Appropriateness of hysterectomies performed for multiple preoperative indications.

OBJECTIVE: To correlate the listing of multiple preoperative indications for hysterectomy with the risk of non-confirmation of the preoperative diagnosis. METHODS: Records of 171 women undergoing consecutive hysterectomies for all indications at a large teaching hospital were reviewed for preoperative indication(s), compliance with published preoperative validation criteria for cases in which tissue pathology was not expected, and histologic verification of the preoperative diagnosis for cases in which tissue pathology was expected. Rates of confirmation (histologic verification plus successful compliance with validation criteria) of the preoperative diagnosis were compared between subgroups of cases in which single indications were listed (N = 124) or multiple indications were listed (N = 47) preoperatively. RESULTS: The rate of confirmation of single indications (115 of 124 cases, 93%) was significantly higher than the rate of confirmation of even one indication in cases in which multiple indications were listed (28 of 47 cases, 60%, P < .0001; relative risk for non-confirmation of multiple indications = 1.55). Multiple indications were more likely to be listed when tissue pathology was not expected, representing 49% of validatable indications as compared with only 18% of histologically verifiable indications (P < .0001). Overall, the rate of compliance with validation criteria (70%) was significantly lower than the rate of histologic verification (90%) (P < .01). CONCLUSION: These data suggest that listing of multiple preoperative indications for hysterectomy is associated with both decreased appropriateness, as reflected in decreased compliance with generally accepted preoperative validation criteria, and decreased diagnostic accuracy, as reflected in lower rates of histologic verification.

Quality assurance indicators and short-term outcome of hysterectomy.

Fifteen gynecologic quality assurance indicators recently published by The American College of Obstetricians and Gynecologists were applied to a previously reported hysterectomy data base. Chart reviews were performed for the most recent 257 cases in the data base, representing an 18-month interval. The indicators were divided into two groups: those intended to identify morbidity and mortality and those intended to screen for appropriateness of care. Rates of actual morbidity and cases that failed to meet published criteria sets for hysterectomy were determined by chart review regardless of the presence of a quality assurance indicator. A total of 135 indicators were identified in 114 (44%) of the 257 cases, including 64 patients (25%) with morbidity indicators and 50 (19%) with appropriateness indicators. Actual morbidity was correctly identified in all 64 cases in which morbidity indicators were present. Three cases with significant morbidity were identified by chart review but not identified by the indicators, yielding positive and negative predictive values of 100 and 98%, respectively, and an overall accuracy of 99% for morbidity indicators. By contrast, 14 of the 50 cases in which appropriateness indicators were present actually failed to meet published criteria sets. An additional seven cases failing to meet criteria sets were identified by chart review and not identified by the indicators, yielding a positive predictive value of 28%, a negative predictive value of 97%, and an overall accuracy of 83% for appropriateness indicators.

The impact of a quality assurance process on the frequency and confirmation rate of hysterectomy.

A criteria-based quality assurance process for hysterectomy was instituted at a large teaching hospital. After this process was initiated, the overall frequency of hysterectomy decreased by 24%, p less than 0.001. Significant reductions were seen in hysterectomy rates for the following indications: chronic pelvic pain (77%, p less than 0.0001), recurrent uterine bleeding (46%, p less than 0.001), preinvasive disease of the uterus (55%, p less than 0.005), and severe infection (70%, p less than 0.025). Adenomyosis was the single indication for which an increase in hysterectomy rate was observed. This increase, however, was completely reversed during the last 2 years of the study. This quality assurance process also resulted in a significant increase in the histologic verification rate (i.e., 82% vs 93%, p less than 0.001). These observations suggest that using such a criteria-based process can reduce the number of hysterectomies performed and improve the accuracy of the preoperative diagnosis.

Consumer advocacy, elective surgery, and the "golden era of medicine".

The process of medical quality assurance evolved logically from the consumer advocacy movement of the past decades. This process has fundamentally altered the personal and legal relationship between patients and physicians. The need for development and adoption of a medically, ethically, and fiscally sound standard of elective surgical practice is clear and immediate. A system that may be used to evaluate the appropriateness of elective surgical procedures is proposed.

Validation of hysterectomy indications and the quality assurance process.

Hysterectomy is one of the most commonly performed major operations in the United States. Despite efforts to explain its high incidence, the perception remains that a significant number of hysterectomies are unjustified. More indications are listed for hysterectomy than for any other major operation. A quality assurance process is presented that requires the surgeon to select preoperatively one designated indication for each hysterectomy performed. The pathology report is expected to verify the surgical indication in 66% of the cases. The other 34% of hysterectomy specimens are not expected to show tissue pathology based on the listed indication. For these cases, predetermined validation criteria must be satisfied in the surgeon's preoperative note. Applying the process in this series of 584 consecutive hysterectomies, 93% (N = 396) of the "pathology expected" indications were verified by the pathology report and 98% (N = 188) of the "no pathology expected" indications were validated by the surgeon's preoperative note. The process of using a single designated indication and reviewing only two documents (the pathology report and the surgeon's preoperative note) has greatly simplified the quality assurance process. This system enables a quality assurance committee to monitor easily the appropriateness of hysterectomy indications for their institution. Information obtained from this process can influence changes regarding the acceptability of certain indications. As a result of this study, adenomyosis, because of its low (38%) verification rate, is no longer considered a reliable preoperative indication for hysterectomy at San Diego Naval Hospital.