The Appropriateness of Recommendations for Hysterectomy

abstract & commentary

Synopsis: Recommendations for hysterectomy were found to be inappropriate in 70% of cases studied.

Source: Broder MS, et al. Obstet Gynecol 2000;95(2): 199-205.

Broder and colleagues were funded by the Agency for Health Care Policy and Research and the Robert Wood Johnson Clinical Scholar’s Program. Their task was to determine whether the recommendations for hysterectomy provided to a large group of women who underwent hysterectomy were appropriate. Two different sets of criteria were used to determine appropriateness of recommendations for hysterectomy. The first was a criteria set developed by the Women’s Health and Hysterectomy Project and the second used three ACOG criteria sets. These criteria sets were developed based on expert opinions rather than outcome data since outcome data are lacking for most indications for hysterectomy.

All hysterectomies performed by physicians of nine capitated medical groups in southern California represented the potential case material. Women who had a hysterectomy for cancer or emergency reasons were excluded. Women had to be English-speaking, have complete inpatient and outpatient data available, provide informed consent, and agree to a structured telephone interview. A total of 497 women met all inclusion criteria.

Seventy percent of the cases did not meet the criteria of the expert panel. In most cases, there was a deficiency of the preoperative evaluation. For example, 45% of women with abnormal bleeding did not have endometrial sampling performed before hysterectomy. Twenty-one percent of patients with pain or bleeding did not have medical therapy offered prior to hysterectomy.

Seventy-six percent of the patients who had a hysterectomy for the indications covered by the ACOG criteria sets did not meet the ACOG criteria. The number failing the ACOG recommendations would have been higher if interviews had not been performed since some information was obtained only from patients, and not from the medical chart—a condition required by the ACOG criteria sets.

Comment by Kenneth L. Noller, MD

I hope that everyone will reread the summary of this article. It is an example of the ever increasing body of literature that can be considered to be a comment on physician "competency." In the near future, "assessment of competency" is going to be required of all certifying boards, hospital staffs, and medical societies. The public is demanding to know if their physicians are "competent." The federal government has heard these demands and is beginning to pressure the various credentialing organizations to develop some means of measuring competency. The faintly veiled threat is that the federal government will step in and perform the assessment if the current credentialing organizations do not implement satisfactory methods. Unfortunately, the goal is difficult to achieve. Should competency be based on outcome results? Postoperative infections? Compliance with criteria sets?

This article should be a wake-up call to physicians. It is likely that we will be judged not only by the success of our treatment of a given condition, but also by our compliance with evaluation algorithms. In this article nearly three-fourths of the patients had a recommendation for hysterectomy without the proper indication or preoperative evaluation. Indeed, the percentage would have been considerably higher if the patients had not been interviewed. In any future system that tries to assess competency it is unlikely that patient interviews will not occur. Therefore, it will be of the utmost importance for us to document everything in the patient chart. "If it’s not in the chart it didn’t happen."

It is likely that, in the future, some physicians will lose their license to practice medicine, or have their license severely restricted, based on chart reviews similar to those performed in this study.

In the article by Broder et al what percent of recommendations for hysterectomy were identified as being inappropriate based on an expert panel criteria set?

a. 10%

b. 25%

c. 40%

d. 70%