Gavin F. Jacobson

Nationwide Use of Laparoscopic Hysterectomy Compared With Abdominal and Vaginal Approaches

OBJECTIVE: To examine factors associated with undergoing laparoscopic hysterectomy compared with abdominal hysterectomy or vaginal hysterectomy. METHODS: This is a cross-sectional analysis of the 2005 Nationwide Inpatient Sample. All women aged 18 years or older who underwent hysterectomy for a benign condition were included. Multivariable analyses were used to examine demographic, clinical, and health-system factors associated with each hysterectomy route. RESULTS: Among 518,828 hysterectomies, 14% were laparoscopic, 64% abdominal, and 22% vaginal. Women older than 35 years had lower rates of laparoscopic than abdominal (odds ratio [OR] 0.85, 95% confidence interval [CI] 0.77–0.94 for age 45–49 years) or vaginal hysterectomy (OR 0.61, 95% CI 0.540.69 for age 45–49 years). The odds of laparoscopic compared with abdominal hysterectomy were higher in the West than in the Northeast (OR 1.77, 95% CI 1.2–2.62). African-American, Latina, and Asian women had 40–50% lower odds of laparoscopic compared with abdominal hysterectomy (P<.001). Women with low income, Medicare, Medicaid, or no health insurance were less likely to undergo laparoscopic than either vaginal or abdominal hysterectomy (P<.001). Women with leiomyomas (P<.001) and pelvic infections (P<.001) were less likely to undergo laparoscopic than abdominal hysterectomy. Women with leiomyomas (P<.001), endometriosis (P<.001), or pelvic infections (P<.001) were more likely to have laparoscopic than vaginal hysterectomy. Laparoscopic hysterectomy had the highest mean hospital charges (

Hysterectomy rates for benign indications

18,821, P<.001) and shortest length of stay (1.65 days, P<.001). CONCLUSION: In addition to age and clinical diagnosis, nonclinical factors such as race/ethnicity, insurance status, income, and region appear to affect use of laparoscopic hysterectomy compared with abdominal hysterectomy and vaginal hysterectomy. LEVEL OF EVIDENCE: III

Hysterectomy rates for benign indications.

OBJECTIVE To investigate the annual rates, types, and indications for hysterectomies performed for benign disease in Kaiser Permanente Northern California from 1994 to 2003. METHODS All women, 20 years or age or older, who were undergoing hysterectomy for benign indications in Kaiser Permanente Northern California from 1994 to 2003 were identified. We analyzed hysterectomy rates by type, indication, and age group. Changes over time were analyzed with the Cochran-Armitage test for linear trend. RESULTS From 1994 to 2003, there were 32,321 hysterectomies performed for benign indications. Hysterectomy rates showed a significant decline, from 4.01 per 1,000 women in 1994 to 3.41 per 1,000 women in 2003 (P for trend < .001). The relative proportions of all hysterectomies performed as laparoscopically assisted vaginal hysterectomy (LAVH) peaked at 13.0% in 1995 and then steadily declined to 3.9% in 2003 (P for trend < .001), whereas the relative proportion of subtotal abdominal hysterectomy increased from 6.9% in 1994 to 20.8% in 2003 (P for trend < .001). Hysterectomy rates declined 11.2% for uterine leiomyoma (relative risk [RR] 0.89, 95% confidence interval [CI] 0.83-0.95), 33.1% for endometriosis (RR 0.67, 95% CI 0.59-0.76), and 18.6% for uterine prolapse (RR 0.81, 95% CI 0.72-0.92). The relative proportion performed for uterine leiomyoma was consistently greater than for all other indications combined. CONCLUSION The rates of hysterectomy for benign indications are decreasing. The type of hysterectomy changed significantly, with LAVH performed less frequently and subtotal abdominal hysterectomy increasing in popularity. Uterine leiomyoma remains the most common indication for benign hysterectomy. LEVEL OF EVIDENCE II-2.

Probability of hysterectomy after endometrial ablation.

OBJECTIVE: To investigate the annual rates, types, and indications for hysterectomies performed for benign disease in Kaiser Permanente Northern California from 1994 to 2003. METHODS: All women, 20 years or age or older, who were undergoing hysterectomy for benign indications in Kaiser Permanente Northern California from 1994 to 2003 were identified. We analyzed hysterectomy rates by type, indication, and age group. Changes over time were analyzed with the Cochran-Armitage test for linear trend. RESULTS: From 1994 to 2003, there were 32,321 hysterectomies performed for benign indications. Hysterectomy rates showed a significant decline, from 4.01 per 1,000 women in 1994 to 3.41 per 1,000 women in 2003 (P for trend < .001). The relative proportions of all hysterectomies performed as laparoscopically assisted vaginal hysterectomy (LAVH) peaked at 13.0% in 1995 and then steadily declined to 3.9% in 2003 (P for trend < .001), whereas the relative proportion of subtotal abdominal hysterectomy increased from 6.9% in 1994 to 20.8% in 2003 (P for trend < .001). Hysterectomy rates declined 11.2% for uterine leiomyoma (relative risk [RR] 0.89, 95% confidence interval [CI] 0.83–0.95), 33.1% for endometriosis (RR 0.67, 95% CI 0.59–0.76), and 18.6% for uterine prolapse (RR 0.81, 95% CI 0.72–0.92). The relative proportion performed for uterine leiomyoma was consistently greater than for all other indications combined. CONCLUSION: The rates of hysterectomy for benign indications are decreasing. The type of hysterectomy changed significantly, with LAVH performed less frequently and subtotal abdominal hysterectomy increasing in popularity. Uterine leiomyoma remains the most common indication for benign hysterectomy. LEVEL OF EVIDENCE: II-2

Comparison of glyburide and insulin for the management of gestational diabetics with markedly elevated oral glucose challenge test and fasting hyperglycemia

OBJECTIVE: To investigate risk factors for hysterectomy after endometrial ablation. METHODS: This was a retrospective cohort analysis of data from Kaiser Permanente Northern California members, aged 25–60 years undergoing endometrial ablation from 1999 to 2004 and collected through 2007. Risk factors assessed included age, presence of leiomyomas, setting of procedure (inpatient or outpatient), and type of endometrial ablation procedure (first generation, radio frequency, hydrothermal, or thermal balloon). Univariable and survival analyses were performed to identify risk factors and estimate probability of hysterectomy. RESULTS: From 1999 to 2004, 3,681 women underwent endometrial ablation at 30 Kaiser Permanente Northern California facilities. Hysterectomy was subsequently performed in 774 women (21%), whereas 143 women (3.9%) had uterine-conserving procedures. Age was a significant predictor of hysterectomy (P<.001). Cox regression analysis found that compared with women aged older than 45 years, women aged 45 years or younger were 2.1 times more likely to have hysterectomy (95% confidence interval 1.8–2.4). Hysterectomy risk increased with each decreasing stratum of age and exceeded 40% in women aged 40 years or younger. Overall, type of endometrial ablation procedure, setting of endometrial ablation procedure, and presence of leiomyomas were not predictors of hysterectomy. In analysis of individual procedure types, concomitant myomectomy was associated with a decreased risk of hysterectomy for patients receiving first-generation endometrial ablation (P=.002), and outpatient location for hydrothermal endometrial ablation increased hysterectomy risk (P<.001). CONCLUSION: Age is more important than type of procedure or presence of leiomyomas in predicting subsequent hysterectomy after endometrial ablation. Women undergoing endometrial ablation at younger than 40 years of age are at elevated risk of hysterectomy, and rather than plateauing within several years of endometrial ablation, hysterectomy risk continues to increase through 8 years of follow-up. LEVEL OF EVIDENCE: II

Hysteroscopic sterilization in a large group practice: experience and effectiveness.

Objective:To compare the effectiveness of glyburide and insulin for the treatment of Gestational diabetes mellitus (GDM) in women who had OGCT ⩾200 mg/dl and fasting hyperglycemia.Study design:A retrospective study was performed among a subset of women treated with glyburide or insulin for GDM from 1999 to 2002 with an OGCT ⩾200 mg/dl and pretreatment fasting plasma glucose ⩾105 mg/dl. Exclusion criteria included pretreatment fasting ⩾140 mg/dl, gestational age ⩾34 weeks and multiple gestation. Maternal and neonatal outcomes were assessed. Statistical methods included bivariate and multivariable logistic regression analyses.Results:In 1999 to 2000, 78 women were treated with insulin; in 2001 to 2002, 44 of 69 (64%) received glyburide. There were no statistically significant differences between the two groups with regards to mean OGCT (230±25 vs 223±23 mg/dl, P=0.07) and mean pretreatment fasting (120±10 vs 119±11 mg/dl, P=0.45). Seven women (16%) failed glyburide. Women in the insulin group were younger (31.5±5.8 vs 35.2±4.7 years, P<0.001) and had a higher mean BMI (32.4±6.4 vs 29.1±5.8 kg/m2, P=0.003) compared to glyburide group. There were no significant differences in birth weight (3524±548 vs 3420±786 g, P=0.65), macrosomia (19 vs 23%, P=0.65), pre-eclampsia (12 vs 11%, P=0.98) or cesarean delivery (39 vs 46%, P=0.45). Neonates in the glyburide group were diagnosed more frequently with hypoglycemia (34 vs 14%, P=0.01). When controlled for confounders, macrosomia was found to be associated with glyburide treatment (OR 3.5, 95% CI 1.1 to 11.4).Conclusion:In women with GDM who had a markedly elevated OGCT and fasting hyperglycemia, glyburide achieved similar birth weights and delivery outcomes but was associated with an increased risk of macrosomia. The possible increased risk of neonatal hypoglycemia in the glyburide group warrants further investigation.

A comparison of medical induction and dilation and evacuation for second-trimester abortion

OBJECTIVE: To estimate device placement and tubal occlusion rates for hysteroscopic sterilization and evaluate risk factors for failure. METHODS: Women undergoing hysteroscopic sterilization at Kaiser Permanente Northern California from January 2004 to December 2006 were identified. Risk factors assessed included age, parity, body mass index (BMI), operative location, and provider experience with the technique. Occlusion was determined by hysterosalpingogram. Univariable analyses were performed to identify factors predictive of successful placement and occlusion. The Cochrane-Armitage test was performed for trend analysis. RESULTS: Hysteroscopic sterilization was attempted in 884 women by 118 physicians at 30 Kaiser Permanente Northern California facilities. The initial placement attempt was successful in 850 patients (96.2%). Patient age, nulliparity, and BMI were not predictive of successful placement. Bilateral occlusion was demonstrated by hysterosalpingogram in 687 of 739 patients (93.0%). There were no significant differences in age, nulliparity, and BMI between those with and without occlusion. Loss to follow-up before a hysterosalpingogram was obtained was 13%. There was no significant increase in occlusion rate with experience (P for trend=.6). CONCLUSION: High placement and occlusion rates were noted from the first insertions, and success was not related to age, parity, BMI, or operator experience. LEVEL OF EVIDENCE: III