Clinical Pathway Increases Utilization of Minimally Invasive, Lower Cost Techniques for Hysterectomy

A new study shows how the implementation of a clinical pathway for hysterectomy can decrease the proportion of total abdominal hysterectomy (TAH) procedures. 

Hysterectomy is one of the most common medical procedures performed in the United States. Although minimally invasive techniques for hysterectomy are associated with lower costs and greater patient satisfaction, TAH—a highly invasive approach that is associated with higher risk of complications and longer hospital stays—is still often used in many practices. 

In a study published in the journal Obstetrics & Gynecology, researchers describe how an evidence-based clinical pathway for hysterectomy can reduce the number of TAH procedures performed. In order to encourage physicians to use the less invasive methods of hysterectomy for benign indications recommended by the American College of Obstetricians and Gynecologists, the University of Pittsburgh Medical Center developed a clinical pathway for hysterectomy by conducting cost and quality analyses and engaging physicians to develop evidence-based guidelines for hysterectomies. After developers were satisfied with the pathway, it was integrated into electronic medical records and implemented into clinical practice in 2012.

A study was then done to evaluate the performance of the hysterectomy clinical pathway. A research team led by Faina Linkov, PhD (Magee-Womens Research Institute, Pittsburgh, PA), retrospectively evaluated data from 6544 hysterectomies performed at University of Pittsburgh Medical Center-affiliated hospitals between 2012 and 2014. Hysterectomies for cancerous indications were excluded from the study. The average age of participants was 48.6 years. Patients were broken up into 3 age groups: 40.8% of patients were younger than 45 years of age; 42.6% of patients were between 45 and 60 years of age; and 16.6% of patients were older than 60 years of age.

Laparoscopy was the most commonly used technique for performing hysterectomies, followed by TAH. Overall, the number of TAH procedures declined in a linear fashion each year of the study, while the number of procedures performed using laparoscopic techniques increased over the same period. The proportion of all hysterectomy procedures that were TAH procedures decreased from 27.8% in 2012 to 22% in 2013 and then to 17% in 2014. The proportion of hysterectomies performed with laparoscopy increased linearly from 41% in 2012 to more than 48% in 2014. The use of vaginal and robotic hysterectomy techniques also increased over the 3-year period, although not significantly.

“This study is the first to demonstrate the effectiveness of a surgical pathway to achieve a decreased proportion of abdominal hysterectomies among hysterectomies performed for benign indications,” the authors wrote. “Because there is still a gap between the best research evidence and the best clinical practice, especially in the fields of obstetrics and gynecology, this project may have immediate implications for gynecologic care across the nation.”

The study had some limitations, most notably that the study took place over a relatively short amount of time and more specific patient characteristics that influence outcomes, such as body mass index, uterine size, race, and comorbidity status, were unavailable to the researchers. The authors suggest that future studies should be designed with longer follow-up periods and should incorporate more quality indicators.

“Implementing clinical pathways such as the one outlined in this study is a promising venue to guide us toward a better evidence-based practice and better patient care,” the authors concluded.—Sean McGuire

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Sanei-Moghaddam A, Ma T, Goughnour SL, et al. Changes in hysterectomy trends after the implementation of a clinical pathway. Obstet Gynecol. 2016;127(1):139-147.