title: Utilization of Minimally Invasive Surgery in Endometrial Cancer Care: A Quality and Cost Disparity.
abstract: OBJECTIVE
  To describe case mix-adjusted hospital level utilization of minimally invasive surgery for hysterectomy in the treatment of early-stage endometrial cancer.
  
  
  METHODS
  In this retrospective cohort study, we analyzed the proportion of patients who had a minimally invasive compared with open hysterectomy for nonmetastatic endometrial cancer using the U.S. Nationwide Inpatient Sample database, 2007-2011. Hospitals were stratified by endometrial cancer case volumes (low=less than 10; medium=11-30; high=greater than 30 cases). Hierarchical logistic regression models were used to evaluate hospital and patient variables associated with minimally invasive utilization, complications, and costs.
  
  
  RESULTS
  Overall, 32,560 patients were identified; 33.6% underwent a minimally invasive hysterectomy with an increase of 22.0-50.8% from 2007 to 2011. Low-volume cancer centers demonstrated the lowest minimally invasive utilization rate (23.6%; P<.001). After multivariable adjustment, minimally invasive surgery was less likely to be performed in patients with Medicaid compared with private insurance (adjusted odds ratio [OR] 0.67, 95% confidence interval [CI] 0.62-0.72), black and Hispanic compared with white patients (adjusted OR 0.43, 95% CI 0.41-0.46 for black and 0.77, 95% CI 0.72-0.82 for white patients), and more likely to be performed in high- compared with low-volume hospitals (adjusted OR 4.22, 95% CI 2.15-8.27). Open hysterectomy was associated with a higher risk of surgical site infection (adjusted OR 6.21, 95% CI 5.11-7.54) and venous thromboembolism (adjusted OR 3.65, 95% CI 3.12-4.27). Surgical cases with complications had higher mean hospitalization costs for all hysterectomy procedure types (P<.001).
  
  
  CONCLUSIONS
  Hospital utilization of minimally invasive surgery for the treatment of endometrial cancer varies considerably in the United States, representing a disparity in the quality and cost of surgical care delivered nationwide.
authors.affiliation: Kelly Gynecologic Oncology Service, Department of Gynecology and Obstetrics, the Department of Surgery, and the Armstrong Institute for Patient Safety and Quality, Johns Hopkins Hospital, Baltimore, Maryland; the University of California San Diego Medical Group, La Jolla, and the Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of California, Irvine, Irvine, California; and the Division of Health Care Policy & Research and the Division of Gynecologic Surgery, Mayo Clinic, Rochester, Minnesota.
authors.forename: Amanda N
authors.initials: AN
authors.lastname: Fader
authors.forename: R Matsuno
authors.initials: RM
authors.lastname: Weise
authors.forename: Abdulrahman K
authors.initials: AK
authors.lastname: Sinno
authors.forename: Edward J
authors.initials: EJ
authors.lastname: Tanner
authors.forename: Bijan J
authors.initials: BJ
authors.lastname: Borah
authors.forename: James P
authors.initials: JP
authors.lastname: Moriarty
authors.forename: Robert E
authors.initials: RE
authors.lastname: Bristow
authors.forename: Martin A
authors.initials: MA
authors.lastname: Makary
authors.forename: Peter J
authors.initials: PJ
authors.lastname: Pronovost
authors.forename: Susan
authors.initials: S
authors.lastname: Hutfless
authors.forename: Sean C
authors.initials: SC
authors.lastname: Dowdy
mesh_terms: D001741:Black or African American / Q000706:statistics & numerical data; D000368:Aged; D016889:Endometrial Neoplasms / Q000601:surgery*; D005260:Female; D006630:Hispanic or Latino / Q000706:statistics & numerical data; D006760:Hospitalization / Q000191:economics; D061847:Hospitals, High-Volume / Q000592:standards / Q000706:statistics & numerical data*; D061846:Hospitals, Low-Volume / Q000592:standards / Q000706:statistics & numerical data*; D006801:Humans; D007044:Hysterectomy / Q000191:economics / Q000379:methods* / Q000592:standards*; D008484:Medicaid / Q000706:statistics & numerical data; D008875:Middle Aged; D019060:Minimally Invasive Surgical Procedures / Q000191:economics / Q000706:statistics & numerical data / Q000639:trends; D012189:Retrospective Studies; D065287:Robotic Surgical Procedures / Q000191:economics / Q000706:statistics & numerical data / Q000639:trends; D013530:Surgical Wound Infection / Q000209:etiology; D014481:United States; D054556:Venous Thromboembolism / Q000209:etiology; D044465:White People / Q000706:statistics & numerical data