title: Analysis of High-, Intermediate-, and Low-Volume Surgeons When Performing Hysterectomy for Uterovaginal Prolapse.
abstract: OBJECTIVE
  To determine if surgeon volume is associated with differences in the use of apical colpopexy and cystoscopy and in the rate of intraoperative complications during hysterectomy for prolapse.
  
  
  METHODS
  We performed a multicenter retrospective review of hysterectomies done for uterovaginal prolapse at 4 hospital systems between January 1, 2008, and December 31, 2011. Low (≤10 cases)-, intermediate (11-49 cases)-, and high (≥50 cases)-volume surgeon groups for the 4-year period were established a priori. Rates of concomitant colpopexy, cystoscopy, and intraoperative complications were determined by chart review for 15% of the cases. Multivariate logistic regression models adjusted for site and other clinical and patient variables were used to estimate associations between surgeon case volume and the use of apical colpopexy and cystoscopy and the rate of intraoperative complications.
  
  
  RESULTS
  Three hundred one surgeons performed 4238 hysterectomies for prolapse during the study period. Six hundred thirty-eight patients were selected for chart review. The rates among high-, intermediate-, and low-volume surgeons for performing colpopexy were 85.2% versus 77.8% versus 61.1% (P < 0.001) and for cystoscopy were 96.8% versus 78.3% versus 74.7% (P < 0.001), respectively. Rates of intraoperative complications among the 3 groups were 4.4%, 11.6%, and 6.3% (P = 0.011), respectively. With adjustment, high-volume surgeons were more likely to do a colpopexy than low-volume surgeons (odds ratio [OR], 1.9; 95% confidence interval [CI], 1.1-3.1); however, the likelihood of colpopexy did not differ between high- and intermediate-volume surgeons (OR, 1.9; 95% CI, 0.84-4.3) or between intermediate- and low-volume surgeons (OR, 0.99; 95% CI, 0.50-2.0). High-volume surgeons were more likely than intermediate-volume (OR, 4.4; 95% CI, 1.7-11.0) and low-volume (OR, 4.5; 95% CI, 2.6-8.0) surgeons to do a cystoscopy. High-volume (OR, 0.42; 95% CI, 0.30-0.61) and low-volume (OR, 0.32; 95% CI, 0.15-0.66) surgeons were less likely than intermediate-volume surgeons to have intraoperative complications. The difference between high- and low-volume surgeons was not statistically significant (OR, 0.77; 95% CI, 0.5-1.2).
  
  
  CONCLUSIONS
  Practice patterns with respect to hysterectomy for prolapse are complex when the use of colpopexy and cystoscopy and rates of intraoperative complications are analyzed by surgeon volume. The finding that intermediate-volume surgeons have the highest rates of intraoperative complications suggests a nonlinear relationship between surgeon volume and avoidance of injury.
authors.affiliation: From the *Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, MI; †Department of Obstetrics and Gynecology, Massachusetts General Hospital, Boston, MA; ‡Department of Obstetrics and Gynecology, Vanderbilt University, Nashville, TN; §School of Public Health, University of Michigan, Ann Arbor, MI; and ∥Department of Obstetrics and Gynecology, Southern California Permanente Medical Group, Irvine, CA.
authors.forename: Daniel M
authors.initials: DM
authors.lastname: Morgan
authors.forename: Samantha
authors.initials: S
authors.lastname: Pulliam
authors.forename: Rony A
authors.initials: RA
authors.lastname: Adam
authors.forename: Carolyn
authors.initials: C
authors.lastname: Swenson
authors.forename: Kenneth
authors.initials: K
authors.lastname: Guire
authors.forename: Neil
authors.initials: N
authors.lastname: Kamdar
authors.forename: Noelani
authors.initials: N
authors.lastname: Guaderrama
mesh_terms: D003127:Colposcopy / Q000706:statistics & numerical data; D003558:Cystoscopy / Q000706:statistics & numerical data; D005260:Female; D006176:Gynecology / Q000706:statistics & numerical data*; D061847:Hospitals, High-Volume / Q000706:statistics & numerical data; D061846:Hospitals, Low-Volume / Q000706:statistics & numerical data; D006801:Humans; D007044:Hysterectomy / Q000706:statistics & numerical data*; D007430:Intraoperative Care / Q000379:methods / Q000706:statistics & numerical data; D008875:Middle Aged; D011183:Postoperative Complications / Q000209:etiology; D010818:Practice Patterns, Physicians' / Q000706:statistics & numerical data; D012189:Retrospective Studies; D014481:United States; D014596:Uterine Prolapse / Q000601:surgery*; D016526:Workload / Q000706:statistics & numerical data*