The VA operates the largest integrated health care system in the country, consisting of 144 hospitals and 1,221 outpatient clinics. This system provides medical care for about 22 million veterans. In 2015, women accounted for nearly 10% of the veteran population and are expected to increase to about 16% by 2040.1 With an expected population increase of 18,000 per year over the next 10 years, women are the fastest growing group of veterans.
The VA acknowledges that women are an integral part of the veteran community and that a paradigm shift must occur to meet their unique health needs. Although clinical services specific to women veterans’ health needs have been introduced within the VA, gynecologic surgical services must be addressed in order to improve access and provide comprehensive women’s health care within the VA system.
About 600,000 hysterectomies are performed annually in the U.S., making this procedure one of the most commonly performed in women.2 Over the past 30 years, technologic advances have allowed surgeons to perform more hysterectomies via minimally invasive methods. Both the American Congress of Obstetricians and Gynecologists and American Association of Gynecologic Laparoscopists have published consensus statements that minimally invasive hysterectomy should be the standard of care.3,4 Studies in non-VA facilities have shown that practice patterns in the route of hysterectomy have evolved with the advancement of surgical equipment and techniques.
It is uncertain, however, whether these changes in practice patterns exist in the VA, because there are limited published data. Given the frequency of hysterectomies in the U.S., the rate and route of this procedure are easily identifiable measures that can be evaluated and utilized as a comparison model for health care received within the VA vs the civilian sector.
The aim of this study was to assess the changes in rate and surgical approach to benign hysterectomy for women veterans at VAMCs and referrals to non-VA facilities over a 10-year period. The authors’ hypothesis was that a minimally invasive approach would be more common in recent years. This study also compares published national data to evaluate whether the VA is offering comparable surgical services to the civilian sector.
The institutional review boards of Indiana University and the Richard L. Roudebush VAMC in Indianapolis, Indiana, approved this retrospective cross-sectional study. The VHA Support Service Center (VSSC) authorized access to VA database information.
All women veterans who underwent hysterectomy for benign indications from fiscal years (FY) 2005 to 2014 were included. In order to identify this group, the authors queried the VA Corporate Data Warehouse (CDW) and the Non-VA Care Cube for all hysterectomy current procedural terminology (CPT) codes typically performed for benign indications, including 58150, 58152, 58180, 58260, 58262, 58263, 58267, 58270, 58290, 58291, 58292, 58293, 58294, 58541, 58542, 58543, 58544, 58550, 58552, 58553, 58554, 58570, 58571, 58572, and 58573. For each patient identified, the following variables were collected: date of the procedure, facility location, primary CPT code, primary ICD-9 code, and patient age. Patients whose primary ICD-9 code was for a malignancy of gynecologic origin were excluded from the study.
The CDW is a national database collected by the VA Office of Information and Technology to provide clinical data for VA analytical purposes. The Non-VA Care Cube identifies services purchased for veterans with non-VA care dollars and, therefore, captures women veterans who were referred outside the VA for a hysterectomy. Additional data collected include age, gender, hospital complexity, place of care, payment location, primary CPT, primary ICD-9, and several other parameters. The annual number of women veterans accessing VA health care was extracted from the VSSC Unique Patients Cube.
Laparoscopic hysterectomy was defined as total laparoscopic hysterectomy, laparoscopic-assisted vaginal hysterectomy, laparoscopic-supracervical hysterectomy, and robotic-assisted laparoscopic hysterectomy. Minimally invasive hysterectomy was defined as all laparoscopic and vaginal hysterectomies.
Frequency distributions between categoric variables were compared using chi-squared tests. The population-adjusted hysterectomy rates were estimated by dividing the total number of hysterectomies by the number of women veterans accessing VA medical care. Hysterectomy rates are reported as rate per 1,000 women per year. A time trend analysis was performed with linear regression to evaluate the slopes of trends for each route of hysterectomy, using Microsoft Excel 2010 (Redmond, WA). The authors analyzed the relationship between route of hysterectomy and fiscal year, using a multivariable logistic regression that was adjusted for age, district, and surgical diagnosis. The adjusted relative risk (RR) for each type of hysterectomy was reported with 95% confidence intervals (CI). All statistical analyses were performed using SPSS 12.0 (Chicago, IL) with P < .05 defined as being statistically significant.To ensure the accuracy of the CDW data, the documented CPT and ICD-9 codes were compared between the CDW and the VA electronic medical records (EMR) for 400 charts selected at random. This cohort represents about 5% of the total charts and was felt to be an adequate measure of the entire sample since the CPT and ICD-9 codes were verified and matched 100% of the time. Demographic and descriptive data regarding body mass index, level of education, race, smoking status, medical comorbidities, and surgical history were excluded from the study because it was either not available or not consistently reported within the CDW.