key: cord-0916660-aowuk3e9
authors: Traylor, Jessica; Koelper, Mr. Nathanael; Kim, Sun Woo; Sammel, Mary D.; Andy, Uduak U.
title: Impact of Surgical Wait Time to Hysterectomy for Benign Gynecologic Disease
date: 2020-09-03
journal: J Minim Invasive Gynecol
DOI: 10.1016/j.jmig.2020.08.486
sha: b932378b3b95574bd572740ab163b5aad930e0c7
doc_id: 916660
cord_uid: aowuk3e9

STUDY OBJECTIVE: To determine the impact of surgical wait time on healthcare utilization and surgical outcomes for women undergoing hysterectomy for benign gynecologic indications. DESIGN: Retrospective cohort study. SETTING: Urban, academic tertiary care center. PATIENTS: Women who underwent hysterectomy for benign disease between 2012 and 2018. INTERVENTIONS: None MEASUREMENTS AND MAIN RESULTS: Women were divided into two groups, dichotomized by surgical wait times > or ≤ 30 days. Healthcare utilization was measured by the number of discrete patient interactions with the healthcare system via phone calls, secure electronic messaging, office and emergency room visits. Univariate and multivariable logistic regression models were performed to assess the association between surgical wait time and healthcare utilization and perioperative outcomes while controlling for confounders. Two hundred and seventy-seven women were included in our analysis: 106 (38.3%) had surgical wait time >30 days (median 47 days, range 24-68 days) and 171 (67.1%) had surgical wait time ≤30 days (median 19 days; range 12-26 days). The groups did not differ by age, insurance status, substance use or comorbid conditions. Women in the surgical wait time >30 days group were more likely to have increased healthcare utilization (69/106, 65% vs 43/171, 25% OR 5.55 95% CI 3.27-9.41). There were no differences in intraoperative complications (9/106, 8% versus 19/171, 11%, p = .482) or postoperative complications (28/106, 26% vs 32/171, 19%, p = .13) between the groups; however, after controlling for potential confounders, women with surgical wait time >30 days were 3.22 times more likely to be readmitted than women with surgical wait time ≤30 days (95% CI 1.27-8.19). CONCLUSION: Surgical wait time >30 days in women undergoing hysterectomy for benign disease is associated with increased healthcare utilization in the interim. Though women who experience longer surgical wait times do not experience worse surgical outcomes, they may be at higher risk for readmission after surgery. Targeted interventions to optimize perioperative coordination of care for women undergoing hysterectomy for benign disease, especially those within vulnerable populations, are needed to improve quality of care, decrease any redundant or inefficient healthcare usage, and reduce any unnecessary delays.

Hysterectomy is the second most commonly performed surgery for women of reproductive age, and accounts for over $5 billion in healthcare costs annually. 1 The United

States spends more per capita on healthcare than any other nation, and approximately twice as much as other high-income countries. 2 Each year healthcare expenditures in the United States continue to rise. The estimated annual health expenditures among American females ≥14 years of age with gynecologic conditions is 10.5 billion dollars. 3 This creates an imperative to better understand how patients utilize the healthcare system and factors associated with inefficient usage of the system. Many factors contribute to healthcare expenditures including service utilization, prices of services, changes in disease prevalence, pharmaceutical fees, and changes in population size and age structure. 4 Differences in service or health care utilization have been associated with changes in surgical wait times. 5 In women with gynecologic malignancy, the time period between diagnosis of cancer and definitive surgical treatment is defined as the surgical wait time. Increased surgical wait times can be influenced by numerous factors, such as patient preference or preoperative planning and medical clearances, but importantly can also reflect structural problems within a health care system. 6 Prior studies have found that surgical treatment delays are associated with worse survival for women with gynecologic malignancies such as uterine cancer. [6] [7] [8] Additionally, surgical delay has also been associated with unplanned emergency admissions. 9 For women with benign diseases such as fibroids and abnormal uterine bleeding, hysterectomy is typically performed electively after exhaustion of medical management; in this setting, surgical wait time reflects the time from definitive decision to perform hysterectomy to the time of surgery. In women awaiting prolapse surgery and other non-gynecologic surgery, there is some evidence that patients waiting for elective surgery for benign conditions can also experience negative outcomes including increased discomfort, decreased quality of life and increased anxiety. [10] [11] [12] However, the impact of surgical wait time in women undergoing hysterectomy for benign indications has not previously been examined. Understanding how surgical wait times affect patients and the healthcare system can provide targets to improve quality of care and reduce healthcare costs. Additionally, although our interest in this issue predates the COVID-19 pandemic, understanding the impact of delaying benign surgeries may help in better assessing the effects of the current pandemic. The objective of this study was to determine the impact of surgical wait time on healthcare utilization and surgical outcomes in women undergoing hysterectomy for benign gynecologic indications. We hypothesized that surgical wait time >30 days is associated with increased healthcare utilization.

We conducted a retrospective cohort study of women who had a hysterectomy for benign disease at the Hospital of the University of Pennsylvania (HUP) between January 2012 and February 2018 and who were seen preoperatively in the resident gynecology clinic. Approval from the University of Pennsylvania Institutional Review Board was obtained. We obtained billing records to identify cases performed by the resident gynecology service and used Current 13 Robotic-assisted laparoscopic cases were included in the appropriate laparoscopic categories.

Women were included in the study if there was documentation of a preoperative visit in the resident gynecology clinic, the Helen O. Dickens Center for Women, and the hysterectomy was performed at the Hospital of the University of Pennsylvania under the care of the resident benign gynecology service. We excluded patients who were incorrectly identified by CPT codes and did not actually have a hysterectomy, were referred outside of the resident clinic for surgery, had a hysterectomy as part of an inpatient admission without a preoperative visit, or who had a preoperative diagnosis of gynecologic malignancy. Standard practice in the resident gynecology clinic is for a patient to attend a preoperative clinic appointment once decision for surgery has been made. At this visit, the patient discusses the intended surgery with a provider and meets with the surgery scheduler to confirm a surgery date within 30 days of their appointment. The patient is expected to receive at least 1 preoperative phone call from the chief resident on the gynecology service prior to surgery. If the patient does not have surgery within 30 days, another visit is made in preoperative clinic prior to the surgery.

Study data were collected and managed using REDCap electronic data capture tools hosted at The University of Pennsylvania. 14 REDCap (Research Electronic Data Capture) is a secure, web-based application designed to support data capture for research studies. The electronic medical record was reviewed for each patient including outpatient records, operative notes, inpatient records, discharge summaries and pathology reports. The following demographic and medical history were abstracted: age, race, insurance type, body mass index (BMI), alcohol Pearson  2 was used to compare categorical variables. Student's t-test, or Wilcoxon rank sum tests were used to compare continuous variables, where appropriate. Multivariable logistic regression models were performed to assess associations between surgical wait time and healthcare utilization and perioperative outcomes while controlling for confounders. Factors suspected to be associated with increased healthcare utilization and any baseline characteristics significantly different between the two groups were included in our model as potential confounders. Our power calculation estimated that with 277 patients we would have 80% power to detect a risk ratio of 1.8 or higher in women with >30 day wait time compared to those with ≤30 day wait time with statistical significance at a P value < 0.05. Statistical analysis was performed using STATA version 14.2 (Stata Corp, College Station, TX).

A total of 292 women underwent a hysterectomy during the study period; 13 women did not obtain preoperative care in the resident clinic and 2 women were diagnosed with a malignancy, thus leaving 277 women that met our inclusion criteria and were included in the analyses ( Table   1 ). Use of leuprolide acetate injection preoperatively was more common in the >30 days group (p<.01) ( Table 1 ). The benign indications for surgery included fibroids, abnormal uterine bleeding (AUB), adenomyosis, endometriosis, chronic pelvic pain, endometrial hyperplasia, cervical dysplasia and pelvic organ prolapse and were not significantly different between the two groups ( Table 2 ). In the >30 days group, the reason for longer surgical wait time was not explicitly documented for most women (58/106, 54.7%). Of those in which the reason for a >30 day wait time was documented, the reasons included: need for medical clearance (n=18), optimization of anemia (n=13), patient preference (n=9), operating room scheduling (n=4), active drug use (n=2), financial concerns (n=1), and patient work schedule (n=1).

There was a statistically significant difference in healthcare utilization between the two groups (Table 3) . Women in the >30 days group were 5.5 times more likely to have increased healthcare utilization (95% CI 3.27-9.41). After controlling for leuprolide use, women in the (Table 4) . We defined administrative calls as those related to scheduling and paperwork (e.g. Family Leave and Medical Act forms). When administrative calls were excluded and after controlling for leuprolide use, the >30 days group still had increased healthcare utilization (OR 3.91, 95% CI 2.20-6.92). This increased utilization remained when expanding administrative calls to include scheduling, paperwork and medical clearance themes (OR 3.52, 95% CI 1.85-6.70).

Secondary outcomes are outlined in Table 5 . There was no statistically significant difference in the rate of perioperative complications or length of hospital stay between the two groups. The overall 30-day readmission rate for the cohort was 8% and women in the >30 days group were 2.85 times more likely to be readmitted than women in the ≤30 days group (95% CI 1.14-7.12). After controlling for hypertension as a potential confounder, the association persisted and women in the >30 days group were 3.22 times more likely to be readmitted (95% CI 1. 27-8.19) . No other covariates (age, BMI, Charlson Comorbidity Index score, insurance carrier, perioperative complications, EBL, surgical approach) were significant confounders.

Readmission indications are listed in Table 6 . While there were no readmissions among women who underwent laparoscopic or robotic hysterectomy, the remaining were distributed between abdominal (9) and vaginal (12) hysterectomies (data not shown).

Twelve women had both a surgical wait time >30 days and a readmission. Most of these women did not have clear documentation of the reason for delay to surgery (n = 5) or had a delay due to need for medical clearance (n = 3). Other reasons for delay in this readmission group for the remaining 5 patients included a positive drug screen on the day of surgery (n=1), surgical coordination with plastic surgery for a joint procedure (n=1), anemia (n=1), use of leuprolide acetate preoperatively (n=1), and inactivation of insurance (n=1).

In our study of women undergoing hysterectomy for benign indications, increased surgical wait time was associated with increased healthcare utilization. Women with wait times >30 days had increased telephone calls and visits between their preoperative visit and surgery date. Additionally, while women with wait times >30 days did not have an increased rate of perioperative complications, they were 3.22 times more likely to be readmitted following their hysterectomy than women with surgical wait time ≤30 days.

Preoperative healthcare utilization has been shown to be a driver of readmission in surgical patients. 16, 17 Our data suggests that increased surgical wait times in women awaiting hysterectomy for benign indications have a significant impact on how healthcare is utilized and may be a marker of healthcare quality; thus, a deeper understanding of the factors that contribute to this waiting time is warranted.

In our study, we found that women planning hysterectomy for benign indications with surgical wait times >30 days have an increased level of healthcare utilization. A study by Walker et al. examined pain-related healthcare utilization among Canadian women awaiting gynecologic surgery. The authors found that approximately one-third of participants experienced unpleasant symptoms (mental distress, pain interference with daily activities, moderate to severe pain intensity) during the preoperative period and the average number of pain-related visits during the year preceding surgery was 3.5 visits per person. 18 These findings underscore the additional burden on the health system when preventable delays occur. If the women underwent their planned surgery in a timely manner, the additional health care utilization would have been avoided leading to decreased expenditures, and greater capacity to care for other patients waiting to be seen. Thus, measures that reduce wait times may reduce barriers to care.

The impact of surgical wait time on clinical outcomes for women awaiting hysterectomy for benign indications has not been well studied. In our study, we did not find a significant difference in perioperative complications between the two groups. Interestingly, however, we found that women with wait times >30 days were more likely to call about their symptoms (10% vs 4%) during the intervening period, suggesting that women with longer wait times were more bothered by their symptoms and seeking relief during the interim. In some respects this is not surprising as utilization may be a function of time; however, some themes from the patient phone calls reflect areas where improvement in perioperative patient navigation can be useful. Thus, although increased wait times for benign gynecologic diagnoses may not impact surgical outcomes, there may be significant impact on patients' quality of life (QOL). This finding is consistent with several studies that have assessed the impact of waiting for elective surgery on patient well being as well as the well-established improvement in quality of life that occurs after hysterectomy. 10, 12, 19 In a prospective, cross-sectional study of women's health-related QOL, Leong et al. found women experienced poor emotional role functioning and had negative impacts on mental health while awaiting surgery for pelvic organ prolapse. 11 In a study that examined QOL among women who underwent hysterectomy, improvements were noted in symptom severity, and 8 QOL domains (concern, activities, energy/mood, control, self-consciousness, and sexual function) at 1-year compared to baseline. 20 Taken together, these findings suggest that increased surgical wait times prior to hysterectomy for benign indications may adversely impact patient well-being and should be minimized, always taking into account patient safety and optimizing any comorbid medical conditions where appropriate.

While there were no significant demographic differences between the two groups, it is important to note that our study population is predominantly African American and insured under Medicaid. A national cross-sectional study describing patterns of ambulatory care use for gynecologic disorders found an association between younger age, black race, Medicaid insurance, and lower household income and increased health care utilization including emergency department and hospital outpatient department visits. 21 These associations underscore the need for continued improvement in patient access, quality of care and education about gynecologic disorders in vulnerable populations. In our study, the primary method of healthcare utilization was via telephone calls. The most common reasons for these calls were: discussion of the surgery, preoperative workup/medical clearance and scheduling. In contrast, in a prospective analysis of phone calls among patients scheduled for total thyroidectomy, the most common reasons for calls were preoperative workup, medications and insurance/work-related. 22 In contrast to our rate of 31%, only 2% of phone calls in their study were related to questions about the surgery. While the difference in reasons for telephone calls between our study and theirs may be related to surgery type, this contrast may reflect differences in patient demographics as their population had a lower proportion (18%) insured under Medicaid. These findings underscore the impact of demographic factors on health care utilization inefficiencies and suggest that improvement in health literacy and patient-centered education about their surgery may decrease redundant health care utilization in vulnerable populations.

The 30-day unplanned readmission rate of 8% in our retrospective cohort is higher than the 2-3% rate that has been reported in the literature and may reflect the poor social determinants of health within our population. 23-25 Significantly, we found an increased likelihood of readmission for women in the group with longer surgical wait time. For most of the women with both wait time >30 days and readmission, the reasons for the increased wait times were not clearly identified from retrospective chart review; however, in 3 three of the 12 women who were readmitted, the longer surgical wait time was attributed to need for medical clearance, which may reflect patient comorbidities more than insufficient or inefficient healthcare access.

Further studies will need to examine this association and investigate the reason for the relationship between surgical wait time and risk of readmission.

Our study has several strengths. We included a large sample of subjects who had a hysterectomy for benign indications. Data was abstracted directly from a comprehensive electronic medical record, and provides accurate and chronological information for each subject.

In an attempt to capture the true impact of the surgical wait time, a comprehensive sample of healthcare utilization methods was included in the analysis.

The study also has some limitations. The retrospective study design imposes a reliance on accurate provider documentation and limits the ability to discern the reasons for surgical wait times, a weakness that could be mitigated by using a prospective study design. There are likely a lot of nuances in the reasons for prolonged surgical wait time and better documentation of these reasons would significantly aid the conclusions we could draw from this study. Nonetheless, our findings are a first step in exploring the impact of delay and suggest that a "benign" indication for hysterectomy does not suggest a lack of urgency. Our data abstraction was limited to the electronic medical record used within one health system, so we are unable to capture interim healthcare utilization at outside institutions. However, given that our clinic and health system is a safety net for many of the women in the surrounding community, we likely captured an accurate depiction of their healthcare utilization. Our cohort included a population of urban and predominantly African American women from a single institution attending a resident clinic.

While this may limit the generalizability of our findings, excluding patients from other clinics was intentional, as the patient population served by the resident clinic represents a community that likely faces greater impact from social determinants of health; thus, has the potential to gain much from improvements in the perioperative process. Finally, we examined utilization during the interval from initial preoperative visit to surgery based on the practice patterns at our institution. It is possible that we did not capture the impact of the entire waiting period as a woman may have begun discussion about hysterectomy with her provider for some time prior to referral to the preoperative clinic.

Longer surgical wait times for benign hysterectomy are associated with increased healthcare utilization in the interim. While patients who experience increased wait times do not have worse surgical outcomes, there may be a significant impact on quality of life. These findings have particular relevance in the current setting of a global pandemic that has required postponement of elective surgeries in certain areas. Further research is needed to better characterize the surgical wait time in women undergoing hysterectomy for benign indications in order to improve efficiency in healthcare utilization and most importantly, to improve the quality of care we provide to our patients. 

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Preoperative blood transfusion, n (%) 15