title: Differences in Patterns of Preoperative Assessment Between High, Intermediate, and Low Volume Surgeons When Performing Hysterectomy for Uterovaginal Prolapse.
abstract: OBJECTIVE
  The aim of the study was to determine whether surgeon case volume is associated with preoperative evaluation of pelvic organ prolapse before a hysterectomy for uterovaginal prolapse including a complete objective evaluation of prolapse (Baden-Walker or Pelvic Organ Prolapse Quantification), an offer of nonsurgical options for therapy (pessary), and a preoperative assessment of urinary incontinence
  
  
  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. The number of hysterectomies per surgeon for 4 years was evaluated to establish low-volume (≤10 cases), intermediate-volume (11-49 cases), and high-volume (≥50 cases) groups. Rates of preoperative standardized prolapse evaluations, offer of pessary, and evaluation of stress urinary incontinence were determined by chart review of 15% of the hysterectomy cases. Adjustment was made in a logistic regression model for age, race, insurance status, and prolapse size.
  
  
  RESULTS
  Three hundred one surgeons performed 4238 hysterectomies for prolapse during the study period. Rates of preoperative assessment by standardized pelvic examination differed between high-, intermediate-, and low-volume surgeons (91.2% vs. 61.3% vs. 48.8%, respectively), as did offer of a pessary (86.5% vs. 71.9% vs. 69.9%, respectively) and preoperative stress test for urinary incontinence (93.5% vs. 72.8% vs. 63.5%, respectively). Regression analysis revealed that high-volume surgeons were more likely than intermediate- or low-volume surgeons to perform a standardized pelvic examination, offer a pessary, or perform preoperative evaluation for urinary incontinence.
  
  
  CONCLUSIONS
  High-volume surgeons were more likely than low-volume surgeons to perform a standardized preoperative pelvic examination, offer a pessary, and evaluate stress urinary incontinence.
authors.affiliation: From the *Division of Urogynecology, Department of Obstetrics and Gynecology, Massachusetts General Hospital, Boston, MA; †Division of Urogynecology, Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, MI; ‡Division of Urogynecology, Department of Obstetrics and Gynecology, Southern California Permanente Medical Group, Irvine, CA; §Division of Statistics, School of Public Health, University of Michigan, Ann Arbor, MI; and ∥Division of Urogynecology, Department of Obstetrics and Gynecology, Vanderbilt University, Nashville, TN.
authors.forename: Samantha J
authors.initials: SJ
authors.lastname: Pulliam
authors.forename: Daniel M
authors.initials: DM
authors.lastname: Morgan
authors.forename: Noelani
authors.initials: N
authors.lastname: Guaderrama
authors.forename: Kenneth
authors.initials: K
authors.lastname: Guire
authors.forename: Rony A
authors.initials: RA
authors.lastname: Adam
mesh_terms: D000704:Analysis of Variance; D002983:Clinical Competence / Q000706:statistics & numerical data*; D005260:Female; D006176:Gynecology / Q000592:standards* / Q000706:statistics & numerical data; D061847:Hospitals, High-Volume / Q000706:statistics & numerical data; D061846:Hospitals, Low-Volume / Q000706:statistics & numerical data; D006801:Humans; D007044:Hysterectomy / Q000379:methods*; D008875:Middle Aged; D010570:Pessaries / Q000706:statistics & numerical data; D010808:Physical Examination / Q000379:methods / Q000706:statistics & numerical data; D010818:Practice Patterns, Physicians'; D011300:Preoperative Care / Q000379:methods*; D012189:Retrospective Studies; D014550:Urinary Incontinence, Stress / Q000175:diagnosis; D014596:Uterine Prolapse / Q000601:surgery*; D016526:Workload