetzina is supported by the National Institutes of Health Building Interdisciplinary Research Careers in Women’s Health K12 Program and the North Carolina Translational and Clinical Sciences Institute (award UL1TR001111). Dr Robinson is supported by the National Institutes of Health under award K01CA172717-01. The database infrastructure used for this project was funded by the Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina; the Cecil G. Sheps Center for Health Services Research, University of North Carolina; the Comparative Effectiveness Research Strategic Initiative of the University of North Carolina’s Clinical and Translational Science Award (UL1TR001111); and the University of North Carolina School of Medicine. We are also grateful to the Carolina Population Center (grant R24 HD050924) for general support and the Carolina Community Network II Cancer Health Disparities Pilot Grant.
Role of the Funder/Sponsor: The funding sources had no role in the design and conduct of the study; collection, management, analysis, or interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.
Disclaimer: The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.
Additional Contributions: We thank Tania Wilkins, MS, Division of Pharmaceutical Outcomes and Policy, Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, for her assistance with data management and analysis. No compensation from a funding sponsor was received.